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1. Complications of
Rhinosinusitis

Department of Otorhinolaryngology

2. Objectives

* Describe the orbital, intracranial, and bony
complications of rhinosinusitis.

e Define risk factors, routes of extension, and typical
findings in patients with complicated rhinosinusitis.

* Detail the classification systems used to categorize
orbital and intracranial complications.

* Identify the indications for surgical intervention.

3. Rhinosinusitis

Inflammation of the mucosal lining
of the nose and paranasal sinuses.

Acute, subacute, and chronic.

One of the most common diseases
in the US.

2 20 million cases of acute
bacterial rhinosinusitis are
diagnosed annually.

* 30 million people suffer from
chronic rhinosinusitis. "!

The cost is substantial and
increasing:

* Acute $3.5 billion/yr.
* Chronic $4.3 billion/yr. "!

4. Complications 233

® Complications of rhinosinusitis range from
relatively benign to potentially fatal.

e The incidence of complications from both
acute and chronic rhinosinusitis has
decreased as a result of the use of
antibiotics.

* Complications can be divided into three
categories: Orbital, intracranial, and bony.

5. Extracranial

Orbital Infections- Orbital cellulitis, or Subperiosteal *
abscess

Hyperostosis & osteitis
Mucoceles
Osteomyelitis- Pott's Puffy Tumor

+ Middle Ear cleft Infections

Intracranial

Meningitis
Epidural/Subdural empyema
Brain Abscess
Dural Venous Sinus Thrombosis-cavernous
/superior sagittal

Pulmonary Infections
Sepsis

6. CT or MRI?
Computed tomography

> Establish technique for
evaluating patients with
sinusitis.

° Excellent anatomic
resolution of bony areas.

Magnetic resonance imaging

° Ithas a superior delineation of
soft tissue.

* Itmay demonstrate infections
without bony artifacts and brain
pathology.

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Orbital complications

* The orbit is the structure
most commonly involved in
complicated sinusitis.

* Orbital extension is usually
the result of ethmoid
sinusitis.

® Children are more prone to
orbital complications,
probably secondary to high
incidence of URI and
sinusitis,

8. Anatomic factors

* Thin lamina papyracea.

* Congenital, surgical, or
traumatic dehiscences in
the medial and superior
walls.

® Anterior & posterior
ethmoid neurovascular
foramina.

* Valveless veins (nose,
paranasal sinuses,
pterygoid plexus, and orbit).

9. Chandler's classification

I. Inflammatory edema (preseptal)

Il. Orbital cellulitis (postseptal)

lll. Subperiosteal abscess

IV. Orbital abscess

V. Cavernous sinus thrombosis

Lid edema, no limitation in ocular
movement or visual change.

Diffuse orbital infection and
inflammation without abscess
formation.

Collection of pus between medial
periosteum and lamina papyracea,
impaired extraocular movement.

Discrete pus collection in orbital
tissues, proptosis and chemosis with
ophthalmoplegia and decreased
vision.

Bilateral eye findings and worsening of
all other previously described findings.

10. "1 à

Periosteum

Maxillary
sinus

11. Orbital Compartments
Anterior compartment

Bons orbit

| Retrobulbar space |
Extraconal
Intraconal

Optic narva

= Optic globe and septum divides the orbit into anterior
and posterior compartments

= Localizing orbital disease to compartment helps
generate a differential diagnosis.

12. Orbital Complications Of Sinusitis | °°°:

Classification se
Periorbital (Pre-Septal) cellulitis
Orbital (Post-Septal) cellulitis
Subperiosteal Abscess
Orbital abscess
Cavernous Sinus Thrombophlebitis

13. I. Inflammatory edema ie
(preseptal cellulitis) 333°

* Infection limited to the
skin and subcutaneous
tissues of the eyelid,
anterior to the orbital
septum.

* Most common and
least severe
complication.

* Represents 70% of all
orbital complications of
sinusitis.

14. Diagnosis

* Eyelid swelling, erythema, and tenderness.

* Visual acuity, pupillary reaction, extraocular motility,
and intraocular pressure are normal.

* CT is usually unnecessary, but, if done, would
reveal diffuse increased density and thickening of
the lid and conjunctiva.

® CT is mandatory when intracranial complications are
suspected or when there is progress in 24 to 48
hours to postseptal inflammation despite therapy. fl

15. Treatment

Broad spectrum oral antibiotics, head elevation, and
management of the underlying cause (nasal decongestant,
mucolytics, and saline irrigations).

Intravenous antibiotics were standard care in children before the
introduction of the Hib vaccine in 1985

Older children and adults with mild cellulitis, outpatient
amoxicillin/clavulanic acid or first-generation cephalosporin. Re-
evaluate in 24-48 hours.

Younger children or more severe cases, admission for
observation and IV antibiotics is standard (2nd or 3rd generation
cephalosporin), then bridge to oral antibiotics for 10 days.

16. Il. Orbital cellulitis

Infectious process
within the orbit proper,
behind the septum, and
within the bony walls of
the orbit.

Orbital contents show
diffuse edema with
inflammatory cells and
fluid, without distinct
abscess formation.

17. Diagnosis

* Eyelid edema, mild proptosis, chemosis, and
orbital pain.

* In severe cases motility may be limited; but visual
acuity is not impaired.

+ Ophthalmologic consultation should be obtained.

* CT with contrast is indicated, and it will show
enhancement of edematous fat, which is usually

maximal in the extraconal fat adjacent to the
affected sinus.

® Enlargement and enhancement of adjacent rectus
muscle is sometimes present.

18. Treatment +

* Admission for daily assessments of visual
acuity and color vision, pupillary reactions, and
extraocular motility. (Ophthalmologist)

* Early intravenous antibiotics and imaging.

* Antibiotic failure is indicated by:

® Progression of vision loss or clinical deterioration
after 48 hours of therapy.

° Failure to improve or persistent fever after 72 hours
of therapy.

19. Surgical drainage

Surgical drainage is recommended:
1. CT evidence of abscess formation.
2 Visual acuity of 20/60 (or worse) on initial evaluation.

3. Severe orbital complications (e.g. blindness or an afferent
pupillary reflex) on initial evaluation.

4. Progression of sign and symptoms despite therapy.
5. Lack of improvement within 48 hours despite therapy.

* Surgical treatment should include adequate drainage of
the infected sinuses.

20. lll. Subperiosteal abscess
(SPA)

* Most commonly located in
the superomedial or
inferomedial orbit in
conjunction with ethmoid
sinusitis.

* Infection breaks through the
lamina papyracea or travels
through the anterior or
posterior ethmoidal foramina.

* May lead to blindness by
direct optic nerve
compression, elevation of
intraorbital pressure, or
proptosis causing a stretch
optic neuropathy.

21. Diagnosis

* Ophthalmologic evaluation is essential.

+ Clinically, SPA is suspected in a patient with orbital
cellulitis that has worsening proptosis and gaze
restriction.

® Color discrimination is better guide of progression
since red/green perception is loss before
deterioration of visual acuity.

® Contrast CT will show a contrast-enhancing mass in
the extraconal space. There is marked proptosis
with a conic deformity of the globe.

* The medium rectus can be displaced (2mm).

22. Treatment

® Controversy exists (surgical vs. medical), especially in children.

» Several studies have suggested that responsiveness to medical treatment is
age associated.

.

.

.

Age < 9 yr.

Absence of frontal sinusitis.

Medial location with absence of gas in the abscess cavity.
Small abscess volume.

Nonrecurrent SPA.

Absence of acute optic nerve or retinal compromise.
Nonodontogenic infection

® Surgical therapy was reserved for clinical deterioration or no improvement
with medical therapy.

23. Oxford and McClay 333

® Older children with SPA managed successfully with
medical therapy.

* The ages of the 18 patients treated medically were
not statistically different from the 25 patients treated
surgically.

Normal vision, pupil, and retina.

No ophthalmoplegia.

Intraocular pressure of less than 20 mm Hg.
Proptosis of 5 mm or less.

Abscess width of 4mm or less.

24. Surgical approaches

.
.

.

.

External ethmoidectomy:

Lynch incision.
Elevation of periosteum.

Lacrimal bone and lamina
papyracea are removed.

Ethemoidectomy.

Disadvantages:

Communication between nasal
cavity and orbit.

Only useful for medially located
abscesses.

Unpleasant scar, facial
dysplasia.

Chen, W (2001). Oculoplastic surgery: the essentials. New York: Thieme Medical Publishers, Inc. 423.

25. Endoscopic approach

* Widely accepted as an * Ethmoidectomy.
alternative to open
approaches.

* Increased bleeding of acute ° Skeletonizing the lamina
inflamed mucosa. papyracea.

* Facial growth:
° Conservative surgical * Drainage of the orbital

resection is advocated. collection by cracking the

lamina with Cottle or Freer.

* The periorbita is not
violated.

26. Trans-nasal Endoscopic Decompression

of Sub-Periosteal Abscess in Children

Vernis

2. mom

27. Combined approaches

Lemoyne puncture
trephination.

Sinus is irrigated, and
endoscopically the
nasofrontal duct is
identify.

Sinusotomy and
ethmoidectomy
External incision used
to drain SPO.

28. Transcaruncular approach :

Bailey, BJ (2006). Head & Neck Surgery - Otolaryngology. 4th ed. Philadelphia: Lippincott Williams &
Wilkins. 499

29. IV. Orbital abscess =

* Progression to this
state often represents
delay in diagnosis and
therapy or
immunocompromised
state.

® May be inside or
outside the muscle
cone (discrete
collection of pus).

hitp:Homodicine. medscape,comiarticle/784888-madin

30. Diagnosis Ss:

* Marked proptosis, chemosis, complete
ophthalmoplegia, visual impairment with risk
for progression to irreversible blindness.

e CT will show diffuse infiltration of the
intraconal and extraconal fat with areas of
cavitation.

® MRI (true necrosis) hypointensity on T1 and
hyperintensity on T2.

31. Treatment

Drainage is mandatory
Endoscopic preferred over
external.

Decompression of one or
more orbital walls may be
necessary (intraoperative
orbital pressure).
Periorbita:

© Endoscopic — extraconal.
* Combined - intraconal.

32. V. Cavernous sinus
thrombosis (CST)

e Results from spread of
infection from sinuses or
middle third of the face.

* Freely anastomosing,
valveless venous system
(superior and inferior
ophthalmic veins).

e S. aureus is most common
pathogen.

* High morbidity/mortality.

Cannon ML, Anonio BL, McCloskey JJ, et al. Cavemous sinus thrombosis complicating sinusitis. Pediat Crit Care Med 2004;5(1):86-6.

33. Diagnosis

® Bilateral orbital
involvement.

® Rapidly progressive
chemosis and
ophthalmoplegia.

® Retinal engorgement.
e Prostration and fever.

® MRI more sensitive than CT
(MR venogram).

® Carotid thrombosis (strokes,
brain abscess, meningitis)

* Pulmonary septic emboli.

Cannon ML, Anonio BL, McCloskey JJ, et al. Cavemous sinus thrombosis. complicating sinusitis, Pediat Grit Gare Med 2004:8(1):46-8
Ebright JR, Pace MT, Niazi AF, Septic thrombosis of the cavemous sinuses, Arch Intern Med 2001;161:267 1-2676.

34. Treatment se

® High-dose IV antibiotics that cross BBB.
* Nafcillin.
® Ceftriaxone.
® Metronidazole.
* Vancomycin.

* 3—4 weeks; 6 — 8 weeks if intracranial complications.

* Selective surgery — drainage of affected sinuses is
advisable.

35. Anticoagulation

The role of rra rm al to minimize progression
of thrombosis is debatable.

lts efficacy is undetermined, since no prospective
trials have been performed.

It yo aggravate intracranial hemorrhagic sequelae
of CST.

Retrospective reviews show that:
° Hemorrhage caused by anticoagulation is rare.

* Early anticoagulation is beneficial if commenced after
excluding the hemorrhagic sequelae radiologically.

36. Steroids

* Many current reviewers don't recommend
their use.

* Is this recommendation valid?
* Dramatic response on orbital inflammation

and optic nerve dysfunction that were
resistant to antibiotics in response to steroids.

37. Intracranial complications

* IC complications are uncommon but devastating.

* Two major mechanism:
* Direct extension.

© Retrograde thrombophlebitis via valveless diploe veins.

* Frontal sinus is rich in diploe veins especially during adolescence.

Meningitis

Epidural abscess

Subdural abscess
Intracerebral abscess
Cavernous sinus thrombosis

Superior sagittal sinus thrombosis

Sphenoid, ethmoid.
Frontal.
Frontal.
Frontal.
Sphenoid, ethmoid.
Frontal.

38. sinusitis
A.Osteomyelitis
B.Pericranial or Periorbital
Abscess
C.Epidural Abscess
D.Subdural Empyema
E.Brain Abscess
F.Meningitis ER
G.Superior Sagittal Sinus sinus
Thrombosis

= 3.7% of patients admitted with sinusitis,
= More common in adolescent boys diyeto“a peak in the vascularity
the diploic venous system of this age, rad p

39. Meningitis

* Neurologic sequelae are common (seizures, hearing
loss).

® The most common pathogen is S. pneumoniae.

* Mental status changes, photophobia, and
meningismus.

® CT will be normal, but MRI typically shows dural
enhancement (falx cerebri, tentorium, and dural
convexities).

® |V antibiotics and endoscopic sinus surgery.
* If no improvement after 24 — 48 hours of antibiotics.

® Early use of ESS has the potential to accelerate clinical
improvement.

40. Intracranial abscess

Between skull and dura

Slow expanding

Mild, non-specific for
weeks. Increase ICP

CT or MRI

IV Abx. + Surgery
(craniotomy / ESS)

Subdural space
no boundaries

Spreads diffusely
convexities,
interhemispheric

Meningismus, rapid
progression to coma

CT may show it but MRI
is better

IV Abx., craniotomy,
ESS, anticonvulsivants,
+/- steroids

Frontal/frontopariental
white/gray matter

Asymptomatic phase
while it coalesces

Subtle if frontal (mood)
H/A, lethargy, seizures,
focal deficits
MRI (T2)
Hypointense with
capsule

ESS / Neurosurgery
(stereotactic vs. open)

41. Venous sinus thrombosis cose

(superior sagittal and cavernous) | °°

Retrograde thrombophlebitis.

Sagittal usually found in association with intracranial
abscesses.

Clinical severity depends on extent of the
thrombosis (extremely ill, high spiking fevers,
meningeal signs, coma).

MRI focal defects of enhancement (MR angio or
venogram).

High dose IV abx., ESS, anticoagulants, Surgery
(thrombectomy, thrombolysis via burr-hole).

42. Bony complications

» Osteomyelitis of the frontal
bone is known as Pott's puffy
tumor.

* Subperiosteal collection of pus
produces a “puffy” fluctuant
swelling.

* Polymicrobial (Streptococcus
sp., Staphylococcus aureus,
Bacteroides, and Proteus)

* IV Abx., drainage of the
abscess with removal of
infected bone. Frontal Dw ne ea ee
obliteration may be performed.

43. Key Points Ss:

* Acute sinusitis is a leading cause of orbital
infection

e Orbital infections may be pre or post-septal

® CECT is the imaging of choice

e CT may not identify all orbital abscesses

* Not all orbital abscesses are medial

* MRI is a valuable modality for complex cases

44. Key Points

e Orbital & intracranial sinus complications are due
to the close proximity of these structures and the
presence of valveless veins.

e The increased incidence of acute sinusitis
complications in children mandates early
treatment with antibiotics and close observation.

e |Image-guided protocols for operative
intervention.

45. Key Points ess

e Children with sinusitis and persistent headache,
fever, nausea, vomiting, &/or any focal neurologic
abnormality should be evaluated with CECT or
CEMRI to exclude Intracranial Complications

* A team approach including otolaryngology,
neurosurgery, intensive care, ophthalmology,
infectious disease, & pediatrics.