Complication Of Sinusitis Flashcards
Complications are said to arise when infection spreads
spreads into or beyond the bony wall of the sinus
LOCAL COMPLICATIONS Sinusitis
- MUCOCELE OF PARANASAL SINUSES AND MUCOUS RETENTION CYSTS
- OSTEOMYELITIS
order of frequency sinuses commonly affected by mucocele
frontal, ethmoidal, maxillary and sphe- noidal
genesis of a mucocele
- Chronic obstruction to sinus ostium ➡️ accumulation of secretions which slowly expand the sinus and destroy its bony walls.
- obstruction of mucous gland duct ➡️Cystic dilatation of mucous gland of the sinus. In this case, wall of mucocele is surrounded by normal sinus mucosa. The contents of mucocele are sterile.
Mucocele of the frontal sinus usually presents in the
superomedial quadrant of the orbit (90%) and displaces the eyeball forward, downward and laterally.
swelling of Mucocele of the frontal sinus
- cystic and nontender; egg-shell crackling may be elicited
- Sometimes, it presents as a cystic swelling in the forehead (10%)
Patient’s complaints in Mucocele of the frontal sinus
headache, diplopia and proptosis
in Mucocele of the frontal sinus Imaging of the frontal sinus usually reveals
clouding of the sinus with loss of scal- loped outline which is so typical of the normal frontal sinus
Treatment for Mucocele of the frontal sinus
frontoethmoidectomy with free drainage of frontal sinus into the middle meatus.
Mucocele of ethmoid sinuses
- expansion of the medial wall of the orbit, displacing the eyeball forward and laterally.
- bulge in the middle meatus of nose.
A mucocele of the ethmoid can be drained by an
intranasal operation, uncapping the ethmoidal bulge and establishing free drainage. Sometimes, it may require external ethmoid operation.
Mucous retention cyst of the maxillary sinus
retention cyst due to obstruction of the duct of seromuci- nous gland and usually does not cause bone erosion
Clinical features of Mucous retention cyst of the maxillary sinus
asymptomatic
incidental finding on radiographs
treatment for Mucous retention cyst of the maxillary sinus
No treatment is generally required for asymp- tomatic retention cysts as most of them regress spontane- ously over a period of time.
Mucocele of the maxillary sinus
complica- tion of chronic sinus inflammation when its ostium is blocked. The sinus fills with mucus and its bony walls get expanded due to expansile process.
diagnostic tool for Mucocele of the maxillary sinus
CT scan and MRI
Mucocele of sphenoid sinus or sphenoethmoidal mucocele
arises from slow expansion and destruction of sphenoid and poste- rior ethmoid sinuses
Clinical features of Mucocele of sphenoid sinus
- superior orbital fissure syndrome
- orbital apex syndrome
- Exophthalmos
- headache in the occiput or vertex
Superior orbital fissure syndrome
involvement of CN III, IV, VI and ophthalmic division of V
orbital apex syndrome
superior orbital fissure syndrome with additional involve- ment of optic and maxillary division of trigeminal nerve.
Treatment for Mucocele of sphenoid sinus
external ethmoidec- tomy with sphenoidotomy
Anterior wall of the sphenoid sinus is removed, cyst wall uncapped and its fluid contents evacuated.
Pyocele
similar to mucocele but its contents are purulent. It can result from infection of a mucocele of any of the sinuses.
Osteomyelitis is infection of
bone marrow
osteitis is infection of
compact bone
Osteomyelitis, following sinus infection, involves
either the maxilla or the frontal bone.
Osteomyelitis of the maxilla is more often seen in which age group
infants and children than adults because of the pres- ence of spongy bone in the anterior wall of the maxilla.
Osteomyelitis of the maxilla the Infection may start in the
dental sac and then spread to the maxilla, but less often, it is primary infection of the maxillary sinus.
Clinical features of Osteomyelitis of the maxilla
erythema, swelling of cheek, oedema of lower lid, purulent nasal discharge and fever. Subperiosteal abscess followed by fistulae may form in infraorbital region , alveolus or palate, or in zygoma. Sequestration of bone may occur.
Treatment of Osteomyelitis of the maxilla
large doses of antibiotics, drainage of any abscess and removal of the sequestra
Complications of Osteomyelitis of maxilla
damage to tempo- rary or permanent tooth-buds, maldevelopment of maxilla, oroantral fistula, persistently draining sinus or epiphora.
Osteomyelitis of frontal bone is more often seen in
adults as frontal sinus is not developed in infants and children
Osteomyelitis of frontal bone results from
acute infection of frontal sinus either directly or through the venous spread
It can also follow trauma or surgery of frontal sinus in the presence of acute infec- tion
Pott’s puffy tumour
Pus form externally under the periosteum as soft doughy swelling
Treatment Osteomyelitis of frontal bone
- large doses of antibiotics, drainage of abscess and trephining of fron- tal sinus through its floor
- removal of sequestra and necrotic bone by raising a scalp flap through a coronal incision
ORBITAL COMPLICATIONS of SINUSITIS
- Inflammatory oedema of lids
- Subperiosteal abscess.
- Orbital cellulitis.
- Orbital abscess
- Superior orbital fissure syndrome
- Orbital apex syndrome
Orbit and its contents are closely related to
ethmoid, frontal and maxillary sinuses
Mc sinus causing orbital Complications of sinusitis
ethmoids as they are separated from the orbit only by a thin lamina of bone— lamina papyracea
Infection travels from these sinuses either by osteitis or as thrombophlebitic process of eth- moidal veins.
Inflammatory oedema of lids
only reactionary.
There is no erythema or tenderness of the lids which characterises lid abscess. It involves only preseptal space, i.e. lies in front of orbital septum. Eyeball movements and vision are normal. Generally, upper lid is swollen in frontal, lower lid in maxillary, and both upper and lower lids in ethmoid sinusitis.
Subperiosteal abscess
Pus collects outside the bone under the periosteum. A subperiosteal abscess from ethmoids forms on the medial wall of orbit and displaces the eyeball forward, downward and laterally; from the frontal sinus, abscess is situated just above and behind the medial canthus and displaces the eyeball downwards and laterally; from the maxillary sinus, abscess forms in the floor of the orbit and displaces the eyeball upwards and for wards.
Orbital cellulitis.
When pus breaks through the perios- teum and finds its way into the orbit, it spreads between the orbital fat, extraocular muscles, vessels and nerves. Clinical features will include oedema of lids, exophthal- mos, chemosis of conjunctiva and restricted movements of the eye ball. Vision is affected causing partial or total loss which is sometimes permanent. Patient may run high fever. Orbital cellulitis is potentially dangerous because of the risk of meningitis and cavernous sinus thrombos
Orbital abscess
Intraorbital abscess usually forms along lamina papyracea or the floor of frontal sinus. Clinical picture is similar to that of orbital cellulitis. Diagnosis can be easily made by CT scan or ultrasound of the orbit. Treatment is i.v. antibiotics and drainage of the abscess and that of the sinus (ethmoidectomy or trephination of frontal sinus).
Superior orbital fissure syndrome
Infection of sphenoid sinus can rarely affect structures of superior orbital fis- sure. Symptoms consist of deep orbital pain, frontal headache and progressive paralysis of CN VI, III and IV, in that order.
Orbital apex syndrome
It is superior orbital fissure syn- drome with additional involvement of the optic nerve and maxillary division of the trigeminal (V2)
INTRACRANIAL COMPLICATIONS
Of sinusitis
- Meningitis and encephalitis 2. Extradural abscess
- Subdural abscess
- Brain abscess
- Cavernous sinus thrombosis.
Infection of which sinus cause INTRACRANIAL COMPLICATIONS
Frontal, ethmoid and sphenoid sinuses are closely related to anterior cranial fossa
CAVERNOUS SINUS THROMBOSIS Aetiology
Infection of paranasal sinuses, particularly those of ethmoid and sphenoid and less commonly the frontal, and orbital complications from these sinus infections can cause thrombophlebitis of the cavernous sinus
The valveless nature of the veins connecting the cavernous sinus causes easy spread of infection.
Furuncle and septal abscess - source and route - cavernous sinus thrombosis
Nose and danger area of face
Pharyngeal plexus
Orbital cellulites or abscess source and route - cavernous sinus thrombosis
Ethmoid sinuses
Ophthalmic veins
Sinusitis source and route - cavernous sinus thrombosis
Sphenoid sinus
Direct
Sinusitis and osteomyelitis of frontal bone source and route - cavernous sinus thrombosis
Frontal sinus
Supraorbital and ophthalmic veins
Cellulitis and abscess of orbit route - cavernous sinus thrombosis
Ophthalmic veins
Abscess of upper lid route for - cavernous sinus thrombosis
Angular vein and ophthalmic veins
Acute tonsillitis or peritonsillar abscess source and route - cavernous sinus thrombosis
Pharynx
Pharyngeal plexus
Petrositis source and route - cavernous sinus thrombosis
Ear
Petrosal venous sinuses
Differences between orbital cellulitis and cavernous sinus thrombosis
Refer book
Clinical features of cavernous sinus thrombophle- bitis
- abrupt Onset of with chills and rigors
- Eyelids get swollen with chemosis and proptosis of eyebal
- Cranial nerves III, IV and VI which are related to the sinus get involved individually and sequentially causing total oph- thalmoplegia.
- Pupil becomes dilated and fixed, optic disc shows congestion and oedema with diminution of vision.
- Sensation in the distribution of V1 (ophthalmic division of CN V) is diminished.
CSF is usually———— cavernous sinus thrombophle- bitis
normal
DD for cavernous sinus thrombosis
orbital cellulitis
CT scan is useful for this.
Treatment of cavernous sinus thrombosis
i.v. antibiotics and attention to the focus of infection, drainage of infected ethmoid or sphenoid sinus. Blood culture should be taken before starting antibiotic therapy. Role of anticoagulants is not clear.
IV. DESCENDING INFECTIONS of Sinusitis
- Otitis media (acute or chronic).
- Pharyngitis and tonsillitis.
- Persistent laryngitis and tracheobronchitis
indicative of chronic sinusitis.
Hypertrophy of lateral lym-
phoid bands behind the posterior pillars (lateral phar- yngitis)
DESCENDING INFECTIONS Chronic sinusitis may also cause
recurrent tonsillitis or granular phar yngitis.
FOCAL INFECTIONS
polyarthritis, tenosy- novitis, fibrositis and certain skin diseases may respond to elimination of infection in the sinuses.
