Chandler´s classification Bilateral eye findings and worsening of all other previously described findings. V. Cavernous sinus thrombosis Discrete pus collection in orbital tissues, proptosis and chemosis with ophthalmoplegia and decreased vision. IV. Orbital abscess Collection of pus between medial periosteum and lamina papyracea, impaired extraocular movement. III. Subperiosteal abscess Diffuse orbital infection and inflammation without abscess formation. II. Orbital cellulitis (postseptal) Lid edema, no limitation in ocular movement or visual change. I. Inflammatory edema (preseptal)
Shapiro ED, Wald ER, Brozanski BA. Periorbital cellulitis and paranasal sinusitis: a reappraisal. Pediatr Infect Dis J 1982;1:91-94.
I. Inflammatory edema (preseptal cellulitis)
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.
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. 
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 (Donahue SP, et al. 1998).
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. 
II. 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.
Cannon ML, Anonio BL, McCloskey JJ, et al. Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med 2004;5(1):86-8. Ebright JR, Pace MT, Niazi AF. Septic thrombosis of the cavernous sinuses. Arch Intern Med 2001;161:2671-2676.
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).
IV 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.
Intracranial abscess ESS / Neurosurgery (stereotactic vs. open) IV Abx., craniotomy, ESS, anticonvulsivants, +/- steroids IV Abx. + Surgery (craniotomy / ESS) Treatment MRI (T2) Hypointense with capsule CT may show it but MRI is better CT or MRI Diagnosis Subtle if frontal (mood) H/A, lethargy, seizures, focal deficits Meningismus, rapid progression to coma Mild, non-specific for weeks. Increase ICP Symptoms Asymptomatic phase while it coalesces Spreads diffusely convexities, interhemispheric Slow expanding Progression Frontal/frontopariental white/gray matter Subdural space no boundaries Between skull and dura Location Intracranial Subdural Epidural *
Venous sinus thrombosis (superior sagittal and cavernous)
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).
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 obliteration may be performed.
Epstein VA, Kern RC. Invasive fungal sinusitis and complications of rhinosinusitis. Otolaryngol Clin N Am 2008;41:505.
The orbit is the most common structure involved in complicated sinusitis.
CT scan is the study of choice to evaluate orbital complications. Whereas, intracranial complications are better assessed with MRI.
Surgical treatment of orbital infections is variable. Preseptal cellulitis rarely requires surgery. While, postseptal infection often require surgery and multiple options are available.
Early Neuro/Neurosurgical consultation is advisable in intracranial complications.
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