Tag: Complications of Sinusitis

Complications of Sinusitis

Complications of Sinusitis


COMPLICATIONS OF SINUSITIS

  • Pansinusitis
  • Otits media,Pharyngitis,Laryngitis,Tracheo-bronchitis.
  • Osteomyelitis of the Maxilla due to maxillary sinusitisMucocele
  • Characterized by pain and swelling in the maxillary region.Radiological examination may show bony necrosis.
  • Treatment:Surgical Drainage through medial wall of Antrum
  • Oro-antral Fistula
  • Dental Abscess

Ophthalmic complications:

  • Peri-orbital and Orbital Cellulitis or Abscess
  • May occur secondary to Maxillary,Ethmoid  or Sphenoid Sinusitis.
  • May occur due to Faciomaxillary trauma and as a complication of Endoscopic sinus surgery.
  • Orbital complications are commoner in children.
  • In case of Orbital Abscess-early drainage is required to prevent pressure necrosis of orbital nerve and blindness.
  • Surgical Drainage via incision in the superomedial aspect of the orbit.

Osteomyelitis of frontal bone due to Frontal Sinusitis

  • May be associated with sequestrum formation and fistula may form.
  • Oedema of the forehead situated slighly above the upper limit of frontal sinus called Pott’s Puffy Tumor.
  • Treatment: Surgical Drainage through floor of sinus
  • Cavernous Sinus Thrombophlebitis

Etiology:

  • Infection may spread from:
  • a.)Paranasal Sinuses:particularly Ethmoidal,Sphenoidal and Frontal Sinuses.
  • b.)Dangerous Area of the face:including external nose,vestibule,septum and upper lip.
  • c.)Orbital Cellulitis and Abscess
  • The spread is via Ophthalmic veins.

Clinical Features:

  • General: fever,malaise,rigors,septicemia,pyemia
  • Ophthalmic: Swelling of the eyelids with chemosis and proptosis.Ophthalmoplegia.Pupils become dilated and fixed with optic disc edema and loss of vision.
  • Cranial Nerves: 3rd,4th,5th,6th cranial nerves may get paralyzed.
  • Investigations:Treatment:Antibiotics,Anticoagulants,Treatment of the primary cause.
  • Blood culture,Fundoscopy,CT scan
  • Intracranial Complications: Epidural Abscess,Subdural Abscess,Meningitis and Frontal lobe Abscess.
  • Frontal lobe abscess:
  • Personality changes may occur in case of frontal lobe absess.

Exam Question

  • Pott’s puffy tumor is a complication of frontal sinusitis due to osteomyelitis of frontal bone . 
  • The probable diagnosis in a patient with history of running nose and pain over 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.
Don’t Forget to Solve all the previous Year Question asked on Complications of Sinusitis

Complications of Sinusitis

Complications of Sinusitis

Q. 1

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

Q. 1

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

Ans. A

Explanation:

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, www.sepeap.org/archivos/pdf/10126.pdf]

  • 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.


Q. 2

Scenario: A 35 year old female presented with acute sinusitis to the ENT specialist. On examination she noticed a swelling over the frontal sinus which is soft doughy in nature and extremely tender.
 
Assertion: Pott’s puffy tumor is a complication of frontal sinusitis.
 
Reason: The presentation is due to osteomyelitis of frontal bone.
 
 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

Q. 2

Scenario: A 35 year old female presented with acute sinusitis to the ENT specialist. On examination she noticed a swelling over the frontal sinus which is soft doughy in nature and extremely tender.
 
Assertion: Pott’s puffy tumor is a complication of frontal sinusitis.
 
Reason: The presentation is due to osteomyelitis of frontal bone.
 
 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

Ans. A

Explanation:

Osteomyelitis of frontal bone results from acute infection of frontal sinus either directly or through the venous spread.

 

Q. 3

Pott puffy tumour occurs as complication of which sinusitis:

 A

Frontal

 B

Sphenoid

 C

Ethmoid

 D

None of the above

Q. 3

Pott puffy tumour occurs as complication of which sinusitis:

 A

Frontal

 B

Sphenoid

 C

Ethmoid

 D

None of the above

Ans. A

Explanation:

If infection in the frontal sinus spreads to the marrow of the frontal bone, localized osteomyelitis with bone destruction can result in a doughy swelling of the forehead classically described as Pott puffy tumour.
 

Q. 4

A patient with history of running nose and pain over 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

Q. 4

A patient with history of running nose and pain over 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

Explanation:

Patients with CST appear quite ill with abrupt onset of fever, headache, nuchal rigidity, nausea, vomiting & eye pain. Testing of cranial nerves reveal unilateral or bilateral palsies of CN III, IV & VI as well as sensory deficits in the ophthalmic branch of trigeminal nerve. Eye findings may include orbital edema & tenderness, retinal haemorrhages, papilledema, proptosis & dilated or sluggish pupils.

It is difficult to differentiate CST from other options based on clinical features. The presence of lateral gaze palsy is typically seen in CST and not in others.

Ref: Greenberg’s text-atlas of emergency medicine – Page 49.


Q. 5

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

Q. 5

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

Ans. A

Explanation:

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.

Think Detail:
Cavernous sinus: is located on the side of the body of sphenoid. The cavernous sinuses consist of extradural venous plexuses surrounded by a dural fold.

 

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.

Clinical features:
Infection of the cavernous sinus is characterized by sepsis, orbital pain, chemosis, proptosis, and ophthalmoplegia. Cavernous sinus thrombosis results in paresis of cranial nerves III, IV, and VI and the opthalmic and maxillary divisions of the cranial nerve V. 
The diagnosis is based primarily on clinical data. CT and MR imaging can provide diagnostic information.Treatment is with broad spectrum antibiotics and should be started early .This has high mortality.
 
Cavernous sinus syndrome: is characterized by multiple cranial neuropathies. The clinical presentation includes impairment of ocular motor nerves, Horner’s syndrome, and sensory loss of the first or second divisions of the trigeminal nerve in various combinations. The pupil may be involved or spared or may appear spared with concomitant oculosympathetic and parasympathetic involvement.
 
Ref: 1) Comprehensive opthalmology,by AK Khurana,4th Edition, Page 384-389; 
2) Parsons ‘ Diseases of the Eye, 20th Edition, Page 456-459;

Q. 6

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

Q. 6

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

Ans. C

Explanation:

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.

However, orbital cellulites term is reserved for infections behind the orbital septum which may or may not spill over to lids. Bacterial OC is more common in children and fulminant infection (& ischemic infarction) with Mucor or Aspergillus typically affects patients with diabetes (esp ketoacidosis) and immunosuppression. Presentation is Extensive swelling of lids with chemosis often obscure proptosis (i.e. most commonly lateral & downwards). Proptosis with impaired mobility resulting in diplopia Pain is severe, increased by movement of eye or pressure Unilateral, tender, warm & red periorbital edema. Painful opthalmoplegia

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.

Orbit abscess usually pointing, towards skin of lid near orbital margin or conjunctival fornix is rare in sinus related but common in post traumatic or post operative cases. Panopthalmitis may supervene & there is grave danger of Meningitis, cerebral symptoms and cavernous sinus thrombosis, (CST). CST should be suspected when there is evidence of bilateral involvement, rapidly progressive proptosis, and congestion of facial, conjunctival and retinal veins. Additional features include abrupt progression of clinical signs a/w prostration, severe headache, nausea and vomittingQ.

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


Q. 7

A patient with history of running nose and pain over 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 Sundrome

Q. 7

A patient with history of running nose and pain over 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 Sundrome

Ans. C

Explanation:

C i.e. Cavernous Sinus Thrombosis


Q. 8

Complications of acute sinusitis:

 A

Orbital cellulitis

 B

Pott’s puffy tumor

 C

Conjunctival chemosis

 D

All

Q. 8

Complications of acute sinusitis:

 A

Orbital cellulitis

 B

Pott’s puffy tumor

 C

Conjunctival chemosis

 D

All

Ans. D

Explanation:



Q. 9

Orbital cellulitis is a complication of:

 A

Parasinusitis

 B

Faciomaxillary trauma

 C

Endoscopic sinus surgery

 D

All of these

Q. 9

Orbital cellulitis is a complication of:

 A

Parasinusitis

 B

Faciomaxillary trauma

 C

Endoscopic sinus surgery

 D

All of these

Ans. D

Explanation:

Q. 10

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

Q. 10

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

Ans. A

Explanation:

 

  • 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.

Q. 11

Cavernous sinus thrombosis following sinusitis results in all of the following signs except:

 A

Constricted pupil in response to light

 B

Engorgement of retinal veins upon ophthalmoscopic examination

 C

Ptosis of eyelid

 D

Ophthalmoplegia

Q. 11

Cavernous sinus thrombosis following sinusitis results in all of the following signs except:

 A

Constricted pupil in response to light

 B

Engorgement of retinal veins upon ophthalmoscopic examination

 C

Ptosis of eyelid

 D

Ophthalmoplegia

Ans. A

Explanation:

 

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.


Q. 12

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

Q. 12

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

Ans. A

Explanation:

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.


Q. 13

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

Q. 13

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. A

Explanation:

Ans. Cavernous sinus thrombosis



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