Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.
Definition
Acute sinusitis =Bacterial sinusitis is following a viral illness lasting up to up to 4-week duration
Chronic Rhino Sinusitis (CRS) is when symptoms last >3 months
Complicated sinusitis= Acute sinusitis can rarely become complicated with orbital or intra cranial spread of infection
Aetiology
Same pathoges as acute sinusitis ie Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis
Pathophysiology
Sinus infection can spread intra orbitally or intra cranially via thrombosed veins.
Periorbita is usually a good barrier to spread of infection.
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| Ethmoid and Frontal sinuses drain to opthalmic vein which has drainage to cavernous sinus |
Signs and symptoms
Preceding:
Most patients may have had a recent URTI
Symptoms of sinusitis:
Nasal obstruction, Purulent nasal discharge, post nasal drip, anosmia, headache
Orbital/ intra cranial symptoms:
Infection can spread through various stages classified by Chandler (Chandler’s Classification)
Chandler’s Classification
Group I – Preseptal cellulitis
Group II – Orbital cellulitis
Group III – Subperiosteal abscess
Group IV – Orbital abscess
Group V – Cavernous sinus thrombosis
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| Chandler's Stages I-V |
Group I (Preseptal cellulitis):
This is actually inflammatory oedema anterior to orbital septum causing the eyelids to swell. This condition is caused due to restricted venous drainage. The eyelids though swollen are not tender. Since the inflammation doesn’t involve postseptal structures there is no chemises. Extraocular muscle movement limitations and vision impairment. Proptosis may be present to a mild degree.
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| Pre septal cellulitis, eye is otherwise not affected |
Group II: Orbital cellulitis
causes pronounced oedema and inflammation of orbital contents without abscess formation. It is imperative to look for signs of proptosis and reduced ocular mobility as these are reliable signs of orbital cellulitis. Chemosis is usually present in this group. Loss of vision is very rare in this group, but vision should be constantly monitored.
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| Chemosis |
Group III:
In this group abscess develops in the space between the bone and periosteum. Orbital contents may be displaced in an inferolateral direction due to the mass effect of accumulating pus. Chemosis and proptosis are usually present. Decreased ocular mobility and loss of vision is rare in this group.
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| sinus opacified, sub periosteal collection, bowing of medial rectus |
Group IV:
Orbital abscess usually involves collection of purulent material within the orbital contents. This could be caused due to relentless progression of orbital cellulitis or rupture of orbital abscess. Severe proptosis, complete ophthalmoplegia, and loss of vision are commonly seen in this group of patients.
Group V:
Cavernous sinus thrombosis – Development of bilateral ocular signs is the classic feature of patients belonging to this group. These patients classically manifest with fever, headache, photophobia, proptosis, ophthalmoplegia and loss of vision. Cranial nerve palsies involving III, IV, V1, V2 and VI are common.
Investigations
1) Sinus pus swab
2) Imaging: CT
Usually stage I & II do not need a CT, unless they fail to improve with medical Rx. Stage III onwards should be investigated with CT.
3) Imaging-MRI if any suggestion of intracranial complication- with MRI
4) Routine bloods
Treatment
1 Monitor vision
2 IV antibiotics
Antibiotics should cover the above pathogens ie Ceftriaxnoe, Augmentin
3 Nasal decongestants
Otrivin soaks Q 4 hrly ( ie kneel down- head on the ground- second person instils 5 drops of otrivin each nostril to soak in to the frontal, ethmoid sninues outflow)
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| The best position to get otrivin into the frontal, ethmoid drainage pathway |
4) Nasal Rinsing- 10 minutes after decongesting (6 times a day)
5) Nasal steroid spary ie Nasonex II BD or more
6) Oral steroids- prednisone high dose for 2 weeks then taper
Surgical Candidates
Subperiosteal abscess- drained externally or intra nasally
Also the sinus drainage is improved surgically
Intra orbital: drained by Ophthalmologist in conduction with a ENT surgeon
Intra cranial collection; drained by Neurosurgeon/ ENT
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