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COMPLICATED ACUTE SINUSITIS
Overview
While most cases of acute sinusitis resolve spontaneously or with medical therapy, consults to evaluate potential complications of sinusitis are common. Acute sinusitis typically develops from a viral or bacterial infection of the paranasal sinuses leading to inflammation, edema, and ultimately obstruction of the sinus outflow tracts. Acute sinusitis is typically managed medically with topical and sometimes systemic medications. This guide will focus on the management of the complications of untreated or progressive acute sinusitis. For this guide, the complications of sinusitis are distilled into orbital and intracranial complications. The presentation and management of invasive fungal sinusitis are discussed in a separate consult guide.
Orbital Complications
Overview
Acute sinusitis can involve the orbit through direct extension, generally through a thin or dehiscent lamina papyracea. In advanced disease, infection can involve the cavernous sinus through propagating thrombophlebitis of the valveless orbital venous system. Orbital complications of sinusitis can present with a wide range of symptoms including periorbital edema, vision changes, ophthalmoplegia, chemosis or proptosis. Any of these signs on history and examination warrant emergent imaging. In cases of early orbital involvement, exam findings may be subtle and include periorbital edema and erythema. The Chandler classification categorizes orbital involvement into five groups:
Group I Preseptal Cellulitis
Group II Orbital Cellulitis
Group III Subperiosteal Abscess
Group IV Orbital Abscess
Group V Cavernous Sinus Thrombosis
For reference, the orbital septum is a fibrous membrane that extends from the periosteum of the orbit as the arcus marginalis and lies just deep to the orbicularis oculi muscle. Transgression of the orbital septum by infection constitutes post-septal involvement. Postseptal infection can lead to optic neuritis, thrombophlebitis, and pressure or traction on the optic nerve leading to blindness. Surgery is indicated for patients in most cases of Chandler Group III-V, but also may be considered for Chandler Groups I-II. While a trial of intravenous antibiotics is appropriate in many cases, surgical treatment should not be delayed in the case of a defined orbital abscess, ophthalmoplegia, or vision loss. An ophthalmology consultation serves as a great resource for management of these orbital complications.
Key Supplies for Consultation
Appropriate PPE including mask, eye protection, gloves, and gown
Headlight
Nasal Speculum
Flexible scope or rigid endoscope (with monitor & tower, if possible)
Antifog solution (Fred)
Culture trap or swab
Oxymetazoline
Flashlight for pupil exam (or can use headlight)
Snellen eye chart for visual acuity
Management
History and detailed head and neck physical exam with attention to the cranial nerve and ophthalmic exam; always test visual acuity and color vision, extraocular movements (while asking if movement is painful), pupillary response to light, and globe position (evaluate for proptosis)
If there is no evidence of sinus disease or inflammation on CT, then one must consider other causes of orbital disease. Ensure ophthalmology is consulted if suspicion of any disease beyond preseptal cellulitis
Initiate empiric broad spectrum antibiotics with coverage of common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella sp., and more rarely Staphylococcus aureus. Polymicrobial infection is more common in adults and in immunosuppressed patients
Consider obtaining sinus cultures (middle meatus)
Blood cultures indicated if the patient exhibits signs /symptoms of systemic illness
Basic laboratory analysis (CBC, CMP, and CRP)
If IV antibiotics are used, patients can generally be de-escalated to oral antibiotics, guided by culture data when available. In cases with osteomyelitis, a longer course may be necessary, and involvement of Infectious Disease may be beneficial
Chandler Group I: Preseptal cellulitis
Characteristic findings on ocular exam: periorbital erythema, edema, and tenderness without ophthalmoplegia or decreased visual acuity (suspect post-septal disease if these are present)
Consider high dose amoxicillin-clavulanate if outpatient vs ampicillin-sulbactam (Unasyn) if admitted
Additional treatments include head of bed elevation, heat packs to affected eye, topical decongestant (typically Afrin for 3 days), saline irrigations and mucolytics such as guaifenesin
Mild preseptal cellulitis in a reliable adult without signs of orbital cellulitis may be followed closely as an outpatient; any signs of systemic disease or eyelid abscess warrant admission
Rarely, may require drainage of eyelid abscess at bedside
Chandler Group II: Orbital Cellulitis
Characteristic findings on ocular exam: diffuse periorbital edema, chemosis, proptosis, intact extraocular movements, intact vision, ophthalmoplegia in severe cases
Admit patient for observation
Initiate parenteral antibiotics: consider ampicillin-sulbactam vs ceftriaxone
Additional acute sinusitis medical treatment (i.e. mucolytics, nasal decongestant, saline sinus irrigations)
Can consider corticosteroids, may defer to ophthalmology
Disease is typically responsive to medical management, however, sinus surgery may play a role in refractory disease. If surgery is required, it typically consists of endoscopic sinus surgery (ESS) of affected sinuses in proximity to the lamina papyracea, most notably a maxillary antrostomy and total ethmoidectomy
Chandler Group III: Subperiosteal abscess
Characteristic findings on exam: proptosis, impaired extraocular movements, periorbital edema, vision intact unless large abscess
Admit patient
Initiate parenteral antibiotics: ceftriaxone or ampicillin-sulbactam, consider adding vancomycin if risk of MRSA or intracranial disease extent
Surgery generally indicated if defined abscess present, no improvement with 24-48 hours of antibiotics, or vision loss
Surgery typically consists of ESS of the affected sinuses in proximity to the lamina papyracea, as well as an endoscopic drainage of the subperiosteal abscess through the lamina papyracea
In select situations, consideration of a combined surgery with oculoplastic surgery may be undertaken
Additional medical management (i.e. head of bed elevation, warm compress to eye, mucolytics, nasal decongestant, saline sinus irrigations)
Parenteral antibiotics transitioned to oral after symptomatic improvement usually minimum of 24 hours after surgery
Chandler Group IV: Orbital Abscess
Characteristic findings on exam: severe proptosis, ophthlamoplegia, periorbital edema, chemosis, vision impairment
Admit patient
Initiate parenteral antibiotics: ceftriaxone or ampicillin-sulbactam, consider adding vancomycin if risk of MRSA or intracranial disease extent
Surgery is usually indicated, in conjunction with ophthalmology
Open or endoscopic drainage of the abscess with ESS of the involved sinuses
Additional medical management (i.e. head of bed elevation, warm compress to eye, mucolytics, nasal decongestant, saline sinus irrigations)
Chandler Group V: Cavernous Sinus Thrombosis
Characteristic findings include bilateral symptoms including ophthalmoplegia, proptosis, decreased visual acuity, multiple cranial nerve palsies III, IV, V, VI
MRI/MRV with contrast for diagnosis confirmation
Ensure hemodynamic stability, evaluate for associated sepsis or meningitis
Initiate parenteral antibiotics: Consider ceftriaxone, vancomycin, metronidazole at meningitis dosages
ESS may be useful for source control and culture data
Ophthalmology & Neurosurgery consultations
Consider anticoagulation
Admit to ICU
Intracranial Complications
Overview
Intracranial complications of sinusitis occur more commonly in children and are classically associated with adolescent males with spread of frontal sinus disease through the veins of Breschet which communicate directly with the dura. However, disease can also spread intracranially from other sites such as the ethmoid or sphenoid sinuses. Extension of the disease intracranially can lead to meningitis, superior sagittal sinus thrombosis, epidural abscess, subdural empyema or abscess, cerebral abscess, or frontal bone osteomyelitis (i.e., Pott’s puffy tumor). Signs and symptoms suggestive of intracranial extension of disease include persistent headache, nuchal rigidity, nausea and vomiting, altered mental status, cranial neuropathies, and focal neurologic deficits. Signs of complicated sinusitis such as frontal swelling or periorbital edema are common prior to intracranial spread of disease. Imaging, most commonly CT with contrast, is indicated although MRI with and without contrast better differentiates subdural empyema or intracranial abscess from adjacent cerebritis and inflammation. Sampling from an involved sinus with endoscopic visualization or trephination (preferable in some cases of isolated frontal sinusitis in order to not disturb the mucosa of the outflow tract or when the degree of infection/inflammation makes endoscopic visualization challenging) can be helpful for identification and susceptibility of the responsible pathogen. ESS may also allow for better source control of the disease. Consultation with infectious disease specialists and neurosurgery is warranted.
Management
Complete head and neck physical exam including rhinoscopy/endoscopic nasal examination with neurologic and cranial nerve exam
Neurosurgical consultation
Obtain cultures from sinus and blood. Lumbar puncture may be required in some cases
Obtain labs: CBC, CMP, CRP
Initiate broad spectrum antibiotics at meningitis dosages that are age and weight based; an optional regimen would usually include vancomycin, ceftriaxone, and metronidazole
Continue IV antibiotics usually for 4-6-week course in conjunction with infectious disease recommendations
Consider corticosteroids if significant cerebral edema is present
Prophylactic antiepileptics usually indicated
Surgery is indicated in almost all cases and involves ESS with or without craniotomy dependent on intracranial disease extent. Goal of surgery is infection source control and culture collection
Close follow up and serial imaging with MRI is typically required
References
Benninger, M.S., et al (2020). Acute Rhinosinusitis: Pathogenesis, Treatment, and Complications. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 643-648). Philadelphia, PA: Elsevier.
Giannoni, C.M. (2013). Complications of Rhinosinusitis. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 573-585). Baltimore, MD: Lippincott Williams & Wilkins.
Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Ashok Kumar, K., Kramper, M., … Corrigan, M. D. (2015). Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery, 152(2_suppl), S1–S39.https://doi.org/10.1177/0194599815572097