The terms 'Rhinosinusitis' refers to a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses.Chronic rhinosinusitis is diagnosed when the duration of symptoms lasts greater than 12 weeks. 1Chronic maxillary sinusitis is the most common form of sinusitis. It is an extremely prevalent disorder that has a significant impact on the quality of life of an affected individual.The causes can be anatomical, physiological, or pathological which ultimately obstructs the free drainage from sinuses causes stasis, and predisposes to infections. Maxillary sinuses are fully dependent on the patency of the anterior ethmoidal region because their ventilation and drainage pass through complicated fissures and narrow compartments. 2It has been estimated that 24 million people are affected by sinusitis annually. 3The prevalence of sinusitis (146/1000) has been reported to exceed that of any other chronic condition and is apparently on the rise. It is estimated that between 30 and 50% of all patients seen by the family practitioner suffer from some form of rhinosinusitis. 4In the USA 20% of outpatient antibiotic prescriptions are due to acute or chronic sinusitis. 5Symptoms of chronic sinusitis are non-specific and may be misleading they are attributed to sinonasal inflammation which is marked by nasal congestion, nasal stuffiness, nasal airway obstruction, and decreased sense of smell and taste. Facial pressure or facial pain may be present along with fatigue malaise, ear pressure, and maxillary dental pain or headache. Based on the clinical examination the cases are sometimes divided into cases with polyps and cases without polyps. The presence of polyps is known as chronic hyperplastic sinusitis causes of it can be ranging from allergy, dusts pollen,environmental factors, bacterial infections. Non allergic factors such as vasomotor rhinitis can also cause chronic sinus

problems. 6 Infection of adenoids and tonsils may spread into the sinuses.With the increase in the incidence of HIV/AIDS, Diabetes, and various other immune suppressor diseases, the incidence of bacterial especially fungal rhinosinusitis is becoming a challenging problem for an ENT Surgeon. Dental infections or extraction of the tooth may cause infection of maxillary antrum from dental canal root. Swimming and diving may cause the direct spread of materials from the nose through the ostium into paranasal sinuses. Fractures involving sinuses may be followed by sinusitis by either direct spread through the fracture site or infections of a blood clot. With the advent of endoscopic anatomy and pathophysiology of the nose and paranasal sinuses, the treatment of sinus disease assured excellent results with less recurrence. There are various modalities of treatment based on the diagnosis of etiological factors treated with medical management or surgical management. The various surgical forms of treatment have been divided for this condition such as Antral wash, Intranasal antrostomy, Caldwell-Luc, FESS. We in the present study tried to evaluate the various modalities of treatment and outcomes in patients with chronic maxillary sinusitis.

This cross-sectional study was conducted in the Department of Otorhinolaryngologyof Prathima Institute of Medical Sciences, Karimnagar, Telangana State. Institutional ethical committee permission was obtained for the study after following the protocol for human studies. Written consent was obtained from all the participants of the study after explaining the nature of the study. Sample size calculation was done with formula 4pq/d2, the following values were used. Confidence Interval 90%, Margin of Error 8%, the proportion of the population affected by the disease is approximately 15% the calculated sample size was 55 we included n=60 cases in our study.

1. Patients presenting with clinical features of chronic rhinosinusitis of all age groups and sexes.

2. Those who were voluntarily willing to participate in the study.

3. Those who were available for follow-up examinations.

1. All patients presenting with clinical features other than sinusitis.

2. All cases of chronic rhinosinusitis involving other than maxillary sinus.

3. Previous cases of chronic rhinosinusitis with postoperative complications.

After the selection of the patient a complete history of present illness including the history, and the family history was noted, and the demographic profile of the patient was recorded. The patient was subjected to general examination from head to toe which included the examination of the Respiratory system and cardiovascular system. ENT examination along with head neck was done.

Investigations: All the n=60 patients were subjected to clinical examination andinvestigated by the following methods.

Haematological: Baseline hematological investigations like Hb%, total WBC counts, differential count, E.S.R, bleeding time, clotting time, platelet count,R.B.S/F.B.S, blood urea, A.E.C, HBsAg, HIV were done for all patients. Radiological: X-Ray (Water's view), C.T Scan PNS-Coronal, and Sagittal sections for selected patients.Diagnostic Nasal EndoscopyHistopathology: H.P.E of tissue obtained during surgery.Microbiology: Culture and sensitivity for bacteria and fungus. Postoperative: Antibiotics for 7-10 days, antihistamines for 10-15 days, nasaldouching, steam inhalations, intranasal steroids (Budesonide, Fluticasone) for 1-2months. Postoperati vesystemic steroids (Prednisolone -tapering dose for 10-15days in some cases).Follow-up:Patients were followed twice weekly for the first 2 weeks, once a week forthe next 2 weeks, once a month for 6 months.At each visit, the examination was done.

Out of the n=60 cases n=33 (55%) were male patients and n=27(45%) were female patients. The youngest case in the study was 15 years and the oldest was 59 years. Most of the cases in both males and females were from the age group 21 -30 years indicating that this group is most affected by the disease given in table 1. The common cause of seeking medical care was symptoms of headache, nasal obstruction and nasal discharge is greater than 90% of cases and 61.67% also reported with pharyngeal infections. In this study, the duration of symptoms in 31 cases was from 6-9 months intermittently. 10 cases had a duration greater than 12 months and 6 cases had a duration of >18 months details shown in table 2. Table 2: symptoms recorded in the cases included in the study After the ENT examination of the selected cases, half of the cases had deviated nasal septum which was the cause of chronic sinusitis. There was hypertrophy of inferior turbinate in 46% of cases and other abnormalities were found ranging from 3% -5% in the cases as shown in table 3. In n=38 cases Functional Endoscopic sinus surgeries were done antral wash was done in n=16 cases, intranasal antrosomy in n=2 cases, Caldwell Luc operation in n=2 cases, maxillary sinscope surgery in n=2 cases given in figure 1.Uncinectomy in n=10 cases, middle meatal antrostomy in n=7 cases, anterior meatal antrostomy in n=6 cases, posterior meatal antrosomy in n=5 cases, sphenoidotomy in n=3 cases frontal sinus surgery in n=1 case, and polypectomy in n=6 cases given in figure 2. Postoperative complications distribution: No major postoperative complications were noted in the postoperative period. The minor postoperative complications include synechiae formation which was noted in n=3 patients (5%) who have undergone FESS at the end of the 2nd week and the incidence dropped to 0% by the end of the 12th week.

Rhinosinusitis presents with variable clinical features in patients depending upon the actual pathogenesis underlying the disease. The present study is an attempt to determine the clinical features, application of required diagnostic criteria used by various authors, correlate the radiological features with the clinical signs, and per-operative findings. Nasal smears, Nasal swabs, and tissue collected during the surgery were subjected to laboratory study to arrive at the diagnosis. An attempt was also made to study the role of various treatment modalities used during the management of the disease.Out of the n=60 cases, the youngest case in the study was 15 years and the oldest was 59 years commonly affected age group was 21-30 years.According to McNeil RA et al; 7 the maximum age incidence was inthe 4thdecade. While in the studies by Vuorinen P et al; 8 Axelsson AA et al; 9 M Kurienet al; 10 found the highest incidence in the 20-29 age group (3rddecade)agreeing with the observations of the present study.In this study, we found 55% were male patients and 45% were female patients. In the current study symptoms of headache 96.67%, nasal obstruction in 93.33%, and nasal discharge in 91.67% of cases.In SR Nayak et al; 11 study the commonest symptom was nasal discharge followed by headache and nasal obstruction. Nasal obstruction was the commonest symptom (96%) followed by postnasal drip (92%) & facial pain/headache (90%) in the study byMathews BL et

al; 12 and Fageeh NA et al; 13 study the commonest complaint was nasal obstruction (76%), headache (74.4%), anosmia (56.5%) & facial pressure/pain (50%).In our study deviated nasal septum was seen in 51.67% of cases. Maru YK et al; 14 found deviated nasal septum in 55.7% of cases and Asruddin et al; 15 found in 38% of cases. Jareoncharsri P et al; 16 septal deviation is obvious in 60(72.3%) of the patients out of 83 cases on DNE. In the current study, we found the commonest organism isolated from the secretions to be Streptococcus pneumoniae(28.33%). Brook I et al; 17 identified chronic rhinosinusitis in the aspirations of sinus secretions by endoscope from 80 patients in their study, demonstrating the Streptococcus pneumoniae is the commonest bacterial cause.Gwaltney JMet al; 18 found Streptococcus pneumoniae (20-45 %)and Haemophilus influenzae (22-35 %) are the predominant organisms in acutebacterial rhinosinusitis in adults.In the present study, all patients received Preoperative Antibiotics, Antihistamines, decongestants, steam inhalations, and in some patients transnasal steroids (Budesonide, Beclomethasone, Fluticasone).In this study, n=38 cases underwent FESS surgery and postoperatively n=30 (78.95%) cases have significant improvement and relief from symptoms of chronic sinusitis.Behin F et a; 19 patients underwent FESS surgery 83% of patients no longer complained of headache and 8% had significant relief. A study conducted by Parsons DS et al; 20 on 34 patients who underwent FESS surgery reported a reduction in intensity in 91%of patients and a reduction in the frequency of headache in 85% of patientsposto peratively.No major postoperative complications were noted in the postoperative period. Theminor postoperative complications include synechiae formationwhich was noted in n=3 patients (5%) who have undergone FESS at the end of the 2nd week and the incidence dropped to 0% by the end of the 12th week. A study by K J Jacob et al; 20 found Synechiae formation between the middle turbinate at the end of 2 weeks and long-term follow-up showed normal endoscopic findings.

Under the limitations of the current study, it was found chronic maxillary sinusitis affects all age groups and however predominantly found in the 3rd decade. The commonest organism responsible was streptococcus pneumoniae. Improvement in the diagnostic techniques and availability of nasal endoscopy and CT scan which can show clearly the anatomy of osteomeatal complex has led to better management of the disease. Nasal endoscopes have allowed a meticulous delicate removal of the diseased mucosa which preserving the normal mucosa and structures consequently the postoperative complications are very few and most of the cases get relief from the symptoms of the disease.