This document discusses complications that can arise from sinusitis, including orbital complications like pre-septal cellulitis, orbital cellulitis, and intraorbital abscesses. Intracranial complications such as meningitis, brain abscesses, and cavernous sinus thrombosis are also described. Chronic complications include mucocoeles, pyoceles, osteomyelitis which can lead to Pott's puffy tumor, oroantral fistulas, and rarely toxic shock syndrome. Medical and surgical treatment options are provided for managing these complications.

1. Complications of
Sinusitis
Dr. Krishna
Koirala
2017-08-30

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

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

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

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

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

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

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

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

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
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

32. Surgical treatment for
abscess• For sinuses:
– Frontal trephination
– External fronto-ethmoidectomy (Lynch
Howarth)
– Functional Endoscopic Sinus Surgery
• For intra-cranial complication: by
Neurosurgeon

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
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
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

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)
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

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