• Nalaka de Silva

Orbital Complications of Sinusitis

Updated: Jun 16, 2019

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.




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