| Orbital
complications
Sinonasal disease accounts for the majority
of orbital infections (up to 85%). Ethmoid sinuses are almost
always implicated in orbital disease; maxillary and frontal
sinuses may also be involved. Spread may be direct with erosion
of the lamina or through a prior fracture or by thrombophlebitic
spread into the orbit.
Orbital complications as staged by Chandler
(1970) are: preseptal cellulitis, orbital cellulitis, subperiosteal
abscess, orbital abscess, and cavernous sinus thrombosis (dural
thrombophlebitis).
Symptoms of orbital disease include: erythema
or edema of the eyelids (common to all orbital infections),
proptosis and ophthalmoplegia (suggestive of orbital cellulitis
or orbital or subperiosteal abscess), decreased visual acuity
(associated with advanced infection.)
Intracranial complications
Intracranial (CNS) complications, namely,
meningitis, subdural empyema, epidural abscess and cerebral
abscess may all complicate acute and chronic sinusitis. The
ethmoids, frontal, and sphenoid sinusitis primarily responsible.
Infection is spread via thrombophlebitis or less commonly
via direct extension of infection.
Common symptoms of increased intracranial
pressure (ICP) (headache, altered mental status, fever, vomiting,
and stiff neck) as well as systemic toxicity usually occur.
The treatment for each of these complications
is similar. A CT scan to evaluate for other CNS complications
and cerebral midline shift or mass effect is necessary. In
cases of meningitis, this is followed by lumbar puncture and
culture if safe. High dose IV antibiotics with CSF penetration
are begun.
Neurosurgical consultation is strongly recommended,
even in cases that are not clearly immediately surgical. Management
of ICP and seizure prevention are necessary.
Meningitis is probably best treated by medical
management initially, after meningitis is controlled and if
it is believed to be due to sinusitis, the offending sinuses
can be opened and drained. If the meningitis cannot be controlled,
then more emergent sinus drainage may be required.
Bony complications
Osteomyelitis (and osteitis) are usually related to acute
frontal sinusitis and may be associated subperiosteal abscess,
the "Pott's puffy tumor" first described by Sir
Percival Pott (1760.) Presentation is that of brawny edema
of the brow with soft doughy swelling; usually there is forehead
pain, low grade fever and leukocytosis.
The spread of infection from the sinus is
either by the hematogenous route (retrograde thrombophlebitis)
or direct (via erosion or through existing fractures or dehiscences.)
CT scan can delineate the extent of disease and evaluate for
other CNS complications. Staph is implicated in the majority
of cases, also seen are Strep pneumo, B-hemolytic strep, anaerobes
in a few cases.
Long term IV antibiotics, as in other cases of osteomyelitis,
is required. Empirically nafcillin is used, followed by culture
specific antibiotics when cultures available. Drainage of
sinus as in the other types of complicated sinusitis is necessary,
usually via trephination or frontoethmoidectomy; ESS can be
used by experienced surgeons, but it may be difficult and
success is less reliable.
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