Acute & Chronic Rhinosinusitis, Stridor, and Tracheostomy

RHINOSINUSITIS

• Acute rhinosinusitis (ARS): symptoms < 12 weeks
• Chronic rhinosinusitis (CRS): symptoms > 12 weeks

Acute Rhinosinusitis (ARS)

• Pathogenesis: Usually bacterial superinfection following viral URTI-induced mucosal damage. Common organisms: S. pneumoniae, H. influenzae, Moraxella catarrhalis. Dental sepsis (anaerobic organisms) causes ~10% of maxillary sinusitis cases.
• Presentation:
  • Maxillary sinusitis: mucopurulent discharge, facial pain, nasal obstruction; referred toothache (superior alveolar nerve irritation)
  • Frontoethmoidal sinusitis: mucopurulent discharge, frontal headache, nasal congestion, hyposmia
  • Nasendoscopy shows inflamed mucosa with mucopus in the middle meatus
• Investigations: CT is now the standard (superseded plain films); shows opacification/mucosal thickening and defines anatomy before surgery.
• Treatment: Most cases resolve with antibiotics, topical decongestants (e.g., ephedrine drops), and topical corticosteroids; saline douching helps. Since penetration of antibiotics into inflamed mucosa is reduced, treatment courses are often prolonged. Endoscopic sinus surgery (ESS) is reserved for those failing medical therapy or developing complications.
• Complications (Chandler classification of orbital spread):
  • I - Preseptal cellulitis
  • II - Orbital cellulitis
  • III - Subperiosteal abscess
  • IV - Orbital abscess
  • V - Cavernous sinus thrombosis (bilateral ptosis, proptosis, ophthalmoplegia, papilloedema, spiking fevers)
  • Intracranial spread (via diploic veins or bone erosion): epidural/subdural/cerebral abscess, meningitis/encephalitis
  • Osteomyelitis of the frontal bone -> Pott's puffy tumour (forehead swelling from anterior table dehiscence)
  • Orbital complications (most often from ethmoiditis) threaten vision - urgent ophthalmology review, contrast CT if proptosis/chemosis/ophthalmoplegia/reduced acuity, and drainage if abscess forms.

Chronic Rhinosinusitis (CRS)

• Symptoms persisting beyond 12 weeks; encompasses both neutrophilic and eosinophilic inflammatory drivers, and is increasingly recognized as an endotype-driven (type 2/eosinophilic vs non-type 2) disease rather than a single entity - relevant to newer biologic therapies (Goldman-Cecil Medicine).
• Commonly subclassified as CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP).
• Microbiology differs from ARS: Staphylococcus aureus, Pseudomonas aeruginosa, and anaerobes are common; chronically inflamed sinuses show reduced bacterial diversity with overgrowth of pathogenic species.
• Unilateral/isolated chronic disease should raise suspicion for odontogenic infection or fungal disease (fungal ball/mycetoma) - important "red flag" for unilateral CRS.
• Associations: allergic rhinitis/asthma, aspirin-exacerbated respiratory disease, cystic fibrosis, primary ciliary dyskinesia, and immune conditions (e.g., eosinophilic granulomatosis with polyangiitis).
• Management principles: intranasal/systemic corticosteroids, saline irrigation, addressing underlying allergy, culture-directed antibiotics for exacerbations, and endoscopic sinus surgery for medically refractory disease; biologics (anti-IL4/13, anti-IgE, anti-IL5) now used for severe CRSwNP with type 2 inflammation.

STRIDOR

Paediatric Stridor - key clinical approach

• History clues:
  • Stridor with feeding/crying/movement in the first year -> laryngomalacia or subglottic stenosis
  • Worse with feeding in first 4 weeks -> vascular ring or tracheo-oesophageal fistula
  • Weak/abnormal cry -> vocal fold palsy
  • Biphasic stridor with URTI -> congenital subglottic stenosis
  • Inspiratory stridor + drooling in a young child -> acute epiglottitis (do NOT lie the child down or examine the mouth/throat - risk of precipitating complete obstruction/respiratory arrest)
  • Biphasic stridor without drooling -> laryngotracheobronchitis (croup)
• Examination: Observe the resting pattern (ideally with the mother handling the child), watch feeding, auscultate trachea/chest, look for associated congenital anomalies. Use transcutaneous pulse oximetry. Have a resuscitation trolley with intubation/tracheostomy equipment ready before examining a stridulous child.
• Causes summary:
  • Congenital: laryngomalacia, laryngeal web, subglottic stenosis
  • Acquired - inflammatory: angioneurotic oedema
  • Traumatic: impacted foreign body, laryngeal fracture
  • Infective: epiglottitis, laryngotracheobronchitis (croup)
  • Neurological: vocal fold palsy
  • Neoplastic: benign laryngeal papillomatosis

TRACHEOSTOMY

1. Upper airway obstruction (e.g., head and neck tumours, bilateral vocal fold palsy, severe angioedema/infection)
2. Prolonged mechanical ventilation / chronic ventilator dependence (most common indication in ICU)
3. Need for pulmonary toilet - facilitating clearance of secretions in patients with poor cough/aspiration risk
4. As an adjunct to another major head and neck procedure
5. Selected cases of severe obstructive sleep apnoea failing conventional therapy

Techniques

• Percutaneous dilatational tracheostomy (PDT): Performed at the bedside in ICU, usually under bronchoscopic guidance. Seldinger technique: needle insertion between 2nd-3rd tracheal rings, guidewire, then serial/graduated dilation before tube placement. Meta-analyses show equivalence to surgical technique with fewer wound infections.
• Open surgical tracheostomy: Preferred when there is obesity (limited kit suitability), anatomical distortion (previous neck surgery, goitre), or coagulopathy/bleeding diathesis. Percutaneous technique is rarely used in children.

Tracheostomy tubes and care

• Most are plastic, available in varying sizes, curves, cuffed/uncuffed, with or without an inner cannula.
• A cuffed tube is used initially post-op to protect the airway from secretions/bleeding, typically changed to an uncuffed tube after 3-4 days once safe.
• Cuff pressure must be monitored and kept low to avoid mucosal capillary occlusion, which risks scarring and subglottic stenosis.
• A removable inner cannula should be used and cleaned regularly to prevent lumen occlusion by dried secretions.
• Tube secured with tapes (tied with neck flexed to avoid slack/displacement on movement) or sutured flanges.

Complications

• Intraoperative: haemorrhage, pneumothorax, damage to surrounding structures (recurrent laryngeal nerve, oesophagus), tube misplacement
• Early postoperative: tube displacement/blockage, surgical emphysema, infection, haemorrhage
• Late: tracheal stenosis, tracheomalacia, tracheo-oesophageal fistula, tracheo-innominate artery fistula (life-threatening late haemorrhage), persistent stoma, granulation tissue (Bailey and Love's Short Practice of Surgery, Table 52.2)