SINUSITIS & ITS

COMPLICATIONS

Sami Alharethy

DEFINITIONS

• Acute – the persistence of upper respiratory symptoms for greater than a 7-day course but lasts less than 4 weeks.

• Subacute - nasal symptoms lasting 4 weeks to 12 weeks

• Chronic– persistence mucosal inflammation for > 12 consecutive weeks despite medical therapy or occurrence of more than 4 episodes a year

Rhinosinusitis

Acute

• Less then 3 months• S. Pneumo, H. Flu, M.

Catarrhalis• More severe symptoms• General stems from acute

viral infection

Chronic

• Greater than 3 months• S. Aureus,Anerobes• α-hemolytic strep, m.

catarrhalis• Milder symptoms• Additional symptoms

present: – chronic cough,

bronchitis, fatigue, malaise, and depression

Signs and Symptoms

• Day and night cough• Purulent nasal discharge• Nasal airway obstruction• Headache, irritability, or facial pain• Fever• Postnasal drip

AnatomyMaxillary Sinus

• Largest and first sinus to develop • Natural ostium drains into Middle M• First and second molar roots dehiscent

in 2%

AnatomyEthmoid Sinus

• First seen at 5 months gestation• Adult size by 12-15 years• Between 10-15 cells• Drainage

– Anterior cells via Middle meatus– Posterior cells via Superior M

AnatomyFrontal Sinus

• Not present at birth– Starts developing at 4 years

• Development not complete until 12-20 years

• Drainage via frontal recess to MM

AnatomySphenoid Sinus

• Pneumatization begins in middle childhood• Reaches adult size by 12-18 years

Pathophysiology

Systemic:

• Viral URI

• Allergy

• Immotile cilia

• Cystic fibrosis

• Immune disorder

Pathophysiology

Local:

Trauma Swimming/Diving Rhinitis Medicamentosa

Pathophysiology

Mechanical:

Choanal Atresia Deviated Septum Polyps/Foreign Body Turbinate/Adenoid Hypertrophy

MUCOCILIARY CLEARANCE

Mucociliary clearance

• Ciliary function very important

• Ostia are small and located in locations not conducive to spont-drainage

Mucociliary clearance

Cilia work best: Temp of 37° Humidity near 100%

Respiratory Epithelium Goblet cells (20%) produce mucus Ciliated cells (80%)

Decreased MCC

• Kartagener syndrome (Primary ciliary dyskinesia)

• Cystic fibrosis

• Radiotherapy

• GERD

• Rhinosinusitis

Primary ciliary dyskinesia

• Autosomal recessive

• Dynein arm defects

• Kartagener syndrome (Associated with dextrocardia, sinusitis, rhinitis, pneumonia, and otitis media)

• Male infertility is common

Cystic Fibrosis

• Autosomal recessive

• Decreased chloride secretion with resultant thicker/stickier mucus adherent to bacteria

• Viscosity leads to dysfunction:– Resp tract Sweat glands – Pancreas Other exocrine glands– GI tract

Treatment principles

• Irrigation and drainage of secretions improve local defense mechanisms

• Antimicrobials

Surgical treatment

• Conservative FESS

Complications of Sinusitis

• Three main categories– Orbital (60-75%)– Intracranial (15-20%)– Bony (5-10%)

• Radiography– Computed tomography (CT) best for orbit– Magnetic resonance imaging (MRI) best for intracranium

Orbital ComplicationsChandler Criteria

• Five classifications– Preseptal cellulitis– Orbital cellulitis– Subperiosteal abscess– Orbital abscess– Cavernous sinus thrombosis

Orbital ComplicationsPreseptal Cellulitis

Orbital ComplicationsOrbital Cellulitis

Orbital ComplicationsSubperiosteal Abscess

• Surgical drainage– Worsening visual acuity or extraocular movement– Lack of improvement after 48 hours

Orbital ComplicationsSubperiosteal Abscess

• Approaches– External ethmoidectomy (Lynch incision) is

most preferred– Endoscopic ideal for medial abscesses– Transcaruncular approach

Orbital ComplicationsOrbital Abscess

• Similar approaches as with subperiosteal abscess– Lynch incision– Endoscopic

Orbital ComplicationsCavernous Sinus Thrombosis

• Symptomatology– Orbital pain

– Proptosis and chemosis

– Ophthalmoplegia

– Symptoms in contralateral eye

– Associated with sepsis and meningitis

• Radiology– Better visualized on MRI

Orbital ComplicationsCavernous Sinus Thrombosis

• Mortality rate up to 30%• Surgical drainage• Intravenous antibiotics

Complications of SinusitisIntracranial

Intracranial ComplicationsTypes

• Five types– Meningitis– Epidural abscess– Subdural abscess– Intracerebral abscess– Cavernous sinus, venous sinus thrombosis

Complications of SinusitisBony

• Pott’s puffy tumor– Frontal sinusitis with acute osteomyelitis

– Subperiosteal pus collection leads to “puffy” fluctuance

• Rare complication