Complications of Sinusitis

Complications of Sinusitis,

1. COMPLICATIONS OF SINUSITIS Dr Harjitpal Singh Assistant Professor(ENT), Dr RKGMC, Hamirpur

2. SINUSITIS CLASSIFICATION Definitions Acute Sx & signs of infectious process < 3 weeks duration Subacute Sx & signs 21 to 60 days Chronic > 60 days of sx & signs Or, 4 episodes of acute sinusitis each > 10 days in a single year

3. GENERAL CONTRIBUTORS TO CHRONIC SINUSITIS Resistant infectious organisms Underlying systemic illness (esp. diabetes) Immunodeficiency Irreversible mucosal changes Anatomic abnormality

4. SINUSITIS PATHOGENESIS Basic cause is osteomeatal complex inflammation & infection Sinus ostia occluded Colonizing bacteria replicate Ciliary dysfunction Mucosal edema Lowered PO 2 & pH

5. SINUSITIS: ETIOLOGIC ORGANISMS Aerobic bacteria Strep. pneumoniae (30) Alpha & beta hemolytic Strep (5) Staph. aureus (5) Branhamella catarrhalis (15 to 20) Hemophilus influenzae (25 to 30) Escherichia coli (5) Anerobes (10 % acute, 66 % chronic) Peptostreptococcus , Propionobacterium , Bacteroides , Fusobacterium Fungi (2 to 5) Viruses (5 to 10)

6. DEFINITION Complications of rhinosinusitis result from progression of acute or chronic infection beyond the paranasal sinuses causing significant morbidity from either local or distant spread.

7. METHODS OF SPREAD OF INFECTION • By direct continuity • Thrombophlebitis of diploic veins leading to infection of the bone marrow • Embolism • Perivascular lymphatics • Perineural sheath.

8. EPIDEMIOLOGY Approximately one in every 12,000 acute rhinosinusitis episodes Most complications tend to occur in children and young adults Majority of complications originating from frontal and ethmoid sinus infections Complications of rhinosinusitis are more in children and adolescents Thinner, more porous bony septa and sinus walls Open suture lines Larger vascular foramina.

9. COMPLICATIONS OF RHINOSINUSITIS Alarming signs and symptoms for intracranial or intraorbital extension of rhinosinusitis include: • High fever • Diplopia • Severe pain • Ptosis • Worsening headache • Chemosis • Meningeal signs • Proptosis • Infraorbital hypesthesia • Abnormal pupillary or extraocular movements • Significant facial swelling Altered mental status

10. COMPLICATIONS OF RHINOSINUSITIS CLASSIFICATION

11. COMPLICATIONS OF RHINOSINUSITIS CLASSIFICATION ACUTE Local Frontal -- Pott’s puffy Tumour Ethmoid -- Orbital cellulitis Maxillary -- Less complications Sphenoid -- Cavernous sinus thrombosis

12. COMPLICATIONS OF RHINOSINUSITIS CLASSIFICATION ACUTE Distant Brain abscess Septicaemia Toxic shock syndrome Chronic Mucocoeles - pyocoeles

13. CLINICAL CLASSIFICATION Orbital (60-75%) Intracranial (15-20%) Bony (5-10%) Chronic Preseptal cellulitis Orbital cellulitis Su b p er i o s t eal abscess Orbital abscess Cavernous sinus thrombosis Meningitis EpiduraI abscess Subdural abscess I n t r ace r e b r al abscess Cavernous or sagittal sinus thrombosis Osteomyelitis (Pott's puffy tumour) Mucocoele/pyocoele

14. CLINICAL CLASSIFICATION(cont) Radiography Computed tomography (CT) best for orbit Magnetic resonance imaging (MRI) best for intracranium

15. CHRONIC COMPLICATIONS Mucocele / pyocele : A retention cyst of mucous glands of sinus Or may be due to blockage of sinus ostium Resulting in thinning and expansion of sinus wall. Frontal and ethmoidal sinuses are the usual sinuses involved. If infection is superadded, it is called pyocele . These round or oval cysts grow concentrically and expand very slowly over 10 years or more.

16. CHRONIC COMPLICATIONS Maxillary Mucocele : It is an incidental finding on radiographs. Rarely requires specific treatment. „ If needed, it can be aspirated through puncture of either inferior meatus or canine fossa .

17. CHRONIC COMPLICATIONS Frontoethmoidal Mucocele : most common Clinical features : Frontal headache, Proptosis , Deep nasal/ periorbital pain and Diplopia . The latter is caused due to inferior & lateral displacement of eyeball. The swelling is cystic, non-tender; eggshell crackling may be elicited. „ Imaging: Radiograph shows clouding of sinus with sclerosis of surrounding skull and loss of scalloped outline of frontal sinus. „ Treatment: Frontoethmoidectomy /Endoscopic marsupialization Ethmoidal mucocele causes a bulge in the middle meatus and is drained by uncapping the ethmoidal bulge (or with external ethmoid operation) and establishing free drainage.

18. FRONTAL SINUS MUCOCELE

19. CHRONIC COMPLICATIONS Sphenoethmoidal Mucocele : Clinical features: Headache (occipital and vertex) Deep nasal pain Diplopia /visual field disturbance Eyeball displacement. Exophthalmos is always present Pain is localized to the orbit/ forehead . Superior Orbital Fissure Syndrome: I involvement of CN III, IV, VI and ophthalmic division of CN V. Orbital Apex Syndrome: Involvement of CN II, III, IV, V1, V2, VI.

20. CHRONIC COMPLICATIONS Sphenoethmoidal Mucocele : Imaging: Radiographic findings confirm the diagnosis. The slow expansion leads to destruction of sphenoid and posterior ethmoid sinuses. Treatment: It includes opening it widely into the nasal cavity. Endoscopic sinus surgery: Anterior wall of the sphenoid sinus is removed, cyst wall uncapped and its fluid contents evacuated. External: Ethmoidectomy with sphenoidotomy is performed.

21. Axial image shows arrows pointing to a large expansile mass in the sphenoid sinus ( SpS ) extending into the posterior ethmoid sinus (PE) which was due to a large sphenoid sinus mucocele . (AE: anterior ethmoid sinus) SPHENOETHMOIDAL MUCOCELE

22. ORBITAL COMPLICATIONS Most commonly involved complication site Proximity to ethmoid sinuses Periorbita /orbital septum is the only soft-tissue barrier Valveless superior and inferior ophthalmic veins Direct extension through lamina papyracea

23. ORBITAL COMPLICATIONS (cont) Impaired venous drainage from thrombophlebitis Progression within 2 days Children more susceptible < 7 years – isolated orbital ( subperiosteal abscess) > 7 years – orbital and intracranial complications

24. ORBITAL COMPLICATIONS (cont) Chandler Criteria CLASS 1- Preseptal cellulitis CLASS 2- Orbital cellulitis CLASS 3- Subperiosteal abscess CLASS 4- Orbital abscess CLASS 5- Cavernous sinus thrombosis

25. CHANDLER CLASSIFICATION

26. PRESEPTAL CELLULITIS Symptomatology Eyelid edema and erythema Extraocular movement intact Normal vision May have eyelid abscess CT reveals diffuse thickening of lid and conjunctiva

27. PRESEPTAL CELLULITIS (cont)

28. PRESEPTAL CELLULITIS (cont)

29. PRESEPTAL CELLULITIS(cont) Treatment Medical therapy typically sufficient Intravenous antibiotics Head of bed elevation Warm compresses Facilitate sinus drainage Nasal decongestants Mucolytics Saline irrigation

30. ORBITAL CELLULITIS Symptomatology : Post- septal infection Eyelid edema and erythema Proptosis and chemosis Limited or no extraocular movement limitation No visual impairment No discrete abscess Low-attenuation adjacent to lamina papyracea on CT

31. ORBITAL CELLULITIS(cont)

32. ORBITAL CELLULITIS(cont) Treatment: Facilitate sinus drainage Nasal decongestants Mucolytics Saline irrigations Medical therapy typically sufficient Intravenous antibiotics Head of bed elevation Warm compresses May need surgical drainage Visual acuity 20/60 or worse No improvement or progression within 48 hours

33. SUBPERIOSTEAL ABSCESS Pus formation between periorbita and lamina papyracea Displace orbital contents downward and laterally Proptosis , chemosis , ophthalmoplegia Risk for residual visual sequelae May rupture through septum and present in eyelids

34. SUBPERIOSTEAL ABSCESS ( cont)

35. SUBPERIOSTEAL ABSCESS (cont)

36. SUBPERIOSTEAL ABSCESS (cont) Treatment: Surgical drainage Worsening visual acuity or extraocular movement impaired Lack of improvement after 48 hours May be treated medically in 50-67% Meta-analysis cure rate 26-93% Combined treatment 95-100%

37. SUBPERIOSTEAL ABSCESS (cont) Treatment: Open ethmoids and remove lamina papyracea Approaches External ethmoidectomy (Lynch incision)is most preferred Endoscopic ideal for medial abscesses Transcaruncular approach Transconjunctival incision Extend medially around lacrimal caruncle

38. ORBITAL ABSCESS Pus formation within orbital tissues Severe exophthalmos and chemosis Ophthalmoplegia Visual impairment Risk for irreversible blindness Can spontaneously drain through eyelid

39. ORBITAL ABSCESS (cont)

40. ORBITAL ABSCESS (cont) Treatment Incise periorbita and drain intraconal abscess Similar approaches as with subperiosteal abscess Lynch incision Endoscopic

41. CAVERNOUS SINUS RELATIONS & CONTENTS

42. CAVERNOUS SINUSTHROMBOSIS / CST Proptosis (often Bilateral) Chemosis Progressive opthalmoplegia Complete loss of vision

43. CAVERNOUS SINUSTHROMBOSIS

44. CAVERNOUS SINUSTHROMBOSIS

45. CAVERNOUS SINUSTHROMBOSIS Treatment Mortality rate up to 30% Surgical drainage Intravenous antibiotics High-dose Cross blood-brain barrier Anticoagulant use is controversial Prevent thrombus propagation Risk intracranial or intra-orbital bleeding

46. CAVERNOUS SINUSTHROMBOSIS Prognosis If prompt treatment is carried out with adequate monitoring of patients during treatment, the prognosis for the return of normal vision is excellent. However, there is a small, but significant risk of diplopia following surgery

47. INTRACRANIAL COMPLICATIONS Occurs more commonly in CRS Mucosal scarring, polypoid changes Hidden infectious foci with poor antibiotic penetration Male teenagers affected more than children

48. INTRACRANIAL COMPLICATIONS ( cont ) Direct extension Sinus wall erosion Traumatic fracture lines Neurovascular foramina (optic and olfactory nerves) Hematogenous spread Diploic skull veins Ethmoid bone

49. INTRACRANIAL COMPLICATIONS ( cont ) Meningitis Epidural abscess Subdural abscess Intracerebral abscess Cavernous sinus, venous sinus thrombosis

50. INTRACRANIAL COMPLICATIONS ( cont ) Symptomatology: Fever (92%) Headache (85%) Nausea, vomiting (62%) Altered consciousness (31%) Seizure (31%) Hemiparesis (23%) Visual disturbance (23%) Meningismus (23%)

51. MENINGITIS Headache,meningismus Fever, septic Cranial nerve palsies Sinusitis is unusual cause of meningitis, Sphenoiditis , Ethmoiditis Usually amenable with medical treatment Drain sinuses if no improvement after 48 hours Hearing loss and seizure sequelae

52. MENINGITIS ( cont )

53. EPIDURAL ABSCESS Second-most common intracranial complication Generally a complication of frontal sinusitis Symptomatology Fever (>50%) Headache (50-73%) Nausea, vomiting Papilledema Hemiparesis Seizure (4-63%)

54. EPIDURAL ABSCESS Frontal sinusitis

55. EPIDURAL ABSCESS ( cont ) Treatment Lumbar puncture contraindicated Prophylactic seizure therapy not necessary Antibiotics Good intracerebral penetration Typically for 4-8 weeks Drain sinuses and abscess Frontal sinus trephination Frontal sinus cranialization

56. SUBDURAL ABSCESS Generally from frontal or ethmoid sinusitis Third-most common intracranial complication, rapid deterioration Mortality in 25-35% Residual neurologic sequelae in 35-55% Accompanies 10% of epidural abscesses

57. SUBDURAL ABSCESS ( cont )

58. SUBDURAL ABSCESS ( cont ) Symptomatology Headaches Fever Nausea, vomiting Hemiparesis Lethargy, coma

59. SUBDURAL ABSCESS ( cont ) Treatment : Lumbar puncture potentially fatal A ggressive medical therapy Antibiotics Anticonvulsants Hyperventilation, mannitol Steroids Drain sinuses and abscess Medical therapy possible if < 1.5cm Craniotomy or stereotactic burr hole Endoscopic or external sinus drainage

60. INTRACEREBRAL ABSCESS Uncommon Frontal & front parietal lobes Generally from Frontal, Sphenoid, Ethmoids Mortality 20-30 % Neurologic sequelae 60% Nausea , vomiting ( 40%) Seizure (25-35 %) Meningismus Papilledema (25%)

61. INTRACEREBRAL ABSCESS ( cont )

62. INTRACEREBRAL ABSCESS ( cont ) Symptomatology: Headache (70%) Mental status change (65%) Focal neurological deficit (65%) Fever (50%)

63. INTRACEREBRAL ABSCESS ( cont ) T r e a tme n t Medical Antibiotics, Anticonvulsants Mannitol Steroids Surgical Bur hole drainage Craniotomy Image-guided aspiration

64. VENOUS SINUS THROMBOSIS Sagittal sinus most common Retrograde thrombophlebitis from frontal sinusitis Extremely ill Increased mortality

65. VENOUS SINUS THROMBOSIS ( cont ) Treatment: Aggressive medical therapy Anticoagulation controversial Thrombus resolution by 6 weeks Increased intracranial pressure outweighs bleeding risk Drain sinuses External Endoscopic

66. BONY: POTT’S PUFFY TUMOR Sir Percival Pott in 1760, it is doughy swelling of forehead due to osteomyelitis of frontal sinus. Gives moth-eaten appearance on X-rays Frontal sinusitis with acute osteomyelitis Subperiosteal pus collection leads to “ puffy/doughy” fluctuance Rare complication Only 20-25 cases reported in post-antibiotic era Less than 50 pediatric cases in past 10 years

67. Clinical features Periorbital or frontal swelling BONY: POTT’S PUFFY TUMOR ( cont )

68. BONY: POTT’S PUFFY TUMOR ( cont )

69. BONY: POTT’S PUFFY TUMOR ( cont )

70. BONY: POTT’S PUFFY TUMOR ( cont ) Surgical and medical therapy Drain abscess and remove infected bone Intravenous antibiotics for six weeks May obliterate frontal sinus to prevent recurrence It may require removal of sequestra and necrotic bone with osteoplastic flap.

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