Introduction:
Acute sinusitis is inflammation and swelling of the paranasal (or just nasal) sinuses, with symptoms lasting more than four weeks. When this occurs in the ethmoid bone, it is known as acute ethmoid sinusitis. A sinus is a cavity inside the bone lined with mucus with an opening (ostium) into the nose. The human body has four pairs of sinuses in four different bones; the sinuses are named after the bones they are present in; they are:
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Ethmoid Sinuses- Present inside the ethmoid bone, near the bridge of the nose on either side.
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Frontal Sinuses- They are seen above the eyes, on each side of the frontal bone.
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Sphenoid Sinuses- Present behind the eyes.
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Maxillary Sinuses- Located in the maxilla (upper jaw) and under the eyes.
All the sinuses operate as a network of interconnected channels, so naming the infection based on the location it is affecting is only for convenience. For example, acute ethmoid sinusitis is named so because the infection (virus or bacteria) that has entered through the nose (or sometimes the eye) has inflamed the walls of the ethmoid sinus. Still, if we look carefully, the same infection will be carried to the other sinuses through the interconnected channels and cause inflammation in them as well. This is why sinusitis (frontal or ethmoid or maxillary or sphenoidal) generally has the same symptoms (non-specific). Therefore, taking the entire upper respiratory tract as a unit is important while treating sinusitis.
What Are the Symptoms of Acute Ethmoid Sinusitis?
As mentioned earlier, the symptoms are nonspecific for each sinus. Still, infection in every sinus more or less has the same symptoms, which helps in the initial diagnosis of sinusitis and ruling out other diseases. They are:
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Fever and headache.
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Facial pain and tenderness, especially when the patient bends over.
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Nasal congestion.
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Purulent (mucus mixed with pus) discharge into the nose that moves down the throat.
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Sore throat and cough.
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Bad breath and phlegm in the spit.
Ideally, the symptoms are relieved once the body’s immune gets rid of the infection, but in a few patients with preexisting conditions, the symptoms get severe and need medical attention; if this happens after four weeks after the onset of the symptoms, then it is considered to be acute ethmoid sinusitis.
What Causes Acute Ethmoid Sinusitis?
Isolated infection of the ethmoid bone is rare; the same infection (virus, bacteria, or fungus) and risk factors that cause sinusitis also cause acute. It is important to know the risk factors for sinusitis because if it is not for them, the body is capable of taking care of the infection; some of them are:
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Allergies.
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A deviated septum.
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Nasal polyps.
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Cystic fibrosis.
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Sarcoidosis (a systemic autoimmune inflammatory condition leading to the formation of lumps).
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Wegener’s granulomatosis (an inflammatory disorder that mainly affects the blood vessels).
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Dental infection.
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Immunodeficiency.
Along with the factors mentioned above, conditions like age, diabetes, hypertension, smoking, etc., also affect the severity of the infection. If untreated, the infection can spread to the eye, causing proptosis (bulging of the eye) and blindness. In addition, life-threatening complications due to infection of the brain are a possibility in acute ethmoid sinusitis because the ethmoid bone forms the floor of the skull and is close to the brain.
How Is Acute Ethmoid Sinusitis Treated?
The clinician will prescribe medication (antibiotics, nonsteroidal anti-inflammatories, corticosteroids, nasal decongestants, etc.) after the initial diagnosis; this will help to reduce inflammation and swelling and open the ostia of the sinuses to facilitate drainage. However, in a few patients in whom medical therapy has failed, the clinician will opt for surgery known as ethmoidectomy, the indications of which are mentioned below:
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The sinusitis has spread to the eyes.
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In patients who are not responding to medical therapy.
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In patients with brain abscesses caused due to sinusitis.
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If the sinusitis is compromising the survival of the patient.
How Is Ethmoidectomy Done?
An otolaryngologist performs the surgery; it can be done in different ways, they are:
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Functional Endoscopic Ethmoidectomy- Done with the help of an endoscope (an illuminated tube with a camera) and a microdebrider (a special instrument with a tiny rotating tip). The camera and the microdebrider are inserted through the nose after anesthesia; they help the surgeon remove the infected tissue and bone without damaging the healthy tissue.
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Intranasal Ethmoidectomy- One of the options available before the invention of an endoscope; the surgeon approached the ethmoid sinus through the nose and resected (cutting) the affected tissue and bone. It was the preferred option for patients with nasal polyps.
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Transantral Ethmoidectomy- This procedure is done by punching a hole in the mouth's maxilla (upper jaw) to reach the ethmoid bone. It is only sometimes preferred owing to the difficulty in the access of the ethmoid sinuses.
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External Ethmoidectomy- Most surgeons are familiar with this approach, which is still preferred in patients with trauma. The surgeon approaches the ethmoid sinuses by placing an incision in the eye's middle and the anterior nasal bone. Care is taken to avoid any lacrimal (eye) secretory structures. This approach offers a clear view of the affected sinus, which is then resected; the surgeon may choose to place a drain post-op to facilitate the lavage of the sinus.
After careful evaluation and appropriate investigations, the surgeon chooses the type of approach, like a computed tomographic (CT) scan. It is important to know the anatomy of the ethmoid bone; before choosing the approach because of a few reasons:
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The literature generalizes the nasal sinuses as paired cavities, but the ethmoid bone contains three to five cavities on either side that drain into the nose. Care should be taken so that only the affected sinuses are treated.
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The cribriform plate of the ethmoid bone forms the base of the skull. This proximity of the ethmoid bone to the brain makes it extremely vulnerable.
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The nasolacrimal gland also opens into the nose through an aperture in the ethmoid bone. Any damage to this duct will cause serious damage to the eyes.
The goal of the surgery is to remove the affected tissue and bone and enlarge the blocked ostia (sinus openings); this is only possible with thorough knowledge of the underlying anatomy.
What Are the Complications of Ethmoidectomy?
Each approach has its own set of risks; a few general complications of ethmoidectomy are:
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Dystopia (droopy eye).
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Diplopia (double vision) or blindness.
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A cerebrospinal fluid leak might happen, given the close proximity of the ethmoid bone to the brain.
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Pituitary (a gland in the brain) damage has also been reported in a few cases.
The above-mentioned complications are surgery-related; however, in a few patients, recurrence of the ethmoid sinusitis may occur if the post-op follow is not followed appropriately.
Conclusion:
Ethmoidectomy is a well-tolerated procedure with a high success rate. Patients recover completely, with almost 98% of them not needing a revision (repeated) ethmoidectomy. The success of this procedure depends on the post-surgery follow-up, where debridement is done to remove the blood clots and crusts. Antibiotics are also prescribed post-surgery for residual infection. Intranasal rinses with a neti pot and nasal decongestants are also part of the recovery.
