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COMPLICATIONS OF SINUSITIS

Nishit J Shah
 Hon. ENT Surgeon, Bombay Hospital and Medical Research Centre, Mumbai
Complications of paranasal sinusitis constitute true surgical and medical emergencies. Whilst sinus complications can occur in apparently young healthy individuals, more often than not, there is some underlying cause such as the patient being immunosuppressed. Complications also occur more frequently in children than in adults. This may be due to dehiscences in the bone, relatively vascularity of bone or the thinness of bones, apart from children being more susceptible to infection. The most common complications of paranasal sinusitis are the orbital complications. Intracranial complications include meningitis, subdural empyema, intracerebral abscess, epidural abscess and rarely cavernous or superior sagittal sinus thrombosis. Other sinus related complications are mucoceles, pyoceles, osteomyelitis, cellulitis, barotrauma and dental complications. In most cases, diagnosis may be confirmed by a combination of a high index of clinical suspicion and MR or CT scanning. For patients with acute complicated sinusitis appropriate antimicrobial agents would include azithromycin, clarithromycin, amox-clav., cefixime, cefdoxime, cefprozil, cefuroxime, clindamycin, ceftibuten, loracarbef, and sparfloxacin. Surgery needs to be done for the resultant condition when indicated (such as abscesses or mucoceles), and the offending sinuses must be cleared (endoscopically or via an external approach) to prevent recurrences.

Complications of paranasal sinusitis constitute true surgical and medical emergencies. These complications appear to be more prevalent and seem to present in a more fulminant manner in the paediatric age group. The most common complication of paranasal sinusitis is orbital cellulitis followed collectively by all the intracranial complications. These include meningitis, subdural empyema, intracerebral abscess, epidural abscess and rarely cavernous or superior sagittal sinus thrombosis. [1] Early diagnosis and aggressive surgical intervention in conjunction with broad-spectrum antibiotics are the key to successful management.

Aetiology

Whilst sinus complications can occur in apparently young healthy individuals, more often than not there is some underlying cause such as the patient being immunosuppressed, or having uncontrolled diabetes. Complications also occur more frequently in children than in adults. This may be due to dehiscences in the bone, relatively vascular bone or the thinness of bones, apart from being more susceptible to infection.

The majority of patients with HIV infection will develop acute sinusitis. The most common organisms isolated in these patients were Streptococcus pneumoniae, Streptococcus viridans and Pseudomonas aeruginosa. Listeria monocytogenes and Candida albicans were also found. [2]

Pathogens

Streptococcus milleri and Haemophilus influenzae were the commonest organisms isolated from sinus aspirates (44 per cent), with a noticeable absence of Streptococcus pneumoniae (10 per cent). Organisms cultured from intracranial, soft tissue or orbital empyemas were predominantly Streptococcus milleri (50 per cent) and Staphylococcus aureus (25 per cent) with an absence of Haemophilus influenzae (four per cent) and Streptococcus pneumoniae (four per cent). [3] Amoxycillin, doxycycline and erythromycin are good first line antibiotics for sinusitis, but for patients with acute complicated sinusitis appropriate antimicrobial agents would include Azithromycin, clarithromycin, amox-clav., cefixime, cefdoxime, cefprozil, cefuroxime, clindamycin, ceftibuten, loracarbef, and sparfloxacin.

General effects

Sinusitis will produce some general effects, irrespective of whether a complication may arise. These should not be neglected, but treated early to curtail sinusitis before it may lead to extra-sinus spread. The commonest complaint is pain in the sinus area, which in acute sinusitis may be quite severe. Referred pain can also be present due to the trigeminal nerve. As in any infection, malaise and pyrexia is an accompanying feature, leading to patient anxiety. The nose is blocked and the patient may have decreased sensation of smell or anosmia. Muco-purulent discharge is often present which could lead to pharyngitis, tonsillitis, laryngitis, tracheitis, bronchitis, or asthma. Chronic sinusitis will produce a post-nasal drip that may result in infections of the upper airway. It also acts as a focus of infection with a potential to spread the infection to other parts of the body. Frequently we find patients with sinusitis who complain of frequent sore throats, pain on swallowing and occasional change of voice. At times, these symptoms may even overshadow the sinus problem. It is thus important to check the nose and sinuses in patients with tonsillitis, pharyngitis, laryngitis and even lower airway infections. Treatment of the sino-nasal passage is necessary if any pathology exists in this area and most patients will find significant improvement in the other airway symptoms.

Sinusitis, in children may be an aggravating factor for chronic reactive lower airway disease, and optimal treatment may decrease the need of asthmatic medication.

Mucocoeles, pyocoeles

The term mucocoeles was first coined by Rollet in 1896. Onodi gave the earliest histological description in 1901. Mucocoeles are chronic, expansile, cyst-like lesions of the paranasal sinuses, containing mucoid secretion and desquamated epithelium. Mucocoeles or pyocoeles are seen most commonly in the frontal sinus and in the ethmoid sinuses and only rarely in the sphenoid and maxillary sinus.

The aetiology is uncertain but is commonly thought to be a result of obstruction to normal sinus drainage. This could happen due to mucosal oedema, inflammatory sinusitis with subsequent sterilisation of the exudate, fractures, tumours, synechiae, or post-operative stenosis of the duct. There have been a few reports of benign fibro-osseous lesions causing mucocoeles. It has also been suggested that a cystic degeneration of a goblet cell gland could result in a mucocoele. Usually there are repeated infections of the sinus resulting in blockage of the ostium. The resultant stenosis of the duct leads to secretions collecting under pressure in the sinus, consequently causing gradual sinus expansion with or without bone erosion. In any case, they are space-occupying lesions that increase in size as mucus secretions continue, and can be exacerbated by active sinusitis. [4]

 

   
Fig1A: Preoperative coronal CT scan of a patient with frontal sinus mucocoele. Fig1B: Postoperative coronal CT scan showing themucocoele marsupialised into the nose with an air filled clear frontal sinus.

 

Due to the sinus expansion, the orbit may get affected and then there will be proptosis, and visual difficulties. External expansion will cause swelling over the sinus area and intracranial expansion could result in intracranial complications.

Apart from routine haematologic investigations, the main investigations are radiological. Plain X-rays of the paranasal sinuses(PNS) in patients with mucocoeles will show expanded sinuses with loss of scalloping. CT scan or MRI is the investigation of choice and one can see a smooth homogeneous mass in an expanded sinus with an absence of infiltration, often pushing into the orbit.

Clinical features include headache, nasal obstruction and swelling over the sinus. Patients with paraocular sinus masses may manifest ocular complications, including proptosis, diplopia, decrease in vision, epiphora, astigmatism and ophthalmoplegia. Orbital displacement, restricted extraocular muscles, chemosis, pain, and optic neuritis could also be present4 (Fig. 1a). Due to the eye symptoms, these patients will usually present first to the ophthalmic surgeon, who after examination and investigations, refer the patient to the otorhinolaryngologist for further management. In advanced frontal sinus lesions, rarely the patient may have convulsions. Examination of the nose reveals congested mucosa, and often we can see the bulge of the mucocoele in the nose (especially with nasal endoscopy) and sometimes other pathology, such as nasal polyposis. On palpation, one can elicit the typical egg shell crackling over the external swelling.

A variety of conservative and surgical procedures have been recommended in the past, however, the problem of visualising the operative area after surgery, the slow rate of mucocoele regrowth and the difficulty of imaging a sinus radiographically after an obliterative procedure, make accurate interpretation of results difficult.

The various approaches suggested for the treatment of mucocoeles include transethmoid transnasal; transcranial transnaso-orbital; transfrontonasal-orbital; trans-sphenoidal; transmaxillo- sphenoidal; subfronto-transnasal; endonasal endoscopic; and external drainage of the mucocoele or pyocoele. Today, the treatment of choice is definitely endoscopic marsupialisation of the mucocoele. Under endoscopic vision, the wall of the mucocoele is identified in the nose and a wide opening is made to drain the contents into the nose (Fig. 1b). No attempt is made to remove the entire mucocoele, but its wall is left behind to line the sinus cavity. There are many advantages to an endoscopic management. The procedure may be done under local anaesthesia as an office procedure; it is safer and quicker as no excision is involved; there is minimal blood loss as the procedure is minimally invasive and there is no external scar; recurrence rates are low as the causative factors such as stenosis or polyposis are also dealt with during the surgery; and follow up is extremely easy and reliable with nasal endoscopy.

Differential diagnosis includes thyroid eye disease, orbital pseudotumour, infection, trauma, benign or malignant tumours, encephalocoele, or meningocoele. [4]

Extrasinus spread

From within the bony confines of the sinuses, infection may spread to extrasinus sites in many possible ways. Erosion of bone due to the pressure within the sinus is probably the most common route of spread of infection along with direct extension through dehiscent areas (flat bone) or neurovascular foramina. The infection may involve the bone leading to osteitis, which then is responsible for an extrasinus complication. Infection is also known to spread to other sites via the haematogenous route and through valveless veins in the sinus wall.

Complications of the eye

Vision and Field Defects

Diseases of the paranasal sinuses may cause visual disturbances, especially diminished visual acuity and visual field defects, by affecting the optic nerve. [5] Usually, an acute orbitopathy is obvious. Chronic sinus disorders can produce "silent" oculomotor disturbances and, at least in the beginning, transient diplopia (e.g. mucocoele) A patient’s vision may be affected even in the absence of significant sinus disease due to nasal optic neuritis. [6]

The most common presenting symptom is headache, followed by visual changes and cranial nerve palsies (cranial nerves 2 - 6 could be involved). Cranial nerve abnormalities are encountered in about 12% of the inflammatory cases. [7]

Galati et al, report 3 patients whose visual loss due to acute bacterial sinusitis reversed after treatment. [8] Sato et al report a case where the vision improved dramatically following sinus surgery. [6] Immediate surgical drainage with antibiotic therapy and correction of any underlying cause are important factors for any chance of vision to be restored.

Isolated inflammatory sphenoid sinusitis, associated with complications is rare. Neurological complications are the most frequent; isolated headache, neuro-ophthalmologic paralysis, meningitis, cavernous sinus thrombosis and intracranial abscess may occur. A bacteriological aetiology was found in 60% of the cases, and a fungal aetiology in 25%. The treatment is based on a large endoscopic marsupialisation of the sphenoid. Recovery is the rule, except for neuro-ophthalmologic paralysis, in which recovery is inconstant. [9]

Orbital Complications

The treatment of orbital complications of nasosinusal processes has seen numerous modifications. Traditionally, cases with purulent collections were treated by external drainage. Currently, the introduction of new optical systems allow such complications to be approached from within the nasal cavity.

 
Fig 2 : Coronal CT scan showing orbital spread of infection from the maxillary sinus

 

Most of the complications were caused by acute inflammation of the ethmoid or sphenoid cells with direct extension through dehiscent areas (flat bone) or neurovascular foramina. Occasionally, the infection may spread from the maxillary sinus (Fig. 2). MRI may have a higher sensitivity in detecting acute inflammatory foci (Fig. 3). Early elimination of the cause of inflammation by functional endoscopic sinus surgery(FESS) prevents spread of the complication. Advantages of FESS included better orientation and surgical access to the paranasal system of infants. [10]

The incidence of orbital infection, manifested by lid swelling alone is more common (stages I and II) than orbital infection involving postseptal findings (stages III, IV and V); 84.16% compared with 15.84%, respectively.[11]

The most common classifications used for orbital complications have been that of Chandler et al. (1970) and Moloney et al. (1987). [12]

Orbital complications
Inflammatory oedema
Orbital cellulitis
Subperiosteal abscess
Orbital abscess
Cavernous sinus thrombosi

 
Fig 3 MR scan showing orbital spread of infection from the maxillary sinus.

 

 
Fig 4 Axial CT scan showing orbital cellulitis..

Inflammatory oedema

The spread of infection is usually from the ethmoids or the frontal. This is the first stage of orbital complications and occurs due to obstruction of venous drainage. There is soft tissue swelling of the eyelids (preseptal), but the eye itself is normal, though there may be some conjunctival congestion. The patient will have signs of sinus infection on examination, and radiological studies will confirm the sinusitis. This stage usually responds to treatment with antibiotics and decongestants. In older patients, subsequent endoscopic clearance of the involved sinus should be undertaken. This is also done if the response to antibiotics is not satisfactory or if there is any evidence of decrease in vision or increasing proptosis.

Orbital cellulitis

Orbital cellulitis occurs when there is spread of infection through the orbital periosteum (Fig. 4). The eyelids are swollen, the conjunctiva is engorged and proptosis is present (Fig. 5). The vision is impaired, and extraocular motility impaired. Orbital cellulitis is a blinding ocular emergency associated with high morbidity. Immediate treatment is necessary to avoid devastating complications such as optic nerve compression, panophthalmitis or intracranial spread of infections. [13] The initial treatment is with intravenous antibiotics and surgery is done depending on the orbital scan and response to the antibiotics. Cases with abscess formation required early surgical drainage. In the majority of children presenting with periorbital cellulitis, the infection resolved with aggressive intravenous antibiotic therapy. According to Samad and Riding, about 17% of children progress to subperiosteal abscess formation as documented by CT scan and require external ethmoidectomy as a drainage procedure. They feel that early hospitalisation and aggressive intravenous antibiotics are effective in resolving periorbital cellulitis. [14] Endoscopic drainage via the nose, may be done by experienced surgeons.

 
Fig 5: Clinical photograph of patient with bilateral ethmoiditis and orbital cellulitis.

 

Subperiosteal abscess

Infection may spread through the orbital periosteum through the bony canal and result in the formation of a subperiosteal abscess. A medial subperiosteal orbital abscess is the most common serious paediatric complication to occur. [15] The patient will have proptosis with displacement of globe and the vision may drop. The abscess can occasionally rupture into the orbit or lids. Broad spectrum intravenous antibiotics must be administered urgently and drainage of abscess considered. Surgical intervention is mandatory whenever antibiotic treatment fails. Most authors prefer open surgical procedures such as external ethmoidectomy, while others recommend transnasal endoscopic drainage as the first attempt at sinus decompression. [15,16]

Orbital abscess

An orbital abscess represents an extremely serious and blinding complication of sinusitis. There is collection of pus in the orbit, which will result in proptosis, ophthalmoplegia and a rapid loss of vision due to ischaemia or optic neuritis.

Urgent surgical decompression and drainage must be undertaken with adjuvant medical treatment in the form of intravenous antibiotics. Most surgeons would recommend the external approach as for a subperiosteal abscess. A combined orbito-otorhinolaryngologic approach is also recommended for drainage of orbital abscess with associated paranasal sinus infection. [17] Wolf et al have advised the endoscopic approach for the well trained surgeon. The main advantages of this approach are the simultaneous treatment of the causative disorders and lack of trauma to further structures as surgery follows the pathogenic route of the abscess formation. The endoscope with 30 or 70 degree angled axis of vision enables the surgeon to explore and drain the abscess cavity, which often is located behind the bulbus, with minimal trauma. For the trained surgeon the field of vision is favourable as compared with the external approach when the abscess is located right in the axis of vision, as one has to cut through healthy tissue and the intact skin, which, especially in children, can lead to long-lasting visible scars. [18]

Indications for surgery in orbital complications

Failure to improve significantly in 24-48 hrs.

Immediately, if visual acuity drops

Increasing proptosis

Demonstration of abscess on CT scan

Cavernous sinus thrombosis

Any orbital complication can proceed to cavernous sinus thrombophlebitis by spread of infection through the ophthalmic veins. Though it has been included in Chandler’s classification on orbital complications, it is actually an intracranial complication of sinusitis. The patient presents typically with spiking fever and rigors. There may be headache, periorbital pain, swelling and proptosis. Chemosis can occur and ophthalmoplegia may develop. Neck stiffness may also be present. A CT scan or MRI can usually detect and diagnose cavernous sinus pathology. The treatment is by intravenous antibiotics and occasionally anticoagulants are used. Surgical intervention is only considered as a last resort. However, the focus of infection in the sinus and orbit (if present) must be cleared early to aid in recovery. [19]

Intracranial Complications

Sinus induced intracranial sepsis can represent a genuine medical and surgical emergency, therefore, a keen awareness of the subtle signs and symptoms of bacterial spread beyond the paranasal sinuses must be maintained. This increased awareness is especially important in mentally retarded and psychomotor handicapped children because they can develop a rapidly fatal course despite the absence of any warning signs. [20]

The most common sinus involved was the frontal, followed by the ethmoid, maxillary and sphenoid. Streptococcus milleri was the most common organism isolated. [21] In a study by Gallagher et al [22] of 15 patients with suppurative intracranial complications of sinusitis, the following incidence was found. Epidural abscess (23%), subdural empyema (18%), meningitis (18%), cerebral abscess (14%), superior sagittal sinus thrombosis (9%), cavernous sinus thrombosis (9%), and osteomyelitis (9%). [22] Most patients present with a classic picture of headache, vomiting, altered mental status and fever. Neck stiffness or convulsions may be present. [23] The diagnosis of suppurative intracranial complications of sinusitis requires a high index of suspicion and confirmation by imaging (Fig. 6). Central to the success of treatment is the management of the primary source of sepsis within the paranasal sinuses in combination with neurosurgical drainage and intravenous antibiotics. This approach has resulted in a mortality rate of 7% and morbidity of 13%. [22] Sinus clearance may be done endoscopically or via the external route, especially when the frontal sinus is involved. Neurosurgical drainage is done via a craniotomy or burr hole.

 
Fig 6: MR scan showing intracranial spread of infection.

 

Meningitis and encephalitis

Patients who develop meningitis will classically present with pyrexia, headache, vomiting and altered sensorium. On examination, these patients will have neck stiffness, they are drowsy, Kernig’s sign and straight leg raising tests are positive. Papilloedema will also be detected with decreased pupil reaction. Imaging and lumbar puncture confirm the diagnosis. The treatment is basically medical with intravenous antibiotics. Subsequent sinus drainage with clearance of disease must be done to prevent recurrence of meningitis.

Extradural abscess

A patient with an extradural abscess will complain of sinus symptoms and severe headache. There is no significant relief with antibiotics, decongestants or even surgical drainage of the sinuses. A CT scan or MRI confirms the diagnosis. The abscess may be treated by aspiration with antibiotic instillation. Excision of the abscess orsurgical drainage could also be done. The responsible sinus must be surgically treated as well.

Subdural abscess and intracerebral abscess

Subdural and intracerebral abscesses are a surgical emergency and must be detected and treated as urgently as possible. These patients will have pyrexia, fits, and localising neurological signs such as hemiparesis. Drowsiness, apathy and signs of raised intracranial pressure such as papilloedema will also be present. Other than aspiration and antibiotics, the treatment is essentially surgical. Neurosurgical drainage either via burr hole or craniotomy is done and subsequent clearance of sinus disease is undertaken.

An overdependance on CT scan might be misleading in the case of evolving abscesses and thus one must reemphasize the need to have a high degree of clinical suspicion to detect intracranial complications of sinusitis at an early stage so that the morbidity and mortality can be minimized.

Pseudotumour cerebri is a clinical syndrome characterised by increased intracranial pressure in the absence of an intracranial tumour. It is most frequently diagnosed in obese young women, but it is also reported in children of all age groups, including infants. A variety of medical conditions have been suggested as possible aetiologic factors, including several infectious diseases. Keren and Lahat report a case of a child with pseudotumour cerebri as the only presenting symptom of acute frontal sinusitis. [24]

Osteomyelitis

Infection spreading into the bony walls of the sinuses can result in osteomyelitis. The patient will have gradual swelling in the affected area with pain of the affected bone. Pyrexia, malaise and occasionally a discharging sinus may be present. Frontal sinus osteomyelitis is more extensive and dangerous than the maxillary and could result in Potts puffy tumour with the patient having severe pain. Kaji et al have reported an intracranial abscess arising from osteomyelitis of the sphenoid sinus in a diabetic patient. [25] The management is with antibiotics and surgical drainage of the affected sinus with removal of sequestra.

Cellulitis, facial abscess

Initial swelling and cellulitis can lead to subperiosteal abscesses if not treated. This is especially significant in view of the location in the ‘dangerous area’ of the face.

Raboso et al report a case of craniofacial necrotizing fasciitis, secondary to a maxillary sinusitis. Their patient was treated intensively with antibiotics, surgical procedures and life-support measures. Despite all efforts, the patient died one week after admission. This highlights the need for early diagnosis and aggressive management as decisive factors for the outcome of the patient. [26]

Barotrauma

Most of us have experienced ear blocking or even pain due to the effects of pressure change when travelling by air (especially on descent) or in high altitude regions. Sinus discomfort and severe pain can occur similarly in the presence of sinusitis, if the ostia are blocked. Sinus barotrauma is even more significant in people who deal continuously with pressure changes (like pilots and divers) as it can affect their careers. Immediate treatment is with analgesics, decongestants and antibiotics. Patients are advised to avoid flying or diving till the obstruction is relieved. Nasal endoscopy and imaging are required to confirm the cause, after which medical or surgical treatment is initiated. FESS usually provides long term relief for chronically suffering patients and professionals can continue their career without fear of pain or complication.

Dental

Sinusitis can result in dental pain and is the most obvious cause of chronic oroantral communication. The tooth most frequently involved in oroantral fistulae (OAF) is the upper second molar, followed by the first molar and the highest incidence is seen in the third and fourth decades of life. The closure of OAF is one of the more challenging problems in oral surgery and long-term successful closure of OAF depends on the technique used, the size and location of the defect, and on the presence or absence of sinus disease. When present, it is essential to clear and provide good ventilation for the sinuses. In most cases this can be done endoscopically, though at times, a Caldwell-Luc procedure might be more appropriate. [27]

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