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 PO2 & 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
1. Preseptal cellulitis
2. Orbital cellulitis
3. Subperioste
al abscess
4. Orbital abscess
5. Cavernous
sinus
thrombosis
1. Meningitis
2. EpiduraI
abscess
3. Subdural
abscess
4. Intracerebr
al abscess
5. 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: Iinvolvement 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. Feature Preseptal Cellulitis Orbital Cellulitis
Proptosis Absent Present
Motility Normal Decreased
Pain on motion Absent Present
Orbital pain Absent Present
Vision Normal May be decreased
Pupillary reaction Normal May be abnormal; ±
afferent pupillary defect
Chemosis Rare Common
Corneal sensation Normal May be reduced
Ophthalmoscopy Normal May be abnormal; ±
venous congestion; ± disc
edema
Systemic signs (e.g., fever,
malaise)
Mild Commonly severe

34. 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

35. SUBPERIOSTEAL ABSCESS (cont)

36. SUBPERIOSTEAL ABSCESS (cont)

37. 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%

38. 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

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

41. ORBITAL ABSCESS (cont)

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

43. CAVERNOUS SINUS RELATIONS & CONTENTS

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

45. CAVERNOUS SINUSTHROMBOSIS

46. CAVERNOUS SINUSTHROMBOSIS

47. 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

48. 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

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

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

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

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

54. 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

55. MENINGITIS(cont)

56. 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%)

57. EPIDURAL ABSCESS
• Frontal
sinusitis

58. 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

59. 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

60. SUBDURAL ABSCESS(cont)

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

62. SUBDURAL ABSCESS(cont)
Treatment:
• Lumbar puncture potentially fatal
Aggressive 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

63. 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%)

64. INTRACEREBRAL ABSCESS(cont)

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

66. INTRACEREBRAL ABSCESS(cont)
Treatment
• Medical
Antibiotics, Anticonvulsants
Mannitol
Steroids
• Surgical
Bur hole drainage
Craniotomy
Image-guided aspiration

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

68. 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

69. 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

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

71. BONY: POTT’S PUFFY TUMOR(cont)

72. BONY: POTT’S PUFFY TUMOR(cont)

73. 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.

74. THANK YOU