Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal, for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology.
A clear and concise explanation of the basic concepts in the subject matter concerned.
He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students
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
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
9. • 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 (?)
Orbital complications
10.
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
12.
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
14.
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
22. Cavernous sinus
Thrombosis
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
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
27. • 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
Introduction
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
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. • 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
Etiology
36. • 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
Clinical Features
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
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
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
50.
51. Toxic shock syndrome
• Rare, potentially fatal complication of sinusitis
• Septicemia due to Staphylococcus aureus or Streptococcus
infection
• C/F:
– Fever, hypotension, skin rashes with desquamation, multi-
system failure
• Treatment
– IV Ceftriaxone 1g TDS
– FESS and drainage of pus from the sinuses
