Complications of sinusitis

1. COMPLICATIONS
OF SINUSITIS

2.  Complications are said to arise when infection
spreads into or beyond the bony wall of the
sinus
 Mainly divided into
1. Local
2. Orbital
3. Intracranial
4. Descending infections
5. Focal infections

3. I . LOCAL COMPLICATIONS
A. MUCOCELE OF PARANASAL SINUSES
AND MUCOUS RETENTION CYST
 There are two views in the genesis of a mucocele:
1. Chronic obstruction to sinus ostium resulting in
accumulation of secretions which slowly expand the
sinus and destroy its bony walls.
2. Cystic dilatation of mucous gland of the sinus mucosa
due to obstruction of its duct. In this case, wall of
mucocele is surrounded by normal sinus mucosa. The
contents of mucocele are sterile.

4. Mucoceleofthefrontalsinus
 Usually presents in the superomedial quadrant
of the orbit (90%) and displaces the eyeball
forward, downward and laterally.
 The swelling is cystic and non tender; egg-
shell crackling may be elicited.
 Sometimes, it presents as a cystic swelling in
the forehead(10%).
 Patient’s complaints are usually mild and may
include headache, diplopia and proptosis.

5. Mucocele of frontal sinus.
Imaging of the frontal sinus usually reveals
clouding of the sinus with loss of scalloped
outline.

6.  Treatment is frontoethmoidectomy with
free drainage of frontal sinus into the middle
meatus

7. Mucoceleofethmoidsinuses
 Seen as expansion of the medial wall of the orbit,
displacing the eyeball forward and laterally.
 It may also cause a bulge in the middle meatus of
nose.
 A mucocele of the ethmoid can be drained by an
intranasal operation, uncapping the ethmoidal
bulge and establishing free drainage.
 Sometimes, it may require external ethmoid
operation.

8. Mucousretentioncystofthemaxillary
sinus
 Presents as a retention cyst due to obstruction
of the duct of seromucinous gland and usually
does not cause bone erosion.
 It is asymptomatic and is observed as an
incidental finding on radiographs.
 No treatment is generally required for
asymptomatic retention cysts as most of them
regress spontaneously over a period of time.

9. Mucoceleofthemaxillarysinus
 Can occur as a complication of chronic sinusitis
when the ostium is blocked.
 The sinus fills with mucus and its bony walls
get expanded due to expansile process.
 CT scan and MRI can help in the diagnosis.
 A polyp, tumour or trauma in the middle
meatus may also obstruct the sinus ostium to
cause a mucocele.

10. Mucoceleofsphenoidsinusor
sphenoethmoidalmucocele
 Arises from slow expansion and destruction of sphenoid and
posterior ethmoid sinuses.
 Clinical features are those of superior orbital fissure
syndrome (involvement of CN III, IV, VI and ophthalmic
division of V) or orbital apex syndrome which is superior
orbital fissure syndrome with additional involvement of
optic and maxillary division of trigeminal nerve.
 Exophthalmos is always present and the pain is localized to
the orbit or forehead.
 Some may complain of headache in the occiput or vertex.
 Treatment is external ethmoidectomy with sphenoidotomy.
Anterior wall of the sphenoid sinus is removed, cyst wall
uncapped and its fluid contents evacuated.

11. Pyoceleormucopyocele
 Is similar to mucocele but its contents are
purulent.
 It can result from infection of a mucocele of
any of the sinuses
 Endoscopic surgery has replaced external
operation of the sinuses for treatment of all
mucocele or mucopyoceles of various sinuses.

12. B.OSTEOMYELITIS
 Osteomyelitis is infection of bone marrow.
 Osteomyelitis, following sinus infection, involves
either the maxilla or the frontal bone.
1. Osteomyelitis of the maxilla.
 It is more often seen in infants and children than
adults because of the presence of spongy bone in the
anterior wall of the maxilla.
 Infection may start in the dental sac and then spread
to the maxilla, but sometimes, it is primary infection
of the maxillary sinus.
 Clinical features are erythema, swelling of cheek,
oedema of lower lid, purulent nasal discharge and
fever.

13.  Subperiosteal abscess followed by fistulae may
form in infraorbital region, alveolus or palate, or in
zygoma.
 Sequestration of bone may occur.
 Treatment consists of large doses of antibiotics,
drainage of any abscess and removal of the
sequestra.
 Osteomyelitis of maxilla may cause damage to
temporary or permanent tooth-buds,
maldevelopment of maxilla, oroantral fistula,
persistently draining sinus or epiphora

14. Osteomyelitis of maxilla with fistula formation in
infraorbital region

15. 2.Osteomyelitis of frontal bone
 It is more often seen in adults as frontal sinus is not developed
in infants and children.
 Osteomyelitis of frontal bone results from acute infection of
frontal sinus either directly or through the venous spread.
 It can also follow trauma or surgery of frontal sinus in the
presence of acute infection.
 Pus may form externally under the periosteum as soft doughy
swelling (Pott’s puffy tumour), or internally as an extradural
abscess.
 Treatment consists of large doses of antibiotics, drainage of
abscess and trephining of frontal sinus through its floor.
 Sometimes, it requires removal of sequestra and necrotic bone
by raising a scalp flap through a coronal incision

16. Case of chronic frontal sinusitis presenting with a fistula in
the floor of the sinus.

17. II.ORBITALCOMPLICATIONS
 Orbit and its contents are closely related to the ethmoid,
frontal and maxillary sinuses, but most of the complications,
however, follow infection of ethmoids as they are separated from the
orbit only by a thin lamina of bone — lamina papyracea.
 Infection travels from these sinuses either by osteitis or as
thrombophlebitic process of ethmoidal veins.
 Orbital complications include:
1. Inflammatory oedema of lids.
 This is only reactionary.
 There is no erythema or tenderness of the lids which characterises lid
abscess.
 It involves only preseptal space, i.e. lies in front of orbital septum.
 Eyeball movements and vision are normal.
 Generally, upper lid is swollen in frontal, lower lid in maxillary, and
both upper and lower lids in ethmoid sinusitis.

18.  2. Subperiosteal abscess.
 Pus collects outside the bone under the periosteum.
 A subperiosteal abscess from ethmoids forms on
the medial wall of orbit and displaces the eyeball
forward, downward and laterally;
 from the frontal sinus, abscess is situated just above
and behind the medial canthus and displaces the
eyeball downwards and laterally;
 from the maxillary sinus, abscess forms in the floor
of the orbit and displaces the eyeball upwards and
forwards.

19. 3. Orbital cellulitis.
 The pus on breaking through the periosteum finds its
way into the orbit, it spreads between the orbital fat,
extraocular muscles, vessels and nerves.
 Clinical features will include oedema of lids,
exophthalmos , chemosis of conjunctiva and restricted
movements of the eye ball.
 Vision is affected causing partial or total loss which is
sometimes permanent.
 Patient may run high fever.
 Orbital cellulitis is potentially dangerous because
of the risk of meningitis and cavernous sinus
thrombosis.

20. 4. Orbital abscess
 Intraorbital abscess usually forms along
lamina papyracea or the floor of frontal sinus.
 Clinical picture is similar to that of orbital
cellulitis.
 Diagnosis can be easily made by CT scan or
ultrasound of the orbit.
 Treatment is i.v. antibiotics and drainage of the
abscess and sinus (ethmoidectomy or trephination
of frontal sinus).

21. Normal Subperiosteal abcess Orbital abcess

22. 5. Superior orbital fissure syndrome
 Infection of sphenoid sinus can rarely affect structures of
superior orbital fissure.
 Symptoms consist of deep orbital pain, frontal
headache and progressive paralysis of CN VI, III and IV
in that order.
6. Orbital apex syndrome.
 It is superior orbital fissure syndrome with
additional involvement of the optic nerve and
maxillary division of the trigeminal (V2)

23. III. INTRACRANIAL COMPLICATIONS
 Frontal, ethmoid and sphenoid sinuses are
closely related to anterior cranial fossa and
infection from these can cause:
1. Meningitis and encephalitis
2. Extradural abscess
3. Subdural abscess
4. Brain abscess
5. Cavernous sinus thrombosis

24. CAVERNOUSSINUSTHROMBOSIS
Aetiology
 Infection of paranasal sinuses, particularly those
of ethmoid and sphenoid and less commonly the
frontal, and orbital complications from these sinus
infections can cause thrombophlebitis of the
cavernous sinus.
 The valveless nature of the veins connecting the
cavernous sinus causeseasy spread of infection.

25. Clinical features.
 Onset of cavernous sinus thrombophlebitis is abrupt
with chills and rigors.
 Patient is acutely ill.
 Eyelids get swollen with chemosis and proptosis of
eyeball.
 Cranial nerves III, IV and VI causing total
ophthalmoplegia which are related to the sinus get
involved individually and sequentially
 Pupil becomes dilated and fixed, optic disc shows
congestion and oedema with diminution of vision.
 Sensation in the distribution of V1 (ophthalmic
division of CN V) is diminished.
 CSF is usually normal.
 Diagnosis : CT scan .

26. Treatment.
 It consists of i.v. antibiotics and attention
to the focus of infection, drainage of infected
ethmoid or sphenoid sinus.
 Blood culture should be taken before
starting antibiotic therapy.

27. IV.DESCENDINGINFECTIONS
 In suppurative sinusitis, discharge constantly flows
into the pharynx and can cause or aggravate:
1. Otitis media (acute or chronic).
2. Pharyngitis and tonsillitis.
 Hypertrophy of lateral lymphoid bands behind the
posterior pillars (lateral pharyngitis) is indicative of
chronic sinusitis.
 It may be unilateral and affect the side of the involved
sinus.
 Chronic sinusitis may also cause recurrent tonsillitis or
granular pharyngitis.
3. Persistent laryngitis and tracheobronchitis.

28. V. FOCAL INFECTIONS
 Doubtful condition
 Due to dissemination of microorganisms or
toxic products .
 Eg :Polyarthritis, tenosynovitis, fibrositis and
certain skin diseases.