Understanding the Serious Complications of Rhinosinusitis

Introduction

• Complications of rhinosinusitis result from the progression of the acute or chronic infection beyond the paranasal sinuses and potentially cause significant morbidity from either local or distant spread. 
• Complications are generally classified as orbital, intracranial, and bony complications. 
• Direct routes of the spread can occur through the neurovascular foramina or the valveless diploeic veins of the Breschet. 
• Local complications may exhibit variations based on the specific sinus group involved. 
• Complications can result either from local progression or distant spread via the bloodstream. 
• Local complications of rhinosinusitis include mucocele, preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, osteomyelitis, meningitis, brain abscess, subdural empyema, and thrombosis of venous sinuses. They occur in approximately 5% of the patients who have been followed up for sinusitis. 

Frontal sinusitis

• Anterior spread will result in a Pott's puffy tumor, which is characterized by the subperiosteal abscess and osteomyelitis. 
• A posterior spread involves acute intracranial complications such as subdural empyema, meningitis, cerebritis, and the intracranial abscess. 
• Subdural empyema is the most common intracranial complication of sinusitis, with frontal sinusitis being the most common cause. 
• Inferior spread of the infection will result in orbital cellulitis. 

Also read: Granulomatous Conditions of the Nose

Ethmoidal Sinus  

• Orbital cellulitis stands out as the primary acute complications arising from ethmoid sinusitis. 
• Present between the frontal sinus anteriorly and the sphenoid sinus posteriorly.
• Fovea Ethmoidalis: Roof of the ethmoidal air cells, separating the ethmoid sinuses from frontal lobe.
• Ethmoidal air cells extends
  • Medially from the middle turbinate and
  • Laterally from the medial wall of the orbit.
• Anterior ethmoidal cells drain into the middle meatus.
• Posterior ethmoidal cells drain into superior meatus.

Maxillary Sinus

• 1st sinus to develop and the first sinus to be visible radiologically.
• Largest of all the sinuses.
• Walls of maxillary sinus

Sphenoid Sinus

• Isolated sphenoid sinusitis is rare but can lead to complications such as meningitis or cavernous sinus thrombosis through direct spread. 
• In cavernous sinus thrombosis, infection may spread from the paranasal sinuses and orbit to the cavernous sinuses via veins such as thrombophlebitis or septic emboli. 
• The most common source of acute sinusitis-related cavernous sinus thrombosis is the sphenoid and ethmoid sinus
• MOST COMMON sinus to be affected in infants and children: ethmoidal sinus.
• MOST COMMON to be affected in adults: maxillary sinus.

Also read: Nasal Tip Surgery and Its Deformities

Complications of Rhinosinusitis

Risk Factors For Simultaneous Orbital And Intracranial Complications 

Risk factors for intracranial infection in children admitted for orbital complications of acute rhinosinusitis

• Male 
• Age 7 years and older 
• Failure to improve after appropriate therapy 
• Changes in neurologic status 
• Frontal sinus opacification on CT 
• Superior or lateral position of orbital abscess 
• Need for surgical intervention to drain orbital abscess

Also read: Granulomatous Conditions of the Nose

Intracranial complications

Brain Abscess

• Brain abscess can occur as a complication of local or distant spread from sinusitis. 
• The frontal sinuses are the most common source of brain abscess, followed by the ethmoid, sphenoid, and maxillary sinuses.
• Hematogenous spread is the most likely mechanism of distant spread. 

Subdural Empyema 

• Subdural empyema is one of the most common intracranial complications of rhinosinusitis, often resulting from hematogenous spread. 
• In subdural empyema, the infection extends beyond the protective dura mater, allowing the possibility of thrombosis of veins in this space. 
• Symptoms of subdural empyema include meningeal irritation, seizures, and focal neurological deficits.

Extradural Empyema 

• Extradural empyema tends to be less symptomatic as the brain is protected by the dura mater.

Clinical Presentation 

• Early symptoms are usually non-specific; early symptoms include headache, fever, seizure, drowsiness, diplopia (5th cranial nerve palsy), eye pain, and nausea. 
• Suppuration from the paranasal sinuses may not always be identified during clinical examination. 
• Adolescent and young adult males are more commonly affected, possibly due to the vascularity of the diploic system in this age group. 
• Frontal lobe abscesses are the most common location for intracranial abscesses. 
• Well-defined intracranial abscesses may present with specific neurological symptoms, such as acute pain, possible loss of consciousness, and meningitis.

Also read: Cerebrospinal Fluid (CSF) : Physiology, Classification

Chronic Complications

• Mucoceles are chronic, slowly expanding lesions in any of the sinuses that may result in bony erosion and can extend beyond the sinus.

Key Points

• The major complications of rhinosinusitis are orbital and intracranial infections, of which orbital complications are the most common.
• The incidence of complications is greatest in children and young adults.
• The speed of initiating treatment and confirming the diagnosis can greatly reduce the mortality and extent of intervention required.
• Multidisciplinary care involving ENT surgeons with ophthalmology, pediatric, and neurology/neurosurgical input as required is a standard of care.

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