Complications of Rhinosinusitis

1
Complications of Rhinosinusitis
Synopsis of Critical Sequelae

• Viet Pham, M.D.
• Patricia Maeso, M.D.
• The University of Texas Medical Branch (utmb
  Health)Department of OtolaryngologyGrand Rounds
  Presentation
• April 22, 2010

(http//www.smbc-comics.com)
All images obtained via Google search unless
otherwise specified. All images used without
permission.
2
Outline

• Anatomy
• Rhinosinusitis
• Acute
• Chronic
• Complications
• Orbital
• Intracranial
• Bony
• Conclusion

Standring S, ed. Gray's Anatomy, 40th Ed. Spain
Churchill Livingstone, 2008.
3
AnatomyMaxillary Sinus

• Largest and first sinus to develop
• At 3 months gestation
• Volume 6-8cm3 at birth
• Volume 15cm3 by adulthood
• Biphasic periods of rapid growth
• First 3 years and between 7-18 years
• Coincides with dental development
• Natural ostium drains into ethmoidal
  infundibulum
• Accessory ostia in 15-40
• Haller cell can impair drainage

Kennedy DW, Bolger WE, Zinreich SJ, eds. Diseases
of the Sinuses Diagnosis and Management.
Hamilton BC Decker, 2001.
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.
4
AnatomyMaxillary Sinus

• Innervation via V2 distribution
• Infraorbital nerve
• Dehiscent intraorbital canal in 14
• Vasculature
• Maxillary artery and vein
• Facial artery
• First and second molar roots dehiscent
  in 2

NOTES Haller cell is an ethmoidal cell that
pneumatizes between maxillary sinus and orbital
floor.
Bailey, et al. 2006. pp 10.
5
AnatomyEthmoid Sinus
Nasolacrimal Duct

• 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

Infundibulum
Uncinate Process
Hiatus Semilunaris
Ethmoid Bulla
Kennedy, et al. 2001
Basal Lamella
Retrobulbar Recess
Hansen JT, ed. Netters Clinical Anatomy, 2nd Ed.
Philadelphia Saunders, 2010.
6
AnatomyEthmoid Sinus
Nasociliary Nerve
Ophthalmic Nerve

• 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

Anterior Ethmoidal Artery
Posterior cells drain into superior
meatus Ophthalmic artery provides anterior and
posterior ethmoidal arteries Cavernous sinus
gives off maxillary and ethmoidal veins
Posterior Ethmoidal Artery
Ophthalmic artery
7
AnatomyFrontal Sinus

• 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.
Frontal Sinus
Frontal Recess
NOTESThe 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 obstruct frontal sinus
drainage by narrowing the frontal recess.
Drainage of the frontal sinus also depends on the
attachment of the superior portion of the
uncinate process
Kennedy, et al. 2001
Posterior Ethmoid
Infundibulum
Basal Lamella
Uncinate Process
8
AnatomyFrontal Cell Types

• Type 1 single cell superior to agger nasi
• Type 2 gt 2 cells superior to agger nasi
• Type 3 single cell from agger nasi into sinus
• Type 4 isolated cell within sinus

NOTESType 3 cell attaches to anterior table.
Type 2
Type 3
Type 4
Type 1
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 131230-5.
9
AnatomyFrontal Sinus
Supratrochlear Nerve

• Vasculature
• Supraorbital artery and vein
• Supratrochlear artery
• Ophthalmic vein
• Foramina of Breschet
• Innervation via V1 distribution
• Supraorbital
• Supratrochlear

Supraorbital Nerve
Supratrochlear Artery
Supraorbital Artery
NOTESForamina of Breschet small venules that
drain the sinus mucosa into the dural veins
10
AnatomySphenoid Sinus
NOTES Approximately 25 of bony capsules
separating the internal carotid artery from the
sphenoid sinus are partially dehiscent. An optic
nerve prominence is present in 40 of 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.

• Evagination of nasal mucosa into sphenoid bone
• First seen at 4 months gestation
• Pneumatization begins in middle childhood
• Minimal volume at birth
• Volume 0.5-8cm3 by adult
• Reaches adult size by 12-18 years
• Sellar type (86)
• Presellar (11)
• Conchal (3)

11
AnatomySphenoid Sinus

• Innervation via sphenopalatine nerve
• V2 distribution
• Parasympathetics
• Vasculature via maxillary artery and vein
• Sphenopalatine artery
• Pterygoid plexus

12
Acute Rhinosinusitis (ARS)

• Inflammation of the nasal mucosa and lining of
  the paranasal sinuses
• Obstruction of sinus ostia
• Impaired ciliary transport
• Viral etiology in majority of cases
• Superimposed bacterial infection in 0.5-2
• Symptoms for at least 7-10 days or worsening
  after 5-7 days
• Symptoms present for lt 4 weeks
• Recurrent ARS with gt 4 episodes, lasting gt 7-10
  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.
13
Acute Rhinosinusitis (ARS)

• Major symptoms
• Facial pain/pressure
• Facial congestion/fullness
• Nasal obstruction
• Nasal discharge/purulence
• Minor symptoms
• Headache
• Fever (non-ARS)
• Halitosis
• Fatigue
• Diagnosis with two major or one major and two
  minor factors

• Hyposmia/anosmia
• Purulence on exam
• Fever (ARS only)
• Dental pain
• Cough
• Ear pain/pressure/fullness

14
Acute Rhinosinusitis (ARS)Microbiology
Children Adults
Streptococcus pneumoniae (30-43) Haemophilus influenzae (20-28) Moraxella catarrhalis (20-28) Other Streptococcus species Anaerobes Streptococcus pneumoniae (20-45) Haemophilus influenzae (22-35) Other Streptococcus species Anaerobes Moraxella catarrhalis Staphylococcus aureus
15
Chronic Rhinosinusitis (CRS)

• Symptoms present for gt 12 consecutive weeks
• Subacute for symptoms between 4-12 weeks
• Chronic inflammation
• Bacterial, fungal, and viral
• Allergic and immunologic
• Anatomic
• Genetic predisposition
• No clear consensus on pathophysiology

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
16199-202.
16
Chronic Rhinosinusitis (CRS)Microbiology
Children Adults
Anaerobes Other Streptococcus species Staphylococcus aureus Streptococcus pneumoniae Haemophilus influenzae Pseudomonas aeruginosa Anaerobes Other Streptococcus species Haemophilus influenzae Staphylococcus aureus Streptococcus pneumoniae Moraxella catarrhalis
17
Complications of Sinusitis

• Incidence has decreased with antibiotic use
• Three main categories
• Orbital (60-75)
• Intracranial (15-20)
• Bony (5-10)
• Radiography
• Computed tomography (CT) best for orbit
• Magnetic resonance imaging (MRI) best for
  intracranium

Siedek et al, 2010
18
Complications of SinusitisOrbital

• 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
• lt 7 years isolated orbital (subperiosteal
  abscess)
• gt 7 years orbital and intracranial complications

NOTES-- close proximity of the orbit to the
paranasal sinuses, particularly the ethmoids,
make it the most commonly involved structure
in sinusitis complications rarely from frontal
or maxillary sinuses -- pediatric population
difference likely related to age-related sinus
development pain and deterioration is not
necessarily always present increase in WBC
only found in 50
19
Orbital ComplicationsMicrobiology
Children Adults
Streptococcus species Staphylococcus aureus Anaerobes (Bacteroides and Fusobacterium species) Gram-negative bacilli Staphylococcus epidermidis Streptococcus pneumoniae Hemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Anaerobes
20
Orbital ComplicationsChandler Criteria

• Five classifications
• Preseptal cellulitis
• Orbital cellulitis
• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Not exclusive, can occur concurrently

Bailey, et al. 2006.
21
Orbital ComplicationsPreseptal Cellulitis

• Symptomatology
• Eyelid edema and erythema
• Extraocular movement intact
• Normal vision
• May have eyelid abscess
• CT reveals diffuse thickening of lid and
  conjunctiva

Bailey, et al. 2006.
22
Orbital ComplicationsPreseptal Cellulitis

• Medical therapy typically sufficient
• Intravenous antibiotics
• Head of bed elevation
• Warm compresses
• Facilitate sinus drainage
• Nasal decongestants
• Mucolytics
• Saline irrigations

Ramadan et al, 2009
23
Orbital ComplicationsOrbital Cellulitis
NOTES Patients may complain of pain and diplopia
and a history of recent orbital trauma or dental
surgery.

• Symptomatology
• Post-septal infection
• Eyelid edema and erythema
• Proptosis and chemosis
• Limited or no extraocular movement limitation
• No visual impairment
• No discrete abscess
• Low-attenuation adjacent to lamina
  papyracea on CT

Bailey, et al. 2006.
Ramadan et al, 2009
24
Orbital ComplicationsOrbital Cellulitis

• Facilitate sinus drainage
• Nasal decongestants
• Mucolytics
• Saline irrigations
• Medical therapy typically sufficient
• Intravenous antibiotics
• Head of bed elevation
• Warm compresses
• May need surgical drainage
• Visual acuity 20/60 or worse
• No improvement or progression within 48
  hours

Harrington JN. Orbital cellulitis. eMedicine, 25
Oct 2010.
25
Orbital ComplicationsSubperiosteal Abscess

• 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

Bailey, et al. 2006.
NOTES Patients will complain of diplopia,
ophthalmoplegia, exophthalmos, or reduced 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.
Ramadan et al, 2009
26
Orbital ComplicationsSubperiosteal Abscess

• Surgical drainage
• Worsening visual acuity or extraocular
  movement
• Lack of improvement after 48 hours
• May be treated medically in 50-67
• Meta-analysis cure rate 26-93 (Coenraad 2009)
• Combined treatment 95-100

27
Orbital ComplicationsSubperiosteal Abscess

• Open ethmoids and remove lamina papyracea
• Approaches
• External ethmoidectomy (Lynch incision)
  is most preferred
• Endoscopic ideal for medial abscesses
• Transcaruncular approach
• Transconjunctival incision
• Extend medially around lacrimal caruncle

Bailey, et al. 2006.
28
Orbital ComplicationsOrbital Abscess

• Symptomatology
• Pus formation within orbital tissues
• Severe exophthalmos and chemosis
• Ophthalmoplegia
• Visual impairment
• Risk for irreversible blindness
• Can spontaneously drain through eyelid
• Drain abscess and sinuses

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.
29
Orbital ComplicationsOrbital Abscess

• Incise periorbita and drain intraconal abscess
• Similar approaches as with subperiosteal abscess
• Lynch incision
• Endoscopic

NOTESTranscaruncular approach allegedly does not
utilize a facial incision.
30
Orbital ComplicationsCavernous Sinus Thrombosis

• Symptomatology
• Orbital pain
• Proptosis and chemosis
• Ophthalmoplegia
• Symptoms in contralateral eye
• Associated with sepsis and meningismus
• Radiology
• Poor venous enhancement on CT
• Better visualized on MRI

Bailey, et al. 2006.
Contralateral involvement is distinguishing
feature of cavernous sinus thrombosis MRI
findings of heterogeneity and increased size
suggest the diagnosis
31
Orbital ComplicationsCavernous Sinus Thrombosis

• Mortality rate up to 30
• Surgical drainage
• Intravenous antibiotics
• High-dose
• Cross blood-brain barrier
• Anticoagulant use is controversial
• Prevent thrombus propagation
• Risk intracranial or intraorbital bleeding

Agayev A, Yilmaz S. Cavernous sinus thrombosis. N
Engl J Med 2008 3592266.
MRI better especially if suspecting intracranial
involvement, too.
32
Cavernous Sinus ThrombosisAnticoagulation

• Harmful
• Bhatia et al (2002)
• Fatal hemorrhagic cerebral infarction
• Subarachnoid hemorrhage reversed with protamine

• 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

NOTES 1980s were retrospective reviews Bhatia
was a literature review
33
Complications of SinusitisIntracranial

• Occurs more commonly in CRS
• Mucosal scarring, polypoid changes
• Hidden infectious foci with poor antibiotic
  penetration
• Male teenagers affected more than children
• Direct extension
• Sinus wall erosion
• Traumatic fracture lines
• Neurovascular foramina (optic and olfactory
  nerves)
• Hematogenous spread
• Diploic skull veins
• Ethmoid bone

NOTES Teenagers affected more because of
developed frontal and sphenoid sinuses, and
because they are more prone to URIs 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.
34
Intracranial ComplicationsTypes

• Five types (not exclusive)
• Meningitis
• Epidural abscess
• Subdural abscess
• Intracerebral abscess
• Cavernous sinus, venous sinus thrombosis
• Common signs and symptoms
• Fever (92)
• Headache (85)
• Nausea, vomiting (62)
• Altered consciousness (31)

• Seizure (31)
• Hemiparesis (23)
• Visual disturbance (23)
• Meningismus (23)

NOTES Not exclusive, can occur concurrently.
Percentages in children (Hicks et al, 2011)
35
Intracranial ComplicationsMeningitis

• Most common intracranial complication of
  sinusitis
• Symptomatology
• Headache
• Meningismus
• Fever, septic
• Cranial nerve palsies
• Sinusitis is unusual cause of meningitis
• Sphenoiditis
• Ethmoiditis
• Usually amenable with medical treatment
• Drain sinuses if no improvement after 48 hours
• Hearing loss and seizure sequelae

NOTES Also incidence of neurologic sequelae
such as hearing loss and seizure disorder.
36
MeningitisMicrobiology
Children Adults
Streptococcus pneumoniae Staphylococcus aureus Other Streptococcus species Anaerobes (Bacteroides and Fusobacterium species) Gram-negative rods Streptococcus pnuemoniae Hemophilus influenzae
37
Intracranial ComplicationsEpidural Abscess

• Second-most common intracranial complication
• Generally a complication of frontal sinusitis
• Symptomatology
• Fever (gt50)
• Headache (50-73)
• Nausea, vomiting
• Crescent-shaped hypodensity on CT

• Papilledema
• Hemiparesis
• Seizure (4-63)

Bailey, et al. 2006.
Ramachandran TS, et al, 2009.
38
Intracranial ComplicationsEpidural Abscess

• Lumbar puncture contraindicated
• Prophylactic seizure therapy not necessary
• Antibiotics
• Good intracerebral penetration
• Typically for 4-8 weeks
• Drain sinuses and abscess
• 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 theres an
associated subdural abscess.
39
Intracranial ComplicationsSubdural Abscess

• Generally from frontal or ethmoid sinusitis
• Symptomatology
• Headaches
• Fever
• Nausea, vomiting
• Hemiparesis
• Lethargy, coma
• Third-most common intracranial
  complication, rapid deterioration
• Mortality in 25-35
• Residual neurologic sequelae in 35-55
• Accompanies 10 of epidural abscesses

Bailey, et al. 2006.
40
Intracranial ComplicationsSubdural Abscess

• Lumbar puncture potentially fatal
• Aggressive medical therapy
• Antibiotics
• Anticonvulsants
• Hyperventilation, mannitol
• Steroids
• Drain sinuses and abscess
• Medical therapy possible if lt 1.5cm
• Craniotomy or stereotactic burr hole
• Endoscopic or external sinus drainage

NOTESNeed antibiotics with good intracerebral
penetration, typically 3-6 weeks Craniotomy is
favored over burr hole placement due to better
exposure
41
Intracranial ComplicationsIntracerebral Abscess

• Uncommon, frontal and frontoparietal lobes
• Generally from frontal sinusitis
• Sphenoid
• Ethmoids
• Symptomatology
• Headache (70)
• Mental status change (65)
• Focal neurological deficit (65)
• Fever (50)
• Mortality 20-30
• Neurologic sequelae 60

Bailey, et al. 2006.

• Nausea, vomiting (40)
• Seizure (25-35)
• Meningismus (25)
• Papilledema (25)

NOTES May have mood swings and behavioral
changes with frontal lobe involvement Worsening
headache with meningismus suggests possible
rupture of the abscess.
42
Intracranial ComplicationsIntracerebral Abscess

• Lumbar puncture potentially fatal
• Aggressive medical therapy
• Antibiotics
• Anticonvulsants
• Hyperventilation, mannitol
• Steroids
• Drain sinuses and abscess
• Medical therapy possible if abscess lt 2.5cm
• Excision or aspiration
• Diagnostic aspiration if lt 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 of CT scanning or MRI.
43
Intracranial AbscessesMicrobiology
Children Adults
Anaerobes (anaerobic Streptococcus, Bacteroides, Fusobacterium species) Staphylococcus aureus Other Streptococcus species (Streptococcus milleri) Gram-negative bacilli (Hemophilus influenzae) Staphylococcus epidermidis Eikenella corrodens Polymicrobial Anaerobes (anaerobic Streptococcus, Bacteroides, Fusobacterium species) Staphylococcus aureus Other Streptococcus species (Streptococcus milleri) Gram-negative bacilli (Hemophilus influenzae) Staphylococcus epidermidis Eikenella corrodens Polymicrobial
NOTES Incidence of anaerobes in suppurative
intracranial complications range from 60-100
44
Intracranial ComplicationsVenous Sinus Thrombosis

• Sagittal sinus most common
• Retrograde thrombophlebitis from frontal
  sinusitis
• Extremely ill
• Subdural abscess
• Epidural abscess
• Intracerebral abscess
• Decreased cavernous carotid artery flow void on
  MRI
• Elevated mortality rate

45
Intracranial ComplicationsVenous Sinus Thrombosis

• Aggressive medical therapy
• Antibiotics
• Steroids
• Anticonvulsants
• Anticoagulation controversial
• Heparin inpatient, warfarin outpatient
• Thrombus resolution by 6 weeks (Gallagher 1998)
• Increased intracranial pressure outweighs
  bleeding risk (Gallagher 1998)
• Drain sinuses
• External
• Endoscopic

46
Complications of SinusitisBony

• Potts puffy tumor
• Frontal sinusitis with acute osteomyelitis
• Subperiosteal pus collection leads to puffy
  fluctuance
• Rare complication
• Only 20-25 cases reported in post-antibiotic era
  (Raja 2007)
• Less than 50 pediatric cases in past 10 years
  (Blumfield 2010)
• Symptomatology
• 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
27406-8.
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.
47
Complications of SinusitisBony

• Associated with other abscesses in 60
• Pericranial
• Periorbital
• Epidural
• Subdural
• Intracranial
• Cortical vein thrombosis
• Frontocutaneous fistula

Upadhyay S. Recurrent Pott's puffy tumor, a rare
clinical entity. Neurol India 2010 58815-7.
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.
Blumfield, et al. 2010.
Bailey, et al. 2006.
48
Potts Puffy TumorMicrobiology
Children Adults
Streptococcus species (Streptococcus milleri) Staphylococcus aureus Anaerobes (Bacteroides species) Gram-negative bacilli (Proteus species) Polymicrobial Streptococcus species (Streptococcus milleri) Staphylococcus aureus Anaerobes (Bacteroides species) Gram-negative bacilli (Proteus species) Polymicrobial
49
Complications of SinusitisBony

• Cooperative effort
• Otolaryngology
• Neurosurgery
• Infectious disease
• Surgical and medical therapy
• Drain abscess and remove infected bone
• Intravenous antibiotics for six weeks
• May obliterate frontal sinus to prevent recurrence

Diaz PM, et al. Tumor hinchado de Pott. Recidiva
tras 10 anos asintomatico. Rev Esp Cirug Oral y
Maxilofac 2007 29(5).
50
Conclusions

• Complications are less common with antibiotics
• Orbital
• Intracranial
• Bony
• Can result in drastic sequelae
• Drain abscess and open involved sinuses
• Surgical involvement
• Ophthalmology
• Neurosurgery

(http//www.smbc-comics.com)
51
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