complications of sinusitis

Complications of Sinusitis

Dr. Vishal Sharma

Definition

1. Adverse progression of infection beyond

muco-periosteal lining of para nasal sinuses

to involve bone & neighboring structures

(orbit, intra-cranial cavity, dentition)

2. Compromise in function of any part of body

due to sinusitis

Etiology1. Weak immune response of host: young

children & immuno-compromised adults

2. Inadequate or inefficient treatment

3. Infection by high virulence organisms

4. Abnormalities of muco-cilliary clearance

5. Persistent allergy & blockade of sinus ostia

Routes of infection1. Via thin bones: lamina papyracea

2. Through natural suture lines

3. Through natural canal: infra-orbital canal

4. Retrograde thrombophlebitis: diploic vein of

Breschet

5. Closely related roots of upper 2nd premolar &

1st molar teeth

6. Peri-arteriolar space of Virchow Robin

Common pathogens• Staphylococcus aureus

• Streptococcus pnemoniae

• Haemophilus influenzae

• Moraxella catarrhalis

• Anaerobes: Bacteroides

• Aspergillus

• Rhizopus

ClassificationA. Acute B. Chronic

1. Local Mucocele (?)

Orbital Pyocele (?)

Intra-cranial C. Associated diseases

Bony Otitis media

Dental Adeno-tonsillitis

2. Distant Bronchiectasis

Toxic shock Atrophic rhinitis

syndrome Nasal polyp

Orbital Complications

1. Pre-septal cellulitis

2. Orbital cellulitis without abscess

3. Orbital cellulitis with extra-periosteal abscess

4. Orbital cellulitis with intra-periosteal abscess

5. Cavernous sinus thrombosis ?: intracranial

6. Orbital apex syndrome

Intracranial Complications1. Meningitis

2. Encephalitis

3. Extra-dural abscess

4. Sub-dural abscess

5. Intra-cerebral abscess

6. Cavernous sinus thrombosis

7. Sagittal sinus thrombosis

Other local complicationsBony

1. Osteitis

2. Osteomyelitis (Pott’s puffy tumour)

Dental

1. Dental abscess

2. Oro-antral fistula

Orbital complications

Introduction• Commonest complication of sinusitis

• Young people at high risk: 85% < 20 yrs age

• Ethmoid sinus most commonly implicated Frontal Sphenoid Maxillary

• Left orbit more commonly involved

Pre-septal cellulitis

Pre-septal cellulitis

• Infection external to peri-orbital septum

• Edema of eyelid: upper lid = frontal sinusitis

lower lid = maxillary

sinusitis

both lids = ethmoid sinusitis

• No erythema / tenderness / proptosis / extra-

ocular movement restriction / vision change

Pre-septal cellulitis

Pre-septal abscess

Pre-septal abscess

Orbital Cellulitis

Orbital Cellulitis

• Infection inside peri-orbital septum

• Diffuse peri-orbital edema

• Mild proptosis present

• Minimal or no restriction of extra-ocular

movement

• No change in vision

Orbital cellulitis

Extra-periosteal abscess

Extra-periosteal abscess

• Localized extra-periosteal pus collection

• Mild proptosis present

• Mild restriction of extra-ocular movement

• Mild vision loss

• Color vision affected first: Red = brown

Blue = black

Extra-periosteal abscess

Intra-periosteal abscess

Intra-periosteal orbital abscess

• Mild chemosis

• Proptosis: severe, asymmetric, quadrantic

Frontal sinusitis = down + forward + lateral

Ethmoid sinusitis = forward + lateral

Maxillary sinusitis = up + forward

• Concurrent, complete, ophthalmoplegia

• Severe vision loss

Proptosis

Chemosis

Cavernous Sinus Thrombosis

Cavernous Sinus Thrombosis

• Rapid onset, hectic fever

• Bilateral orbital pain + severe chemosis

• Bilateral absent pupillary reflex

• Bilateral symmetrical axial proptosis

• Sequential ophthalmoplegia (VI III IV)

• Papilloedema + loss of vision

• Painful paraesthesia of V1, V2

Cavernous sinus thrombosis

Cavernous sinus thrombosis

C.T. with venogram

Absence of

contrast in

cavernous

sinuses

C.T. scan with contrast

C.S.T. Orbital abscess

Bilateral Unilateral

Rapidly progressive Slowly progressive

Hectic fever Low grade fever

Severe chemosis Mild chemosis

Paraesthesia of V1, V2 No paraesthesia

Sequential ophthalmoplegia

Concurrent pan-ophthalmoplegia

Symmetric axial proptosis Asymmetric quadrantic proptosis

Orbital apex syndrome

• Frontal headache + deep orbital pain

• Optic nerve involvement (vision loss)

• Paralysis of abducens nerve

• Paralysis of oculomotor nerve

• Paralysis of trochlear nerve

• Painful paraesthesia of V1, V2

Evaluation of orbital complication

1. Eye examination: Ophthalmology consultation

• Edema of eyelids

• Displacement of eyeball

• Ocular movement

• Visual acuity

• Fundoscopy for papilledema

2. CT scan PNS (including orbit): coronal & axial

1. Broad spectrum, high dose IV antibiotics

(Ceftriaxone + Metronidazole)

2. NSAIDs

3. Topical / oral decongestants

4. Mucolytics: Bromhexine, Ambroxol

5. Nasal saline irrigation

Medical Treatment

Surgical Treatment

For sinusitis:

1. Frontal trephination

2. External fronto-ethmoidectomy (Lynch Howarth)

3. Functional Endoscopic Sinus Surgery

For orbital complication:

1. Sub-periosteal abscess drainage

2. Orbital decompression

Lynch – Howarth incision

Frontal sinus trephination

Sub-periosteal abscess drainage

• Incision made b/w caruncle (C) & semilunar

fold (S)

• Tissue b/w caruncle & semilunar fold incised

with tenotomy scissors

• Periosteum (P) incised & elevated with Freer

elevator until abscess (A) is found & drained

Sub-periosteal abscess drainage

Indications for orbital decompression

• No improvement in orbital symptoms in 24-

48 hours of treatment

• CT scan evidence of orbital abscess

• Visual acuity of 20 / 60 or worse

Techniques of decompression

1. Patterson’s trans-orbital approach

2. Endoscopic intra-nasal approach

3. Trans-antral approach

4. Combined intra-nasal & trans-antral approach

• Medial wall + floor of orbit removed

• Removal of 1 wall = 2 - 3 mm decompression

• Removal of 2 walls = 4 - 7 mm decompression

Result of orbital complications

• Exposure keratitis

• Uveitis

• Choroiditis

• Ophthalmoplegia

• Glaucoma

• Permanent vision loss

Intra-cranial complications

• 2nd commonest complication of sinusitis

• Most common in adolescents & young adults

(diploic venous system at peak vascularity)

• Frontal sinus most commonly implicated

Ethmoid Sphenoid Maxillary

• Commonest route of spread = retrograde

thrombophlibitis via Diploic vein of Breschet 

Introduction

Intra-cranial complications

Clinical Features• Fever

• Deep-seated headache

• Nausea & projectile vomiting

• Neck stiffness

• Seizures

• Altered sensorium & mood changes

• Late: bradycardia / hypotension / stupor

C.T.: Frontal lobe abscess

Frontal lobe abscess

Investigations & Medical Tx

• Neurosurgery consultation

• CT scan PNS + brain with contrast

• MRI with contrast: investigation of choice

• High dose IV broad spectrum antibiotics:

Ceftriaxone & Metronidazole for 4-6 week

• Steroids: controversial

Surgical TreatmentFor sinusitis:

1. Frontal trephination

2. External fronto-ethmoidectomy (Lynch Howarth)

3. Functional Endoscopic Sinus Surgery

For intra-cranial complication: by Neurosurgeon

1. Burr hole drainage: for small abscess

2. Craniotomy: for large brain abscess

Sequelae

• Seizures: 7.5%

• Hemiparesis: 2 - 17 %

• Hemiplegia

• Death: 15 - 43 %

Mucocoele of

P.N.S.

Introduction

• Definition: epithelium lined, mucus filled sac

completely filling paranasal sinus

& capable of expansion

• Incidence:

• Frontal = 65 % Ethmoid = 25 %

• Maxillary = 10 % Sphenoid = rare

1. Chronic obstruction of sinus ostium with

retention of normal sinus mucus within sinus

cavity

2. Mucous retention cyst: develops from

obstruction of ducts of sero-mucinous glands

within sinus mucosa

Etiology

Cystic, non-tender swelling above inner canthus

with egg-shell crackling sensation on palpation

Proptosis: Frontal = down + forward + lateral

Ethmoid = forward + lateral

Maxillary = up + forward

Diplopia & restricted eyeball movement

Frontal headache, retro-orbital or facial pain

Clinical Features

Differential diagnosis

• Acute / chronic sinusitis

• Retention cyst

• Dermoid cyst

• Cholesterol granuloma

• Paranasal sinus tumours

• Antro-choanal polyp

Investigations

X-ray PNS: expanded frontal sinus, loss of

scalloped margins, translucency, depression or

erosion of supra-orbital ridge

CT scan: homogenous smooth walled mass

expanding sinus, with thinning of bone

Ring enhancement on contrast = pyocoele

Frontal mucocoele

Fronto-ethmoid mucocele

Fronto-ethmoid mucocoele

Fronto-ethmoid mucocoele with proptosis

Maxillary mucocoele

Ethmoid + sphenoid mucocoele

Sphenoid mucocoele

1. Antibiotics + nasal decongestants

2. External fronto-ethmoidectomy:

by Lynch – Howarth’s approach

3. Endoscopic fronto-ethmoidectomy

4. Endoscopic decompression (marsupialization)

5. Osteoplastic flap repair

Treatment

Lt ethmoid mucocoele

Pre-op CT scan (axial)

Drainage + Marsupialization

Post-op CT scan (coronal)

Osteoplastic flap procedure

Osteoplastic flap procedure

Osteoplastic flap procedure

Frontal sinus mucocoele

Frontal pyocoele + fistula

Pott’s puffy tumour

Frontal sinus osteomyelitis (Percival Pott, 1760)

Fluctuant swelling over forehead anteriorly

May spread posteriorly subdural abscess

Tx: 6 week antibiotics + drainage of pus &

debridement of bone + obliteration of frontal

sinus by osteoplastic flap technique

Pott’s puffy tumour

Oro-antral fistula Communication b/w

oral cavity & maxillary

antrum

Tx: closure by

a. Buccal mucosal

advancement flap

b. Palatal flap

c. Buccal fat pad flap

Oro-antral fistula

Maxillary sinusitis + fistula

Buccal mucosal advancement flap

Buccal mucosal advancement flap

Fistula closed

Buccal fat pad

Palatal flap closure

Combination of all 3 flaps

Combined flap closure

Toxic shock syndrome• Rare, potentially fatal complication

• Septicaemia due to Staphylococcus aureus or

Streptococcus infection

• C/F: fever, hypotension, skin rashes with

desquamation, multi-system failure

• Tx: 1. IV Ceftriaxone 1g Q8H

2. Drainage of sinus pus

Thank You