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

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. • 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

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

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

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

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. • 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

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. • 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

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. 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
Treatment

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

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