Complications of Rhinosinusitis Synopsis of Critical Sequelae ppt

 First 3 years and between 7-18 years  Coincides with dental development Notes: The anterior wall forms the facial surface of the maxilla, the posterior wall borders the infratempora

 First 3 years and between 7-18 years

 Coincides with dental development

Notes: The anterior wall forms the facial surface of the maxilla,

the posterior wall borders the infratemporal fossa, the medial

wall constitutes the lateral wall of the nasal cavity, the floor of

the sinus is the alveolar process, and the superior wall serves

as the orbital floor

molar roots dehiscent

in 2%

NOTES: Haller cell is an ethmoidal cell that

pneumatizes between maxillary sinus and

orbital floor

Anatomy

Ethmoid Sinus

 First seen at 5 months gestation

 Agger nasi

 Uncinate

 Ethmoid bulla

 Ground/basal lamella

 Posterior wall of most posterior ethmoid cell

 Adult size by 12-15 years

Hansen JT, ed Netter’s Clinical Anatomy, 2nd Ed Philadelphia: Saunders, 2010

Infundibulum Uncinate Process Hiatus Semilunaris Ethmoid Bulla Basal Lamella

Retrobulbar Recess

Anatomy

Ethmoid Sinus

 Drainage

 Anterior cells via ethmoid infundibulum

 Posterior cells via sphenoethmoid recess

 Innervation via V1 distribution

 Branches from nasociliary nerve

 Anterior and posterior ethmoids

 Vasculature

 Ophthalmic artery

 Maxillary and ethmoid veins

Nasociliary Nerve

Anterior Ethmoidal Artery

Posterior Ethmoidal Artery

Ophthalmic Nerve

Ophthalmic artery

Posterior cells drain into superior meatus

Ophthalmic artery provides anterior and posterior

ethmoidal arteries

Cavernous sinus gives off maxillary and

ethmoidal veins

Anatomy

Frontal Sinus

 Starts developing at 4 years

 Radiographically visualized at 5-6 years

12-20 years

 Volume 4-7cm3 by adulthood

 No or poor pneumatization in 5-10%

 Anterior: posterior agger nasi

 Lateral: lamina papyracea

 Medial: middle turbinate

Basal Lamella

Infundibulum

Posterior Ethmoid Uncinate

Process

NOTES:The anterior table of the frontal sinus is twice as thick

as the posterior table, which separates the sinus from the

anterior cranial fossa The floor of the sinus also functions as

the supraorbital roof, and the drainage ostium is located in the

posteromedial portion of the sinus floor

A markedly pneumatized agger nasi cell or ethmoidal bulla can

obstruct frontal sinus drainage by narrowing the frontal recess

Drainage of the frontal sinus also depends on the attachment of

the superior portion of the uncinate process

Anatomy

Frontal Cell Types

Sold arrow – Frontal cell type

Dashed arrow – Agger nasi cell DelGaudio JM, et al Multiplanar computed tomography analysis of frontal recess cells Arch Otolaryngol Head Neck Surg 2005; 131:230-5

NOTES:Type 3 cell attaches to anterior table

Supraorbital Nerve

Supratrochlear Artery

Supraorbital Artery

NOTES:Foramina of Breschet: small venules that

drain the sinus mucosa into the dural veins

Anatomy

Sphenoid Sinus

In most cases, the posteroinferior end of the superior turbinate was located in the same horizontal plane as the floor of the sphenoid sinus The ostium was located medial to the superior turbinate in 83% of cases and lateral to it in 17%

Acute Rhinosinusitis (ARS)

paranasal sinuses

 Obstruction of sinus ostia

 Impaired ciliary transport

 Viral etiology in majority of cases

 Superimposed bacterial infection in 0.5-2%

 Symptoms for at least 7-10 days or worsening

after 5-7 days

 “Recurrent ARS” with > 4 episodes, lasting > 7-10

days

NOTES: Most viral upper respiratory tract infections are caused by rhinovirus ,

but coronavirus, influenza A and B, parainfluenza , respiratory syncytial virus ,

adenovirus , and enterovirus are also causative agents

Acute Rhinosinusitis (ARS)

Acute Rhinosinusitis (ARS)

Chronic Rhinosinusitis (CRS)

 Bacterial, fungal, and viral

NOTES: One of the major problems with identifying the pathogenesis of CRS is that neither symptoms, findings, nor radiographs, taken independently, are sufficient basis for the diagnosis One study showed that current symptom-based criteria had only a 47% correlation with a positive CT scan result

Stankiewicz JA, Chow JM: A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity Am J Rhinol 2002; 16:199-202

Complications of Sinusitis

Siedek et al, 2010

Complications of Sinusitis

Orbital

 Most commonly involved complication site

 Continuum of inflammatory/infectious changes

 Children more susceptible

NOTES:

close proximity of the orbit to the paranasal sinuses, particularly the ethmoids, make it the most commonly involved structure in sinusitis complications; rarely from frontal or maxillary sinuses

pediatric population difference likely related to age-related sinus development

* pain and deterioration is not necessarily always present

* increase in WBC only found in 50%

Moraxella catarrhalis Staphylococcus aureus

Anaerobes

Bailey, et al 2006

Orbital Complications

Preseptal Cellulitis

Orbital Complications

Orbital Cellulitis

Orbital Complications

Subperiosteal Abscess

 Symptomatology

 Rim-enhancing hypodensity with mass effect

sinusitis etiology

Ramadan et al, 2009

NOTES: Patients will complain of diplopia,

ophthalmoplegia, exophthalmos, or reduced visual

acuity The patient has limited ocular motility or pain

on globe movement toward the abscess.; may have

normal movement early on Orbital signs include

proptosis, chemosis, and visual impairment

Orbital Complications

Orbital Abscess

Orbital Complications

Orbital Abscess

 Symptoms in contralateral eye

 Associated with sepsis and meningismus

 Poor venous enhancement on CT

 Better visualized on MRI

Contralateral involvement is distinguishing feature of cavernous

sinus thrombosis

MRI findings of heterogeneity and increased size suggest the

diagnosis

 Risk intracranial or intraorbital

Cavernous Sinus Thrombosis

reversed with protamine

NOTES: 1980s were retrospective reviews

Bhatia was a literature review

Complications of Sinusitis

Intracranial

 Mucosal scarring, polypoid changes

 Hidden infectious foci with poor antibiotic penetration

 Sinus wall erosion

 Traumatic fracture lines

 Neurovascular foramina (optic and olfactory nerves)

 Diploic skull veins

 Ethmoid bone

NOTES: Teenagers affected more because of developed frontal and sphenoid sinuses, and

because they are more prone to URI’s 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 this

mode, the subdural space may be selectively infected without contamination of the intermediary

structure; a subdural empyema can exist without evidence of extradural infection or osteomyelitis

 Cranial nerve palsies

 Sphenoiditis

 Ethmoiditis

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

Other Streptococcus species

Anaerobes (Bacteroides and

Fusobacterium species)

Gram-negative rods

Streptococcus pnuemoniae Hemophilus influenzae

Intracranial Complications

Epidural Abscess

 Antibiotics

 Good intracerebral penetration

 Typically for 4-8 weeks

 Frontal sinus trephination

 Frontal sinus cranialization

 Stereotactic-guided drainage

NOTES: Will likely need antibiotics for 4-8 weeks;

usually vancomycin and 3 rd or 4 th generation

cephalosporin

Prophylactic seizure therapy not necessary unless

there’s an associated subdural abscess

complication, rapid deterioration

Intracranial Complications

Subdural Abscess

 Antibiotics

 Anticonvulsants

 Hyperventilation, mannitol

 Steroids

 Medical therapy possible if < 1.5cm

 Craniotomy or stereotactic burr hole

 Endoscopic 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

Intracranial Complications

Intracerebral Abscess

Intracranial Complications

Intracerebral Abscess

 Lumbar puncture potentially fatal

 Aggressive medical therapy

 Drain sinuses and abscess

 Diagnostic aspiration if < 2.5cm or cerebritis

 Stereotactic-guided aspiration

NOTES: 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 the abscess, increase the risk of ventricular rupture, and alter the appearance on CT scans Steroid therapy can also produce a rebound effect when discontinued If used to reduce cerebral edema, therapy should be of short duration The appropriate dosage, the proper timing, and any effect of steroid therapy on the course of the disease are unknown The procedures used are aspiration through a bur hole and complete excision after craniotomy Aspiration is the most common procedure and is often performed using a stereotactic procedure with the guidance

of CT scanning or MRI

Other Streptococcus species (Streptococcus milleri)

Gram-negative bacilli (Hemophilus influenzae)

Staphylococcus epidermidis

Eikenella corrodens

Polymicrobial

NOTES: Incidence of anaerobes in

suppurative intracranial complications

range from 60-100%

Intracranial Complications

Venous Sinus Thrombosis

artery flow void on MRI

Intracranial Complications

Venous Sinus Thrombosis

(Gallagher 1998)

outweighs bleeding risk (Gallagher 1998)

Complications of Sinusitis

Bony

 Frontal sinusitis with acute osteomyelitis

 Subperiosteal pus collection leads to “puffy” fluctuance

 Only 20-25 cases reported in post-antibiotic era (Raja 2007)

 Less than 50 pediatric cases in past 10 years (Blumfield 2010)

 Fever

 Neurologic findings

 Periorbital or frontal swelling

 Nasal congestion, rhinorrhea

NOTES: Sir Percivall Pott described Pott's Puffy tumor in 1768 as a

local subperiosteal abscess due to frontal bone suppuration

resulting from trauma Pott reported another case due to frontal

sinusitis

NOTES: Sir Percivall Pott described Pott's Puffy

tumor in 1768 as a local subperiosteal abscess due

to frontal bone suppuration resulting from trauma

Pott reported another case due to frontal sinusitis

Pott’s Puffy Tumor

Microbiology

Streptococcus species (Streptococcus milleri)

Staphylococcus aureus

Anaerobes (Bacteroides species)

Gram-negative bacilli (Proteus species)

Polymicrobial

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