Complications of Rhinosinusitis Dr Mohammad Aloulah Assistant Professor

Complications of Rhinosinusitis Dr. Mohammad Aloulah Assistant Professor King Abdulaziz Univerity hospital

Objectives l Describe the orbital, intracranial, and bony complications of rhinosinusitis. l Define risk factors, routes of extension, and typical findings in patients with complicated rhinosinusitis. l Detail the classification systems used to categorize orbital and intracranial complications. l Identify the indications for surgical intervention.

Rhinosinusitis Inflammation of the mucosal lining of the nose and paranasal sinuses. Acute, subacute, and chronic. One of the most common diseases in the US. l 20 million cases of acute bacterial rhinosinusitis are diagnosed annually. l 30 million people suffer from chronic rhinosinusitis. [1] The cost is substantial and increasing: l Acute $3. 5 billion/yr. l Chronic $4. 3 billion/yr. [1]

Complications l l l Complications of rhinosinusitis range from relatively benign to potentially fatal. The incidence of complications from both acute and chronic rhinosinusitis has decreased as a result of the use of antibiotics. Complications can be divided into three categories: Orbital, intracranial, and bony.

Extracranial • • • Orbital Infections- Orbital cellulitis, or Subperiosteal abscess Hyperostosis & osteitis Mucoceles Osteomyelitis- Pott’s Puffy Tumor Middle Ear cleft Infections Intracranial • • Meningitis Epidural/Subdural empyema Brain Abscess Dural Venous Sinus Thrombosis–cavernous /superior sagittal Pulmonary Infections Sepsis

CT or MRI? Computed tomography l l Establish technique for evaluating patients with sinusitis. Excellent anatomic resolution of bony areas. Magnetic resonance imaging l It has a superior delineation of soft tissue. l It may demonstrate infections without bony artifacts and brain pathology.

Orbital complications l The orbit is the structure most commonly involved in complicated sinusitis. l Orbital extension is usually the result of ethmoid sinusitis. l Children are more prone to orbital complications, probably secondary to high incidence of URI and sinusitis.

Anatomic factors l l Thin lamina papyracea. Congenital, surgical, or traumatic dehiscences in the medial and superior walls. Anterior & posterior ethmoid neurovascular foramina. Valveless veins (nose, paranasal sinuses, pterygoid plexus, and orbit).

Chandler´s classification I. Inflammatory edema (preseptal) Lid edema, no limitation in ocular movement or visual change. II. Orbital cellulitis (postseptal) Diffuse orbital infection and inflammation without abscess formation. III. Subperiosteal abscess Collection of pus between medial periosteum and lamina papyracea, impaired extraocular movement. IV. Orbital abscess Discrete pus collection in orbital tissues, proptosis and chemosis with ophthalmoplegia and decreased vision. V. Cavernous sinus thrombosis Bilateral eye findings and worsening of all other previously described findings.

Orbital Compartments n n Optic globe and septum divides the orbit into anterior and posterior compartments Localizing orbital disease to compartment helps generate a differential diagnosis.

Orbital Complications Of Sinusitis Classification 1. 2. 3. 4. 5. Periorbital (Pre-Septal) cellulitis Orbital (Post-Septal) cellulitis Subperiosteal Abscess Orbital abscess Cavernous Sinus Thrombophlebitis

I. Inflammatory edema (preseptal cellulitis) l Infection limited to the skin and subcutaneous tissues of the eyelid, anterior to the orbital septum. l Most common and least severe complication. l Represents 70% of all orbital complications of sinusitis.

Diagnosis l Eyelid swelling, erythema, and tenderness. l Visual acuity, pupillary reaction, extraocular motility, and intraocular pressure are normal l CT is usually unnecessary, but, if done, would reveal diffuse increased density and thickening of the lid and conjunctiva. l CT is mandatory when intracranial complications are suspected or when there is progress in 24 to 48 hours to postseptal inflammation despite therapy. [3]

Treatment l Broad spectrum oral antibiotics, head elevation, and management of the underlying cause (nasal decongestant, mucolytics, and saline irrigations). l Intravenous antibiotics were standard care in children before the introduction of the Hib vaccine in 1985 l Older children and adults with mild cellulitis, outpatient amoxicillin/clavulanic acid or first-generation cephalosporin. Reevaluate in 24 -48 hours. l Younger children or more severe cases, admission for observation and IV antibiotics is standard (2 nd or 3 rd generation cephalosporin), then bridge to oral antibiotics for 10 days.

II. Orbital cellulitis l Infectious process within the orbit proper, behind the septum, and within the bony walls of the orbit. l Orbital contents show diffuse edema with inflammatory cells and fluid, without distinct abscess formation.

Diagnosis l Eyelid edema, mild proptosis, chemosis, and orbital pain. l In severe cases motility may be limited; but visual acuity is not impaired. l Ophthalmologic consultation should be obtained. l CT with contrast is indicated, and it will show enhancement of edematous fat, which is usually maximal in the extraconal fat adjacent to the affected sinus. l Enlargement and enhancement of adjacent rectus muscle is sometimes present.

Treatment l Admission for daily assessments of visual acuity and color vision, pupillary reactions, and extraocular motility. (Ophthalmologist) l Early intravenous antibiotics and imaging. l Antibiotic failure is indicated by: l Progression of vision loss or clinical deterioration after 48 hours of therapy. l Failure to improve or persistent fever after 72 hours of therapy.

Surgical drainage is recommended: 1. CT evidence of abscess formation. 2. Visual acuity of 20/60 (or worse) on initial evaluation. 3. Severe orbital complications (e. g. blindness or an afferent pupillary reflex) on initial evaluation. 4. Progression of sign and symptoms despite therapy. 5. Lack of improvement within 48 hours despite therapy. * Surgical treatment should include adequate drainage of the infected sinuses.

III. Subperiosteal abscess (SPA) l Most commonly located in the superomedial or inferomedial orbit in conjunction with ethmoid sinusitis. l Infection breaks through the lamina papyracea or travels through the anterior or posterior ethmoidal foramina. l May lead to blindness by direct optic nerve compression, elevation of intraorbital pressure, or proptosis causing a stretch optic neuropathy.

Diagnosis l Ophthalmologic evaluation is essential. l Clinically, SPA is suspected in a patient with orbital cellulitis that has worsening proptosis and gaze restriction. l Color discrimination is better guide of progression since red/green perception is loss before deterioration of visual acuity. l Contrast CT will show a contrast-enhancing mass in the extraconal space. There is marked proptosis with a conic deformity of the globe. l The medium rectus can be displaced (2 mm).

Treatment l Controversy exists (surgical vs. medical), especially in children. l Several studies have suggested that responsiveness to medical treatment is age associated. l l Absence of frontal sinusitis. l Medial location with absence of gas in the abscess cavity. l Small abscess volume. l Nonrecurrent SPA. l Absence of acute optic nerve or retinal compromise. l l Age < 9 yr. Nonodontogenic infection Surgical therapy was reserved for clinical deterioration or no improvement with medical therapy.

Oxford and Mc. Clay l l Older children with SPA managed successfully with medical therapy. The ages of the 18 patients treated medically were not statistically different from the 25 patients treated surgically. l l l Normal vision, pupil, and retina. No ophthalmoplegia. Intraocular pressure of less than 20 mm Hg. Proptosis of 5 mm or less. Abscess width of 4 mm or less.

Surgical approaches External ethmoidectomy: l Lynch incision. l Elevation of periosteum. l Lacrimal bone and lamina papyracea are removed. l Ethemoidectomy. Disadvantages: l Communication between nasal cavity and orbit. l Only useful for medially located abscesses. l Unpleasant scar, facial dysplasia. Chen, W (2001). Oculoplastic surgery: the essentials. New York: Thieme Medical Publishers, Inc. 423.

Endoscopic approach l Widely accepted as an alternative to open approaches. l Ethmoidectomy. l Increased bleeding of acute inflamed mucosa. l Skeletonizing the lamina papyracea. l Facial growth: l Drainage of the orbital collection by cracking the lamina with Cottle or Freer. l The periorbita is not violated. l Conservative surgical resection is advocated.

Combined approaches l l Lemoyne puncture trephination. Sinus is irrigated, and endoscopically the nasofrontal duct is identify. Sinusotomy and ethmoidectomy External incision used to drain SPO.

Transcaruncular approach Bailey, BJ (2006). Head & Neck Surgery - Otolaryngology. 4 th ed. Philadelphia: Lippincott Williams & Wilkins. 499.

IV. Orbital abscess l Progression to this state often represents delay in diagnosis and therapy or immunocompromised state. l May be inside or outside the muscle cone (discrete collection of pus). http: //emedicine. medscape. com/article/784888 -media

Diagnosis l Marked proptosis, chemosis, complete ophthalmoplegia, visual impairment with risk for progression to irreversible blindness. l CT will show diffuse infiltration of the intraconal and extraconal fat with areas of cavitation. l MRI (true necrosis) hypointensity on T 1 and hyperintensity on T 2.

Treatment l l Drainage is mandatory Endoscopic preferred over external. Decompression of one or more orbital walls may be necessary (intraoperative orbital pressure). Periorbita: l l Endoscopic – extraconal. Combined – intraconal.

V. Cavernous sinus thrombosis (CST) l Results from spread of infection from sinuses or middle third of the face. l Freely anastomosing, valveless venous system (superior and inferior ophthalmic veins). l S. aureus is most common pathogen. l High morbidity/mortality. Cannon ML, Anonio BL, Mc. Closkey JJ, et al. Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med 2004; 5(1): 86 -8.

Diagnosis l l l l Bilateral orbital involvement. Rapidly progressive chemosis and ophthalmoplegia. Retinal engorgement. Prostration and fever. MRI more sensitive than CT (MR venogram). Carotid thrombosis (strokes, brain abscess, meningitis) Pulmonary septic emboli. Cannon ML, Anonio BL, Mc. Closkey JJ, et al. Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med 2004; 5(1): 86 -8. Ebright JR, Pace MT, Niazi AF. Septic thrombosis of the cavernous sinuses. Arch Intern Med 2001; 161: 2671 -2676.

Treatment l High-dose IV antibiotics that cross BBB. l Nafcillin. l Ceftriaxone. l Metronidazole. l Vancomycin. * 3 – 4 weeks; 6 – 8 weeks if intracranial complications. l Selective surgery – drainage of affected sinuses is advisable.

Anticoagulation l The role of anticoagulation to minimize progression of thrombosis is debatable. l Its efficacy is undetermined, since no prospective trials have been performed. l It may aggravate intracranial hemorrhagic sequelae of CST. l Retrospective reviews show that: l Hemorrhage caused by anticoagulation is rare. l Early anticoagulation is beneficial if commenced after excluding the hemorrhagic sequelae radiologically.

Steroids l Many current reviewers don’t recommend their use. * Is this recommendation valid? l Dramatic response on orbital inflammation and optic nerve dysfunction that were resistant to antibiotics in response to steroids.

Intracranial complications l l IC complications are uncommon but devastating. Two major mechanism: l l Direct extension. Retrograde thrombophlebitis via valveless diploe veins. * Frontal sinus is rich in diploe veins especially during adolescence. Meningitis Sphenoid, ethmoid. Epidural abscess Frontal. Subdural abscess Frontal. Intracerebral abscess Frontal. Cavernous sinus thrombosis Sphenoid, ethmoid. Superior sagittal sinus thrombosis Frontal.

Cranial & Intracranial complications of sinusitis A. Osteomyelitis B. Pericranial or Periorbital Abscess C. Epidural Abscess D. Subdural Empyema E. Brain Abscess F. Meningitis G. Superior Sagittal Sinus Thrombosis n n 3. 7% of patients admitted with sinusitis More common in adolescent boys due to a peak in the vascularity of the diploic venous system of this age group

Meningitis l l l Neurologic sequelae are common (seizures, hearing loss). The most common pathogen is S. pneumoniae. Mental status changes, photophobia, and meningismus. CT will be normal, but MRI typically shows dural enhancement (falx cerebri, tentorium, and dural convexities). IV antibiotics and endoscopic sinus surgery. l l If no improvement after 24 – 48 hours of antibiotics. Early use of ESS has the potential to accelerate clinical improvement.

Intracranial abscess Epidural * Subdural Intracranial Between skull and dura Subdural space no boundaries Frontal/frontopariental white/gray matter Slow expanding Spreads diffusely convexities, interhemispheric Asymptomatic phase while it coalesces Mild, non-specific for weeks. Increase ICP Meningismus, rapid progression to coma Subtle if frontal (mood) H/A, lethargy, seizures, focal deficits Diagnosis CT or MRI CT may show it but MRI is better MRI (T 2) Hypointense with capsule Treatment IV Abx. + Surgery (craniotomy / ESS) IV Abx. , craniotomy, ESS, anticonvulsivants, +/- steroids ESS / Neurosurgery (stereotactic vs. open) Location Progression Symptoms

Venous sinus thrombosis (superior sagittal and cavernous) l l l Retrograde thrombophlebitis. Sagittal usually found in association with intracranial abscesses. Clinical severity depends on extent of the thrombosis (extremely ill, high spiking fevers, meningeal signs, coma). MRI focal defects of enhancement (MR angio or venogram). High dose IV abx. , ESS, anticoagulants, Surgery (thrombectomy, thrombolysis via burr-hole).

Bony complications l Osteomyelitis of the frontal bone is known as Pott’s puffy tumor. l Subperiosteal collection of pus produces a “puffy” fluctuant swelling. l Polymicrobial (Streptococcus sp. , Staphylococcus aureus, Bacteroides, and Proteus) l IV Abx. , drainage of the abscess with removal of infected bone. Frontal obliteration may be performed. Epstein VA, Kern RC. Invasive fungal sinusitis and complications of rhinosinusitis. Otolaryngol Clin N Am 2008; 41: 505.

Key Points l l l Acute sinusitis is a leading cause of orbital infection Orbital infections may be pre or post-septal CECT is the imaging of choice CT may not identify all orbital abscesses Not all orbital abscesses are medial MRI is a valuable modality for complex cases

Key Points l l l Orbital & intracranial sinus complications are due to the close proximity of these structures and the presence of valveless veins. The increased incidence of acute sinusitis complications in children mandates early treatment with antibiotics and close observation. Image-guided protocols for operative intervention.

Key Points l l Children with sinusitis and persistent headache, fever, nausea, vomiting, &/or any focal neurologic abnormality should be evaluated with CECT or CEMRI to exclude Intracranial Complications A team approach including otolaryngology, neurosurgery, intensive care, ophthalmology, infectious disease, & pediatrics.