complications of sinusitis
DESCRIPTION
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) - PowerPoint PPT PresentationTRANSCRIPT
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