Complications of Sinusitis
M. Bradley Evans, M.D.
January 9, 2003

The objective of my talk today is to describe the relevant anatomy, physiology and pathogenesis of orbital and intracranial complications of sinusitis as well as to describe the classifications of these complications. I will also discuss the diagnostic and therapeutic strategies when dealing with the complications of sinusitis that extend to the orbit and the cranial vault.

To briefly review the relative anatomy, the orbit is a quadrilateral pyramidal cavity comprised of seven separate bones. It is important to consider the relationship of the paranasal sinuses to the orbit and the intracranial vault when considering complications spreading to these areas. The medial wall of the orbit includes the lamina papyracea which is adjacent to the ethmoid cells, the roof of the orbit which forms the floor of the frontal sinus and the floor of the orbit which forms the roof of the maxillary sinus. Venous drainage is key when remembering how infections spread from the sinuses to the orbit. The venous drainage forms a vascular network that interconnects with the nasal cavity, orbit, and paranasal sinuses. It is very important to remember that these veins are valveless, which allows the retrograde expansion of the infection. The superior and inferior ophthalmic veins drain the portions of the paranasal sinuses through the orbit and eventually into the cavernous sinus. The cavernous sinuses contain several cranial nerves including III, IV, V1 and VI as well as the internal carotid artery. It is important to remember that the cavernous sinus communicates with the contra-lateral cavernous sinus, which will also become important when talking about cavernous sinus thrombosis. Seventy-five percent of orbital infections are related to sinusitis, with the most commonly implicated sinus being the ethmoid sinus. These infections are more common in children and spread to the orbit in several different ways. Spread can occur via penetration through bony dehiscences, either congenital, surgical or traumatic, osteitis of the bone or retrograde thrombophlebitis through the valveless venous network described above.

The classification of orbital complications was proposed by Chandler in 1970: group I is preseptal cellulitis, Group II is orbital cellulitis, Group III is subperiosteal abscess, Group IV is orbital abscess and Group V is cavernous sinus thrombosis.

Preseptal cellulitis is infection that is limited to the skin and the subcutaneous tissues of the eyelid, which is anterior to the orbital septum. Clinically, you will see erythema and swelling of the eyelid with no limitation of extraocular movement and no impairment of visual acuity. If a CT is obtained it will show eyelid edema being a diffuse process of the tissues anterior to the orbital septum and the characteristic finding is that the tissues posterior to the septum are radiographically normal.

Orbital cellulitis is a diffuse edema of the orbital contents with infiltration of the adipose tissue with inflammatory cells and bacteria. In most cases, the patient presents clinically with severe eyelid edema along with some impairment of the visual acuity late in the process. Impairment of extraocular movements also occurs in most cases.

Group III or subperiosteal abscess is defined as a collection of pus between the periorbita and the bony wall of the orbit. It is a circumscribed swelling, which tends to displace the globe in a lateral or downward direction. The patient presents with chemosis, proptosis and limited mobility of the extraocular muscles along with some visual loss with progression of the disease. This is considered by most to be a medical and surgical emergency. However, some studies have shown that people do tend to observe these for over 24 to 48 hours to see if there is resolution before surgical intervention is undertaken. On CT scan or MRI this is seen as a contrast enhancing mass in the extraconal space with a ring enhanced lesion or an air fluid level being pathognomonic of an abscess. These abscesses are most commonly located in the supramedial or inferomedial orbit, which is intuitive because of its location next to the ethmoid sinuses.

Group IV, orbital abscess, is a collection of pus within the orbital tissues. The patient presents with marked proptosis, chemosis and ophthalmoplegia with usually severe impairment of vision. This process is sometimes difficult to distinguish from orbital cellulitis. There is a diffuse infiltration of the orbital fat with massive proptosis, extraocular enlargement and occasionally gas formation seen in the orbital tissues on CT or MRI.

Group V or cavernous sinus thrombosis is the constellation of signs and symptoms seen in the less severe cases of Group III or Group IV. However, there is a progression of the proptosis, chemosis and ophthalmoplegia with the key being appearance of similar signs in the contralateral eye. Anytime the contralateral eye is beginning to be affected by this infection then it has most surely extended to the cavernous sinus and is communicating contralaterally. These patients are extremely ill on presentation with signs of meningitis and multiple cranial nerve palsies bilaterally.

There are five categories of intracranial complications. These complications are relatively uncommon since the advent of antibiotics, with the prevalence reported anywhere between 0.3% and 2.4% in hospitalized patients. Mortality rates still remain high however with reported rate between 5% and 21% in the literature. Up to 40% of these patients will have permanent disability such as convulsions or hemiparesis. The frontal sinus is the most commonly implicated sinus followed by the ethmoid sinus, with reports of maxillary sinusitis and sphenoid sinusitis causing complications as well. There is differing data in the literature on the most common intracranial complication, but most state meningitis as being the most common. Adolescents and young adult males are most frequently affected, possibly because the valveless diploic system is the most vascular at this age. The pathogenesis is not unlike orbital complications, the most common being retrograde thrombophlebitis through diploic veins of the skull and the ethmoid bone or communicating vein, or direct extension of disease through anatomic pathways through either congenital or traumatic dehiscences, sinus wall erosion or existing foramina. The first complication, meningitis, classically presents as headache, fever, nuchal rigidity and irritability followed by somnolence and delirium. These patients may have focal neurologic deficits with involvement of the cranial nerves at the skull base or inflammation over the hemispheres. To prevent uncal herniation, it is always important to obtain a CT scan to rule out space occupying lesions before a lumbar puncture is obtained.

Epidural abscesses are defined as a collection of pus between the bony calvarium and the dura. The signs and symptoms may be subtle with small abscesses. Neurologic symptoms may be minimal, but this diagnosis should be considered in all patients with persistent headache and spiking fevers. Appropriate imaging should be obtained accordingly. A large collection of pus may cause focal motor or sensory deficits, seizures and an altered level of consciousness.

Subdural abscesses are defined as pus in the space between the dura and the pia mater. These patients usually have a fulminant course with early symptoms including intense headache, meningitis and fever. As the process continues, the patient develops an altered level of consciousness with hemiparesis and seizures developing late in the course of the disease. CT or MRI, when obtained, demonstrates a thin, enhancing collection over the cerebral convexity and/or the cerebral fissures. Bilateral or multiple collections are not uncommon.

Because of its proximity to the frontal sinus, which is the most commonly implicated sinus in these infections, intracerebral abscesses most commonly develop in the frontal lobe. The clinical features depend on the various phases of the abscess formation. These abscesses go through distinct phases when they are intracerebral with the initial stage lasting approximately one to two weeks and presenting with mild symptoms including fever, lethargy, agitation and persistent headache. The second stage is also the quiescent period, which is heralded by the progression of the inflammatory process with central liquefaction and necrosis without expansion of the abscess cavity. During this time, few if any new clinical signs or symptoms will develop because there is no expansion of the cavity. The third stage is organization and expansion of the abscess, during which the patient will typically present with signs of increased intracranial pressure and mass effect of the abscess pushing on the brain. It’s also important to remember again that epidural abscesses in the frontal lobes are notorious for being silent, and small abscesses may be asymptomatic other than subtle mood changes.

The final category of intracranial complications is dural sinus thrombophlebitis, which usually includes either cavernous sinus thrombosis or superior sagittal sinus thrombosis. Cavernous sinus thrombosis is lumped in as Group V with orbital complications. However, it can also be considered an intracranial complication. Superior sagittal sinus thrombosis is usually associated with an epidural or a subdural empyema. The patients present with focal neurologic deficits and seizures, and progression may lead to a stupor and coma. This is a very serious disease with poor prognosis and includes neurologic sequelae commonly including hemiparesis and seizures.

The organisms that cause these infections are not unlike any other bacteria that cause acute sinusitis, with the most common being Strep pneumoniae, Hemophilus influenza and Branhamella catarrhalis in children along with Strep pneumoniae, Staph aureus and mixed cultures including anaerobic organisms such as Bacteroides spp. in adults. It is important to remember that 33% to 50% of these cultures grow no organism, presumably due to treatment with antibiotics prior to the culture.

As in any condition, the history and physical examination is the cornerstone of the diagnosis, with emphasis on the ophthalmologic and neurologic examinations to document decrease in visual acuity, limitation of extraocular movement, and cranial nerve deficits, if present. Radiologic studies that can be performed include plain radiographs, which are very nonspecific but can show the presence or absence of air fluid levels in the sinuses, opacification of different sinuses and bony destruction. CT scan is the radiologic procedure of choice when diagnosing these infections. CT provides detailed information of bone and soft tissue with images being able to be obtained in the axial and coronal planes. MRI does provide superior soft tissue resolution and tissue characterization when compared to CT scans and it is the method of choice in evaluation of soft tissue masses and complicated inflammatory diseases of sinuses, especially when there is a question of extension of the infection intracranially or intraorbitally. Recently, orbital ultrasound has been gaining popularity in the diagnosis and in following the progression of intraorbital infection. This is a very inexpensive study, which in most cases can be performed at the bedside if needed. Orbital ultrasound can demonstrate different parts of the globe including periorbital fat, extraocular muscles, optic nerve and space occupying lesions. Orbital ultrasound can usually differentiate between orbital abscess and orbital cellulitis if it is in question on the CT scan.

The mainstay of management in patients with any complicated sinusitis is antibiotics. The patient should be placed on antibiotics as soon as complicated sinusitis is suspected or diagnosed. If the patient only has simple inflammatory edema of the eyelids or preseptal cellulitis, oral antibiotics usually suffice. Amoxicillin is usually a good choice. For any other complication, the patient should be placed on broad-spectrum intravenous antibiotics with a good cocktail being a third generation cephalosporin and metronidazole or clindamycin to cover anaerobic organisms and a penicillin or vancomycin to cover gram positives. If the cultures do grow a specific organism, then the antibiotic should be tailored appropriately. The duration of treatment with antibiotics varies with most patients being treated between two and six weeks with IV antibiotics followed by oral antibiotics to complete three to six weeks of coverage. Topical nasal vasoconstrictors should be started as well. When intracranial complications are diagnosed, anti-convulsive therapy is usually started prophylactically. It is controversial if anticoagulation should be used for dural sinus thrombophlebitis. There are strong arguments for both cases.

Indications for surgery include progression of the disease over 24 hours or the lack of resolution over 48 to 72 hours. Any decrease in visual acuity or extraocular mobility should probably be managed surgically. Demonstration of an abscess on CT scan, either subperiosteal, orbital, or intracranial, should be drained.

Specific techniques regarding surgery of the sinuses and the orbit are essentially divided into two schools of thought, with literature supporting both. Some physicians advocate using endoscopic techniques to drain the affected sinuses. Orbital complications have been tackled with these techniques as well, with some studies showing that virtually any abscess in the orbit, subperiosteal or orbital, can be reached by endoscopic means except for those in the lateral orbit. However, there are still those that advocate traditional techniques using external ethmoidectomy through a Lynch incision to drain a subperiosteal orbital abscess along with eradication of the ethmoid cells. Also still commonly performed today is the frontal sinus trephination to irrigate and open up the frontal sinus if this can’t be reached endoscopically. Along with trephination of the frontal sinus some authors have advocated leaving a catheter in place for repeated irrigations. This can also be done with the maxillary sinus if that is the sinus implicated.

When intracranial complications are diagnosed, a neurosurgical consult should be obtained. There is considerable debate in the literature about how these intracranial complications should be managed. The argument between burr holes versus a craniotomy for evacuation of sub-dural abscesses has been fairly well resolved in favor of a craniotomy. Some studies advocate CT guided drainage for intracerebral abscesses, however some authors advocate performing a craniotomy with aspiration and drainage of the abscess versus local excision the abscess.

In summary, orbital and intracranial complications of sinusitis have significantly decreased since the advent of antibiotics. However, they do still occur occasionally and a physician should have a heightened awareness of the patient with complicated sinusitis. The pathogenesis is related to the anatomy and the physiology of the sinuses and their surrounding structures. The diagnosis is made by history and physical exam, CT and MRI, as well as orbital ultrasound when indicated. The management of these patients involves a combination of medical and surgical therapy including antibiotics and drainage of the affected sinuses in conjunction with drainage of the orbital cavity by either endoscopic or traditional means. Neurosurgical consultation should be obtained to assist in the management of intracranial complications.

Case Presentation

J.G. is a 13-year-old Hispanic male, with no significant past medical history, who was transferred to Ben Taub General Hospital pediatric service from LBJ Hospital. He originally admitted with a four-day history of headache, vomiting, and fever to 103 degrees. The patient reported headache off and on for eight months across forehead, which was now increased in intensity. He also reported progressive right eyelid swelling and tenderness.

On presentation, the patient was febrile to 101.8 degrees, and physical examination was significant for right periorbital edema and erythema. There was no proptosis, chemosis, or restricted extraocular movements. Visual acuity was normal. Nasal examination revealed inflamed appearing nasal mucosa with minimal mucopurulent secretions. Neurological examination was normal. The remainder of the physical examination was unremarkable.

Significant laboratory evaluation revealed WBC 13, ESR 78 with the remainder of the laboratory examination normal. A CT scan of the head was obtained which revealed bilateral opacification of multiple ethmoid cells with complete opacification of the left maxillary sinus and left frontal sinus. Right preseptal cellulitis and left epidural abscess were noted as well. The patient was placed on cefotaxime, metronidazole and vancomycin, and otolaryngology was consulted along with ophthalmology and neurosurgery. After confirmation of history and physical exam findings and review of radiological examinations, the patient was taken to the operating room where endoscopic sinus surgery including bilateral maxillary antrostomies, anterior and posterior ethmoidectomies and left frontal sinusotomy were performed by otolaryngology service along with left frontal craniotomy with evacuation of epidural abscess by neurosurgical service. Cultures taken in the operating room remained negative.

The patient recovered uneventfully and remained on intravenous antibiotics for a total of 42 days followed by two weeks of oral clarithromycin. The patient was also placed on nasal saline spray, and flunisolide spray upon discharge. Follow up CT scan revealed no evidence of residual disease in sinuses, orbit or cranium, and the patient continues to do well.

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