Q2 Paranasal Sinuses — MEFS Written Answer

SECTION 1

Anatomy & Structure of the Paranasal Sinuses

3 marks

Overview: Four paired sinuses lined with mucous membranes and ciliated epithelium. Cilia sweep mucus into the nasal cavity via drainage ostia. Functions include: lightening the skull, voice resonance, humidifying inspired air, and warming air.

Nerve supply: Trigeminal nerve (CN V) — explains referred pain patterns to teeth, eyes, and forehead.

Sinus	Location	Drainage	Pain Pattern
Maxillary	Within maxillary bone, below orbits, lateral to nose. Largest sinus.	Middle meatus (ostium high on medial wall — poor drainage)	Cheeks, upper teeth, hard palate, frontal, nasal, orbital areas
Ethmoid	Between eyes, within ethmoid bone. Multiple small air cells (anterior, middle, posterior).	Middle and superior meatus	Between eyes; possible anosmia
Frontal	Within frontal bone, above orbits, forehead	Frontonasal duct → middle meatus	Supraorbital ridge, forehead
Sphenoid	Deep within sphenoid bone, posterior to nasal cavity	Sphenoethmoidal recess	Deep retro-orbital headache, vertex

📚 Ref: ICOM TMJ and Sinus ppt (Year 4 Google Classroom); Gray H. Gray's Anatomy 42nd ed. Elsevier 2021.

SECTION 2

Signs and Symptoms of Sinus Infections

5 marks

General Features of Sinusitis

Dull facial ache to severe pressure/pain over affected sinus
Nasal congestion and obstruction
Purulent yellow-green nasal discharge
Postnasal drip — mucus draining to throat
Fever and systemic malaise
Headache worse on bending forward (increased sinus pressure)
Toothache — upper molars (maxillary sinus floor proximity)
Reduced smell: hyposmia or anosmia (ethmoid involvement)
Fatigue

Sinus-Specific Pain Map

🟠 Frontal Sinusitis Pain over supraorbital ridge and forehead. Worse in morning, improves as sinus drains through day.

🟣 Ethmoid Sinusitis Pain between the eyes. Associated anosmia. Periorbital swelling possible.

🔵 Maxillary Sinusitis Cheek pain, upper teeth ache, hard palate, frontal, nasal and orbital areas. Most common.

🟢 Sphenoid Sinusitis Deep retro-orbital headache, vertex pain. Rare but serious — proximity to cavernous sinus.

📚 Ref: ICOM TMJ and Sinus ppt (Year 4 Google Classroom) — extracted text and pain maps.

SECTION 3

Causes of Sinusitis

4 marks

Predisposing / Structural Factors

Allergies: mould, pollen, dust — mucosal oedema blocks ostia
Structural problems: deviated nasal septum, small sinus ostium — impaired drainage
Nasal polyps: obstruct drainage pathways
Smoking: impairs mucociliary clearance
Fractured skull: sinus damage or ossification of ostium preventing drainage
Decongestant overuse: rhinitis medicamentosa — rebound congestion

Infective Causes

Viral URTI: most common trigger — mucosal swelling blocks ostia
Bacterial superinfection: Streptococcus pneumoniae, Haemophilus influenzae (most common bacteria)
Dental infection: upper molar root abscess → maxillary sinusitis (roots close to sinus floor)
Chronic allergy: persistent mucosal inflammation

Category	Examples	Mechanism
Viral	Rhinovirus, influenza	Mucosal oedema → ostial obstruction → secondary infection
Bacterial	S. pneumoniae, H. influenzae	Superinfection of obstructed sinus
Allergic	Pollen, dust, mould	IgE-mediated mucosal swelling
Structural	Deviated septum, polyps	Mechanical obstruction of drainage
Dental	Upper molar abscess	Direct spread to maxillary sinus floor
Iatrogenic	Decongestant overuse	Rhinitis medicamentosa — rebound

📚 Ref: ICOM TMJ and Sinus ppt (Year 4 Google Classroom); NICE CKS Sinusitis 2023.

SECTION 4

Differential Diagnosis

2 marks

Condition	Key Features	Distinguishing from Sinusitis
Migraine	Unilateral, throbbing, photophobia, nausea, aura	No purulent discharge, no fever, episodic
Trigeminal Neuralgia	Lancinating, electric shock, seconds duration	No congestion, triggered by touch/eating
Dental Abscess	Localised tooth pain, swelling, percussion tenderness	Dental exam, no nasal symptoms
Acute Glaucoma	Severe eye pain, visual disturbance, fixed dilated pupil	⚠️ Emergency — refer immediately
Tension Headache	Bilateral band pressure, no fever, no discharge	No nasal symptoms, no positional change

📚 Ref: ICOM Headaches ppt (Year 4 Google Classroom).

SECTION 5

Osteopathic Treatment

4 marks

Direct Sinus Techniques

Frontal lift: bilateral contact on frontal bone, superior traction to decompress frontal sinus
Infraorbital / supraorbital milking: rhythmic pressure along orbital ridges toward nasal opening
Maxillary oscillation: rhythmic technique over maxillary bones to promote drainage
Maxillary sinus milking: along nasal folds toward nasal opening

Intraoral Techniques (Consent Required)

Internal maxillary separation: gloved thumbs on hard palate — lateral traction to widen palatal suture and open maxillary ostia
Soft palate sinus pumping: intraoral rhythmic pressure — avoid triggering gag reflex

Lymphatic and Drainage Techniques

Thoracic duct / clavicular pump: enhance lymphatic return from head and neck
SCM and scalenes soft tissue: reduce lymphatic congestion in anterior cervical chain
Longus colli soft tissue: anterior cervical release
Galbreath technique: mandibular drainage — promotes Eustachian tube drainage (useful in otitis media with sinusitis)
Indirect Galbreath (paediatric): 30° angle for babies/children vs 50° for adults

🦴 Osteopathic Safety — Intraoral Techniques

Always obtain informed consent before intraoral techniques
Gloves are essential — universal precautions
Avoid triggering gag reflex — position carefully
Discontinue immediately if patient shows distress
Contraindicated in acute dental infection, oral ulceration, or patient refusal

⚠️ Note: Intraoral techniques require specific training and patient consent. Document consent in clinical notes.

📚 Ref: ICOM TMJ and Sinus ppt (Year 4 Google Classroom); ICOM Cranial and Somatic Technique Guide.

🚨 Red Flags — Refer Immediately

Fractured skull / CSF rhinorrhoea: clear watery nasal discharge after head trauma — emergency
Orbital cellulitis: proptosis, restricted eye movement, periorbital swelling — emergency
Severe fever with neck stiffness / meningism: exclude meningitis — emergency
Visual disturbance / diplopia: cavernous sinus involvement — emergency
Altered consciousness: intracranial spread — emergency
Symptoms not resolving after 10 days: consider bacterial sinusitis, refer for antibiotics
Unilateral symptoms with blood-stained discharge: exclude malignancy

📚 References

ICOM TMJ and Sinus ppt — Year 4 Google Classroom (primary source)
ICOM Headaches ppt — Year 4 Google Classroom
ICOM Cranial and Somatic Technique Guide — Year 4
NICE CKS Sinusitis (2023). Available at: cks.nice.org.uk/sinusitis
Gray H. Gray's Anatomy. 42nd ed. Elsevier; 2021.
Kumar P, Clark M. Kumar & Clark's Clinical Medicine. 10th ed. Elsevier; 2021.
DiGiovanna EL, Schiowitz S, Dowling DJ. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Lippincott; 2005.

Paranasal Sinuses — MEFS Written Answer

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