Bacterial, viral, and fungal infections can all be sources of sinonasal inflammation in CRS. Bacteria may play both direct and indirect roles in the pathophysiology of CRS, as seen with the biofilm and superantigen theories. The most common organisms isolated in CRS patients include S. aureus, coagulase-negative staphylococci, anaerobes, Pseudomonas aeruginosa.
Many different genera of fungus have been documented to cause sinus disease including Aspergillus, Bipolaris, Rhizopus, and Alternaria. Fungal sinusitis can vary from a relatively benign process to an acute life-threatening disease depending on the host and a variety of factors including diabetes, immunosupression, and allergy.
A fungal ball is the development of a noninvasive conglomeration of fungal hyphae into a mass. This condition arises due to the implantation of fungus into an otherwise normal sinus. Patients are usually immunocompetent with no other risk factors. The maxillary sinus is most commonly involved, followed by the sphenoid and ethmoid sinuses. Treatment is simple surgical removal of the fungal ball with aeration of the affected sinus. Antifungal therapy is usually unnecessary after surgery.
Allergic Fungal Rhinosinusitis (AFS)
Allergic fungal sinusitis is a subtype of CRS characterized by the presence of allergic mucin, which is thick inspissated mucus with eosinophils and fungal hyphae. The widely accepted diagnostic criteria for AFS were described by Bent and Kuhn in 1994. The five criteria are type I hypersensitivity to fungi, nasal polyps, characteristic CT scan findings (Figure 15–1), eosinophilic mucin without fungal invasion into sinus tissue, and positive fungal stains. Typically, polypoid tissue is seen anterior to a mass consisting of mucin, fungal elements, Charcot-Leyden crystals, and eosinophils. Sinus expansion and bony remodeling are hallmark features of this process. Typical CT scan findings include heterogeneous areas of signal intensity within the affected sinuses. The areas of increased signal intensity are thought to be due to the accumulation of heavy metals such as iron, manganese, and calcium within the inspissated allergic mucin. Magnetic resonance imaging (MRI) scans can also assist in the diagnosis. Treatment is primarily surgical with postoperative topical and systemic steroids. Immunotherapy, systemic steroids, and postoperative management by an allergist may be necessary to reduce recurrence.
Coronal CT scan: Allergic fungal sinusitis. Note the heterogeneous signal characteristics in the maxillary sinuses.
Invasive Fungal Sinusitis
Invasive fungal sinusitis is a disease seen almost exclusively in immunocompromised individuals. This condition is characterized by the rapid development of progressive invasive fungal infection. The typical fungal pathogens are Aspergillus, Mucor, and Rhizopus. Gillespie and O'Malley reviewed 25 patients with invasive fungal sinusitis, and looked at their presentation. Nearly two-thirds presented with either fever or facial periorbital pain, and up to half presented with nasal congestion and headache. In this study, 88% presented with two or more of these findings, and just over a quarter had visual complaints or ophthalmoplegia. Rapid diagnosis and treatment is essential to limit the disease progression. In one small study, biopsy of the middle turbinate at had a 75% sensitivity and 100% specificity in diagnosing invasive fungal sinusitis. Pathologic examination of the black necrotic intranasal or palatal debris demonstrates arterial and venous thrombosis due to direct fungal invasion. The treatment consists of (1) debriding all involved structures, (2) aggressive intravenous antifungal therapy, and (3) normalizing the underlying immunocompromised state (usually neutropenia or uncontrolled diabetes).
Benninger MS, Ferguson BJ, Hadley JA. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003 Sep;129(3 Suppl):S1–32. (This task force summarized the impact of CRS and proposed an updated definition in 2003.)
Meltzer EO, Hamilos DL, Hadley JA. Rhinosinusitis: establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg. 2004 Dec;131(6 Suppl):S1–62. (Five national societies reached a consensus on definitions and strategies for clinical research to improve the diagnosis and future research in rhinosinusitis.)
Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice guideline on adult sinusitis. Otolaryngol Head Neck Surg. 2007 Sep;137(3):365–377. (The most recent guidelines illustrating the current recommendations on the diagnosis and treatment of rhinosinusitis.)
Chiu AG. Osteitis in chronic rhinosinusitis. Otolaryngol Clin North Am. 2005 Dec;38(6):1237–1242. (The author describes the possible association between bone infection and inflammation with chronic sinusitis.)
Krouse JH. Allergy and chronic rhinosinusitis. Otolaryngol Clin North Am 2005 Dec;38(6):1257–1266. (A nice review on the possible role of allergy in chronic sinusitis.)
Seiberling KA, Grammer L, Kern RC. Chronic rhinosinusitis and superantigens. Otolaryngol Clin North Am 2005 Dec;38(6):1215–1236. (This group describes the possible association between bacterial superantigens and CRS.)
Chakrabarti A, Denning DW, Fergusuon BJ et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope 2009 Sep;119(9):1809–1818. (This article reviews the recent literature on fungal sinusitis.)
Weschta M, Rimek D, Formanek M et al. Topical antifungal treatment of chronic rhinosinusitis with nasal polyps: a randomized, double – blind clinical trial. J Allergy Clin Immunol 2004 Jun;113(6):1122–1128. (These authors showed that nasal amphotericin B was not effective in treating CRS.)
Ebbens FA, Georgalas C, Luiten S et al. The effect of topical amphotericin B on inflammatory markers in patients with chronic rhinosinusitis: a multicenter randomized controlled study. Layngoscope 2009 Feb;119(2):401–408. (This article demonstrated no appreciate benefit on objective markers of CRS with nasal amphotericin B.)
Gillespie MB, O'Malley BW. An algorithmic approach to the diagnosis and management of invasive fungal rhinosinusitis in the immunocompromised patient. Otolaryngol Clin North Am 2000;33:323–334. (Review of the diagnosis and management of invasive fungal sinusitis.)
Many staging systems have been used to stratify patients with CRS according to objective levels of disease. Two commonly used staging systems found in the literature will be described briefly in this section.
The Lund–Mackay staging system is widely used in radiologic assessment of CRS. The scoring system is based on CT scan findings that are obtained after an adequate trial of medical treatment. Each sinus group is then assigned a numeric grade: 0 = no abnormality, 1 = partial opacification, and 2 = total opacification. The sinus groups include the maxillary, frontal, sphenoidal, anterior ethmoidal, and posterior ethmoidal sinuses. The ostiomeatal complex is scored only as 0 (not obstructed) or 2 (obstructed). Thus, a total score of 0–24 is possible, and each side can be considered separately (0–12).
Lund–Kennedy Endoscopic Scores
In this staging system, the endoscopic appearances of the nose are also quantified for the presence of polyps (0 = none, 1 = confined to middle meatus, 2 = beyond middle meatus), discharge (0 = none, 1 = clear and thin, 2 = thick and purulent), and edema, scarring or adhesions, and crusting (for each: 0 = absent, 1 = mild, 2 = severe).
Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolaryngol Head Neck Surg 1997 Sep;117(3 Pt 2):S35–S40.
A complete head and neck exam with anterior rhinoscopy is essential in all patients suspected of having rhinosinusitis. Findings of mucopurulence, edema, septal deflection, and polyps should be noted. The middle meatus is often well visualized after appropriate decongestion.
Rigid endoscopy or flexible fiberoptic endoscopy are useful to better evaluate the nasal cavity, sinuses, and nasopharynx. Findings that should be noted in the examination are septal deviations, edema of the turbinates, and the presence of mucus, pus, polyps, or erythema. Two critical areas to examine are the osteomeatal complex lateral to the middle turbinate and the sphenoethmoidal recess. Endoscopically guided cultures should be taken of any purulence in the nasal cavity or sinuses and sent for aerobic, anaerobic, fungal, and acid-fast bacilli cultures.
Computed tomography (CT) scanning is currently the method of choice for sinus imaging. Because a viral upper respiratory infection may cause abnormalities on CT that are indistinguishable from rhinosinusitis, imaging in ABRS has limited usefulness except when complications are suspected. On the other hand, symptoms of CRS do not correlate well with findings. Therefore, CT and/or nasal endoscopy is necessary to make the diagnosis. In addition to providing excellent visualization of mucosal thickening, air fluid levels, and bony structures, coronal scans give optimal visualization of the osteomeatal complex and are conveniently oriented for the surgeon in terms of surgical planning. Sagittal views can help delineate frontal sinus anatomy and confirm the presence of Onodi cells (Figure 15–2).
Coronal CT scan in a patient with chronic rhinosinusitis and allergic rhinitis. Note the left concha bullosa.
When compared to CT scans, MRI of the sinuses provides better soft tissue contrast resolution and tissue characterization. MRI offers better differentiation of benign obstructed secretions from tumor, and can be a helpful modality with suspected orbital or intracranial extension. For these reasons, MRI scanning should be the imaging method of choice in the evaluation of soft tissue masses, complicated sinus inflammatory diseases, and intracranial or intraorbital extension of sinus pathology.
Historically, standard radiographs were used to evaluate the sinuses. The conventional paranasal sinus evaluation included the following views: Caldwell (to visualize the frontal and ethmoid sinuses), Waters (for the maxillary sinuses), lateral (for the anterior and superior walls of the frontal, maxillary, and sphenoid sinuses), and submental vertex views (for the ethmoid and sphenoid sinuses).
Laboratory tests and immunologic studies may be helpful for patients who fail to improve with conventional medical and surgical treatments. A variety of conditions such as Wegener granulomatosis, Churg–Strauss syndrome, and sarcoidosis can be causes of recurrent sinusitis. Nasal crusting can occur secondary to dryness of the mucosa in Sjogren syndrome. Some common laboratory tests for these conditions include cytoplasmic-antineutrophil cytoplasmic antibody, perinuclear-antineutrophil cytoplasmic antibody, IgE, erythrocyte sedimentation rate, c-reactive protein, rheumatoid factor, and antinuclear antibody. Testing for HIV and IgG levels should be also considered in refractory patients.
The differential diagnoses of acute and chronic sinusitis are many and include the following: the common cold, temporomandibular joint (TMJ) pain, headache (including migraine), trigeminal pain, and sinus neoplasms. Allergic and odontogenic causes of symptoms should also be excluded. The symptoms of facial pressure and pain, purulent nasal discharge, nasal congestion, hyposmia, tooth pain, and a poor response to nasal decongestants can help differentiate these entities.
Sinus neoplasms are relatively uncommon, but are critical to exclude. A history of unilateral nasal obstruction and epistaxis warrants further workup, including CT scan and nasal endoscopy. Changes in vision and cranial nerve deficits, particularly in the distribution of the infraorbital nerve, should also cause suspicion. Palatal numbness or dry eyes can also be due to lesions in the pterygopalatine fossa (see Chapter 17, Paranasal Sinus Neoplasms).
Treatment of Chronic Rhinosinusitis
Medical management of CRS can be simplified into three groups: antimicrobial, anti-inflammatory, and mechanical. It is helpful to break down treatments from each group, and combine them when appropriate into a comprehensive treatment plan. Also, it is important at this time to consider the side effects of each therapy, and weigh them with the patient's symptom severity and other medical conditions. In general, medical management of CRS should include 3–4 weeks of culture directed (or broad spectrum) antibiotics, a nasal steroid spray, and nasal saline irrigation. Strong consideration should be given to a tapered course of oral steroids unless contraindicated.
Benninger MS, Ferguson BJ, Hadley JA. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003 Sep;129(3 Suppl):S1–32.
Lund VJ. Maximal medical therapy for chronic rhinosinusitis. Otolaryngol Clin North Am 2005 Dec;38(6):1301–1310. (Well-written review of the current medical treatments of chronic sinusitis.)
Antimicrobial medications are best given for patients with CRS after cultures have been performed. After the correct antibiotic is chosen, there are multiple ways to deliver it, including oral, intravenous, or topical. Oral antibiotics are the mainstay of treatment in the management of CRS to clear infection and to treat exacerbations of CRS. In contrast to antibiotic therapy for acute sinusitis, antibiotics should be used for at least 3–4 weeks. Ideally, antibiotic therapy should be culture-directed, particularly after failure of prior antibiotic use.
Topical antibiotics have the theoretical advantage of high local levels of drug with minimal systemic absorption, lower costs, and decreased morbidity when compared to IV antibiotics. A study by Vaughn and Carvalho showed that after a 3-week course of culture directed nebulized antibiotics, patients demonstrated improvements in posterior nasal discharge, and facial pain/pressure. These patients also had a longer infection-free period, and improved endoscopic exams. There were no major side effects to treatment, and minor side effects were usually benign and self-limiting.
Antifungal therapy for CRS is still controversial at this time. Recent double-blind, placebo controlled trials have not shown substantial improvement in CRS based on objective and subjective criteria after treatment with amphotericin B. Nonetheless, some patients with CRS treated with oral antifungals do benefit.
Vaughan WC, Carvalho G. Use of nebulized antibiotics for acute infections in chronic sinusitis. Otolaryngol Head Neck Surg 2002 Dec;127(6):558–568.
Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice guideline on adult sinusitis. Otolaryngol Head Neck Surg 2007 Sep;137(3):365–377.
Weschta M, Rimek D, Formanek M et al. Topical antifungal treatment of chronic rhinosinusitis with nasal polyps: a randomized, double–blind clinical trial. J Allergy Clin Immunol 2004 Jun;113(6):1122–1128.
Ebbens FA, Georgalas C, Luiten S et al. The effect of topical amphotericin B on inflammatory markers in patients with chronic rhinosinusitis: a multicenter randomized controlled study. Laryngoscope 2009 Feb;119(2):401–408.
Steroid Nasal Sprays and Oral Steroids
Mucosal inflammation and polyposis, which can lead to the obstruction of sinus ostia, are critical in the pathogenesis of most cases of CRS. Nasal steroid sprays directly address this problem by reducing mucosal inflammation and the site of polyps, thereby limiting postoperative recurrence. Common adverse effects with nasal steroids include nasal irritation, mucosal bleeding, and crusting. Systemic side effects are uncommon, and therefore nasal steroids are often prescribed for maintenance therapy in those with CRS. For better frontal sinus penetration, an eyedropper can be used to instill standard nasal steroid spray solution. Placement of drops at home can be done by the patient kneeling and then placing the forehead on the floor (Moffit's position) or with the head hanging off the bed (Mygind's position).
Systemic steroids are highly effective at reducing mucosal inflammation and nasal polyp bulk in CRS. Oral steroids decrease white blood cell migration, production of inflammatory mediators, antibody production, histamine release, and swelling through a variety of mechanisms. However, a thorough discussion with patients regarding the risks of systemic steroid administration is mandatory. A tapered regimen may be given during severe CRS flare-ups and in the postoperative period, but their use should be limited and carefully monitored.
Nasal Irrigation and Other Mechanical Treatments
Nasal saline irrigation is an important component in the treatment of CRS. Frequent rinsing prevents the accumulation of nasal crusts and promotes mucociliary clearance. Hypertonic saline may increase the rate of clearance in certain cases. Nasal irrigation is well tolerated by patients, without any evidence of significant harmful side effects. Work by the senior author has demonstrated the efficacy of 1% baby shampoo nasal irrigations for patients with CRS recalcitrant to surgery and isotonic saline irrigations. Patients with CRS were treated with twice-a-day sinus irrigation with 1% baby shampoo, which led to improvement in SNOT-22 scores for nearly 50% of patients who remained symptomatic despite surgical and conventional medical management. Greatest improvements were in reducing thickened nasal secretions and postnasal drainage. Baby shampoo nasal irrigation has promise as an inexpensive, well-tolerated adjuvant therapy to conventional medical therapies for symptomatic patients after FESS.
Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice guideline on adult sinusitis. Otolaryngol Head Neck Surg 2007 Sep;137(3):365–377.
Chiu AG, Palmer JN, Woodworth BA et al. Baby shampoo nasal irrigations for the symptomatic post-functional endoscopic sinus surgery patient. Am J Rhinol 2008 Jan–Feb;22(1):34–37. (Novel research illustrating the use of diluted baby shampoo irrigation for patients with thick mucus and chronic sinusitis.)
Decongestants, and Leukotriene Antagonists, and Other Therapies
Systemic decongestants and mucolytic agents such as guaifenesin may provide some symptomatic relief. Given the favorable side effects of these agents, they are often added to the therapeutic regimen. Leukotriene receptor antagonists (montelukast, zafirlukast) and macrolide antibiotics, which have anti-inflammatory effects, may also prove to be useful therapeutics.
Budesonide is used for the maintenance treatment of asthma and as prophylactic therapy in children aged 12 months to 8 years. While not FDA approved for use in CRS, use of budesonide respules (Pulmicort Respules; AstraZeneca LP, Wilmington, Delaware) for patients with nasal polyps or significant mucosal edema has been gaining popularity in the United States. A recent study for patients with chronic sinusitis found that use of budesonide 0.25 mg once a day for 30 days improved SNOT-20 scores without suppression of the hypothalamic–pituitary–adrenal axis. Budesonide can be used both in nasal irrigation or can be applied directly from respules.
Oxymetazoline hydrochloride and other topical nasal decongestant sprays cause intense vasoconstriction of the nasal mucosa. Rebound swelling (rhinitis medicomentosa) may incite a vicious cycle, leading to complete nasal obstruction and subsequent sinus disease. Oxymetazoline spray may be used for very short periods of time (less than 3 days) for symptomatic relief usually in ABRS or acute exacerbations of CRS.
Sachanandani NS, Piccirillo JF, Kramper MA et al. The effect of nasally administered budesonide
respules on adrenal cortex function in patients with chronic rhinosinusitis. Arch Otolaryngol Head Neck Surg
2009 Mar;135(3):303–307. (Describes the use of topical budesonide
respules for CRS.)
For patients with documented allergic disease, ongoing allergy management is beneficial. Environmental avoidance, topical nasal steroids, and immunotherapy may prevent exacerbations of allergic rhinitis. Immunotherapy is most effective for pollen, dust, molds, and pet dander allergies. Traditionally, treatments are via a subcutaneous route, but more recently sublingual immunotherapy has been gaining popularity especially in Europe. There is also a potentially beneficial role in aspirin desensitization for those patients with aspirin-exacerbated respiratory disease and Samter's triad.
Krouse JH. Allergy and chronic rhinosinusitis. Otolaryngol Clin North Am 2005 Dec;38(6):1257–1266.
Maximal medical therapy for CRS is typically defined as 4–6 weeks of broad spectrum or culture-directed antibiotics, nasal steroids, nasal irrigation, allergy management, and a short course of oral steroids. Surgical therapy may be necessary if the patient remains symptomatic, and there is evidence of persistent mucosal disease or sinus obstruction on CT scan or endoscopic evaluation. Patients with clear anatomic abnormalities, large sinonasal polyps, or allergic fungal sinusitis may be better candidates for primary surgical therapy.
Patients should be strongly encouraged to stop smoking prior to considering sinus surgery. Current tobacco use is associated with worse outcomes after endoscopic sinus surgery when compared to nonsmokers. Work by Senior et al. demonstrated active smokers have higher rates of disease relapse after sinus surgery, requiring more revision surgeries than nonsmokers. In this study, 100% of patients with severe disease required a revision operation for persistent symptoms.
Senior BA, Kennedy DW, Tanabodee J. Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998 Feb;108(2):151–157. (Excellent paper describing the long-term benefits of FESS.)
Functional Endoscopic Sinus Surgery (FESS)
Kennedy coined the term “functional endoscopic sinus surgery” to emphasize that surgery should aim at restoring normal sinus function and ventilation without excessive removal of potentially reversibly diseased tissue. Functional endoscopic sinus surgery is based on several key observations: (1) widely patent antrostomies in nonanatomic positions may fail to drain sinuses due to the directionality of mucociliary flow; (2) the ostiomeatal unit is anatomically constricted; and (3) the stripping of sinus mucosa leads to delayed healing and the loss of normal ciliary function. Thus, a conservative endoscopic technique has been developed. The keys to the technique are the use of “through-cutting” instruments that preserve sinonasal mucosa and the excellent visualization made possible with modern telescopes. Mucosal polyps can be carefully débrided, the natural ostia enlarged, and the ethmoid sinuses unroofed, which opens them to the nasal cavity. The improvement in symptoms with FESS may be expected in more than 90% of patients.
Relationship with Other Treatments
Sinus surgery should be considered as only a part of the treatment plan. Any underlying medical conditions, such as diabetes mellitus, immunodeficiency, tobacco use, and atopic disease, must also be addressed if ultimate success in treatment is to be obtained. Patients will require meticulous postoperative care including debridements, and, finally, long-term medical maintenance therapy.
The complications of surgical therapy are related to the close anatomic proximity of the paranasal sinuses to the brain and orbits. An intimate knowledge of the patient's individual anatomy is critical to reduce complications. Serious morbidity is rare, and includes cerebrospinal fluid leak (CSF) leaks, orbital injury, and intracranial hemorrhage. Injury to the medial wall of the orbit may cause the prolapse of orbital fat into the nasal cavity. A violation of the orbital wall, with subsequent hemorrhage and orbital hematoma, may lead to compression of the optic nerve and blindness. Damage to the cribriform plate region may lead to CSF leak, herniation of cranial contents, meningitis, or intracranial bleeding. In one large meta-analysis of patients who underwent FESS, the authors found the major complication rate was 0.85%, with CSF leak being the most common complication. Minor complications occurred in 6.9% of patients, with orbital penetration and middle turbinate adhesions being the most common.
Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME. Functional endoscopic sinus surgery: theory and diagnostic evaluation. Arch Otolaryngol 1985;111:576–582. (Landmark paper describing the theory of endoscopic sinus surgery.)
May M, Levine HL, Mester SJ et al. Complications of endoscopic sinus surgery: analysis of 2108 patients – incidence and prevention. Laryngoscope 1994 Sep;104(9):1080–1083. (These authors compared their experience with FESS to 11 other series to look at the complications of sinus surgery.)
Complications of Rhinosinusitis
Chandler divided the progression of sinonasal orbital infections into five stages (Table 15–3). The first stage is periorbital edema, which presents with cellulitis of the eyelids without visual loss or ophthalmoplegia. The second stage describes infection extending through the orbital septum and is classified as orbital cellulitis. These patients present with pain, proptosis, and chemosis. With orbital cellulitis, there may be some degree of ophthalmoplegia related to edema of the extraocular muscles, and a mild decrease in visual acuity related to corneal edema. The third stage involves formation of a subperiosteal abscess. The fourth stage is the formation of an orbital abscess. Severe proptosis, chemosis, ophthalmoplegia, and visual loss are usually present. The fifth stage results from retrograde thrombophlebitis of the valveless ophthalmic veins that can lead to cavernous sinus thrombosis.
Table 15–3. Potential Orbital Complications of Sinusitis. ||Download (.pdf)
Table 15–3. Potential Orbital Complications of Sinusitis.
- No limitation of extraocular movements and vision is normal.
- Infection is anterior to the orbital septum
- Infection of the soft tissue posterior to the orbital septum
- Pus collection beneath the periosteum of the lamina papyracea.
- Globe is usually displaced in inferolateral direction
- Pus collection in the orbit.
- Associated with limitation of extraocular movements, exophthalmos, and visual changes.
|Cavernous sinus thrombosis|
- Septic thrombosis of the cavernous sinuses
- Fever, ophthalmoplegia, ptosis, proptosis, chemosis, blindness, meningitis
Periorbital edema can usually be treated in an outpatient setting with oral antibiotics and close follow-up in the absence of medical comorbidities such as uncontrolled diabetes. Orbital cellulitis usually responds to intravenous antibiotics, whereas subperiosteal and orbital abscesses require operative drainage of the abscess with concurrent sinus surgery. Cavernous sinus thrombosis can truly be life-threatening. Even in the post-antibiotic era, the mortality rate of cavernous sinus thrombosis is 30%. Intravenous antibiotic treatment should be instituted immediately, and, if indicated, the involved sinuses should be surgically drained. The role of anticoagulation to prevent further thrombus formation and systemic steroid therapy is controversial. The incidence of all orbital complications is higher in the pediatric population than in adults.
In the antibiotic era, intracranial complications of sinusitis have become less commonplace, but nevertheless continue to occur and be associated with significant morbidity and mortality. Meningitis usually occurs by extension of infection from the ethmoid or sphenoid sinuses. On examination, patients with this complication may have a diminished sensorium or may be obtunded. The typical signs of meningitis, such as Kernig and Brudzinski signs, may be present. If meningitis secondary to sinus infection is suspected, a high-resolution CT scan of the brain with contrast and a sinus CT scan should be obtained. A CT scan of the brain is critical both to rule out mass effect and to delineate any other intracranial complications. Lumbar puncture is diagnostic and provides material for culture. The treatment for meningitis involves intravenous antibiotics and surgical drainage of the sinuses. Anaerobic organisms are reported to be the most common pathogens in suppurative intracranial complications of sinusitis, but aerobic and mixed infections are also common.
An epidural abscess is a collection of purulent material between the bone of the skull and the dura, typically in relation to frontal sinusitis. The further spread of infection, either by direct extension or by hematogenous seeding, may lead to subdural empyema and eventually to brain abscess (Figure 15–3). Draining both the abscess and the offending sinuses is mandatory, and long-term antibiotics are often necessary. Regardless of the treatment, morbidity is high, particularly with subdural involvement, and can result in long-term neurologic sequela.
Axial CT scan demonstrating intracranial abscess.
Pott puffy tumor is an osteomyelitis of the frontal bone with the development of a subperiosteal abscess manifesting as a puffy swelling on the forehead or scalp. It usually occurs as a complication of frontal sinusitis. Treatment is prompt surgical drainage and initiation of broad-spectrum antibiotics.
May M, Levine HL, Mester SJ et al. Complications of endoscopic sinus surgery: analysis of 2108 patients —incidence and prevention. Laryngoscope 1994 Sep;104(9):1080–1083.
Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414. (This important paper describes the possible orbital complications associated with sinusitis and outlines a staging system.)
Gallagher RM, Gross CW, Phillips CD. Suppurative intracranial complications of sinusitis. Laryngoscope 1998 Nov;108(11 Pt 1): 1635–1642. (Describes the authors experience with 22 cases of intracranial complications of sinusitis.)
Ebright JR, Pace MT, Niazi AF. Septic thrombosis of the cavernous sinuses. Arch Intern Med. 2001 Dec 10—24;161(22): 2671–2676. (This article describes a rare complication of sinusitis and its management.)
We would like to acknowledge Ashish R. Shah, MD, Frank N. Salamone, MD, and Thomas A. Tami, MD for their contribution to this chapter in the previous editions of CDT.