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a
Fig. 29.8 MRI of a large mucocele of the left sphenoid sinus, resulting in abducens nerve palsy of the left eye. (a)
Axial. (b) Coronal plane
b
The chronic inammatory response observed
in CRS can worsen existing airway pathology or
lead to adult-onset asthma [15].
Minor complications associated with CRS
tend to occur with local tissue alterations that
may lead to osteitis and bone erosion [16].
Medical therapies widely used at treating
CRSsNP, including antibiotics and systemic corticosteroids, can also cause various local or systematic complications.
Diagnosis
Physical Examination
Clinical assessment remains the key to diagnosing orbital complications of rhinosinusitis.
Visual acuity, ocular motility and colour discrimination should be specically assessed.
Each modality can be affected, but not necessarily in a set order. For example, loss of red and
green colour perception due to increased intraorbital pressure may be noted before worsening
of visual acuity. Tonometry can prove helpful,
but whilst being sensitive, it is not specic. All
cranial nerves should be assessed, especially
cranial nerves II, III, IV, V1, V2 and VI that can
be involved in orbital and intracranial
complications.
Intracranial complications tend to present in a
more “nonspecic” manner with symptoms such
as headache or fever—if any at all. More specic
signs and symptoms such as neck stiffness, alteration in mental state or vomiting should lead to
an earlier diagnosis.
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V. Chatzinakis and C. Georgalas
Radiology
To our knowledge, there have been no large randomized, controlled trials, comparing computing
topographic scanning to ultrasonography or magnetic resonance imaging in the diagnosis of rhinosinusitis complications. As far as orbital
complications are concerned, it is the author’s
opinion that contrast CT should be the study of
choice. It is relatively inexpensive, widely available, quick and detailed and can assess bone erosion and any extension of inammation.
Enhancement of orbital fat usually indicates an
intraorbital complication of variable severity. An
orbital or subperiosteal abscess can be readily identied from its characteristic appearance of a relatively low-attenuation central necrotic component
and a capsular ring enhancement with contrast.
The appropriate use of computed tomography in
children with sinus disease has been addressed by a
clinical consensus statement. This recommends
careful consideration be given to the risk–benet
ratio. A CT sinus scan is however recommended in
children who fail to respond to treatment and those
with complications of infection [17].
On the other hand, MRI can prove superior to
CT in soft tissue differentiation, parenchymal
extension or marrow-space involvement without
exposing the patient to irradiation. MRI is often
performed concurrently with MRA when cavernous sinus thrombosis is suspected. However,
MRI is more expensive, is less available, requires
sedation/anesthesia in younger children, is susceptible to image degradation by movement and
is more time-consuming than a CT scan.
Laboratory Tests
Although not specic, an elevated white blood
cell count with a prevalence of neutrophils is very
common in complicated acute rhinosinusitis.
Leukopenia is also possible, but this is typically
related to worse outcome. C-reactive protein
(CRP) is an index of inammation and is usually
elevated, but due to its low specicity, it is more
useful to monitor the early recovery period rather
than to establish the diagnosis.
In intracranial complications like bacterial
meningitis, blood cultures and CSF analysis and
culture are often helpful in conrming a more precise diagnosis and yielding an infective pathogenic
microorganism. Cerebrospinal uid, acquired via
a lumbar puncture, will normally reveal >5 white
blood cells/μL, >50mg/dL of protein and <40mg/
dL of glucose in cases of bacterial infection [18].
If an intracranial abscess is suspected, radiological imaging of the head is mandatory before a
lumbar puncture is performed, since brain herniation is a signicant risk. Elevation of intracranial
pressure to levels higher than 200mm H2O is also
a potential risk of intracranial infection and must
be excluded prior to lumbar puncture.
Treatment
Principles ofManagement
The principles of treating complicated rhinosinusitis, especially acute infection as described above,
follow a common pattern: As a general rule, hospital admission is necessary for diagnosis and
treatment. Evaluation from the ENT specialist, an
ophthalmologist and/or a neurosurgeon should be
considered according to the likely complication.
Appropriate intravenous antibiotic treatment
should be started as soon as possible once an
orbital or intracranial complication is suspected.
A second-line antibiotic (usually third-generation
cephalosporin) that crosses the blood–brain barrier or a quinolone as an alternative is often instigated as rst-line antibiotics, such as ampicillin/
sulbactam or amoxicillin/clavulanate, may have
already been administered prior to the complication and hospital admission.
Sometimes an antibiotic that is effective
against a multiresistant Staphylococcus aureus,
such as vancomycin, should be prescribed, especially when treating intracranial complications.
Intranasal use of topical vasoconstrictors/decongestants is common practice, but their effectiveness
has not been denitively proven. As a general rule,
if the patient responds poorly to intravenous antibiotics after 24–48h, then surgical exploration and
drainage should occur without further delay. Whilst
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363
planning the procedure, communication between
all subspecialties involved is vital.
Surgical Management
Orbital Complications
Preseptal and orbital cellulitis, and small medially
located subperiosteal abscesses (<2cm diameter),
usually respond well to systemic intravenous antibiotics. Larger periorbital and orbital abscesses
require surgical intervention and drainage.
Endoscopic transnasal drainage of abscesses
is a well-established technique that avoids an
external facial scar, shortens hospital stay and has
a good outcome. The external approach via a
Lynch–Howarth incision is an alternative technique, especially if endoscopic expertise is not
easily available. The transcaruncular approach
offers the possibility of external drainage without
leaving an external scar.
The endoscopic drainage approach commences
with a medial meatal antrostomy and anterior ethmoidectomy. The lamina papyracea is identied
and partially removed to expose the periorbita. The
periorbita may or may not need to be incised with
a sickle knife (subperiosteal or intraconal). The
subperiosteal abscess is exposed and drained. Pus
samples should be obtained and sent for culture.
External or combined approaches are reserved
for laterally located abscesses or when the endoscopic approach fails to relieve intraorbital
pressure.
Frontal sinus osteitis with a subperiosteal
abscess (or Pott’s puffy tumor) will require a
Draf II/Draf III procedure or rarely an osteoplastic approach to the frontal sinus, if reconstruction
of the anterior wall is mandated. Alternatively, a
minimally invasive external procedure (such as a
trephination of the frontal sinus) may be used,
with or without cannulation and topical installation of antibiotics in the frontal sinus.
plication and treat “en route” the affected sinus
whenever possible. In the presence of purulent
sinusitis, adequate drainage of the involved sinus
should be considered as sine qua non. Whether
the drainage of the affected sinus (usually the
frontal) will be via an endoscopic approach or an
external trephination/exploration is debatable:
Whilst some studies have shown potentially better outcomes by using the endoscopic approach
[19], the counter-argument involves the risk of a
postoperative frontal ostium stenosis as a result
of operating endoscopically in a heavily inamed,
oedematous frontal recess. Craniotomy, a transfrontal approach, image-guided aspiration or
simple burr-hole drainage may be used to drain
epidural abscesses, brain abscesses or subdural
empyemas, with the aim of reducing intracranial
pressure and lowering the risk of recurrence from
residual disease. Meningitis is the sole intracranial complication that has not been associated
with better outcomes after endoscopic sinus
drainage. The surgical treatment of cavernous
sinus thrombosis includes drainage of the primary source of infection in the sinuses: The cav-
Intracranial Complications
Intracranial complications are typically associated with frontal sinusitis, ethmoiditis or sphenoiditis, and surgical intervention will generally
be necessary in almost all cases. The goal of such
an intervention is to address the endocranial com-
Fig. 29.9 Epidural abscess as a result of osteomyelitis of
the frontal sinus (Pott’s puffy tumor) showing at Fig.29.4
(asterisk)
364
25
20
15
10
SNOT score
SNOT score
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V. Chatzinakis and C. Georgalas
ernous sinus itself is not exposed as this has been
shown to cause higher morbidity.
Clinical Examples
Case 1: A Case of Pott’s Puffy Tumor with
Epidural Abscess
A 14-year-old-boy was referred with progressive
acute frontal sinusitis. He developed severe headache and nausea over 24h that failed to respond to
iv analgesics. He had tachycardia (108bpm) and
pyrexia (38.6°C), and the white blood cell count
was elevated. Vital signs met the criteria of sepsis.
Examination showed a soft mass on his forehead, consistent with osteomyelitis of the frontal
sinus (Pott’s puffy tumor). The diagnosis was
conrmed by a CT scan, which also revealed an
underlying epidural abscess (Fig.29.9).
The frontal sinus was drained by endoscopic
ethmoidectomy and drainage by a Draf II procedure that preserved the bony wall of the frontal
drainage pathway. The epidural abscess was
drained by a neurosurgical team after completion
of the endoscopic procedure.
The patient recovered fully and showed no
sign of recurrence over a 3-year follow-up
time.
A 4-year-old boy presented with acute onset of
proptosis of the left eye 10days after an upper
respiratory tract infection. Orbital palpation
showed mild tenderness but no restriction of eye
movement. The swelling had commenced 3days
ago and had not improved with oral amoxicillin/
clavulanate.
Endoscopy showed severe unilateral mucosal
oedema but no evidence of mucopurulent
discharge.
Intravenous antibiotics were initiated by the
paediatricians, but he failed to no improve after
Case 2: A Case of Subperiosteal Abscess of
the Left Orbit
Fig. 29.11 Case 3
SNOT-22 score, over
1year follow-up
5
0
30/8/18 19/11/18 11/2/19 25/11/19 date 4
20
Fig. 29.10 MRI of a left subperiosteal abscess. Note the
collection (arrows) affecting the medial rectus muscle as
well as the eyelid oedema (asterisk)
6
4
2
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Fig. 29.12 Case 3: Endoscopic view of the patent frontal
sinus drainage pathway (Draf 3 neo-ostium), 3years after
surgery
365
shows a patent Draf III neo-ostium (Figs.29.7c
and 29.12).
Areas ofControversy
1. Endoscopic versus open drainage for the fron-
tal sinus in cases of acute infection with endocranial complications.
2. Is it ever safe to treat medically a well-dened
orbital abscess?
3. Do antibiotics reduce the incidence of endo-
cranial or orbital complications of ARS?
4. Do we always need to deal with the sinuses in
cases of endocranial complications?
24 h. A scan was planned, but due to parental
concern about irradiation, he underwent an MRI
scan of the orbits that revealed a subperiosteal
abscess (Fig.29.10).
Ipsilateral endoscopic medial antrostomy and
anterior ethmoidectomy were performed, resulting in almost complete resolution of symptoms
within the next 48h.
Case 3: A Case of Chronic Frontal Fungal
Sinusitis with Coexisting Mucocele
Α 17-year-old girl presented with a 12-month history of nasal obstruction, sleep disordered breathing and mild swelling of the right eye for 6months
(Fig. 29.7b). She was initially diagnosed with
allergy. Her SNOT-22 score was 20 (Fig.29.11).
She had diplopia in downward gaze and nasal
endoscopy showed a polypoid mass blocking the
anterior ethmoids.
An MRI scan was suggestive of a mucocele of
the far lateral region of the right frontal sinus.
She underwent endoscopic surgery and drainage via a Draf III procedure. Nasal polyps surrounded by thick mucus were removed. She had
a small defect of the right orbital roof that
explained her diplopia.
Histopathology and cultures conrmed the
presence of “allergic” eosinophilic mucin
consistent with a diagnosis of allergic fungal
sinusitis. Three years later, she remains
asymptomatic, and endoscopic examination
Key Learning Points
• Whilst the clinical presentation may vary
between patients, infection can progress rapidly to become severe and dangerous.
• Early orbital periorbital complications of sinusitis usually respond to intravenous antibiotics.
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V. Chatzinakis and C. Georgalas
• Early treatment with empiric intravenous antibiotics should be instigated to all patients with
suspected complications.
• Antibiotic choice is determined by the most
likely pathogens. These pathogens are
typically Streptococcus pneumoniae,
Staphylococcus aureus and Pseudomonas
aeruginosa.
• The threshold for requesting a CT scan of the
sinuses, orbit and head should be low.
• Endoscopic sinus surgery (ESS) remains the
gold standard for treating most infective complications of ARS.
• Endoscopic surgical drainage should be performed early and not be considered as the last
resort.
• Drainage of primary frontal/ethmoid sinus
infection via ESS and a Draf II drainage procedure is likely to improve the clinical outcomes in patient with orbital and intracranial
complications [19].
• Dexamethasone reduces local oedema and
inammation. The role of dexamethasone has
been revised over the past few decades. It is
now considered to improve the long-term outcome of sinogenic meningitis [20].
• Orbital abscess and cavernous sinus thrombosis are rare but serious surgical emergencies
that require prompt intervention with highdose broad-spectrum intravenous antibiotics
and surgical exploration.
References
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S, Vicente G, Xu G, Zia MR, Gulati A, Fang SY, Shi L,
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6. Mortimore S, Wormald PJ. The Groote Schuur hospital classication of the orbital complications of
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8. Velasco e Cruz AA, Demarco RC, Valera FC,
dos Santos AC, Anselmo-Lima WT, Marquezini
RM. Orbital complications of acute rhinosinusitis: a new classication. Braz J Otorhinolaryngol.
2007;73(5):684–8. https://doi.org/10.1016/s1808-
8694(15)30130- 0. PMID: 18094811.
9. Osborn MK, Steinberg JP. Subdural empyema and
other suppurative complications of paranasal sinusitis. Lancet Infect Dis. 2007;7(1):62–7. https://
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10. Younis RT, Anand VK, Davidson B. The role of
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imaging in patients with sinusitis with complications. Laryngoscope. 2002;112(2):224–9. https://doi.
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11. Todman MS, Enzer YR. Medical management versus surgical intervention of pediatric orbital cellulitis: the importance of subperiosteal abscess
volume as a new criterion. Ophthalmic Plast Reconstr
Surg. 2011;27(4):255–9. https://doi.org/10.1097/
IOP.0b013e3182082b17. PMID: 21415801.
12. Gavriel H, Yeheskeli E, Aviram E, Yehoshua L,
Eviatar E.Dimension of subperiosteal orbital abscess
as an indication for surgical management in children.
Otolaryngol Head Neck Surg. 2011;145(5):823–7.
https://doi.org/10.1177/0194599811416559. Epub
2011 Jul 21. PMID: 21778515.
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13. Ghegan MD, Lee FS, Schlosser RJ.Incidence of skull
base and orbital erosion in allergic fungal rhinosinusitis (AFRS) and non-AFRS.Otolaryngol Head Neck
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otohns.2005.11.025. PMID: 16564378.
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M, Minov J, Brozek G, Dahlen SE, Toskala E,
Kowalski ML, Olze H, Howarth P, Krämer U, Baelum
J, Loureiro C, Kasper L, Bousquet PJ, Bousquet J,
Bachert C, Fokkens W, Burney P. Asthma in adults
and its association with chronic rhinosinusitis: the
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16. Scangas GA, Gudis DA, Kennedy DW. The natural history and clinical characteristics of paranasal
sinus mucoceles: a clinical review. Int Forum Allergy
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alr.21178. Epub 2013 May 20. PMID: 23696282.
17. Setzen G, Ferguson BJ, Han JK, Rhee JS, Cornelius
RS, Froum SJ, Gillman GS, Houser SM, Krakovitz
PR, Monfared A, Palmer JN, Rosbe KW, Setzen M,
Patel MM.Clinical consensus statement: appropriate
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18. Durand ML, Calderwood SB, Weber DJ, Miller SI,
Southwick FS, Caviness VS Jr, Swartz MN. Acute
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8416268.
19. Van der Poel NA, Hansen FS, Georgalas C, Fokkens
WJ. Minimally invasive treatment of patients with
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Klein M. Dramatic reduction of mortality in pneumococcal meningitis. Crit Care. 2016;20(1):312.
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Further Reading
Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I,
Baroody F, Cohen N, Cervin A, Douglas R, Gevaert
P, Georgalas C, Goossens H, Harvey R, Hellings P,
Hopkins C, Jones N, Joos G, Kalogjera L, Kern B,
Kowalski M, Price D, Riechelmann H, Schlosser R,
Senior B, Thomas M, Toskala E, Voegels R, Wang de Y,
Wormald PJ.EPOS 2012: European position paper on
rhinosinusitis and nasal polyps 2012. A summary for
otorhinolaryngologists. Rhinology. 2012;50(1):1–12.
https://doi.org/10.4193/Rhino50E2. PMID: 22469599.
Georgalas C, Fokkens W. Rhinology and skull base
surgery. From the lab to the operating room—an
evidence- based approach. Thieme. 2019.
Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt
JA, Baroody FM, Batra PS, Bernal-Sprekelsen M,
Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ,
Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ,
Douglas R, Ferguson B, Fokkens WJ, Georgalas C,
Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey
R, Hellings P, Hopkins C, Jankowski R, Javer AR,
Kern R, Kountakis S, Kowalski ML, Lane A, Lanza
DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong
A, Mann W, Marple BF, McMains KC, Metson R,
Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR,
Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis
AJ, Ramadan HH, Ramakrishnan VR, Riechelmann
H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior
BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK,
Toskala E, Voegels R, Wang de Y, Weitzel EK, Wise
S, Woodworth BA, Wormald PJ, Wright ED, Zhou
B, Kennedy DW. International consensus statement
on allergy and rhinology: rhinosinusitis. Int Forum
Allergy Rhinol. 2016;6(Suppl 1):S22–S209. https://
doi.org/10.1002/alr.21695. PMID: 26889651.
Section V
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Benign and Malignant Sinonasal Tumours
Sinonasal Papilloma
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UsamahHadi andAndrewC.Swift
30
Introduction
Sinonasal papilloma is an unusual benign tumor
that can have extraordinary recurrence rates and
the potential for transformation into squamous
cell carcinoma. As a unilateral nasal mass, it
presents as a challenging condition. The unilateral sinonasal symptoms, isolated nasal tumor,
polypoid growth, or radiological sinus opacity
are common entities that can mimic a host of
clinical and other pathologic diseases. This unilaterality increases the burden for the surgeon to
establish the correct diagnosis and treat the condition appropriately. The challenges posed during early tumor development result from the
lesion forming in closed anatomical spaces without inducing noticeable symptoms. It is only in
later stages of the disease when the tumor
enlarges that symptom becomes apparent. The
mainstay of management is surgical resection of
the tumor. However, surgery for inverted papil-
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978-3-031-28690-2_30.
loma has evolved from basic removal of nasal
polypoid masses to extensive but precise endoscopic techniques.
The benign nature of the tumor led to surgical
resection being performed by most ENT surgeons, but individual experience was often limited. Once the concept of the “oncological
approach” of extensive resection via lateral rhinotomy and medial maxillectomy became fashionable, the operation was often done by surgeons
with a head and neck interest.
With the development of endoscopic techniques and a better understanding of the biological behavior, the management has
progressed. Most tumors can now be treated
very effectively with endoscopic endonasal
techniques with much improvement in the
postoperative morbidity. There is still a place
for external surgery, but this is now used with
expert planning, often being combined with
endoscopic surgery.
U. Hadi
Department of Otolaryngology HNS, American
University of Beirut Medical Center, Beirut, Lebanon
Rhinology Division, American University of Beirut
Medical Center, Beirut, Lebanon
e-mail: uh00@aub.edu.lb
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. C. Swift et al. (eds.), Contemporary Rhinology: Science and Practice,
https://doi.org/10.1007/978-3-031-28690-2_30
A. C. Swift (*)
Liverpool Head and Neck Centre, Liverpool
University Hospitals Foundation Trust,
Liverpool, UK
371
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U. Hadi and A. C. Swift
Terminology: WHO Denition
The terminology of sinonasal papilloma is confusing and imprecise [1]. Older historical terms
such as Schneiderian papilloma and Ringertz
tumor are so well established that they continue
to be used. The Schneiderian membrane is a historical term for the nasal mucosa, named in honor
of a seventeenth-century German anatomist,
Professor Konrad Viktor Schneider of Wittenberg
(1614–1680), who published his work on the
nasal mucous membrane and catarrh, refuting the
a
theory that nasal secretions originated from the
pituitary gland.
A sinonasal papilloma is dened as a benign
epithelial tumor composed of well-differentiated
columnar or ciliated respiratory epithelium with
variable squamous differentiation [2].
The nomenclature of papilloma lacks precision, and various terms are used. The World
Health Organization classied sinonasal papilloma into three histological subtypes: these
include inverted, exophytic, and oncocytic subtypes (Fig.30.1a–c).
b
c
Fig. 30.1 Histological subtypes of sinonasal papilloma: (a) Inverted papilloma. (b) Exophytic papilloma. (c) Oncocytic
papilloma
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