Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Complications of Sinusitis Orbital complications Sinonasal disease accounts for the majority of orbital infections (up to 85%). Ethmoid sinuses are almost always implicated in orbital disease; maxillary and frontal sinuses may also be involved. Spread may be direct with erosion of the lamina or through a prior fracture or by thrombophlebitic spread into the orbit. Orbital complications as staged by Chandler (1970) are: preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis (dural thrombophlebitis). Preseptal cellulitis is an inflammation and infection of the eyelids, outside the orbital septum. Orbital cellulitis is a diffuse infiltration of bacteria and inflammatory cells in the orbit. A subperiosteal abscess is a collection of pus between the periorbita and the bony orbit walls. Orbital abscess refers to a discrete collection of pus within the orbital tissues; systemic symptoms are common and orbital apex syndrome may occur. Cavernous sinus thrombosis is a late stage and highly morbid disease. Infection is spread posteriorly through the venous channels; patients have proptosis, ophthalmoplegia, decreased visual acuity, paplliedema, dilated pupil, mental status decline, and superior orbital fissure syndrome; bilateral symptoms herald this entity. Symptoms of orbital disease include: erythema or edema of the eyelids (common to all orbital infections), proptosis and ophthalmoplegia (suggestive of orbital cellulitis or orbital or subperiosteal abscess), decreased visual acuity (associated with advanced infection.) Evaluation should include a thorough ophthalmologic examination and thin cut CT with contrast of the orbits and paranasal sinuses. The offending organisms include: Strep pneumo and microaerophilic Strep (#1 in adults), H.flu (#1 in children), S. aureus, S. epidermidis, gram negative organisms and anaerobes; in adults, the infection is usually mixed. Empirically B-lactamase resistant antibiotics are indicated. Then treat as cultures direct. In the treatment of sinusitis, local and systemic decongestion play an important role. Surgical intervention is frequently required and should be considered as indicated. Frank abscesses should be evacuated urgently. Small subperiosteal abscesses with normal vision, normal EOMI, mild proptosis may be treated conservatively with IV antibiotics. All patients with orbital complications managed medically should be closely observed with frequent visual checks. Patients who experience a decrease in visual acuity, worsening extraocular muscle function or failure to improve in 48-72 hours should undergo surgical sinus drainage. Intracranial complications Intracranial (CNS) complications, namely, meningitis, subdural empyema, epidural abscess and cerebral abscess may all complicate acute and chronic sinusitis. The ethmoids, frontal, and sphenoid sinusitis primarily responsible. Infection is spread via thrombophlebitis or less commonly via direct extension of infection. Common symptoms of increased intracranial pressure (ICP) (headache, altered mental status, fever, vomiting, and stiff neck) as well as systemic toxicity usually occur. However, the infection may be "silent" in the frontal lobes with only subtle personality changes until late in the process. High morbidity and mortality despite antibiotics and aggressive treatment still exist. The offending organisms are the same ones implicated in sinusitis (Strep, Staph, anaerobes and GNR). Streptococcal species are most commonly responsible for CNS complications. Exceptions include cerebral abscess and epidural abscess near a focus of osteomyelitis when Staph is more common. The treatment for each of these complications is similar. A CT scan to evaluate for other CNS complications and cerebral midline shift or mass effect is necessary. In cases of meningitis, this is followed by lumbar puncture and culture if safe. High dose IV antibiotics with CSF penetration are begun. Neurosurgical consultation is strongly recommended, even in cases that are not clearly immediately surgical. Management of ICP and seizure prevention are necessary. Meningitis is probably best treated by medical management initially, after meningitis is controlled and if it is believed to be due to sinusitis, the offending sinuses can be opened and drained. If the meningitis cannot be controlled, then more emergent sinus drainage may be required. In general, for the other CNS complications it is necessary to provide drainage of the offending sinus; this may be performed at the same time as any drainage of intracranial abscesses if that is being undertaken. In some cases of epidural abscess, frontal trephination and removal of the posterior sinus wall to drain the purulent collection may be sufficient ,but others will require a craniotomy. Later, in most cases the frontal sinus should be definitively addressed, usually by cranialization or obliteration. A subdural empyema should be addressed by a neurosurgical approach for drainage of the subdural collection and by an otolaryngologic approach to surgically address sinuses. Cerebral abscess may be treated by high dose antibiotics and drainage of offending sinus; some cerebral abscess may resolve with this regimen, others will require CT guided or surgical drainage. Mortality is still 20%-40% with death resulting from rupture of abscess into a ventricle or mass effect with brain stem compression or herniation. Bony complications Osteomyelitis (and osteitis) are usually related to acute frontal sinusitis and may be associated subperiosteal abscess, the "Pott's puffy tumor" first described by Sir Percival Pott (1760.) Presentation is that of brawny edema of the brow with soft doughy swelling; usually there is forehead pain, low grade fever and leukocytosis. The spread of infection from the sinus is either by the hematogenous route (retrograde thrombophlebitis) or direct (via erosion or through existing fractures or dehiscences.) CT scan can delineate the extent of disease and evaluate for other CNS complications. Staph is implicated in the majority of cases, also seen are Strep pneumo, B-hemolytic strep, anaerobes in a few cases. Long term IV antibiotics, as in other cases of osteomyelitis, is required. Empirically nafcillin is used, followed by culture specific antibiotics when cultures available. Drainage of sinus as in the other types of complicated sinusitis is necessary, usually via trephination or frontoethmoidectomy; ESS can be used by experienced surgeons, but it may be difficult and success is less reliable. Patients may require debridement of infected bone if fails to respond to antibiotics. After osteomyelitis is controlled, more definitive surgical treatment of the frontal sinuses is considered. If there is any question of chronic or persistent frontal sinusitis then a bilateral osteoplastic flap sinus obliteration with fat graft should be undertaken. Radionucleotide scanning can be used to follow the resolution of disease, similar to other cases of osteomyelitis and malignant otitis externa.
Case Presentation A 45-year-old white male presented to Ophthalmology service with right orbital swelling and pain. He had a temperature of 99° and reported a several day history of sinus congestion and rhinorrhea. The patient had a long history of heavy alcohol use and previous blunt trauma and a frontal sinus fracture was suspected. On exam he had significant periorbital erythema and edema, as well as a fluctuant mass in the R upper eyelid. The vision was 20/20. The WBC = 14.9. The patient was placed on Nafcillin and Fortax. A CT scan revealed a R preseptal (upper eyelid) abscess and pansinusitis. The eyelid abscess was drained by the Ophthalmology service. Three days following admission the Otolaryngology service was consulted for evaluation. At this time he had significant improvement in the periorbital edema and a follow-up CT showed no progression of disease and no intracranial involvement. Local and systemic decongestants were added to his regime and broad spectrum antibiotics were continued. The abscess cultures grew anaerobic strep and B-hemolytic Strep. Culture specific antibiotics were given for a total of 6 weeks. The patient underwent frontal sinus obliteration from which he had an uneventful recovery. Intraoperatively the sinus floor was found to have a linear dehiscent area consistent with prior fracture. On follow-up he has been doing well.
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