Complications of Rhinosinusitis Synopsis of Critical Sequelae Viet - - PowerPoint PPT Presentation
Complications of Rhinosinusitis Synopsis of Critical Sequelae Viet Pham, M.D. Faculty Advisor: Patricia Maeso, M.D. The University of Texas Medical Branch (UTMB Health) Department of Otolaryngology Grand Rounds Presentation April 22, 2010
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Standring S, ed. Gray's Anatomy, 40th Ed. Spain: Churchill Livingstone, 2008.
At 3 months gestation
Volume 6-8cm3 at birth
Volume 15cm3 by adulthood
First 3 years and between 7-18 years
Coincides with dental development
Accessory ostia in 15-40%
Haller cell can impair drainage
Kennedy DW, Bolger WE, Zinreich SJ, eds. Diseases of the Sinuses – Diagnosis and
Notes: The anterior wall forms the facial surface of the maxilla, the posterior wall borders the infratemporal fossa, the medial wall constitutes the lateral wall of the nasal cavity, the floor of the sinus is the alveolar process, and the superior wall serves as the orbital floor.
Bailey, et al. 2006. pp 10.
NOTES: Haller cell is an ethmoidal cell that pneumatizes between maxillary sinus and
First seen at 5 months gestation
Five ethmoid turbinals
Agger nasi Uncinate Ethmoid bulla Ground/basal lamella Posterior wall of most posterior ethmoid cell
Between 3-4 cells at birth
Adult size by 12-15 years
Between 10-15 cells
Volume 2-3cm3 by adulthood
Hansen JT, ed. Netter’s Clinical Anatomy, 2nd Ed. Philadelphia: Saunders, 2010. Kennedy, et al. 2001
Nasolacrimal Duct Infundibulum Uncinate Process Hiatus Semilunaris Ethmoid Bulla Basal Lamella Retrobulbar Recess
NOTES: The lateral portions form the medial walls of the orbits, the sphenoid establishes the posterior face, the superior surface is formed by the skull base of the anterior cranial fossa, and many of the key structures of the lateral nasal wall, derived from basal lamellas, extend posteroinferiorly from the skull base. The lateral wall of the ethmoid sinus, or lamina papyracea, forms the paper-thin medial wall of the orbit. The midline vertical plate of the ethmoid bone is composed of a superior portion in the anterior cranial fossa called the crista galli and an inferior portion in the nasal cavity called the perpendicular plate of the ethmoid bone that contributes to the nasal septum. The anterior cranial fossa is separated from the ethmoid air cells superiorly by the horizontal plate of the ethmoid bone, which is composed of the thin medial cribriform plate and the thicker, more lateral ethmoid
the cribriform plate, which is the thinnest bone in the entire skull base. The ethmoid sinuses are separated by a series of recesses demarcated by five bony partitions or lamellae. These lamellae are named from the most anterior to posterior: first (uncinate process), second (bulla ethmoidalis), third (ground or basal lamella), fourth (superior turbinate), and fifth (supreme turbinate).
Drainage
Anterior cells via ethmoid infundibulum
Posterior cells via sphenoethmoid recess
Innervation via V1 distribution
Branches from nasociliary nerve
Anterior and posterior ethmoids
Vasculature
Ophthalmic artery
Maxillary and ethmoid veins
Nasociliary Nerve Anterior Ethmoidal Artery Posterior Ethmoidal Artery Ophthalmic Nerve Ophthalmic artery
Posterior cells drain into superior meatus Ophthalmic artery provides anterior and posterior ethmoidal arteries Cavernous sinus gives off maxillary and ethmoidal veins
Not present at birth
Starts developing at 4 years
Radiographically visualized at 5-6 years
Development not complete until 12- 20 years
Volume 4-7cm3 by adulthood
No or poor pneumatization in 5-10%
Drainage via frontal recess
Anterior: posterior agger nasi
Lateral: lamina papyracea
Medial: middle turbinate
Tollefson TT, Strong EB. Frontal Sinus Fractures. eMedicine 13 Jul 2009. Kennedy, et al. 2001
Frontal Sinus Frontal Recess Basal Lamella Infundibulum Posterior Ethmoid Uncinate Process
NOTES:The anterior table of the frontal sinus is twice as thick as the posterior table, which separates the sinus from the anterior cranial fossa. The floor of the sinus also functions as the supraorbital roof, and the drainage ostium is located in the posteromedial portion of the sinus floor A markedly pneumatized agger nasi cell or ethmoidal bulla can
Drainage of the frontal sinus also depends on the attachment of the superior portion of the uncinate process
Type 1 Type 2 Type 3 Type 4
Sold arrow – Frontal cell type Dashed arrow – Agger nasi cell
DelGaudio JM, et al. Multiplanar computed tomography analysis of frontal recess cells. Arch Otolaryngol Head Neck Surg 2005; 131:230-5.
NOTES:Type 3 cell attaches to anterior table.
Supratrochlear Nerve Supraorbital Nerve Supratrochlear Artery Supraorbital Artery
NOTES:Foramina of Breschet: small venules that drain the sinus mucosa into the dural veins
NOTES: Approximately 25% of bony capsules separating the internal carotid artery from the sphenoid sinus are partially
individuals with dehiscence in 6%. In most cases, the posteroinferior end of the superior turbinate was located in the same horizontal plane as the floor of the sphenoid sinus. The ostium was located medial to the superior turbinate in 83% of cases and lateral to it in 17%.
Obstruction of sinus ostia
Impaired ciliary transport
Superimposed bacterial infection in 0.5-2%
Symptoms for at least 7-10 days or worsening after 5-7 days
NOTES: Most viral upper respiratory tract infections are caused by rhinovirus, but coronavirus, influenza A and B, parainfluenza, respiratory syncytial virus, adenovirus, and enterovirus are also causative agents.
NOTES: One of the major problems with identifying the pathogenesis of CRS is that neither symptoms, findings, nor radiographs, taken independently, are sufficient basis for the diagnosis. One study showed that current symptom-based criteria had only a 47% correlation with a positive CT scan result. Stankiewicz JA, Chow JM: A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity. Am J Rhinol 2002; 16:199-202.
Siedek et al, 2010
Most commonly involved complication site
Proximity to ethmoid sinuses
Periorbita/orbital septum is the only soft-tissue barrier
Valveless superior and inferior ophthalmic veins
Continuum of inflammatory/infectious changes
Direct extension through lamina papyracea
Impaired venous drainage from thrombophlebitis
Progression within 2 days
Children more susceptible
< 7 years – isolated orbital (subperiosteal abscess)
> 7 years – orbital and intracranial complications
NOTES:
involved structure in sinusitis complications; rarely from frontal or maxillary sinuses
* pain and deterioration is not necessarily always present * increase in WBC only found in 50%
Bailey, et al. 2006.
Bailey, et al. 2006.
Ramadan et al, 2009
Bailey, et al. 2006. Ramadan et al, 2009
NOTES: Patients may complain
history of recent orbital trauma
Harrington JN. Orbital cellulitis. eMedicine, 25 Oct 2010.
Symptomatology
Pus formation between periorbita and lamina papyracea
Displace orbital contents downward and laterally
Proptosis, chemosis, ophthalmoplegia
Risk for residual visual sequelae
May rupture through septum and present in eyelids
Rim-enhancing hypodensity with mass effect
Adjacent to lamina papyracea
Superior location with frontal sinusitis etiology
Diagnostically accurate 86- 91%
Ramadan et al, 2009
NOTES: Patients will complain of diplopia,
visual acuity. The patient has limited ocular motility or pain on globe movement toward the abscess.; may have normal movement early on. Orbital signs include proptosis, chemosis, and visual impairment.
(Coenraad 2009)
Transconjunctival incision Extend medially around lacrimal caruncle
Bailey, et al. 2006.
Bailey, et al. 2006. Kirsch CFE, Turbin R, Gor D. Orbital infection imaging. eMedicine, 24 Mar 2010. Lafferty KA. Orbital infections. eMedicine, 22 Sep 2009.
Lynch incision
Endoscopic
NOTES:Transcaruncular approach allegedly does not utilize a facial incision.
Orbital pain
Proptosis and chemosis
Ophthalmoplegia
Symptoms in contralateral eye
Associated with sepsis and meningismus
Poor venous enhancement on CT
Better visualized on MRI
Contralateral involvement is distinguishing feature of cavernous sinus thrombosis MRI findings of heterogeneity and increased size suggest the diagnosis
Agayev A, Yilmaz S. Cavernous sinus thrombosis. N Engl J Med 2008; 359:2266.
MRI better especially if suspecting intracranial involvement, too.
Beneficial
Southwick et al (1986)
Reduction in mortality
Not recommended for other dural sinus thrombosis
Levine et al (1988)
No change in mortality
Mortality reduction with added early
Bhatia et al (2002)
PTT ratio 1.5-2.5
INR 2-3
Anticoagulate for 3 months
Fatal hemorrhagic cerebral infarction
Subarachnoid hemorrhage reversed with protamine
NOTES: 1980s were retrospective reviews Bhatia was a literature review
Mucosal scarring, polypoid changes
Hidden infectious foci with poor antibiotic penetration
Sinus wall erosion
Traumatic fracture lines
Neurovascular foramina (optic and olfactory nerves)
Diploic skull veins
Ethmoid bone
NOTES: Teenagers affected more because of developed frontal and sphenoid sinuses, and because they are more prone to URI’s than adults. Thrombophlebitis originating in the mucosal veins progressively involves the emissary veins of the skull, the dural venous sinuses, the subdural veins, and, finally, the cerebral veins. By this mode, the subdural space may be selectively infected without contamination of the intermediary structure; a subdural empyema can exist without evidence of extradural infection or osteomyelitis.
NOTES: Not exclusive, can occur concurrently. Percentages in children (Hicks et al, 2011)
Headache
Meningismus
Fever, septic
Cranial nerve palsies
Sphenoiditis
Ethmoiditis
NOTES: Also incidence of neurologic sequelae such as hearing loss and seizure disorder.
Ramachandran TS, et al, 2009.
Good intracerebral penetration
Typically for 4-8 weeks
Frontal sinus trephination
Frontal sinus cranialization
Stereotactic-guided drainage
NOTES: Will likely need antibiotics for 4-8 weeks; usually vancomycin and 3rd or 4th generation cephalosporin Prophylactic seizure therapy not necessary unless there’s an associated subdural abscess.
Antibiotics
Anticonvulsants
Hyperventilation, mannitol
Steroids
Medical therapy possible if < 1.5cm
Craniotomy or stereotactic burr hole
Endoscopic or external sinus drainage
NOTES:Need antibiotics with good intracerebral penetration, typically 3-6 weeks Craniotomy is favored over burr hole placement due to better exposure
(40%)
NOTES: May have mood swings and behavioral changes with frontal lobe involvement Worsening headache with meningismus suggests possible rupture of the abscess.
Lumbar puncture potentially fatal
Aggressive medical therapy
Antibiotics
Anticonvulsants
Hyperventilation, mannitol
Steroids
Drain sinuses and abscess
Medical therapy possible if abscess < 2.5cm
Excision or aspiration
Diagnostic aspiration if < 2.5cm or cerebritis Stereotactic-guided aspiration
Endoscopic or external sinus drainage
NOTES: Antibiotic regimen is typically 6-8 weeks; typically ceftriaxone, vancomycin or nafcillin, and metronidazole Corticosteroid use is controversial. Steroids can retard the encapsulation process, increase necrosis, reduce antibiotic penetration into the abscess, increase the risk of ventricular rupture, and alter the appearance on CT scans. Steroid therapy can also produce a rebound effect when discontinued. If used to reduce cerebral edema, therapy should be of short duration. The appropriate dosage, the proper timing, and any effect of steroid therapy on the course of the disease are unknown. The procedures used are aspiration through a bur hole and complete excision after craniotomy. Aspiration is the most common procedure and is often performed using a stereotactic procedure with the guidance
NOTES: Incidence of anaerobes in suppurative intracranial complications range from 60-100%
(Gallagher 1998)
Frontal sinusitis with acute osteomyelitis
Subperiosteal pus collection leads to “puffy” fluctuance
Only 20-25 cases reported in post-antibiotic era (Raja 2007)
Less than 50 pediatric cases in past 10 years (Blumfield 2010)
Headache
Fever
Neurologic findings
Periorbital or frontal swelling
Nasal congestion, rhinorrhea
Sabatiello M, et al. The Potts puffy tumor: an unusual complication of frontal sinusitis, methods for its detection. Pediatr Dermatol 2010; 27:406-8.
NOTES: Sir Percivall Pott described Pott's Puffy tumor in 1768 as a local subperiosteal abscess due to frontal bone suppuration resulting from trauma. Pott reported another case due to frontal sinusitis.
Upadhyay S. Recurrent Pott's puffy tumor, a rare clinical entity. Neurol India 2010; 58:815-7. Bailey, et al. 2006. Blumfield, et al. 2010.
NOTES: Sir Percivall Pott described Pott's Puffy tumor in 1768 as a local subperiosteal abscess due to frontal bone suppuration resulting from trauma. Pott reported another case due to frontal sinusitis.
Diaz PM, et al. Tumor hinchado de Pott. Recidiva tras 10 anos
(http://www.smbc-comics.com)
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