Complication of Chronic Rhinosinusitis

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COMPLICATION OF CRSORBITAL INTRACRANIAL BONY CHRONIC

PRESEPTAL CELLULITIS

MENINGITIS OSTEOMYELITIS (POTT’S PUFFY

TUMOUR)

MUCOCELE

ORBITAL CELLULITIS EPIDURAL ABSCESS

SUBPERIOSTEAL ABSCESS

SUBDURAL ABSCESS

ORBITAL ABSCESS INTRACEREBRAL ABSCESS

CAVERNOUS SINUS THROMBOSIS

CAVERNOUS SAGITTAL SINUS

THROMBOSIS

Orbital Complication

**Chandler’s classification system.• Pre-septal cellulitis• Orbital cellulitis• Sub-periosteal abscess• Orbital abscess• Cavernous sinus thrombosis

**orbit & its content are closely related to 3 sinus ethmoid, frontal & maxillary

Anatomy Of the Orbit

Orbital Septum

• Thin membrane that originate from orbital periosteum which insert into anterior surface of tarsal plates of the eyelid.

• Anatomical landmark which separate superficial eyelid from deeper orbital structure.

**Fx: prevent infection in eyelid extending into the orbit.

• Infection of soft tissue of eyelid and periocular region anterior to orbital septum.

• Pathophysiology– Spread of URTI by venous &

lymphatic channels– Direct inoculation from trauma– Spread from skin & adjacent

structural infection• Clinical features

– Periorbital erthema & oedema, pain, conjunctivitis, epiphora and blurred vision.

**if oedema severe enough cannot open the eye

Pre-septal Cellulitis

• Infection of the orbital tissues posterior to orbital septum.

• Pathophysiology– Extension of infection from periorbital

structure especially paranasal sinus**Most common infection from ethmoid sinus.– Direct inoculation from trauma/surgery– Haematogenous spread

• Clinical features– Fever, malaise, history of recent

sinusitis/URTI– exophthalmos, partial/total vision loss,

conjunctiva chemosis, restrict eye movement

– Headache, rhinorrhea

Orbital Cellulitis

• An abscess between the periosteum and cortical plate of the bone.

• Clinical features-- eyelid edema/

erythema/ warmth, conjunctival injection with chemosis and restricted ocular motility with or without diplopia.

Subperiosteal abscess

• Pus accumulation in the orbital soft tissues behind the globe

• Due to : extended infection into the orbital fat associated with inflammatory edema, purulence, and fat necrosis

• Features : Severe chemosis, ptosis and complete ophthalmoplegia (cranial nerves II, III, IV, V, and VI) and visual loss

Orbital Abscess

• The cavernous sinuses receive venous blood from the facial as well as the sphenoid and middle cerebral veins. They, in turn, empty into the inferior petrosal sinuses, then into the internal jugular veins and the sigmoid sinuses via the superior petrosal sinuses.

• This complex web of veins contains no valves; blood can flow in any direction depending on the prevailing pressure gradients. Since the cavernous sinuses receive blood via this distribution, infections of the face including the nose, tonsils, and orbits can spread easily by this route.

• This intimate juxtaposition of veins, arteries, nerves, meninges, and paranasal sinuses accounts for the characteristic etiology and presentation of cavernous sinus thrombosis (CST).

• CST is more commonly seen with sphenoid and ethmoid and to a lesser degree with frontal sinusitis.

• Staphylococcus aureus accounts for approximately 70% of all infections.Streptococcus pneumoniae, gram-negative bacilli, and anaerobes can also be seen. Fungi are a less common pathogen and may include Aspergillus andRhizopus species.

Cavernous Sinus Thrombosis

Intracranial Complication

• Meningitis is an inflammation of the membranes (meninges) surrounding your brain and spinal cord.

• Acute bacterial meningitis usually occurs when bacteria enter the bloodstream and migrate to the brain and spinal cord. But it can also occur when bacteria directly invade the meninges, as a result of an ear or sinus infection, or a skull fracture, or rarely, after some surgeries.

• A number of strains of bacteria can cause acute bacterial meningitis. The most common include Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus), Haemophilus influenzae (haemophilus), Listeria monocytogenes (listeria).

Meningitis

• An epidural abscess is a collection of pus between the outer covering of the brain and the bones of the skull

• Clinical Features : Fever, headache, lethargy, nausea, vomiting, pain at the site of recent surgery that gets worse

• Neurological symptoms depend on the location of the abscess :

1. decreased ability to move 2. Loss of sensation3. Weakness

Frontal sinusitis showing epidural abscess

Epidural Abscess

• Subdural abscess is an intracranial focal collection of purulent material located between the dura mater and the arachnoid mater.

• In infants and young children, subdural empyema most often occurs as a complication of meningitis. In such cases, subdural empyema should be differentiated from reactive subdural effusion (ie, sterile collection of fluid due to increased efflux of intravascular fluids from increased capillary wall fenestrations into the subdural space).

• In older children and adults, it occurs as a complication of paranasal sinusitis, otitis media, or mastoiditis.

• Infection usually enters through the frontal or ethmoid sinuses; less frequently, it enters through the middle ear, mastoid cells, or sphenoid sinus.

• This often occurs within 2 weeks of a sinusitis episode, with the infection spreading intracranially through thrombophlebitis in the venous sinuses.

• Infection also may extend directly through the cranium and dura from an erosion of the posterior wall of the mastoid bone or frontal sinus.

Subdural abscess

• A brain abscess is a pus-filled swelling in the brain caused by an infection. It is a rare and life threatening condition.

• Pathophysiology: 1. an infection in another part of the skull,

such as an ear infection, sinusitis or dental abscess, spreads directly into the brain

2. an infection in another part of the body, such as the lung infection pneumonia, spreads into the brain via the blood

3. trauma, such as a severe head injury, that cracks open the skull allowing bacteria or fungi to enter the brain

• Clinical features:- Severe headache, changes in mental status, weakness or paralysis on one side of the body, fever , seizures

Intracerebral abscess

Sagittal (a) and axial (b) gadolinium-enhanced T1-weighted MRI images from a patient who presented with headache, word-finding difficulties, stuttering speech, and right hand/foot numbness. Note the peripheral enhancement of a lesion in the left insula with surrounding edema.

• Cavernous sinus thrombosis is a rare and life-threatening condition in which a blood clot develops in the cavernous sinuses.

• Pathophysiology: Most cases of cavernous sinus thrombosis

occur when a bacterial infection in another part of the skull or face spreads into the cavernous sinuses.

A blood clot then forms inside the cavernous sinuses in an attempt to prevent the infection from spreading further into the body.

This blood clot places the brain under increasing pressure by restricting the blood flow, which can damage the brain, eyes and central nervous system.

• Clinical Feature:- a sharp and severe headache, swelling and

bulging of the eyes, eye pain that is often severe

Cavernous sinus thrombosis (CST)

A 23-year-old woman with headache. CT scan demonstrates a subtle right transverse sinus thrombosis with high attenuation (arrows). No hemorrhagic infarction is seen.

Bone Complication

• POTT'S PUFFY TUMOR

The marked swelling over the right orbit is due to an infection of the frontal bone (frontal sinusitis and frontal bone osteomyelitis). In this case the infection has spread directly to the epidural space - hence the altered sensorium. Pott's Puffy Tumor accounts for about 40% of epidural abscesses; these patients are likely to present with fever (60%), headache (40%), nuchal rigidity (35%), seizures (10%), and focal neurological deficits (5%).

The cause of Pott's Puffy Tumor is usually streptococci or anaerobic organisms. Overall, about two-thirds of intracranial abscesses arise from infection involving the paranasal sinuses, middle ear, or mastoid.

Osteomyelitis (POTT'S PUFFY TUMOR)

Chronic Complication

• Paranasal sinus mucocoeles represent complete opacification of one or more paranasal sinuses by mucous, often associated with bony expansion.

• Mucoceles most likely occur as a result of obstruction of the ostium of a sinus with resultant accumulation of mucus and eventual expansion of the sinus.

• The frontal sinus is particularly prone to developing a mucocoeles, and up to two-thirds of all mucocoeles occur there. The ethmoidal sinuses rare the next most common, whereas maxillary and sphenoidal sinuses are infrequently involved.

• Mucocoeles are best imaged with a combination of CT (to assess bony changes) and MRI (to assess any extension into the orbit or intracranial compartment).

Mucocoeles

• Involving frontal sinus • Involving ethmoid sinus