Please note that the following is a general guideline only.
Definition
Acute sinusitis =Bacterial sinusitis is following a viral illness lasting up to up to the 4-week duration
Chronic Rhino Sinusitis (CRS) is when symptoms last >3 months.
Complicated sinusitis= Acute sinusitis can rarely become complicated with orbital or intracranial spread of infection.
Aetiology
Same pathogen as acute sinusitis ie Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
Pathophysiology
Sinus infection can spread intra orbitally or intra cranially via thrombosed veins.
Periorbita is usually a good barrier to spread of infection.
Ethmoid and Frontal sinuses drain to opthalmic vein which has drainage to cavernous sinus
Signs and symptoms
Preceding:
Most patients may have had a recent URTI
Symptoms of sinusitis:
Nasal obstruction, Purulent nasal discharge, post nasal drip, anosmia, headache
Orbital/ intracranial symptoms:
Infection can spread through various stages classified by Chandler (Chandler’s Classification)
Chandler’s Classification
Group I – Preseptal cellulitis
Group II – Orbital cellulitis
Group III – Subperiosteal abscess
Group IV – Orbital abscess
Group V – Cavernous sinus thrombosis
Chandler's Stages I-V
Group I (Preseptal cellulitis):
This is actually inflammatory oedema anterior to orbital septum, causing the eyelids to swell. This condition is caused due to restricted venous drainage. The eyelids though swollen, are not tender. Since the inflammation does not involve postseptal structures, there are is chemosis. Extraocular muscle movement limitations and vision impairment. Proptosis may be present to a mild degree.
Pre septal cellulitis, eye is otherwise not affected
Group II: Orbital cellulitis
causes pronounced oedema and inflammation of orbital contents without abscess formation. It is imperative to look for signs of proptosis and reduced ocular mobility as these are reliable signs of orbital cellulitis. Chemosis is usually present in this group. Loss of vision is very rare in this group, but vision should be constantly monitored.
Chemosis
Group III:
In this group abscess develops in the space between the bone and periosteum. Orbital contents may be displaced in an inferolateral direction due to the mass effect of accumulating pus. Chemosis and proptosis are usually present. Decreased ocular mobility and loss of vision is rare in this group.
sinus opacified, sub periosteal collection, bowing of medial rectus
Group IV:
Orbital abscess usually involves collection of purulent material within the orbital contents. This could be caused due to relentless progression of orbital cellulitis or rupture of orbital abscess. Severe proptosis, complete ophthalmoplegia, and loss of vision are commonly seen in this group of patients.
Group V:
Intra Cranial Cavernous sinus thrombosis – Development of bilateral ocular signs is the classic feature of patients belonging to this group. These patients classically manifest with fever, headache, photophobia, proptosis, ophthalmoplegia and loss of vision. Cranial nerve palsies involving III, IV, V1, V2 and VI are common.
Investigations
1) Sinus pus swab
2) Imaging: CT
Usually stage I & II do not need a CT, unless they fail to improve with medical Rx. Stage III onwards should be investigated with CT.
3) Imaging-MRI if any suggestion of intracranial complication- with MRI
4) Routine bloods
Treatment
1 Monitor vision
2 IV antibiotics
Antibiotics should cover the above pathogens ie Ceftriaxnoe, Augmentin
3 Nasal decongestants
Otrivin soaks Q 4 hrly ( ie kneel down- head on the ground- the second person instils 5 drops of otrivin each nostril to soak into the frontal, ethmoid sinuses outflow)
Want to add a caption to this image? Click the Settings icon.
The best position to get otrivin into the frontal, ethmoid drainage pathway
4) Nasal Rinsing- 10 minutes after decongesting (6 times a day)
5) Nasal steroid sprays ie Nasonex II BD or more
6) Oral steroids- high prednisone dose for 2 weeks then taper
Surgical Candidates
Subperiosteal abscess- drained externally or intranasally
Also, the sinus drainage is improved surgically
Intraorbital: drained by Ophthalmologist in conduction with an ENT surgeon
Intracranial collection; drained by Neurosurgeon/ ENT
Potts Puffy Tumour
Other complications include Potts Puffy Tumour which is osteomyelitis of the skull. This usually occurs thru a thromboses of a vein due to frontal sinusitis. This is first treated medically in a similar way followed by surgical drainage of frontal sinus. some of these conditions require prolonged post op antibiotics.
Comments