Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4407_Библиотеки_им_академика_М_И_Перельмана
.pdf
216
https://t.me/med1917
SECTION II — Diseases of Nose and Paranasal Sinuses
be irrigated with normal saline two or three times daily
until frontonasal duct becomes patent. This can be determined by adding a few drops of methylene blue to
the irrigating fluid and its exit seen through the nose.
Drainage tube is removed when frontonasal duct becomes patent.
COMPLICATIONS
1. Orbital cellulitis.
2. Osteomyelitis of frontal bone and fistula formation.
3. Meningitis, extradural abscess or frontal lobe abscess,
if infection breaks through the posterior wall of the
sinus.
4. Chronic frontal sinusitis, if the acute infection is neglected or improperly treated.
ACUTE ETHMOID SINUSITIS
AETIOLOGY
Acute ethmoiditis is often associated with infection of
other sinuses. Ethmoid sinuses are more often involved
in infants and young children.
CLINICAL FEATURES
1. Pain. It is localized over the bridge of the nose, medial
and deep to the eye. It is aggravated by movements of
the eye ball.
2. Oedema of lids. Both eyelids become puffy and swollen. There is increased lacrimation. Orbital cellulitis is
an early complication in such cases.
3. Nasal discharge. On anterior rhinoscopy, pus may be
seen in middle or superior meatus depending on the
involvement of anterior or posterior group of ethmoid
sinuses.
4. Swelling of the middle turbinate.
Visual deterioration and exophthalmos indicate abscess in the posterior orbit and may require drainage of
the ethmoid sinuses into the nose through an external
ethmoidectomy incision.
COMPLICATIONS
1. Orbital cellulitis and abscess.
2. Visual deterioration and blindness due to involvement
of optic nerve.
3. Cavernous sinus thrombosis.
4. Extradural abscess, meningitis or brain abscess.
ACUTE SPHENOID SINUSITIS
AETIOLOGY
Isolated involvement of sphenoid sinus is rare. It is often
a part of pansinusitis or is associated with infection of
posterior ethmoid sinuses.
CLINICAL FEATURES
1. Headache. Usually localized to the occiput or vertex.
Pain may also be referred to the mastoid region.
2. Postnasal discharge. It can only be seen on posterior
rhinoscopy. A streak of pus may be seen on the roof
and posterior wall of nasopharynx or above the poste-
rior end of middle turbinate.
X-rays. Opacity or fluid level may be seen in the sphenoid sinus. Lateral view of the sphenoid sinus is taken in
supine or prone position and is helpful to demonstrate
the fluid level. CT scan is more useful.
DIFFERENTIAL DIAGNOSIS
Mucocele of the sphenoid sinus or its neoplasms may
clinically simulate features of acute infection of sphenoid
sinus and should always be excluded in any case of isolated sphenoid sinus involvement.
TREATMENT
Medical treatment is the same as for acute maxillary
sinusitis.
TREATMENT
Treatment is the same as for acute infection of other
sinuses.
Chapter 37
https://t.me/med1917
Chronic Rhinosinusitis
DEFINITION
It is a chronic inflammatory disease of nasal and paranasal sinus mucosa where symptomatology has continued beyond
12 weeks. Sometimes there are acute exacerbations superimposed on chronic rhinosinusitis (CRS), where symptoms
worsen but return to baseline of CRS after treatment.
AETIOLOGY
It is a multifactorial disease caused by infection (bacterial)
or inflammatory processes (allergy, eosinophilic vasculitis
or sarcoidosis). For clinical purposes, it is divided into two
categories:
1. CRS without polyps
2. CRS with polyps
CRS Without Polyps
It is bacterial in origin; several of them have been isolated. Some cases are due to progression of acute → subacute → chronic rhinosinusitis. Bacteriology of CRS is
different from that of acute rhinosinusitis. Organisms
isolated in CRS are Staphylococcus aureus, Pseudomonas
aeruginosa, Klebsiella pneumoniae and Escherichia coli. Anaerobic organisms are also found. Thus bacteriology is diverse and polymicrobial in nature. In many cases it is a
progression from acute rhinosinusitis where bacteria have
become resistant due to inadequate treatment in terms of
dose and duration of administration of antibiotics. There
are also predisposing factors which initiate or cause progression of the disease.
predisposing Factors (table 37.1)
1. Structural deformities. Deformities such as deviated septum, concha bullosa and prominent agger nasi cells,
etc. (Table 37.2) which compromise ostiomeatal com-
plex, lead to sinusitis of the frontal, maxillary, ethmoid
or sphenoid sinuses. Events following sinus ostial obstruction are shown in Figure 37.1.
2. Impairment of mucociliary clearance. Cilia are important
to clear normal sinus secretions. Loss of ciliary function can result from infection, inflammation and toxins (such as pollution and smoking). In primary ciliary dysfunction, cilia are defective and nonfunctional.
Ciliary function is also disrupted by environmental
pollution and occupational noxious gases.
3. Cystic fibrosis and Young syndrome. Mucus is too thick
and viscous to be moved by cilia.
4. Osteitis/osteomyelitis. Bacterial infection set up inflammatory changes in the bone with subsequent reactive
mucosal inflammation which becomes chronic and
nonresponsive to treatment. It is more often seen after
nasal and paranasal sinus surgery.
5. Dental infections. Premolars and molars are related
to the maxillary sinus. Dental infections, root abscesses, orodental fistula following tooth extractions
and foreign bodies during root canal treatment introduce infections into sinus. Dental infections are
polymicrobial in nature and also have anaerobic organisms.
6. Asthma. It is estimated that nearly half of the cases of
CRS have asthma.
7. Allergy. It causes oedema of the nasal mucosa and obstructs the sinus ostia.
TABLE 37.1 PREDISPOSING FACTORS FOR
CHRONIC RHINOSINUSITIS
Patient factors
• Anatomicstructuraldeformitiesobstructingsinusostia
• Smoking
• Snuffdipping
• Prolongedintranasalmedications
• Primaryimmunedeciency
• IgG deficiency
• Acquiredimmunedeciency
• HIV
• Prolonged use of steroids
• Chemotherapy
• Use of immune suppressant drugs in organ transplant
patients
• Leukaemia
• Primary ciliary dyskinesia
• Cysticbrosis
• Aspirinsensitivity
Environmental factors
• Aeroallergens
• Allergic rhinitis and asthma
• Toxinsandchemicals
• Environmental pollution
• Occupational (chemicals, dust, noxious gases)
• Pathogens
• Bacteria (aerobic, anaerobic)
• Fungi
• Mycobacteria
TABLE 37.2 ANATOMICAL STRUCTURAL FACTORS
WHICH BLOCK OSTIA
• Conchabullosa
• Paradoxicalmiddleturbinate
• Conchabullosaofcontralateralsideandpushingtheseptum
• Septaldeviationpushingthemiddleturbinatelaterally
• Hallercellobstructingthedrainageofmaxillarysinus
• Inversionofuncinatedprocess
• Pneumatizationofuncinatedprocess
217
218
https://t.me/med1917
Figure 37.1. Sequence of events following sinus ostial obstruction
leading to chronic rhinosinusitis.
SECTION II — Diseases of Nose and Paranasal Sinuses
8. Biofilm. It is a protective mechanism by which microorganisms form a polysaccharide film around their
colonies. The film, though permitting nutrients to
organisms and providing an exit for excretions, is impervious to antibiotics, leading to bacterial resistance,
chronicity and refractoriness to treatment.
pathophisiology. CRS is a multifactorial disease.
The causative factors form a vicious cycle depicted in
Figure 37.2. The cycle runs in both clockwise and anti-
clockwise directions.
symptoms. The cardinal symptoms of CRS with polyps are:
1. nasal obstruction,
2. nasal or postnasal purulent discharge,
3. facial pain and pressure, and
4. disturbance of smell (hyposmia or anosmia).
signs. Endoscopic examination of nose may reveal:
1. oedema of nasal mucosa in the anterior or posterior
ostiomeatal complex and
2. purulent discharge.
Nasal endoscopy should be done first without and
then with a nasal decongestant.
diagnosis. At least two of the aforementioned symptoms and one of the signs should be present to make the
diagnosis.
CT scan of the sinuses will reveal mucosal inflamma-
tion, the extent of disease and any predisposing factors.
treatment
MeDicaL
1. Antibiotics. As the disease is polymicrobial in nature,
broad-spectrum antibiotics should be chosen based
on the culture and sensitivity of discharge from the
middle meatus. Many of the organisms are resistant
to antibiotics. S. aureus may be methicillin resistant.
A low-dose prolonged treatment with macrolide has
been given (more than 12 weeks). Macrolides are bacteriostatic and also have an anti-inflammatory effect.
2. Saline irrigations. They help to wash out bacteria and
also disrupt biofilms.
3. Topical decongestants. They provide the symptomatic
relief from nasal obstruction and open the sinus ostia.
They are preferably used a few minutes before a steroid
spray, so that the spray can reach all decongested areas.
4. Steroid sprays. Steroids are anti-inflammatory in nature
and relieve oedema.
5. Anti-allergy treatment. Patients who are allergic benefit
by the use of antihistamines and leukotriene receptor antagonists (such as montelukast). Antihistamines
thicken the mucus.
Figure 37.2. Causative factors and pathophysiology of chronic sinusitis.
Chapter 37 — Chronic Rhinosinusitis
https://t.me/med1917
219
SurgicaL. Endoscopic sinus surgery is used for those
who fail medical treatment. Structural variants which
obstruct sinus drainage are corrected to provide drainage
and ventilation to sinuses.
Medical treatment should be continued after surgery
for long-term relief.
CRS With Polyposis
Polyp formation in the nose and sinuses can be due to infectious processes or systemic disorders such as (i) primary ciliary dyskinesia, (ii) cystic fibrosis, (iii) Samter triad
(aspirin sensitivity, nasal polypi and asthma), (iv) asthma
(7% of patients with asthma have polypi), (v) Churg–
Strauss syndrome (asthma, peripheral eosinophilia, pulmonary infiltrates and systemic eosinophilic vasculitis)
and allergic fungal sinusitis (see Chapter 32).
Symptomatology is similar to that seen in CRS without polyps but examination of nose shows multiple nasal
polyps. Ethmoidal polypi may be so extensive that they
erode into the orbit or extend to the anterior cranial fossa. A superadded infection and sinuses filled with purulent discharge may be seen.
diagnosis. It can be made easily on history, physical ex-
amination and imaging studies. CT scan of sinuses reveals
the extent of disease, predisposing structural abnormalities,
amount of destruction of bony walls and any extension to
orbit and cranial cavity. In case of suspected extension into
orbit or cranial cavity, MRI with contrast may be required.
treatment
1. Medical systemic steroids. They have anti-inflammatory
effects and prevent the release of cytokines. Due to
their side effects, prolonged use is not advised. They
have been used preoperatively to reduce size of polyps
and postoperatively to prevent recurrence.
2. Steroid nasal sprays. They decrease polyp size and oede-
ma of nasal mucosa.
3. Nasal irrigations. They are helpful in removing patho-
gens, allergen load and thick mucus.
4. Antibiotics. They can be used in cases of acute exacerba-
tions of CRS with Streptococcus pneumoniae, Haemophi-
lus influenzae and Moraxella. Antibiotics remove bacte-
ria and down-regulate inflammatory mediators.
5. Management of allergy. In patients with history of
known allergies, immunotherapy may be prescribed.
6. Treatment of asthma. Asthma is a co-morbid condition
in case of CRS and should be treated with help from a
respiratory physician.
Medical treatment often fails in massive nasal polyposis and requires endoscopic surgery. All polyps are removed, and drainage and ventilation provided to all involved sinuses.
Many cases require revision surgery for recurrence of
polypi.
Cases of cystic fibrosis and ciliary dyskinesia require
specific modifications of endoscopic surgery to provide
dependent drainage in maxillary and sphenoid sinuses
infections, as ciliary function is nonexistent and the mucus is too thick to allow drainage.
Older surgical techniques used to treat chronic sinusitis of individual sinuses are described in the following
section. Present day treatment of choice for CRS with
or without polypi is endoscopic sinus surgery popularly
called FESS (functional endoscopic sinus surgery).
OLDER SURGICAL TECHNIQUES FOR
CHRONIC SINUSITIS
CHRONIC MAXILLARY SINUSITIS
1. Antral puncture and irrigation. Sinus cavity is irrigated with a cannula passed through the inferior meatus.
Removal of pus and exudates helps the sinus mucosa
to revert to normal.
2. Intranasal antrostomy. It is indicated if sinus irriga-
tions fail to resolve infection. A window is created in
the inferior meatus to provide aeration to the sinus
and its free drainage.
3. Caldwell–Luc operation. In this operation, antrum
is entered through its anterior wall by a sublabial incision. All irreversible diseases are removed and a
window is created between the antrum and inferior
meatus.
Details of the above operations are described in the section on Operative Surgery.
CHRONIC FRONTAL SINUSITIS
1. Intranasal drainage operations. Correction of deviated septum, removal of a polyp or anterior portion
of middle turbinate, or intranasal ethmoidectomy provide drainage through the frontonasal duct. Treatment
of associated maxillary sinusitis also helps to resolve
chronic frontal sinusitis.
2. Trephination of frontal sinus (see p. 215).
3. External frontoethmoidectomy (Howarth’s or
Lynch operation). The frontal sinus is entered
through its floor by a curvilinear incision round the
inner margin of the orbit. Diseased mucosa is removed, ethmoid cells exenterated and a new frontonasal duct created.
4. Osteoplastic flap operation. It may be unilateral or
bilateral. A coronal or a brow incision is used. The anterior wall of frontal sinus is reflected as an osteoplastic
flap, based inferiorly. The diseased tissues are removed
and the sinus drained through a new frontonasal duct.
If it is desired to obliterate the sinus, all diseased as
well as healthy mucosa are stripped off and the sinus
obliterated with fat.
CHRONIC ETHMOID SINUSITIS
1. Intranasal ethmoidectomy. This operation is done
for chronic ethmoiditis with polyp formation. The
ethmoid air cells and the diseased tissue are removed
between the middle turbinate and the medial wall of
orbit by the intranasal route. The frontal and sphenoid
sinuses can also be drained by this operation.
2. External ethmoidectomy. In this operation, ethmoid
sinuses are approached through medial orbital incision. Access can also be obtained to sphenoid and
frontal sinuses and the operation is called fronto-
spheno-ethmoidectomy.
220
https://t.me/med1917
Figure 37.3. Aspergillus fungus. Note septate hyphae with acute angle branching (arrow). (A) H&E stain, ×200. (B) Gomori methenamine silver
stain, ×200.
SECTION II — Diseases of Nose and Paranasal Sinuses
CHRONIC SPHENOIDITIS
sphenoidotomy. Access to the sphenoid sinus can be
obtained by removal of its anterior wall. This is accomplished by external ethmoidectomy or trans-septal approach, usually the former, because of the coexistence of
ethmoid disease with chronic sphenoiditis.
FUNGAL INFECTIONS OF SINUSES
Many different species of fungi are found to involve the
paranasal sinuses; the more common being the Aspergil-
lus, Alternaria, Mucor or Rhizopus. They may involve single
or multiple sinuses. Four different varieties of fungal infection of sinuses are seen:
1. Fungal ball. It is due to implantation of fungus into an
otherwise healthy sinus which on CT shows a hyperdense area with no evidence of bone erosion or expansion. Maxillary sinus is the most commonly involved
followed by sphenoid, ethmoid and the frontal in that
order. Treatment is surgical removal of the fungal ball
and adequate drainage of the sinus. No antifungal
therapy is required.
2. Allergic fungal sinusitis. It is an allergic reaction to the
causative fungus and presents with sinunasal polyposis
and mucin. The latter contains eosinophils, CharcotLeyden crystals and fungal hyphae. There is no invasion of the sinus mucosa with fungus. Usually more
than one sinus are involved on one or both sides. CT
scan shows mucosal thickening with hyperdense areas.
There may be expansion of the sinus or bone erosion
due to pressure, but no fungal invasion. Treatment is
endoscopic surgical clearance of the sinuses with provision of drainage and ventilation. This is combined
with pre and postoperative systemic steroids.
3. Chronic invasive sinusitis. Here the fungus invades
into the sinus mucosa. There is bone erosion by fungus. Patient presents with chronic rhinosinusitis. CT
scan shows thickened mucosa with opacification of
sinus and bone erosion. Patient may have intracranial
or intraorbital invasion. Histopathology shows fungal
invasion of submucosa and granulomatous reaction
with multinucleated giant cells.
4. Fulminant fungal sinusitis. It is an acute presentation
and is mostly seen in immunocompromised or diabetic individuals. Common fungal species are Mucor or
Aspergillus (Figure 37.3).
• Mucor causes rhinocerebral disease. Due to invasion
of the blood vessels, mucor fungus causes ischaemic
necrosis presenting as a black eschar, involving inferior turbinate, palate or the sinus. It spreads to the face,
eye, skull base and the brain. Treatment is surgical debridement of necrotic tissue and i.v. amphotericin B.
• Aspergillus infection can also cause acute fulminant
sinusitis with tissue invasion. Such patients present
with acute sinusitis and develop sepsis and other sinus complications. Unlike Mucor infection, there is
no black eschar. Treatment is antifungal therapy and
surgery.
FUNCTIONAL ENDOSCOPIC SURGERY
OF SINUSES (FIGURES 37.4 AND 37.5)
Better understanding of the pathophysiology of recurrent and chronic sinusitis and the fact that most of the
changes are reversible, if proper drainage and ventilation
is provided to the sinuses has, in more recent years, led to
the development of endoscopic surgery of sinuses. This
Figure 37.4. Functional endoscopic surgery of paranasal sinuses
without monitor and camera.
Figure 37.5. Endoscopic surgery in progress. Endoscope and other
https://t.me/med1917
surgical instruments are passed through the nose and surgery performed
by looking at the monitor.
Chapter 37 — Chronic Rhinosinusitis
221
has further been made possible by advances in technology, such as development of:
1. Rigid endoscopes, which provide better illumination
and magnification and permit visualization of structures situated at different angles.
2. Microsurgical instruments, which permit precise and
limited surgery, directed at specific sites, to remove obstruction to the sinus ostia.
Endoscopes can also be passed through a cannula into
the maxillary sinus to visualize its interior and take accurate biopsies or deal with certain pathological conditions
such as small cysts and polyps.
With endoscopic surgery, it is now possible to cure
selected cases of chronic and recurrent infections of the
frontal, maxillary, ethmoid and sphenoid sinuses without resort to external operations (see section on Operative
Surgery).
Page left intentionally blank
https://t.me/med1917
Chapter 38
https://t.me/med1917
Complications of Sinusitis
As long as infection is confined only to the sinus mucosa,
it is called sinusitis. Complications are said to arise when
infection spreads into or beyond the bony wall of the
sinus (see Table 38.1 and Figure 38.1).
I. LOCAL COMPLICATIONS
A. MUCOCELE OF PARANASAL SINUSES
AND MUCOUS RETENTION CYSTS
The sinuses commonly affected by mucocele in the
order of frequency are the frontal, ethmoidal, maxillary
and sphenoidal. There are two views in the genesis of a
mucocele:
1. Chronic obstruction to sinus ostium resulting in accumulation of secretions which slowly expand the sinus
and destroy its bony walls.
2. Cystic dilatation of mucous gland of the sinus mucosa due to obstruction of its duct. In this case, wall of
mucocele is surrounded by normal sinus mucosa. The
contents of mucocele are sterile.
Mucocele of the frontal sinus (Figure 38.2) usually pre-
sents in the superomedial quadrant of the orbit (90%) and
displaces the eyeball forward, downward and laterally.
The swelling is cystic and nontender; egg-shell crackling
may be elicited. Sometimes, it presents as a cystic swelling
in the forehead (10%). Patient’s complaints are usually
mild and may include headache, diplopia and proptosis.
Imaging of the frontal sinus usually reveals clouding of
the sinus with loss of scalloped outline which is so typical
of the normal frontal sinus (see Figure 38.3). Treatment is
frontoethmoidectomy with free drainage of frontal sinus
into the middle meatus.
Mucocele of ethmoid sinuses causes expansion of the
medial wall of the orbit, displacing the eyeball forward
and laterally. In addition, it may cause a bulge in the
middle meatus of nose. A mucocele of the ethmoid can
be drained by an intranasal operation, uncapping the
ethmoidal bulge and establishing free drainage. Sometimes, it may require external ethmoid operation.
Mucous retention cyst of the maxillary sinus presents as a
retention cyst due to obstruction of the duct of seromucinous gland and usually does not cause bone erosion. It
is asymptomatic and is observed as an incidental finding on radiographs. No treatment is generally required
for asymptomatic retention cysts as most of them regress
spontaneously over a period of time.
Mucocele of the maxillary sinus can occur as a compli-
cation of chronic sinus inflammation when its ostium is
blocked. The sinus fills with mucus and its bony walls
get expanded due to expansile process. CT scan and MRI
can help in the diagnosis. A polyp, tumour or trauma in
the middle meatus may also obstruct the sinus ostium to
cause a mucocele.
Mucocele of sphenoid sinus or sphenoethmoidal mucocele
arises from slow expansion and destruction of sphenoid
and posterior ethmoid sinuses. Clinical features are those
of superior orbital fissure syndrome (involvement of CN
III, IV, VI and ophthalmic division of V) or orbital apex
syndrome which is superior orbital fissure syndrome with
additional involvement of optic and maxillary division
of trigeminal nerve. Exophthalmos is always present and
the pain is localized to the orbit or forehead. Some may
complain of headache in the occiput or vertex. Treatment
is external ethmoidectomy with sphenoidotomy. Anterior wall of the sphenoid sinus is removed, cyst wall uncapped and its fluid contents evacuated.
Pyocele or mucopyocele is similar to mucocele but its
contents are purulent. It can result from infection of a
mucocele of any of the sinuses.
Endoscopic surgery has replaced external operation of
the sinuses for treatment of all mucocele or mucopyoceles of various sinuses.
B. OSTEOMYELITIS
Osteomyelitis is infection of bone marrow and should be
differentiated from osteitis which is infection of the com-
pact bone. Osteomyelitis, following sinus infection, involves either the maxilla or the frontal bone.
1. Osteomyelitis of the maxilla. It is more often seen in
infants and children than adults because of the pres-
ence of spongy bone in the anterior wall of the maxilla.
Infection may start in the dental sac and then spread
to the maxilla, but less often, it is primary infection
of the maxillary sinus. Clinical features are erythema,
swelling of cheek, oedema of lower lid, purulent nasal
discharge and fever. Subperiosteal abscess followed by
fistulae may form in infraorbital region (Figure 38.4),
alveolus or palate, or in zygoma. Sequestration of bone
may occur. Treatment consists of large doses of anti-
biotics, drainage of any abscess and removal of the
sequestra.
Osteomyelitis of maxilla may cause damage to temporary or permanent tooth-buds, maldevelopment of
maxilla, oroantral fistula, persistently draining sinus or
epiphora.
2. Osteomyelitis of frontal bone (Figure 38.5). It is more
often seen in adults as frontal sinus is not developed
in infants and children. Osteomyelitis of frontal bone
results from acute infection of frontal sinus either directly or through the venous spread. It can also follow trauma or surgery of frontal sinus in the presence
of acute infection. Pus may form externally under
223
224
https://t.me/med1917
SECTION II — Diseases of Nose and Paranasal Sinuses
TABLE 38.1 COMPLICATIONS OF PARANASAL
SINUS INFECTION
A. Local • Mucocele/Mucopyocele
• Mucousretentioncyst
• Osteomyelitis
• Frontal bone (more common)
• Maxilla
B. Orbital • Preseptalinammatoryoedema
of lids
• Subperiostealabscess
• Orbitalcellulitis
• Orbitalabscess
• Superiororbitalssuresyndrome
• Orbitalapexsyndrome
C. Intracranial • Meningitis
• Extraduralabscess
• Subduralabscess
• Brainabscess
• Cavernoussinusthrombosis
D. Descending infections
E. Focal infections
Figure 38.3. CT scan of mucocele of the left frontoethmoid region.
Note the left eyeball has been displaced downwards and laterally
(arrows) (different patient).
Figure 38.1. Complications of sinusitis.
Figure 38.2. Mucocele of frontal sinus. Note swelling above the
medial canthus of left eye (arrow).
Figure 38.4. Osteomyelitis of maxilla with fistula formation in
infraorbital region (arrow).
the periosteum as soft doughy swelling (Pott’s puffy
tumour), or internally as an extradural abscess. Treat-
ment consists of large doses of antibiotics, drainage
of abscess and trephining of frontal sinus through its
floor. Sometimes, it requires removal of sequestra and
necrotic bone by raising a scalp flap through a coronal
incision (Figure 38.5).
II. ORBITAL COMPLICATIONS
Orbit and its contents are closely related to the ethmoid,
frontal and maxillary sinuses, but most of the complications, however, follow infection of ethmoids as they
Figure 38.5. Case of chronic frontal sinusitis presenting with a fistula
https://t.me/med1917
exuding pus in the floor of the sinus.
are separated from the orbit only by a thin lamina of
bone—lamina papyracea. Infection travels from these
sinuses either by osteitis or as thrombophlebitic process
of ethmoidal veins.
Orbital complications include:
1. Inflammatory oedema of lids. This is only reactionary. There is no erythema or tenderness of the lids
which characterises lid abscess. It involves only preseptal space, i.e. lies in front of orbital septum. Eyeball
movements and vision are normal. Generally, upper
lid is swollen in frontal, lower lid in maxillary, and
both upper and lower lids in ethmoid sinusitis.
2. Subperiosteal abscess. Pus collects outside the bone
under the periosteum. A subperiosteal abscess from
ethmoids forms on the medial wall of orbit and displaces the eyeball forward, downward and laterally;
from the frontal sinus, abscess is situated just above
and behind the medial canthus and displaces the eyeball downwards and laterally; from the maxillary sinus,
abscess forms in the floor of the orbit and displaces the
eyeball upwards and forwards.
3. Orbital cellulitis. When pus breaks through the periosteum and finds its way into the orbit, it spreads between the orbital fat, extraocular muscles, vessels and
nerves. Clinical features will include oedema of lids,
Chapter 38 — Complications of Sinusitis
exophthalmos, chemosis of conjunctiva and restricted
movements of the eye ball. Vision is affected causing
partial or total loss which is sometimes permanent.
Patient may run high fever. Orbital cellulitis is potentially dangerous because of the risk of meningitis and
cavernous sinus thrombosis.
4. Orbital abscess. Intraorbital abscess usually forms
along lamina papyracea or the floor of frontal sinus.
Clinical picture is similar to that of orbital cellulitis.
Diagnosis can be easily made by CT scan or ultrasound
of the orbit. Treatment is i.v. antibiotics and drainage
of the abscess and that of the sinus (ethmoidectomy or
trephination of frontal sinus).
5. Superior orbital fissure syndrome. Infection of sphenoid sinus can rarely affect structures of superior orbital fissure. Symptoms consist of deep orbital pain,
frontal headache and progressive paralysis of CN VI,
III and IV, in that order.
6. Orbital apex syndrome. It is superior orbital fissure
syndrome with additional involvement of the optic
nerve and maxillary division of the trigeminal (V2)
(Figure 38.6).
225
III. INTRACRANIAL COMPLICATIONS
Frontal, ethmoid and sphenoid sinuses are closely related
to anterior cranial fossa and infection from these can cause:
1. Meningitis and encephalitis
2. Extradural abscess
3. Subdural abscess
4. Brain abscess
5. Cavernous sinus thrombosis.
CAVERNOUS SINUS THROMBOSIS
aetiology. Infection of paranasal sinuses, particularly those of ethmoid and sphenoid and less commonly
the frontal, and orbital complications from these sinus
infections can cause thrombophlebitis of the cavernous sinus(es). Other sources of infection are listed in
Table 38.2. The valveless nature of the veins connecting
the cavernous sinus causes easy spread of infection.
Figure 38.6. Orbital complications of sinusitis. (A) Normal. (B) Subperiosteal abscess. (C) Orbital abscess.
Соседние файлы в папке Библиотека им академика М.И. Перельмана