Complications of Sinusitis
A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is
| A |
Cavernous sinus thrombosis |
|
| B |
Orbital cell ulitis |
|
| C |
Acute Ethmoidal sinusitis |
|
| D |
Orbital apex syndrome |
A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is
| A |
Cavernous sinus thrombosis |
|
| B |
Orbital cell ulitis |
|
| C |
Acute Ethmoidal sinusitis |
|
| D |
Orbital apex syndrome |
Cavernous sinus thrombosis [Ref:Khurana 4/e, p 384-389; Parsons’ 20/e, p 456-459; Dhingra ENT 5/e, p 213-214; Yonoff & Duker Ophthalmology 1076-1077, 1460-1461; http://en.wikipedia.org/wiki/cavernous_sinus_thrombosis, http://emedicine.medscape.com/article/791704-overview, http://www.sepeap.org/archivos/pdf/10126.pdf%5D
- Repeated pain over medial canthus and chronic use of nasal decongestants suggest chronic ethmoidal sinusitis.
- Patient’s other symptoms suggest that she has landed up in complicated sinusitis
- Now lets see the symptoms one by one ?
There is sudden onset of ?
– Chills & rigor Systemic symptoms
– Diplopia on lateral gaze –> s/o VI C.N. (abducent) involvement leading to lateral rectus palsy
– Proptosis & chemosis
b/o venous congestion
– Optic disc congestion
- So, among the given options ?
- Orbital apex syndrome (OAS) can be ruled out as visual loss is often the initial manifestations of an OAS (not seen in this patient).
|
Orbital apex syndrome •Orbital apex syndrome is caused by any etiology (infective, neoplastic,granulomatous inflammation or traumatic) that involves the structures in the orbital apex (posterior orbit). Orbital apex consists of the superior orbital fissure + optic canal. Thus so: Orbital apex syndrome Superior orbital fissure syndrome + optic nerve signs •Superior orbital fissure syndrome is caused by involvement of all extraocular peripheral nerves passing through the superior orbital fissure i.e. III, IV, VI, & VI. •Orbital apex syndrome is characterized by: – Ophthalmoplegia (due to paresis of III, IV, VI, & VI cranial nerves), – Ptosis, – Anaesthesia in the region supplied by ophthalmic division of Vth nerve (decreased corneal sensation and -Early visual loss and afferent papillary defect (caused by optic nerve involvement). |
- The remaining two options; cavernous sinus thrombosis & orbital cellulitis can impose adignostic difficulty. Both of these have almost similar presentation with some differences.
- Abrupt onset of chills & rigor, mod. proptosis and lateral gaze palsy favour cavernous sinus thrombosis (CST). In orbital cellulitis onset is slow & systemic features are mild & there is restricted ocular movement in all directions from the beginning.
- Optic disc congestion & vision loss in late stages are found both in CST & orbital cellulitis.
| Differences in CST, Orbital cellulitis & OAS |
|
Clinical features |
CST |
Orbital Cellulitis |
OAS |
|
Onset |
Abrupt |
Slow |
Slow |
|
Systemic features |
Marked |
Mild |
Mild |
|
Laterality |
Initially unilateral, but can become bilateral in more than 50% cases |
Unilateral |
Unilateral |
|
Proptosis |
Moderate |
Marked |
Mild to moderate |
|
Chemosis |
Moderate |
Marked |
Mild |
|
Vision |
Not affected in early stages |
Not affected in early stages |
Lost in early stages |
|
Ophthalmo- plegia |
Sequential & complete -4 lateral gaze palsy to start with ,as 6th C.N. is involved first* |
Concurrent & complete |
Concurrent & complete |
|
Edema in mastoid region |
Present (Diagnostic sign) |
Absent |
Absent |
*6th cranial nerve passes through the cavernous sinus (separated only by endothelial lining), so is involved first in CST.
| A | Both Assertion and Reason are true, and Reason is the correct explanation for Assertion | |
| B | Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion | |
| C |
Assertion is true, but Reason is false |
|
| D |
Assertion is false, but Reason is true |
- Osteomyelitis of frontal bone results from an acute infection of frontal sinus either directly or through the venous spread.
- Pott’s puffy tumor is a complication of frontal sinusitis due to osteomyelitis of frontal bone.
- The probable diagnosis in a patient with a history of running nose and pain over the medial aspect of the eye presenting with sudden onset of high-grade fever, prostration, chemosis, proptosis and diplopia on lateral gaze with congestion of the optic disc would be Cavernous Sinus Thrombosis.
- Complications of acute sinusitis are Orbital cellulitis, Pott’s puffy tumor, and Conjunctival chemosis.
- Orbital cellulitis may occur as a complication of Parasinusitis, Faciomaxillary trauma, Endoscopic sinus surgery.
- Frontal lobe abscess may be associated with fever, papilloedema, Personality changes, and headache
Pott’s puffy tumour occurs as a complication of which sinusitis:
| A |
Frontal |
|
| B |
Sphenoid |
|
| C |
Ethmoid |
|
| D |
None of the above |
- Pott’s puffy tumor is a osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and edema over the forehead and scalp.
- It is a complication of frontal sinusitis or trauma.
A patient with a history of running nose and pain over the medial aspect of the eye presents with sudden onset of high-grade fever, prostration, chemosis, proptosis, and diplopia on lateral gaze with congestion of the optic disc. Which of the following is the most likely diagnosis?
| A |
Acute ethmoidal sinusitis |
|
| B |
Orbital Cellulitis |
|
| C |
Cavernous Sinus Thrombosis |
|
| D |
Orbital Apex Syndrome |
- Ans.C. Cavernous sinus thrombosis
- Patients with Cavernous Sinus thrombosis appear quite ill with abrupt onset of fever, headache, nuchal rigidity, nausea, vomiting & eye pain. Testing of cranial nerves reveals unilateral or bilateral palsies of CN III, IV & VI as well as sensory deficits in the ophthalmic branch of the trigeminal nerve. Eye findings may include orbital edema & tenderness, retinal hemorrhages, papilloedema, proptosis & dilated or sluggish pupils.
- The presence of lateral gaze palsy is typically seen in CST and not in others.
A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is:
| A |
Cavernous sinus thrombosis |
|
| B |
Orbital cellulitis |
|
| C |
Acute Ethmoidal sinusitis |
|
| D |
Orbital apex syndrome |
Patient is suffering from cavernous venous thrombosis, as a complication of chronic ethmoidal sinusitis. The facial veins make clinically important connections with the cavernous sinus through the superior ophthalmic veins. Cavernous sinus thrombosis usually results from infections in the orbit, nasal sinuses, and superior part of the face.
Structures
|
Within its cavity |
Internal carotid artery Abducent nerve
Carotid sympathetic plexus
|
|
Lateral wall |
Oculomotor nerve Trochlear nerve
Opthalmic division of trigeminal nerve
Maxillary division of trigeminal nerve
|
Tributaries:
|
Anteriorly |
Opthalmic veins (connects with the facial vein) |
|
Posteriorly |
Superior petrosal sinus (connects with transverse sinus)
Inferior petrosal sinus (conncets with internal juglar vein)
|
|
Medially |
Anterior and posterior intercavernos sinuses (connects the two cavernous sinuses) |
|
Superiorly |
Superficial middle cerebral vein (from latwral surface of the brain) Cerebrsl veins from inferior surface of brain
|
Cavernous sinus thrombosis (CST) is a late complication of facial or paranasal sinus infection, resulting in thrombosis of the cavernous sinus and inflammation of its surrounding anatomic structures, including cranial nerves.
A Young girl with previous history of repeated pain over medial canthus and chronic use of decongestants now presents with intense chills, rigors, and diplopia on lateral gaze. Examination shows optic disc congested.
Most likely diagnosis would be:
| A | Ethmoidal Sinusitis | |
| B |
Orbital Cellulitis |
|
| C |
Cavernous Sinus Thrombosis |
|
| D |
Orbital Apex syndrome |
C i.e. Cavernous Sinus Thrombosis
Periostitis
- It is rare inflammation of periosteum mostly affecting orbital margin.
- Mostly d/t trauma, TB, syphilis or extension of inflammation from neightbouring tissue.
- Deep orbit involvement causes less definite signs.
- There may be pain of deep seated nature, proptosis with deviation of direction of eye
- If apex of orbit is involved (orbital apex syndrome) various ocular motor palsies may develop with trigeminal anaesthesia & neuralgia and occasionly amaurosis d/t involvement of optic nerveQ.
Orbital Cellulitis (OC)
It is a purulent inflammation of cellular tissue of orbit. It is most common d/t extension of inflammation from neighbouring tissue esp nasal sinuses (mc. ethmoid). Other less common causes are penetrating injuries (esp with retained foreign
body with in 72 hours), septic operations, posterior extension of suppurative infections of eyelids or eyeball eg panopthalmitis, facial erysipelas, or dacrocystitis, metastases in pyaemia
Preseptal orbital cellulites involves structures anterior to orbital septum i.e. largely lids and presents as a swelling of lids, with erythema, chemosis and conjunctival discharge. But there is no proptosis, or restriction of ocular movements or visual function.
Rapid onset of severe malaise, fever, pain
Vision may be impaired owing to retrobulbar optic neuritis or compression of otic nerve or its blood supply at the apex of orbit
Fundus is difficult to examine; it may be normal or show engorgement of veins and optic neuritis developing later into optic atrophy.
Cavernous Sinus Thrombosis
- Infection may occur via obital veins, as in septic lesions of face, orbital cellulites, erysipelas, and infective conditions of mouth, pharynx, ear, nose and accessory sinuses, or as a metastasis in infectious diseases or septic condition.
- The patient presents with almost same features as in orbital cellulites, but with systemic symptoms such as fever, rigors, vomiting, headache, altered sensorium and severe cerebral symptomsQ.
- Another important diagnostic feature is transference of symptoms to the fellow eye 0, which occurs in 50% of cases where as bilateral orbital cellulitis is very rare. The first sign of other eye involvement is often paralysis of the opposite lateral rectus Q & this should be carefully watched for in any suspicious case of inflammatory unilateral proptosis.
- These is severe supra orbital pain d/t involvement of ophthalmic division of trigeminal nerve, and paresis of ocular motor nerves.
- In later stages pupil is dilated, eye immobilized and cornea anesthetic.
- Proptosis occurs in almost all cases, but is of late onset in cases of otic origin.
- Retinal veins may be greathy engorged and when this occurs it is usually accompanied by pronounced disc swelling (both indicating extensive implication of orbital veins)
- Bilateral (but more pronounced on the side of aural lesion), typical papilledema is most common in otitic cases & indicate meningitis or cerebral abscess
- Simultaneous bilateral CST, with proptosis and disc swelling, occurs in disease of sphenoid sinuses.
- Edema in the mastoid region behind the ear (d/t thrombosis of emissary vein) confirms the diagnosis.
|
Feature |
Cavernous sinus thrombosis |
Orbital cellulites |
Panopthalmitis |
|
Leteralality |
Unilateral initially but very soon becomes bilateral |
Unilateral |
Unilateral |
|
Proptosis (degree) |
Moderate |
Marked |
Moderate |
|
Vison |
Initially not affected |
Initially not affected |
Complete loss from beginning |
|
Cornea & anterio chamber |
Initially clear |
Initially clear |
Hazy d/t corneal edem, Pus in anterior chamber |
|
Ocular movements |
Complete limitation to palsy |
Markedly limited |
Painful & limites |
|
Mastoid edema |
Present |
No |
No |
|
Systemic systems eg fever etc. |
Marked |
Mild |
Mild |
| A | Acute ethmoidal sinusitis | |
| B |
Orbital Cellulitis |
|
| C |
Cavernous Sinus Thrombosis |
|
| D |
Orbital Apex Sundrome |
C i.e. Cavernous Sinus Thrombosis
Complications of acute sinusitis:
| A |
Orbital cellulitis |
|
| B |
Pott’s puffy tumor |
|
| C |
Conjunctival chemosis |
|
| D |
All |
Orbital cellulitis is a complication of:
| A |
Parasinusitis |
|
| B |
Faciomaxillary trauma |
|
| C |
Endoscopic sinus surgery |
|
| D |
All of these |
A 24-year-old female with long standing history of sinusitis present with fevers, headache (recent origin) and personality changes; Fundus examination revealed papilledema. Most likely diagnosis is:
| A |
Frontal lobe abscess |
|
| B |
Meningitis |
|
| C |
Encephalitis |
|
| D |
Frontal bone osteomyelitis |
- Patient is presenting with fever, headache and personality changes which is typical of frontal lobe abscess (which is a complication of chronics sinusitis). In meningitis and encephalitis although patient presents with fever and headache, but personality changes are not seen.
- Frontal bone osteomyelitis (Pott’s puffy tumor) presents as doughy swelling on forehead.
| A |
Constricted pupil in response to light |
|
| B |
Engorgement of retinal veins upon ophthalmoscopic examination |
|
| C |
Ptosis of eyelid |
|
| D |
Ophthalmoplegia |
Ptosis and ophthalmoplegia occur in cavernous sinus thrombosis due to involvement of III, IV and V cranial nerves.
Retinal vessels are also engorged but pupils are fixed and dilated (not constricted), due to involvement of III nerve and sympathetic plexus.
A young female patient with long history of sinusitis presented with frequent fever along with personality changes and headache of recent origin. The fundus examination revealed papilledema. The most likely diagnosis is :
| A |
Frontal lobe abscess |
|
| B |
Meningitis |
|
| C |
Encephalitis |
|
| D |
Frontal bone osteomyelitis |
Answer is A (Frontal lobe abscess) :
Development of headache, fever and papilledema in the setting of sinusitis suggest an infective pathology causing raised introcranial tension. Further, presence of personality changes suggest a mass lesion affecting the frontal lobe. A brain abscess typically presents as an expanding intracranial mass lesion, and the presence of personality changes limits such a mass lesion to the frontal lobe. A frontal lobe abscess thus explains the presence of an infectious mass lesion causing personality changes.
A 19 years old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills and rigor, diplopia on lateral gaze, moderate proptosis and chemosis. On examination optic disc is congested. Most likely diagnosis is:
| A |
Cavernous sinus thrombosis |
|
| B |
Orbital cellulitis |
|
| C |
Acute ethmoidal sinusitis |
|
| D |
Orbital apex syndrome |
Ans. Cavernous sinus thrombosis
Friends alwasy remember in cavernous sinus thrombosis there is bilateral orbital involvement whereas in orbital celiulitisit, it is unilateral.
Differences between orbital cellulitis and cavernous sinus thrombosis
| Orbital Cellulitis | Cavernous sinus thrombosis | |
|
Source
Onset and progress Crania nerve involvement Side Toxemia Fever Mortality
|
Commonly ethmoid sinuses
Show Involved concurrently with complete ophthalmoplegia Usually involve affected side eye Absent Present Less
|
Nose, sinuses, orbit, ear and pharynx
Abrupt Involved individually and progressively Involves both eyes Present High temperature with chills Very high
|
