Complications of Sinusitis

FESS

Complications of Sinusitis

• Arise from disease extending to local areas.
• Intracranial
• Orbital
• Sinus-related (local)
• Descending infections

Local

• Complications are limited to the sinuses.

• Retention cyst:
• Cystic transformation of the mucosal lining.

• Pyocoele:
• Infection of a mucocele.

• Osteomyelitis.

Mucocele:

Pott's Puffy Tumor:

• Is osteomyelitis of the frontal bone.

• Infection of frontal sinus spreads to overlying bone.

• Causes a subperiosteal abscess.

Orbital complications

Classified by Chandlers' classification:

1. Preseptal cellulitis.

2. Orbital cellulitis.

• Common in ethmoid sinusitis.

• Presents with swelling of both eyelids.

3. Subperiosteal abscess.

4. Orbital abscess.

5. Cavernous sinus thrombosis.

Intracranial Complications

• Frontal/ethmoidal sinuses → break into the anterior cranial fossa.

• Sphenoidal sinus → break into the middle cranial fossa.

• Types of intracranial abscesses:
• Extradural/Epidural abscess: Pus between bone and dura.
• Subdural abscess: Pus between dura and brain parenchyma.
• Brain abscess: Infection of brain parenchyma.

• Meningitis.

• Encephalitis.

• Cavernous sinus thrombosis.

Clinical features:

• History of sinusitis.

• Personality/behavioural change.

Epistaxis

• Bleeding from the nose.

Blood Supply of Nose

Upper half:

• Supplied by Internal Carotid Artery (ICA).

• ICA branch: Ophthalmic Artery.
• Ophthalmic artery branches:
• Anterior Ethmoidal Artery (AEA):
• Supplies anterosuperior septum.
• Posterior Ethmoidal Artery (PEA):
• Supplies posterosuperior septum.

Lower half:

• Supplied by External Carotid Artery (ECA).

• ECA branches: Facial Artery and Internal Maxillary Artery.
• Facial Artery branch:
• Superior Labial Artery:
• Supplies anteroinferior septum.
• Internal Maxillary Artery branches:
• Supplies posteroinferior septum.
• Sphenopalatine artery
• Greater Palatine Artery

Plexuses:

• Kiesselbach's Plexus/Little's area:
• Arterial Plexus.
• Anastomosis of arteries in anteroinferior septum
• except posterior ethmoidal artery
• Bleeding here is Anterior Epistaxis.
• Mild bleeding
• Common in children
• M/c: Trauma

• Woodruff's Plexus:
• Venous plexus.
• Located in posteroinferior septum.
• Bleeding here is Posterior Epistaxis.
• Severe bleeding
• Common in adults
• M/c: HTN

Comparison of Anterior and Posterior Epistaxis:

Feature	Anterior Epistaxis	Posterior Epistaxis
Incidence	More common	Less common
Most Common Cause	Trauma	Hypertension
Age	Common in children	Common after 40 years of age
Bleeding	Mild	Severe
Rx	• Local pressure • Anterior pack	• Requires hospitalization • Postnasal pack

Artery Ligation Sites:

• Anterior and posterior ethmoidal arteries:
• Ligated near medial wall of orbit.

• Internal maxillary artery:
• Ligated in Pterygopalatine fossa.

• Sphenopalatine artery:
• Ligated in Sphenopalatine foramen.

Causes of Epistaxis

• Local Causes:
• Infection.
• Trauma (most common cause overall).
• Foreign body.
• Neoplasm of nose and paranasal sinus.
• Deviated nasal septum.

• General/Systemic Factors:
• Hypertension (most common general cause).
• Disorders of Blood vessels.
• Liver disease.
• Renal disease.
• Mediastinal tumors.

• Idiopathic causes

Protocol for Epistaxis

1. Hippocrates maneuver/Trotters method:
• Pinch nose, bend forward.

2. Initial medical review and resuscitation:
• History.
• IV fluid.
• Blood investigation.

3. Prepare for nasal endoscopy: Use 4% xylocaine + adrenaline.

4. Nasal endoscopy.

5. Single bleeding point: Cauterize.

6. Diffuse bleeding point/no endoscopy:
• Anterior nasal packing.



• Pack from roof to floor.
• Pack from vestibule to choana.
• Used:
• Ribbon gauze.
• Merocel packs/sponge.

7. If anterior packing fails: Posterior nasal packing.
• Place pack in nasopharynx.
• Also do anterior nasal packing.

8. If packing fails: Ligate the artery.
• Order of ligation:
1. Sphenopalatine Artery.
• TESPAL: Transnasal endoscopic sphenopalatine artery ligation.
2. Internal Maxillary Artery.
• Site: Sphenopalatine/pterygopalatine fossa
• Approach:
1. Endoscopic.
2. Caldwell Luc procedure:
• Sublabial incision



3. External carotid artery.
4. Ethmoidal Artery.

One Liner (Epistaxis Summary)

• Most common cause of epistaxis is trauma.

• Most common cause in children is nasal picking.

• Most common cause of unilateral foul-smelling discharge in children is foreign body.

• Most common cause of recurrent profuse epistaxis in adolescent males is JNA.

• Most common site is Little's area/Kiesselbach plexus.

• Anterior venous epistaxis occurs from the Retro columella vein.

• Artery of epistaxis is sphenopalatine artery.

• Posterior epistaxis occurs from Woodruff's plexus.

Fractures of the facial skeleton

• Categories: Upper third, Middle third, Lower third.

• Middle third is most common site for fractures of the nose.

Nasal fractures

• Asch’s Forcep: For septum fractures.

• Ash will bend , cartilage bends

• Walsham Forcep: For nasal bone.

I. Chevallet fracture:

• From below

• Vertical fracture.

II. Jarjaway fracture:

• From front

• Horizontal fracture.

III. Naso-orbito-ethmoid fracture:

• Involves depression of orbit and ethmoid bone.

• Leads to pig nose deformity.

• High chance of CSF leakage.

• RX: ABCD → Immediate Sx (open reduction and internal fixation)

Zygomatiomaxillary complex Fracture

• Second most common fracture.

• Known as tripod fracture.

• Three fracture lines:
• Zygomaticofrontal.
• Zygomaticotemporal.
• Zygomaticomaxillary.

• Infraorbital nerve is involved.

• Presents with step deformity.

Fracture floor of Orbit

• Known as Blow-out fracture.

• Blunt Trauma to Orbit

• Occurs due to tennis ball injury (trauma direct to orbit)

• Orbit contents may herniate into maxillary sinus.

• Floor is more susceptible than medial wall.

• Radiological sign: Teardrop sign.

• Infraorbital nerve is involved.

• Other symptoms
• Enophthalmos (sunken eye)
• Diplopia on upward gaze
• Loss of sensitivity over the cheek

Maxillary fractures or LeFort fracture or Pterygoid fractuere

 

Lefort 1 fracture:

• Line runs from floor of nose and maxillary sinus.

• Hallmark: Hanging palate and hanging teeth.

• CSF Rhinorrhea least likely

• Geurins sign
• Greater palatine artery hemorrhage
• Bluish discoloration of palate.

Lefort 2 fracture or Pyramidal fracture:

• Line goes from nasion, medial wall of orbit, floor of orbit, to maxilla.

• Pyramidal

• Hallmark: Hanging maxilla.

• CSF rhinorrhoea may be associated.

Lefort 3 fracture:

• Line goes from nasion, medial wall of orbit, lateral wall of orbit, floor of orbit, and zygoma.

• Called craniofacial disjunction.

• High risk of CSF rhinorrhoea.

Fractures of temporal bone

Uhrlich classification

• Temple il uchaykk ponam (Uhrlich classification )

Longitudinal fracture	Transverse fracture
Parallel to long axis of petrous bone	Perpendicular to long axis of petrous bone
More common	Less common
TM perforation ++	Not common
Less	High risk of facial nerve palsy
CHL ↑↑	SNHL risk ↑↑
CSF otorrhea common	Paradoxical CSF rhinorrhea
Less	Otic capsule involvement common

Fractures of mandible

• Subcondylar fracture:
• Most common site.
• Countercoup injury → Trauma is on opp side

• Guardsman fracture / parade ground fracture
• Bilateral subcondylar fracture.
• Trauma on the symphysis menti

Immobilization:

• Not for more than 4 weeks.

• because it can result in TMJ ankylosis.
• Permanent difficulty in opening the mouth.

CSF Rhinorrhea

• Leak of CSF into the nasal cavity

• Most common cause:
• Trauma (95%)
• m/c Fovea ethmoidalis
• Non-traumatic (spontaneous):
• Raised intracranial pressure.

• Most common site:
• Cribriform plate of ethmoid

• Most common presentation:
• Unilateral watery nasal discharge

Biochemical analysis

• β2 Transferrin Test:
• Investigation of choice and diagnostic.

• β Trace Protein Test:
• Also a diagnostic test.

Diagnosis

• Note: These tests do not conclusively confirm CSF

Test/Sign	Description/Interpretation
Halo / Target / Double Ring Sign	Outer and inner ring on filter paper. In traumatic CSF rhinorhhea → d/t mixing of blood and CSF
Sniff Test	CSF cannot be sniffed back.
Handkerchief Test	No stiffening of handkerchief.
Reservoir Sign (Teapot Sign)	Dripping of CSF on bending forward.
Valsalva Manoeuvre	Increases CSF leak.

Radiological Examination

 

Imaging	Features
HRCT of temporal bone	• IOC for site of leak.
CT Cisternography	• Contrast in sulcal spaces • Identifies exact site of active leak.
Intrathecal fluorescein	• Identifies exact site of active leak.
MRI	• Can be done if radiation is a concern.

Treatment

• Initial (for 2 weeks)
• Propped up position.
• Avoid straining.
• Stool softeners.
• Prophylactic antibiotics

• After 2 weeks
• Surgical Mx : Endoscopic > Open repair

Tumors of nose and PNS

Osteoma

• Most common benign tumor of paranasal sinuses.

• Most common site: Frontal sinus.

• Histologic pattern: Loss of trabecular pattern.

Treatment:

• External Frontoethmoidectomy
• Lynch Howarth incision.

Gardner Syndrome

Inverted Papilloma

• Benign, pre-malignant condition.

• M/c site Middle Meatus

• Arise from pseudostratified columnar epithelium (Schneiderian membrane)

• A/w Human Papilloma virus (HPV).

• Also called:
• Transitional cell papilloma.
• Ringertz tumor.
• Schneiderian papilloma.

• Locally invasive.

• Premalignant
• Associated with malignancy in 5 - 10%.

Clinical features:

• Blood stains in nasal discharge.

• Nasal obstruction.

• Projections from lateral wall of nose.

Histopathology:

• Finger-like projections grow towards stroma.

Treatment:

• Medial Maxillectomy
• via lateral rhinotomy / midfacial degloving approach
• Endoscopic > External approach
• Remove:
• Lateral wall of nose
• Medial wall of maxilla

• Recurrent:
• Cidofovir

• Avoid radiotherapy ⇒ turns malignant

CT Scan

Maxillary sinus carcinoma

Ohngren’s Line:

• Imaginary line for prognostication.

• Malignancy above has poor prognosis.

• Malignancy below has good prognosis.

Ledermans Classification:

• Used for prognosis.

Clinical Features:

• Dull pain over maxillary sinus.

• Ipsilateral epiphora.

• Blood-stained nasal discharge.

• Nasal obstruction.

• Toothache.

Investigation :

• Biopsy
• Mitotic figures

• CT scan

Surgical:

Surgical Approaches (Sx approach)

• Gluck Sorensen incision
• Total laryngectomy
• Gluck gluck sound when holding larynx

Total Maxillectomy

• Removes:
• maxilla,
• maxillary sinuses,
• ipsilateral palate,
• lateral wall of nose,
• ethmoid sinus,
• ipsilateral eyeball.

• Chemotherapy.

• Radiotherapy.

Esthesioneuroblastoma / Olfactory Neuroblastoma

• Neuroendocrine, hormone-secreting tumour
• arising from olfactory mucosa.

• Highly vascular
• appears cherry-red, polypoidal mass.