17 complication of sinusitis

1. COMPLICATIONS OF SINUSITIS

2.  Introduction
 Surgical Anatomy
 Routes of Spread
 Risk Factors
 Classification
 Clinical Features & Management

3. RHINOSINUSITIS
• Definition - Group of disorders charcterised by inflammation of
lining of nasal cavity.
• Symptoms of
– Nasal congestion
– Rhinorrhoea
– Sneezing
– Itching

4. CLASSIFICATION :ON BASIS OF TIME-FRAME *
 Acute rhinosinusitis (ARS)
 Acute onset of symptoms
 Duration of symptoms < 12 weeks
 Symptoms resolve completely
 Recurrent acute rhinosinusitis
 > 1 to < 4 episodes of ARS / year
 Complete recovery between attacks
 Symptom free period > 8 weeks between attacks
 Chronic rhinosinusitis
 Duration of symptoms > 12 weeks
 Persistent inflammatory changes on imaging > 4 weeks after medical Rx
 Ac Exacerbation of CRS
 Worsening of existing symptoms or appearance of new symptoms
 Complete resolution of acute symptoms between attacks
*Rhino sinusitis Task Force of the American Academy of Otorhinolaryngology- Head and Neck Surgery classification.

5. CLASSIFICATION OF COMPLICATIONS:
 ACUTE:
 Local
 Orbital
 Intracranial
 Bony
 Dental
 Systemic:
 Toxic shock syndrome
 Septicaemia
 CHRONIC:
 Mucocoele/ Pyocoele
 OTHERS:
 Polyarthritis
 Tenosynovitis
 OME

6. INTRODUCTION
 Complications are said to arise when infection spreads
into or beyond the wall of the sinus’
 Preantibiotic era: frequent
 17% died of meningitis
 20% blinded 1
 Now a rarity
 3% mortality2
 10% blindness3 once complications develops
 1 . Gamble Archives of Ophthalmology 1933 10:483-497
 2 . Schramm, Curtin and Kennerdell Laryngoscope 1982
 3 . Patt and Manning Otolary, Head Neck Surgery 1991 104:789-95

7. SURGICAL ANATOMY
 Maxillary sinus
 Birth: 7–8 × 4–6 mm
 Adult: 31–32 × 18–20 mm
 Volume (adult): 15 mL
 Biphasic growth
 invasion into the alveolar process following
eruption of permanent dentition.

8. SURGICAL ANATOMY
 Maxillary Sinus:
 Relatively symmetrical
 Rarely absent
 Roof forms orbital floor traversed by infra orbital
canal may be dehiscent
 Posterior edge contributes to infraorbital fissure
 Inferiorly floor encroached by dentition

9. SURGICAL ANATOMY
 Maxillary Bone & Sinus:
 Posterior surface ( Infratemporal surface):
 Convex
 Grooved by post sup alveolar n
 Inferiorly bears the maxillary tuberosity  attachment of
Medial Pterygoid ms
 Medial nasal surface:
 Contains large defect  maxillary hiatus  completed by
bones & mucous memb natural ostia

10. SURGICAL ANATOMY
 Frontal Bone & Sinus:
 Forms Forehead & Orbital roof (thin+/- dehiscence)
 Also forms roof of ethmoid sinus
 Sinus:
 28 *27*17 mm
 Variable pneumatization variable shape & size
 Drains into frontal recess
 Absent in 1%
 Usually paramedian intersinus septa
 Partially dehiscent in 9%

11. SURGICAL ANATOMY
 Frontal Bone & Sinus: Relations:-
 Inf : Orbit
Ethmoid labyrinth
Nasal cavity
 Sup : Ant Cranial Fossa
Olfactory niche, bulb, tract
 Med : Cribriform plate

12. SURGICAL ANATOMY
 Ethmoid Bone & Sinus:
 2 ethmoid labyrinth laterally constitute orbital
plate (L. Papyracea) extremely thin +/- dehiscent
 Perpendicular plate of ethmoid in between
 Intervening cribriform plate & crista galli 
fenestrations  olfactory filaments, ethmoidal
vessels & nerve, dural prolongations traverse

13.  Ethmoid Bone & Sinus
 Relations:-
 Superiorly : ACF & Frontal bone
 Laterally : Orbit
 Posteromedially : Sphenoid
 Posterolaterally : Optic N
 Medially : Nasal Cavity
SURGICAL ANATOMY

14. SURGICAL ANATOMY
 Sphenoid Bone & Sinus:
 Largest bone of skull base divides ACF & MCF
 Adult: 20 × 22 × 16 mm; volume: 7.5 mL
 Body with variable pneumatization
 Conchal , presellar, sellar, mixed
 Sinus divided by paramedian septum
 May be incomplete
 Completely absent in 1%

15. SURGICAL ANATOMY
ORBITAL APEX AND SUPERIOR ORBITAL FISSURE:
RIGHT SIDE

16. SURGICAL ANATOMY
 Sphenoid Bone & Sinus: Relations:-
 Ant : Post ethmoidal cells
 Post : Occipital bone,
: Basilar A & Brain Stem
 Lat : Cavernous Sinus
: ICA & Sympathetic plx
: Abducen N
: CN III, IV, V1, V2
 Inf : Roof of nasopharynx
 Sup : Olf tract, Optic chiasma
: Pituitary gland
: Frontal Lobe

17. SURGICAL ANATOMY: CAVERNOUS SINUS
 Largest venous sinus: In MCF on either side of body of
sphenoid
 Divided into number of spaces/caverns by trabeculae
 2 cm long X 1 cm wide
 Structures on lateral wall
 CN III, IV, V1, V2
 Structures thro’ centre
 ICA + Sympathetic plx
 Abducen N

18. CAVERNOUS SINUS: RELATIONS:-
 Sup:
 Optic tract and chiasma
 Olfactory tract
 ICA
 Inf:
 Foramen lacerum
 Med:
 Pituitary gland
 Sphenoidal air cells
 Lat
 Temporal lobe
 Ant
 Sup orb fissure & Orbital apex
 Post:
 Apex of petrous temporal bone
 Crus cerebri of midbrain
Temporal lobe

19. CAVERNOUS SINUS: INCOMING CHANNELS
 Orbit:
 Sup ophthalmic vn
 Inf ophthalmic vn & br
 Central retinal vn
 Brain:
 Supf Middle Cerebral Vn
 Inf Cerebral Vn
 Meninges:
 Spheno-parietal sinus
 Middle Meningeal Vn

20. CAVERNOUS SINUS: COMMUNICATIONS
 Trans sinus thro’ Sup
petrosal sinus
 IJV thro’ Inf petrosal sinus
 Pterygoid plx of vn thro’
Emissary vn
 Facial vn thro’ Sup
ophthalmic vn
 Communicate with each
other thro’ Intercavernous
sinus & Basilar plx of vn

21. SURGICAL ANATOMY: ORBITAL SEPTUM
 The orbicularis oculi (O) overlies the
orbital septum (S)retains the orbital
fat pads (F) within the orbit.
 The septum fuses with the maxillary
periosteum (P) inferiorly and the
tarsus (T) superiorly.
 The septum is perforated by the
vessels and nerves which pass from
the orbital cavity to the face and scalp.
 The eyelids are richly supplied with
blood.

22. SURGICAL ANATOMY: ORBIT

23. ROUTES OF SPREAD

24. ROUTES OF SPREAD
 Local:
 Natural dehiscence or weakness of surrounding bone
 When natural routes blocked
 Massive osteolysis in acute infection
 Lamina papyracea/ infraorbital canal/ suture lines
 Associated thromboplebitis
 Diploic veins of Breschet: Frontal & Sphenoid
 At peak vascularity in adolescent
 Valveless veins between sinus & orbit
 Roots of 2nd premolar & molars
 Distant:
 Hematogenous spread : Rare

25. RISK FACTORS
 Patient factors:
 More common in young: 85% under 20 yrs
 Immunocompromised & Diabetes
 Abnormal mucociliary clearance Chronicity of disease
 Allergy Chronicity of disease
 Local anatomical variations
 Patient compliance to treatment
 Pathogenic factors:
 URTI Viremia rarely encephalitis
 Invasive fungal rhinosinusitis: Mucor
 Staph aureus  Brain abscess
 Treatment factors:
 Inappropiate & Inadequate antibiotic therapy

26. BACTERIOLOGY:
 ORBITAL:
 Aerobes
 Staphylococcus aureus
 Haemophilus influenza
 Strept. pneumoniae
 Moraxella catarrhalis
 Streptococcus milleri
 Streptococcus pyogenes
 Anaerobes
 INTRACRANIAL:
 Aerobes
 Staphylococcus aureus
 Strept. Pneumoniae
 Haemophilus influenza
 Streptococcus sp
 Pseudomonas aeruginosa
 Klebsiella sp
 Anaerobes

27. A. ORBITAL COMPLICATION
 Pre-antibiotic era: 17-20% died of meningitis or
had permanent blindness
 Commonly due to ethmoiditis in young and
frontal sinusitis in adult.
 Higher frequency during winter & spring

28. A. ORBITAL COMPLICATIONS
 Hubert 1937
 Inflammatory edema of eyelids
 Subperiosteal abscess with
 Edema of eyelids or
 Spread of pus to lids
 Abscess of orbital tissues
 Orbital cellulitis – Mild to severe
 Cavernous sinus thrombosis
 Smith & Spencer 1948

29. A. ORBITAL COMPLICATIONS
CHANDLER, LANGENBRUNNER, STEVENS 1970
1. Preseptal cellulitis
2. Orbital cellulitis without
abscess
3. Orbital cellulitis with
sub/extraperiosteal abscess
4. Orbital cellulitis with
intraperiosteal abscess
5. Cavernous sinus thrombosis

30. A. ORBITAL COMPLICATIONS: STAGE 1
 Oedema of lids
 Painless/ non-tender
 No visual loss
 Globe unaffected
 No restricted extra-
ocular movements

31. A. ORBITAL COMPLICATIONS: STAGE 2
 Orbital cellulitis without abscess
 Diffuse edema of adipose tissue
 Proptosis, Chemosis, Edema
 Associated Pain
 +/- Dilated pupil
 +/- Visual loss
 +/- Ophthalmoplegia
 +/- Afferent pupillary defect

32. A. ORBITAL COMPLICATIONS: STAGE 3
 Orbital cellulitis with sub/ extra-
periosteal abscess
 Proptosis
 Globe displaced inferolaterally
 Decreased EOM
 Vision decreased
 Onidi cells optic nerve vulnerable

33. A. ORBITAL COMPLICATIONS: STAGE 3

34. A. ORBITAL COMPLICATIONS: STAGE 4
 Orbital cellulits with intra-periosteal
abscess
 Severe proptosis and chemosis
 Fixed pupil
 Severe globe displacement
 Rapid fixation of EOM
 Opthalmoplegia
 Visual loss due to optic neuropathy(13%)
 “Orbital Apex Syndrome”
 Ophthalmoplegia & Dilated pupil
 Paraesthesia in distribution of maxilary &
ophthalmic division of trigeminal n
 Blindness & Temporal headache

35. A. ORBITAL COMPLICATIONS: STAGE 5
 Cavernous Sinus Thrombosis
 Bright 1831
 Uncommon, no incidence data
 Typically affects young adults
 Pathophysiology:
 Bacterial growth
 Induces thrombosis
 Thrombus: good growth medium
 More bacterial growth
 Thrombophlebitis extend posteriorly
 Orbit to Cavernous sinus
 Contralateral Cavernous sinus bilateral eye symptoms
 Then Intracranially

36. A. ORBITAL COMPLICATIONS: STAGE 5
 Fatal prior to antibiotic era (pre-1940s)
 Mortality estimate: 14-79%
 Morbidity estimate: 50%
 Cranial neuropathies & Visual loss
 Clinical features:
 Onset: 1-21 days (Avg: 5-6 days)
 Progressive & bilateral eye symptom
 Proptosis and fixation of eye ball
 Bilateral orbital apex syndrome
 Meningitis
 Systemic featutes
 High grade fever & headache
 Tachycardia, hypotension

37. A. ORBITAL COMPLICATIONS: STAGE 5

38. A. ORBITAL COMPLICATIONS: STAGE 5
 Complications:
 Intracranial infection
 Meningitis
 Encephalitis
 Abscess
 Pituitary insufficiency
 Hemorrhagic infarction
 Death

39. A. ORBITAL COMPLICATIONS: MANAGEMENT
 History
 General ENT examination
 Complete neurological examination
 Rigid endoscopy of nose
 Swabs

40. A. ORBITAL COMPLICATIONS: MANAGEMENT

41. A. ORBITAL COMPLICATIONS: MANAGEMENT
 Other investigations:
 CBC
 Blood biochemistry
 Blood cultures
 Lumbar puncture
 Neuroimaging (CT, MRI)
 Expansion of cavernous sinuses
 Convex bowing of lateral wall
 Abnormal filling defects
 Dilation of superior ophthalmic vein
 Dural enhancement of cavernous sinus border

42. A. ORBITAL COMPLICATIONS: MANAGEMENT
 Empiric high dose IV antibiotics
 Third generation cephalosporin
 Anti-staphylococcal penicillin
 Metronidazole
 Continued treatment with IV antibiotics for at least 2
wks after apparent clinical resolution
 Steroids controversial (except if pituitary insufficiency)
 Anticoagulation in CST
 No consensus for use despite theoretical rationale
 Risks include systemic and intracranial bleeding

43. A. ORBITAL COMPLICATIONS:
LONG TERM SEQUELAE
 Permanent visual loss
 Ophthalmoplegia
 Exposure Keratitis & Ulceration
 Other ocular changes :
 Uveitis
 Choroiditis
 Glaucoma
 Iris prolapse
 Rupture of the globe

44. B. INTRACRANIAL COMPLICATIONS:
 Less common than orbital complications
 Both can coexist
 More common in adolescent
& young adults
 Male preponderance
 Includes:
 Meningitis, Encephalitis
 Subdural Abscess(2,3) > Frontal Lobe(4) abscess >
Extradural Abscess (1)
 Cavernous Sinus Thrombosis

45. B. INTRACRANIAL COMPLICATIONS:
CLINICAL PRESENTATION
 Thrombophlebitis:
 Septic thrombophlebitis  multiple
abscesses formation
 Associated thrombosis of Cavernous sinus &
Sup Sagittal sinus
 Usually >10yrs, Uncommon in infants
 Presentation: Acute or Chronic
 Fever, leucocytosis and headache
 Seizures, rigidity and focal neurological signs
 Features of Increased ICP
 Features of meningitis & encephalitis

46. B. INTRACRANIAL COMPLICATIONS:
MANAGEMENT
 High index of suspicion
 History
 ENT & Full neurological examination
 If abscess suspected  CECT (or MRI)
 Fundoscopy Lumbar puncture
 IV antibiotics (Cefuroxime+Flagyl) – 4-6weeks
 Serial CT
 Steroids – controversial

47. B. INTRACRANIAL COMPLICATIONS: MANAGEMENT
 Surgery:
 Treat complication & sinusitis
 Drain Extradural abscess via approach to frontal
sinuses
 Neurosurgical assistance:
 Burr holes: For extradural abscess / solitary abscess
 Formal craniotomy:

48. B. INTRACRANIAL COMPLICATIONS:
 Prognosis:
 Mortality : 15-43% despite antibiotics
 Incidence increases with age
 Multiple subdural abscess with coritcal thrombosis carries
worst prognosis
 Morbidity: Permanent in 40%
 Convulsions
 Hemiparesis
 Early treatment better outcome

49. C. BONY COMPLICATIONS:
POTT’S PUFFY TUMOUR
 Described by Sir Percival Pott in 1970
 Frontal bone is diploic with marrow cavity
 Sinusitis Osteomyelitis of frontal bone
 Anteriorly Forehead  Potts Puffy tumour
 Posteriorly Subdural abscess
 Presentation
 Fluctuant swelling +/- Pain
 Causative Org. : Staph & Strepto- & Anaerobes
 Investigation:
 Blood investigation + CECT
 Treatment
 Medical: IV Antibiotics
 Surgical: Bilateral coronal incision +Bone debridement

50. C. BONY COMPLICATIONS:
POTT’S PUFFY TUMOUR

51. D. DENTAL COMPLICATIONS
 Common with Maxillary Sinusitis
 Close association of dentition with floor of sinus
 Acute sinusitis : Dental pain
 Dental abscess : Mistaken for Sinusitis
 May coexist

52. E. SYSTEMIC COMPLICATIONS
 Toxic Shock Syndrome
 Rare , Potentially Fatal
 Frequently associated with Staph aureus / Streptococcus
 Features of Toxaemia: Fever , Hypotension, Rash & MODS
 Septicaemia:
 Hematogenous spread
 Blood culture
 Features of SIRS
 Shock
 MODS

53. F. CHRONIC COMPLICATIONS : MUCOCOELE
 Definition:
 Epithelial lined mucus containing sac completely filling the
sinus and capable of expansion
 1820, Langenback : ‘Hydatides’
 1896, Rollet : ‘mucocoele’
 Incidence: 4% of case of unilateral proptosis
 Most common sites: F(65%)> E(25%)> M(10%)> S
 Age grp: 40-70 yrs
 < 5% bilateral or multiloculated 53

54. F. CHRONIC COMPLICATIONS : MUCOCOELE
 Theories: Chronic rinosinusitis Increased osteolysis
 Active Bone resorption & formation
 Pressure erosion
 Cystic degeneration of seromucimous glands
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55. F. CHRONIC COMPLICATIONS : MUCOCOELE
 Initial ophthalmic referral
 Clinical features:
 Proptosis
 Diplopia
 Displacement of globe
 Limited ocular movement
 Visual impairment
 Mass
 Endoscopy:
55

56. F. CHRONIC COMPLICATIONS : MUCOCOELE
56
 Imaging:
Loss of Scalloping of frontal sinus

57. F. MUCOCOELE: CECT PNS
FRONTAL MUCOCOELE BILOCULATED ETHMOID MUCOCOELE
57
Homogenous smooth walled mass expanding the sinus

58. F. MUCOCOELE: CULTURE OF ASPIRATE
 Mixed infection:
 Staph aureus
 Alpha hemolytic Streptococci
 Heamophillus sp
 GNB
 Anaerobic bacteria
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59. F. MUCOCOELE: TREATMENT
 Surgery is the treatment
 Goals:
 Eradication of disease
 Minimal morbidity
 Prevention of recurrence
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60. F. MUCOCOELE: TREATMENT
 Approach:
 Endoscopic drainage:
 Type I-III
 External approach
 Osteoplastic flap
+/- sinus cavity obliteration
 Combined approach
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