complications of sinusitis

1. Complications of Sinusitis Dr. Krishna Koirala 2018-08-13

2. Definition • Progress of infection beyond the muco-periosteal lining of paranasal sinuses to involve the bone and neighboring structures (orbit, intra-cranial cavity, dentition) • Compromise in function of any part of body due to sinusitis

3. Etiology • Weak immune response of host • Young children and immuno -compromised adults • Inadequate / inefficient treatment • Infection by highly virulent organisms • Abnormalities of muco- cilliary clearance • Persistent allergy and blockade of sinus ostia

4. Routes of infection • Via thin bones eg. lamina papyracea • Through natural suture lines • Through natural canal: infra-orbital canal • Retrograde thrombophlebitis: diploic vein of Breschet • Closely related roots of upper 2nd premolar & 1st molar teeth • Periarteriolar spaces of Virchow Robin

5. Classification • Acute • Local • Orbital • Intracranial • Bony • Dental • Distant • Toxic shock syndrome • Chronic • Mucocele • Pyocele • Associated diseases (?) • Otitis media • Adeno -tonsillitis • Bronchiectasis

6. Orbital Complications ( Chandler et al 1970) 1. Pre-septal cellulitis 2. Orbital cellulitis without abscess 3. Orbital cellulitis with extra/ sub-periosteal abscess 4. Orbital cellulitis with intra-periosteal abscess 5. Cavernous sinus thrombosis

7. Intracranial Complications 1. Meningitis 2. Encephalitis 3. Extra-dural abscess 4. Sub-dural abscess 5. Intra-cerebral abscess 6. Cavernous sinus thrombosis 7. Sagittal sinus thrombosis

8. Bony • Osteitis • Osteomyelitis (Pott’s puffy tumour) • Dental • Dental abscess • Oro-antral fistula

9. Orbital complications • 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 (?)

11. Pre-septal cellulitis • Inflammation external to orbital septum • Edema of eyelids: • Upper lid : frontal sinusitis • Lower lid : maxillary sinusitis • Both lids : ethmoid sinusitis • No tenderness , visual loss , limitation of extra-ocular movement

13. Orbital Cellulitis without abscess • Inflammation of adipose tissue deep to peri-orbital septum without suppuration • Diffuse peri -orbital edema with erythema • Mild proptosis • No restriction of extra-ocular movement • No change in vision

15. Extra-periosteal abscess • Most common form of orbital cellulitis • Localized extra-periosteal pus collection • Mild proptosis, restriction of extra-ocular movement , vision loss • Color vision affected first • Red = brown • Blue = black

16. Extra-periosteal abscess

17. Orbital cellulitis with Intra-periosteal abscess • Mild chemosis (edema of conjunctiva) • Proptosis: severe, asymmetric, quadrantic • Frontal sinusitis : down + forward + lateral • Ethmoid sinusitis :forward + lateral • Maxillary sinusitis : up + forward • Concurrent and complete ophthalmoplegia • Visual loss due to optic neuropathy (up to 13% of cases)

18. Intra-periosteal abscess

19. 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) • Papilledema + loss of vision • Painful paresthesia of V1, V2

20. Cavernous Sinus Thrombosis

21. B/L chemosis + proptosis

23. Evaluation of orbital complication • Ophthalmology consultation • Look for edema of eyelids, displacement of eyeball (proptosis),restriction of ocular movement • Visual acuity and color vision examination • Fundoscopy for papilledema • CT scan PNS (including orbit): coronal and axial cuts

24. Medical Treatment • Broad spectrum, high dose IV antibiotics • Ceftriaxone + Metronidazole+ Amikacin • NSAIDs • Topical / oral nasal decongestants • Mucolytics:Bromhexine, Ambroxol, Guaphanesin • Nasal saline irrigation

25. Surgical Treatment • For sinusitis • Frontal sinus trephination • External fronto-ethmoidectomy (Lynch Howarth) • Functional Endoscopic Sinus Surgery ( FESS) • For orbital complications • Sub-periosteal abscess drainage • Orbital decompression

26. Intra-cranial complications

27. Introduction • 2nd most common 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 thrombophlebitis via Diploic vein of Breschet

28. Intra-cranial complications

29. Clinical Features • Fever • Deep-seated headache • Nausea & projectile vomiting • Neck stiffness • Seizures • Altered sensorium & mood changes • Late: bradycardia / hypotension / stupor

30. Frontal lobe abscess

31. Investigations and Medical Treatment • Neurosurgery consultation • CT scan PNS + brain with contrast • MRI with contrast: investigation of choice • High dose broad spectrum I.V. antibiotics: Ceftriaxone & Metronidazole for 4-6 week • Steroids : controversial

32. Surgical treatment for abscess • For sinuses: • Frontal trephination • External fronto-ethmoidectomy (Lynch Howarth) • Functional Endoscopic Sinus Surgery • For intra-cranial complication: by Neurosurgeon • Burr hole drainage for small abscess • Craniotomy for large brain abscess

33. Mucocoele of P.N.S.

34. Introduction • Definition: epithelium lined, mucus filled sac filling the paranasal sinus that is capable of expansion • Incidence: • Frontal : 65 % • Ethmoid : 25 % • Maxillary : 10 % • Sphenoid : rare

35. Etiology • Chronic obstruction of sinus ostium with retention of normal sinus mucus within sinus cavity • Mucous retention cyst : Develops from obstruction of ducts of sero mucinous glands within sinus mucosa

36. Clinical Features • Cystic, non-tender swelling above inner canthus with egg-shell crackling sensation on palpation • Proptosis: • Frontal :downward + forward + lateral • Ethmoid : forward + lateral • Maxillary : up + forward • Diplopia & restricted eyeball movement • Frontal headache, retro-orbital or facial pain

37. Fronto-ethmoid mucocele

38. Investigations • X-ray PNS OM view: expanded frontal sinus, loss of scalloped margins, translucency, depression or erosion of supra-orbital ridge • CT scan:homogenous smooth walled mass expanding the sinus with thinning of bone • Ring enhancement on contrast: pyocoele

39. Fronto-ethmoid mucocele

40. Fronto-ethmoid mucocoele with proptosis

41. Sphenoid mucocoele

42. Treatment 1. Antibiotics and nasal decongestants 2. External fronto-ethmoidectomy by Lynch – Howarth’s approach 3. Endoscopic fronto-ethmoidectomy 4. Endoscopic decompression (marsupialization) 5. Osteoplastic flap repair

43. Lt. Ethmoid mucocoele

44. Drainage + Marsupialization Post-op CT scan (coronal)

45. Frontal pyocele + fistula

46. Osteoplastic flap procedure for frontal sinus mucocele

47. Pott’s puffy tumour • Frontal sinus osteomyelitis (Percival Pott, 1760) • Fluctuant swelling over forehead anteriorly • May spread posteriorly leading to subdural abscess • Treatment • Six week course of broad spectrum antibiotics • Drainage of pus & debridement of bone • Obliteration of frontal sinus by osteoplastic flap technique

48. Pott’s puffy tumour

49. Oro-antral fistula • Fistulous tract communicating between oral cavity and maxillary antrum • Treatment : closure by • Buccal mucosal advancement flap • Palatal flap • Buccal fat pad flap