Complication of Sinus Disease

7/28/2019 Complication of Sinus Disease

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Complications of Sinusitis

Incidence has decreased with antibiotic useThree main categories

Orbital (60-75%)Intracranial (15-20%)Bony (5-10%)

RadiographyComputed tomography (CT) best for orbitMagnetic resonance imaging (MRI) best for intracranium

Siedek et al, 2010


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Orbital ComplicationsChandler Criteria

Five classificationsPreseptal cellulitisOrbital cellulitisSubperiosteal abscessOrbital abscessCavernous sinus thrombosis

Not exclusive, can occur concurrently

Bailey, et al . 2006.


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Orbital ComplicationsPreseptal Cellulitis

SymptomatologyEyelid edema and erythemaExtraocular movement intactNormal visionMay have eyelid abscess

CT reveals diffuse thickening of lid andconjunctiva

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Orbital ComplicationsPreseptal Cellulitis

Medical therapy typically sufficientIntravenous antibioticsHead of bed elevationWarm compresses

Facilitate sinus drainageNasal decongestantsMucolytics

Saline irrigations

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Orbital ComplicationsOrbital Cellulitis

SymptomatologyPost-septal infectionEyelid edema and erythemaProptosis and chemosisLimited or no extraocular movement limitationNo visual impairmentNo discrete abscess

Low-attenuation adjacent to laminapapyracea on CT

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NOTES: Patients may complain of pain anddiplopia and a history of recent orbital traumaor dental surgery.:


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Orbital ComplicationsOrbital Cellulitis

Facilitate sinus drainageNasal decongestantsMucolyticsSaline irrigations

Medical therapy typically sufficientIntravenous antibioticsHead of bed elevation

Warm compresses

May need surgical drainageVisual acuity 20/60 or worseNo improvement or progression

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Orbital ComplicationsSubperiosteal Abscess

SymptomatologyPus formation between periorbita and lamina papyraceaDisplace orbital contents downward and laterallyProptosis, chemosis, ophthalmoplegiaRisk for residual visual sequelaeMay rupture through septum and present in eyelids

Rim-enhancing hypodensity with mass effect Adjacent to lamina papyraceaSuperior location with frontal

sinusitis etiologyDiagnostically accurate 86-91 %

Ramadan et al, 2009

NOTES: Patients will complain of diplopia,ophthalmoplegia, exophthalmos, or reduced visualacuity. The patient has limited ocular motility or painon globe movement toward the abscess.; may have

normal movement early on. Orbital signs includeproptosis, chemosis, and visual impairment.


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Orbital ComplicationsSubperiosteal Abscess

Surgical drainageWorsening visual acuity or extraocular movement

Lack of improvement after 48 hours

May be treated medically in 50-67%Meta-analysis cure rate 26-93% (Coenraad 2009)Combined treatment 95-100%


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Orbital ComplicationsOrbital Abscess

SymptomatologyPus formation within orbital tissuesSevere exophthalmos and chemosisOphthalmoplegiaVisual impairmentRisk for irreversible blindnessCan spontaneously drain through eyelid

Drain abscess and sinuses

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Lafferty KA. Orbital infections. eMedicine , 22 Sep 2009.


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Orbital ComplicationsOrbital Abscess

Incise periorbita and drain intraconal abscessSimilar approaches as with subperiostealabscess

Lynch incisionEndoscopic

NOTES:Transcaruncular approach allegedly does not utilize a facial incision.


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Orbital ComplicationsCavernous Sinus Thrombosis

SymptomatologyOrbital painProptosis and chemosis

OphthalmoplegiaSymptoms in contralateral eye

Associated with sepsis and meningismus

RadiologyPoor venous enhancement on CT

Better visualized on MRI

Contralateral involvement is distinguishing feature of cavernoussinus thrombosis

MRI findings of heterogeneity and increased size suggest thediagnosis


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Orbital ComplicationsCavernous Sinus Thrombosis

Mortality rate up to 30%Surgical drainage

Intravenous antibioticsHigh-doseCross blood-brain barrier

Anticoagulant use iscontroversial

Prevent thrombus propagationRisk intracranial or intraorbitalbleeding

Agayev A, Yilmaz S. Cavernous sinus thrombosis.N Engl J Med 2008; 359:2266.

MRI better especially if suspecting intracranial involvement, too.


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Complications of SinusitisIntracranial

Occurs more commonly in CRSMucosal scarring, polypoid changesHidden infectious foci with poor antibiotic penetration

Male teenagers affected more than childrenDirect extension

Sinus wall erosionTraumatic fracture linesNeurovascular foramina (optic and olfactory nerves)

Hematogenous spreadDiploic skull veinsEthmoid bone

NOTES: Teenagers affected more because of developed frontal and sphenoid sinuses, andbecause they are more prone to URIs than adults.

Thrombophlebitis originating in the mucosal veins progressively involves the emissary veins of the skull, the dural venous sinuses, the subdural veins, and, finally, the cerebral veins. By thismode, the subdural space may be selectively infected without contamination of the intermediarystructure; a subdural empyema can exist without evidence of extradural infection or osteomyelitis.


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Intracranial ComplicationsTypes

Seizure (31%)Hemiparesis (23%)Visual disturbance (23%)Meningismus (23%)

Five types (not exclusive)MeningitisEpidural abscessSubdural abscessIntracerebral abscessCavernous sinus, venous sinus thrombosis

Common signs and symptomsFever (92%)Headache (85%)Nausea, vomiting (62%)

Altered consciousness (31%)NOTES: Not exclusive, can occur concurrently. Percentages in children (Hicks et al , 2011)


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Intracranial ComplicationsMeningitis

Most common intracranial complication of sinusitisSymptomatology

Headache

MeningismusFever, septicCranial nerve palsies

Sinusitis is unusual cause of meningitisSphenoiditis

EthmoiditisUsually amenable with medical treatmentDrain sinuses if no improvement after 48 hoursHearing loss and seizure sequelae

NOTES: Also incidence of neurologic sequelae such as hearing loss and seizure disorder.


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Intracranial ComplicationsEpidural Abscess

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PapilledemaHemiparesisSeizure (4-63%)

Second-most common intracranial complicationGenerally a complication of frontal sinusitis

SymptomatologyFever (>50%)Headache (50-73%)Nausea, vomiting

Crescent-shaped hypodensity on CT


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Intracranial ComplicationsEpidural Abscess

Lumbar puncture contraindicatedProphylactic seizure therapy not necessary

Antibiotics Good intracerebral penetrationTypically for 4-8 weeks

Drain sinuses and abscessFrontal sinus trephinationFrontal sinus cranializationStereotactic-guided drainage

NOTES: Will likely need antibiotics for 4-8 weeks;usually vancomycin and 3 rd or 4 th generationcephalosporin

Prophylactic seizure therapy not necessary unless

theres an associated subdural abscess.


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Intracranial ComplicationsSubdural Abscess

Generally from frontal or ethmoid sinusitisSymptomatology

HeadachesFever Nausea, vomitingHemiparesisLethargy, coma

Third-most common intracranialcomplication, rapid deterioration

Mortality in 25-35%Residual neurologic sequelae in 35-55%

Accompanies 10% of epidural abscesses


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Intracranial ComplicationsSubdural Abscess

Lumbar puncture potentially fatal Aggressive medical therapy

Antibiotics

AnticonvulsantsHyperventilation, mannitolSteroids

Drain sinuses and abscessMedical therapy possible if < 1.5cm

Craniotomy or stereotactic burr holeEndoscopic or external sinus drainage

NOTES:Need antibiotics with good intracerebral penetration, typically 3-6 weeks

Craniotomy is favored over burr hole placement due to better exposure


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Intracranial ComplicationsIntracerebral Abscess

Uncommon, frontal and frontoparietal lobesGenerally from frontal sinusitis

Sphenoid

EthmoidsSymptomatology

Headache (70%)Mental statuschange (65%)

Focal neurologicaldeficit (65%)Fever (50%)

Mortality 20-30%Neurologic sequelae 60%

Nausea, vomiting(40%)

Seizure (25-35%)Meningismus (25%)Papilledema (25%)

NOTES: May have mood swingsand behavioral changes withfrontal lobe involvement

Worsening headache with

meningismus suggests possiblerupture of the abscess.


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Intracranial ComplicationsIntracerebral Abscess

Lumbar puncture potentially fatal Aggressive medical therapy

Antibiotics AnticonvulsantsHyperventilation, mannitolSteroids

Drain sinuses and abscessMedical therapy possible if abscess < 2.5cmExcision or aspiration

Diagnostic aspiration if < 2.5cm or cerebritisStereotactic-guided aspiration

Endoscopic or external sinus drainageNOTES: Antibiotic regimen is typically 6-8 weeks; typically ceftriaxone, vancomycin or nafcillin, and metronidazole

Corticosteroid use is controversial. Steroids can retard the encapsulation process, increase necrosis, reduce antibiotic penetration into theabscess, increase the risk of ventricular rupture, and alter the appearance on CT scans. Steroid therapy can also produce a rebound effectwhen discontinued. If used to reduce cerebral edema, therapy should be of short duration. The appropriate dosage, the proper timing, andany effect of steroid therapy on the course of the disease are unknown. The procedures used are aspiration through a bur hole and completeexcision after craniotomy. Aspiration is the most common procedure and is often performed using a stereotactic procedure with the guidanceof CT scanning or MRI.


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Intracranial ComplicationsVenous Sinus Thrombosis

Sagittal sinus most commonRetrograde thrombophlebitis fromfrontal sinusitisExtremely ill

Subdural abscessEpidural abscessIntracerebral abscess

Decreased cavernous carotidartery flow void on MRIElevated mortality rate


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Intracranial ComplicationsVenous Sinus Thrombosis

Aggressive medical therapy AntibioticsSteroids

Anticonvulsants

Anticoagulation controversialHeparin inpatient, warfarin outpatientThrombus resolution by 6 weeks

(Gallagher 1998)Increased intracranial pressureoutweighs bleeding risk (Gallagher 1998)

Drain sinusesExternalEndoscopic


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Complication of Sinus Disease

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