Complications of RhinosinusitisAll images obtained via Google search unless otherwise specified. All images used without permission.(http://www.smbc-comics.com)Synopsis of Critical Sequelae

OutlineStandring S, ed. Gray's Anatomy, 40th Ed. Spain: Churchill Livingstone, 2008.AnatomyRhinosinusitisAcuteChronicComplicationsOrbitalIntracranialBonyConclusion

AnatomyMaxillary SinusLargest and first sinus to develop At 3 months gestationVolume 6-8cm3 at birthVolume 15cm3 by adulthoodBiphasic periods of rapid growthFirst 3 years and between 7-18 yearsCoincides with dental developmentNatural ostium drains into ethmoidal infundibulumAccessory 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.

AnatomyMaxillary SinusBailey, et al. 2006. pp 10.Innervation via V2 distributionInfraorbital nerveDehiscent intraorbital canal in 14%VasculatureMaxillary artery and veinFacial arteryFirst and second molar roots dehiscent in 2%NOTES: Haller cell is an ethmoidal cell that pneumatizes between maxillary sinus and orbital floor.

AnatomyEthmoid SinusFirst seen at 5 months gestationFive ethmoid turbinalsAgger nasiUncinateEthmoid bullaGround/basal lamellaPosterior wall of most posterior ethmoid cellBetween 3-4 cells at birthAdult size by 12-15 yearsBetween 10-15 cellsVolume 2-3cm3 by adulthoodHansen JT, ed. Netters Clinical Anatomy, 2nd Ed. Philadelphia: Saunders, 2010.Kennedy, et al. 2001Nasolacrimal DuctInfundibulumUncinate ProcessHiatus SemilunarisEthmoid BullaBasal LamellaRetrobulbar Recess

AnatomyEthmoid SinusDrainageAnterior cells via ethmoid infundibulumPosterior cells via sphenoethmoid recessInnervation via V1 distributionBranches from nasociliary nerveAnterior and posterior ethmoidsVasculatureOphthalmic arteryMaxillary and ethmoid veins

Nasociliary NerveAnterior Ethmoidal ArteryPosterior Ethmoidal ArteryOphthalmic NerveOphthalmic arteryPosterior cells drain into superior meatusOphthalmic artery provides anterior and posterior ethmoidal arteriesCavernous sinus gives off maxillary and ethmoidal veins

AnatomyFrontal SinusNot present at birthStarts developing at 4 yearsRadiographically visualized at 5-6 yearsDevelopment not complete until 12-20 yearsVolume 4-7cm3 by adulthoodNo or poor pneumatization in 5-10%Drainage via frontal recessAnterior: posterior agger nasiLateral: lamina papyraceaMedial: middle turbinateTollefson TT, Strong EB. Frontal Sinus Fractures. eMedicine 13 Jul 2009.Kennedy, et al. 2001Frontal SinusFrontal RecessBasal LamellaInfundibulumPosterior EthmoidUncinate ProcessNOTES: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 floorA 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

AnatomyFrontal Cell TypesType 1: single cell superior to agger nasiType 2: > 2 cells superior to agger nasiType 3: single cell from agger nasi into sinusType 4: isolated cell within sinusType 1Type 2Type 3Type 4Sold arrow Frontal cell type Dashed arrow Agger nasi cellDelGaudio 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.

AnatomyFrontal SinusVasculatureSupraorbital artery and veinSupratrochlear arteryOphthalmic veinForamina of BreschetInnervation via V1 distributionSupraorbitalSupratrochlearSupratrochlear NerveSupraorbital NerveSupratrochlear ArterySupraorbital ArteryNOTES:Foramina of Breschet: small venules that drain the sinus mucosa into the dural veins

AnatomySphenoid SinusEvagination of nasal mucosa into sphenoid boneFirst seen at 4 months gestationPneumatization begins in middle childhoodMinimal volume at birthVolume 0.5-8cm3 by adultReaches adult size by 12-18 yearsSellar type (86%)Presellar (11%)Conchal (3%)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%.

AnatomySphenoid SinusInnervation via sphenopalatine nerveV2 distributionParasympatheticsVasculature via maxillary artery and veinSphenopalatine arteryPterygoid plexus

Acute Rhinosinusitis (ARS)Inflammation of the nasal mucosa and lining of the paranasal sinusesObstruction of sinus ostiaImpaired ciliary transportViral etiology in majority of casesSuperimposed bacterial infection in 0.5-2%Symptoms for at least 7-10 days or worsening after 5-7 daysSymptoms present for < 4 weeksRecurrent ARS with > 4 episodes, lasting > 7-10 daysNOTES: 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.

Acute Rhinosinusitis (ARS)Major symptomsFacial pain/pressureFacial congestion/fullnessNasal obstructionNasal discharge/purulenceMinor symptomsHeadacheFever (non-ARS)HalitosisFatigueDiagnosis with two major or one major and two minor factors

Hyposmia/anosmiaPurulence on examFever (ARS only)

Dental painCoughEar pain/pressure/fullness

Acute Rhinosinusitis (ARS)Microbiology

ChildrenAdultsStreptococcus pneumoniae (30-43%)Haemophilus influenzae (20-28%)Moraxella catarrhalis (20-28%)Other Streptococcus speciesAnaerobesStreptococcus pneumoniae (20-45%)Haemophilus influenzae (22-35%)Other Streptococcus speciesAnaerobesMoraxella catarrhalisStaphylococcus aureus

Chronic Rhinosinusitis (CRS)Symptoms present for > 12 consecutive weeksSubacute for symptoms between 4-12 weeksChronic inflammationBacterial, fungal, and viralAllergic and immunologicAnatomicGenetic predispositionNo 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; 16:199-202.

Chronic Rhinosinusitis (CRS)Microbiology

ChildrenAdultsAnaerobesOther Streptococcus speciesStaphylococcus aureusStreptococcus pneumoniaeHaemophilus influenzaePseudomonas aeruginosaAnaerobesOther Streptococcus speciesHaemophilus influenzaeStaphylococcus aureusStreptococcus pneumoniaeMoraxella catarrhalis

Complications of SinusitisIncidence has decreased with antibiotic useThree main categoriesOrbital (60-75%)Intracranial (15-20%)Bony (5-10%)RadiographyComputed tomography (CT) best for orbitMagnetic resonance imaging (MRI) best for intracraniumSiedek et al, 2010

Complications of SinusitisOrbitalMost commonly involved complication siteProximity to ethmoid sinusesPeriorbita/orbital septum is the only soft-tissue barrierValveless superior and inferior ophthalmic veinsContinuum of inflammatory/infectious changesDirect extension through lamina papyraceaImpaired venous drainage from thrombophlebitisProgression within 2 daysChildren more susceptible< 7 years isolated orbital (subperiosteal abscess)> 7 years orbital and intracranial complicationsNOTES: -- 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%

Orbital ComplicationsMicrobiology

ChildrenAdultsStreptococcus speciesStaphylococcus aureusAnaerobes (Bacteroides and Fusobacterium species)Gram-negative bacilliStaphylococcus epidermidisStreptococcus pneumoniaeHemophilus influenzaeMoraxella catarrhalisStaphylococcus aureusAnaerobes

Orbital ComplicationsChandler CriteriaFive classificationsPreseptal cellulitisOrbital cellulitisSubperiosteal abscessOrbital abscessCavernous sinus thrombosisNot exclusive, can occur concurrentlyBailey, et al. 2006.

Orbital ComplicationsPreseptal CellulitisSymptomatologyEyelid edema and erythemaExtraocular movement intactNormal visionMay have eyelid abscessCT reveals diffuse thickening of lid and conjunctivaBailey, et al. 2006.

Orbital ComplicationsPreseptal CellulitisMedical therapy typically sufficientIntravenous antibioticsHead of bed elevationWarm compressesFacilitate sinus drainageNasal decongestantsMucolyticsSaline irrigations

Ramadan et al, 2009

Orbital ComplicationsOrbital CellulitisSymptomatologyPost-septal infectionEyelid edema and erythemaProptosis and chemosisLimited or no extraocular movement limitationNo visual impairment No discrete abscessLow-attenuation adjacent to lamina papyracea on CT

Bailey, et al. 2006.Ramadan et al, 2009NOTES: Patients may complain of pain and diplopia and a history of recent orbital trauma or dental surgery.:

Orbital ComplicationsOrbital CellulitisFacilitate sinus drainageNasal decongestantsMucolyticsSaline irrigationsMedical therapy typically sufficientIntravenous antibioticsHead of bed elevationWarm compressesMay need surgical drainageVisual acuity 20/60 or worseNo improvement or progression within 48 hoursHarrington JN. Orbital cellulitis. eMedicine, 25 Oct 2010.

Orbital ComplicationsSubperiosteal AbscessSymptomatologyPus formation between periorbita and lamina papyraceaDisplace orbital contents downward and laterallyProptosis, chemosis, ophthalmoplegiaRisk for residual visual sequelaeMay rupture through septum and present in eyelidsRim-enhancing hypodensity with mass effectAdjacent to lamina papyraceaSuperior location with frontal sinusitis etiologyDiagnostically accurate 86-91%Bailey, et al. 2006.Ramadan et al, 2009NOTES: 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.

Orbital ComplicationsSubperiosteal AbscessSurgical drainageWorsening visual acuity or extraocular movementLack of improvement after 48 hoursMay be treated medically in 50-67%Meta-analysis cure rate 26-93% (Coenraad 2009)Combined treatment 95-100%

Orbital ComplicationsSubperiosteal AbscessOpen ethmoids and remove lamina papyraceaApproachesExternal ethmoidectomy (Lynch incision) is most preferredEndoscopic ideal for medial abscessesTranscaruncular approachTransconjunctival incisionExtend medially around lacrimal caruncle

Bailey, et al. 2006.

Orbital ComplicationsOrbital AbscessSymptomatologyPus formation within orbital tissuesSevere exophthalmos and chemosisOphthalmoplegiaVisual impairmentRisk for irreversible blindnessCan spontaneously drain through eyelidDrain abscess and sinusesBailey, et al. 2006.Kirsch CFE, Turbin R, Gor D. Orbital infection imaging. eMedicine, 24 Mar 2010.Lafferty KA. Orbital infections. eMedicine, 22 Sep 2009.

Orbital ComplicationsOrbital AbscessIncise periorbita and drain intraconal abscessSimilar approaches as with subperiosteal abscessLynch incisionEndoscopicNOTES:Transcaruncular approach allegedly does not utilize a facial incision.

Orbital ComplicationsCavernous Sinus ThrombosisSymptomatologyOrbital painProptosis and chemosisOphthalmoplegiaSymptoms in contralateral eyeAssociated with sepsis and meningismusRadiologyPoor venous enhancement on CTBetter visualized on MRIBailey, et al. 2006.Contralateral involvement is distinguishing feature of cavernous sinus thrombosisMRI findings of heterogeneity and increased size suggest the diagnosis

Orbital ComplicationsCavernous Sinus ThrombosisMortality rate up to 30%Surgical drainageIntravenous antibioticsHigh-doseCross blood-brain barrierAnticoagulant use is controversialPrevent thrombus propagationRisk intracranial or intraorbital bleedingAgayev A, Yilmaz S. Cavernous sinus thrombosis. N Engl J Med 2008; 359:2266.MRI better especially if suspecting intracranial involvement, too.

Cavernous Sinus ThrombosisAnticoagulationBeneficialSouthwick et al (1986)Reduction in mortalityNot recommended for other dural sinus thrombosisLevine et al (1988)No change in mortalityMortality reduction with added earlyBhatia et al (2002)PTT ratio 1.5-2.5INR 2-3Anticoagulate for 3 monthsHarmfulBhatia et al (2002)Fatal hemorrhagic cerebral infarctionSubarachnoid hemorrhage reversed with protamineNOTES: 1980s were retrospective reviewsBhatia was a literature review

Complications of SinusitisIntracranialOccurs more commonly in CRSMucosal scarring, polypoid changesHidden infectious foci with poor antibiotic penetrationMale teenagers affected more than childrenDirect extensionSinus wall erosionTraumatic fracture linesNeurovascular foramina (optic and olfactory nerves)Hematogenous spreadDiploic skull veinsEthmoid boneNOTES: 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.

Intracranial ComplicationsTypes

Seizure (31%)Hemiparesis (23%)Visual disturbance (23%)Meningismus (23%)Five types (not exclusive)MeningitisEpidural abscessSubdural abscessIntracerebral abscessCavernous sinus, venous sinus thrombosisCommon signs and symptomsFever (92%)Headache (85%)Nausea, vomiting (62%)Altered consciousness (31%)

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

Intracranial ComplicationsMeningitisMost common intracranial complication of sinusitisSymptomatologyHeadacheMeningismusFever, septicCranial nerve palsiesSinusitis is unusual cause of meningitisSphenoiditisEthmoiditisUsually amenable with medical treatmentDrain sinuses if no improvement after 48 hoursHearing loss and seizure sequelaeNOTES: Also incidence of neurologic sequelae such as hearing loss and seizure disorder.

MeningitisMicrobiology

ChildrenAdultsStreptococcus pneumoniaeStaphylococcus aureusOther Streptococcus speciesAnaerobes (Bacteroides and Fusobacterium species)Gram-negative rodsStreptococcus pnuemoniaeHemophilus influenzae

Intracranial ComplicationsEpidural AbscessBailey, et al. 2006.Ramachandran TS, et al, 2009.

PapilledemaHemiparesisSeizure (4-63%)Second-most common intracranial complicationGenerally a complication of frontal sinusitisSymptomatologyFever (>50%)Headache (50-73%)Nausea, vomitingCrescent-shaped hypodensity on CT

Intracranial ComplicationsEpidural AbscessLumbar puncture contraindicatedProphylactic seizure therapy not necessaryAntibiotics Good intracerebral penetrationTypically for 4-8 weeksDrain sinuses and abscessFrontal sinus trephinationFrontal sinus cranializationStereotactic-guided drainageNOTES: Will likely need antibiotics for 4-8 weeks; usually vancomycin and 3rd or 4th generation cephalosporinProphylactic seizure therapy not necessary unless theres an associated subdural abscess.

Intracranial ComplicationsSubdural AbscessGenerally from frontal or ethmoid sinusitisSymptomatologyHeadachesFeverNausea, vomitingHemiparesisLethargy, comaThird-most common intracranial complication, rapid deteriorationMortality in 25-35%Residual neurologic sequelae in 35-55%Accompanies 10% of epidural abscessesBailey, et al. 2006.

Intracranial ComplicationsSubdural AbscessLumbar puncture potentially fatalAggressive medical therapyAntibioticsAnticonvulsantsHyperventilation, mannitolSteroidsDrain sinuses and abscessMedical therapy possible if < 1.5cmCraniotomy or stereotactic burr holeEndoscopic or external sinus drainageNOTES:Need antibiotics with good intracerebral penetration, typically 3-6 weeksCraniotomy is favored over burr hole placement due to better exposure

Intracranial ComplicationsIntracerebral AbscessUncommon, frontal and frontoparietal lobesGenerally from frontal sinusitisSphenoidEthmoidsSymptomatologyHeadache (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 involvementWorsening headache with meningismus suggests possible rupture of the abscess.

Intracranial ComplicationsIntracerebral AbscessLumbar puncture potentially fatalAggressive medical therapyAntibioticsAnticonvulsantsHyperventilation, mannitolSteroidsDrain sinuses and abscessMedical therapy possible if abscess < 2.5cmExcision or aspirationDiagnostic aspiration if < 2.5cm or cerebritisStereotactic-guided aspirationEndoscopic or external sinus drainageNOTES: Antibiotic regimen is typically 6-8 weeks; typically ceftriaxone, vancomycin or nafcillin, and metronidazoleCorticosteroid 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.

Intracranial AbscessesMicrobiologyNOTES: Incidence of anaerobes in suppurative intracranial complications range from 60-100%

ChildrenAdultsAnaerobes (anaerobic Streptococcus, Bacteroides, Fusobacterium species)Staphylococcus aureusOther Streptococcus species (Streptococcus milleri)Gram-negative bacilli (Hemophilus influenzae)Staphylococcus epidermidisEikenella corrodensPolymicrobial

Intracranial ComplicationsVenous Sinus ThrombosisSagittal sinus most commonRetrograde thrombophlebitis from frontal sinusitisExtremely illSubdural abscessEpidural abscessIntracerebral abscessDecreased cavernous carotid artery flow void on MRIElevated mortality rate

Intracranial ComplicationsVenous Sinus ThrombosisAggressive medical therapyAntibioticsSteroidsAnticonvulsantsAnticoagulation controversialHeparin inpatient, warfarin outpatientThrombus resolution by 6 weeks (Gallagher 1998)Increased intracranial pressure outweighs bleeding risk (Gallagher 1998)Drain sinusesExternalEndoscopic

Complications of SinusitisBonyPotts puffy tumorFrontal sinusitis with acute osteomyelitisSubperiosteal pus collection leads to puffy fluctuanceRare complicationOnly 20-25 cases reported in post-antibiotic era (Raja 2007)Less than 50 pediatric cases in past 10 years (Blumfield 2010)SymptomatologyHeadacheFeverNeurologic findingsPeriorbital or frontal swellingNasal congestion, rhinorrheaSabatiello 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.

Complications of SinusitisBonyAssociated with other abscesses in 60%PericranialPeriorbitalEpiduralSubduralIntracranialCortical vein thrombosisFrontocutaneous fistulaUpadhyay 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.

Potts Puffy TumorMicrobiology

ChildrenAdultsStreptococcus species (Streptococcus milleri)Staphylococcus aureusAnaerobes (Bacteroides species)Gram-negative bacilli (Proteus species)Polymicrobial

Complications of SinusitisBonyCooperative effortOtolaryngologyNeurosurgeryInfectious diseaseSurgical and medical therapyDrain abscess and remove infected boneIntravenous antibiotics for six weeksMay obliterate frontal sinus to prevent recurrenceDiaz PM, et al. Tumor hinchado de Pott. Recidiva tras 10 anos asintomatico. Rev Esp Cirug Oral y Maxilofac 2007; 29(5).

ConclusionsComplications are less common with antibioticsOrbitalIntracranialBonyCan result in drastic sequelaeDrain abscess and open involved sinusesSurgical involvementOphthalmologyNeurosurgery(http://www.smbc-comics.com)

ReferencesBailey BJ, Johnson, JT, Newlands SD, eds. Head and Neck Surgery Otolaryngology, 4th Ed. Philadelphia: Lippincott, 2006:307-11, 406, 493-503.Benninger MS, Ferguson BJ, Hadley JA, et al: Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003; 129:S1-S32.Benson BE, Riauba L. Sinusitis, Acute. eMedicine 10 Feb 2009. Accessed 21 Mar 2011 .Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: area anticoagulants indicated? A review of the literature. J Laryngol Otol 2002; 116:667-76.Blumfield E, Misra M. Pott's puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emerg Radiol 2011 Mar 5 [Epub ahead of print].Brook I. Brain abscess. eMedicine 26 Jun 2008. Accessed 10 Apr 2011 .Brook I, Bajracharya H. Sinusitis, Chronic. eMedicine 17 Jun 2009. Accessed 21 Mar 2011 .Brook I, Friedman EM. Intracranial complications of sinusitis in children: a sequela of periapical abscess. Ann Otol Rhinol Laryngol 1982; 91:41-3.Caversaccio M, Heimgartner S, Aebi C. Orbital complications of acute pediatric rhinosinusitis: medical treatment versus surgery and analysis of the computer tomogram. Laryngorhinootologic 2005; 84:817-21.Coenraad S, Buwalda J. Surgical or medical management of subperiosteal orbital abscess in children: a critical appraisal of the literature. Rhinology 2009; 47:18-23.Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970; 80: 1414-28.Dawodu ST, Lorenzo NY. Subdural empyema. eMedicine 11 Mar 2009. Accessed 10 Apr 2011 .Eweiss A, Mukonoweshuro W, Khalil HS. Cavernous sinus thrombosis secondary to contralateral sphenoid sinusitis: a diagnostic challenge. J Laryngol Otol 2010; 124:928-30.Flint PW, et al, eds. Cummings Otolaryngology: Head and Neck Surgery, 5th Ed. Philadelphia: Mosby Elsevier, 2010. ch 47.Gallagher RM, Gross CW, Phillips CD. Suppurative intracranial complications of sinusitis. Laryngoscope 1998; 108:1635-42.

ReferencesGarcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology 2000; 107:1454-8.Giannoni CM, Sulek M, Friedman EM. Intracranial complications of sinusitis: A pediatric series. Am J Rhinol 1998; 12:173-8.Goldberg AN, Oroszlan G, Anderson TD. Complications of frontal sinusitis and their management. Otolaryngol Clin North Am 2001; 34:211-25.Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS 1998; 2:351-5.Greenlee JE. Subdural empyema. In: Mandell GL, ed. Principles and Practice of Infectious Diseases, Vol 1. 4th Ed. New York: Churchill, 1994:900-3.Gwaltney JM Jr. Acute community-acquired sinusitis. Clin Infect Dis 1996; 23:1209-23; quiz 1224-5.Gwaltney JM, Scheld WM, Sande MA, et al. The microbial etiology and antimicrobial therapy of adults with acute community-acquired sinusitis: A fifteen-year experience at the University of Virginia and review of other selected studies. J Allergy Clin Immunol 1992; 90:457-62.Herrmann BW, Forsen JW Jr. Simultaneous intracranial and orbital complications of acute rhinosinusitis in children. Int J Pediatr Otorhinolaryngol 2004; 68:619-25.Hicks CW, Weber JG, Reid JR, Moodley M. Identifying and managing intracranial complications of sinusitis in children. Pediatr Infect Dis 2011; 30:222-6.Janfaza P, Montgomery WW, Salman SD. Nasal cavities and paranasal sinuses. In: Janfaza P, Nadol JB, Galla R, et al, eds. Surgical Anatomy of the Head and Neck. Philadelphia: Lippincott Williams & Wilkins, 2001:259-318.Karaman E, Hacizade Y, Isildak H, Kaytaz A. Pott's puffy tumor. J Craniofac Surg 2008; 19:1694-7.Kayhan FT, Sayin I, Yazici ZM, Erdur O. Management of orbital subperiosteal abscess. J Craniofac Surg 2010; 21:1114-7.Kuhn FA. Chronic frontal sinusitis: the endoscopic frontal recess approach. Operat Tech Otolaryngol Head Neck Surg 1996; 7:222-9.Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997; 117:S1-S7.Lee KJ, ed. Essential Otolaryngology - Head and Neck Surgery, 9th Ed. New York: McGraw-Hill, 2008. pp 365-6.Levine SR, Twyman RE, Gilman S. The role of anticoagulation in cavernous sinus thrombosis. Neurology 1988; 38:517-22.Marshall AH, Jones, NS. Osteomyelitis of the frontal bone secondary to frontal sinusitis. J Laryngol Otol 2000; 114:944-6.

ReferencesMiaskiewicz B, Lukomski M, Starska K, Jozefowicz-Korezynska M. Orbital complication in acute and chronic sinusitis. H Pol Merkur Lekarski 2005; 19:388-9.Oxford LE, McClay J. Complications of acute sinusitis in children. Otolaryngol Head Neck Surg 2005; 133:32-7.Pasha R. Otolaryngology Head and Neck Surgery, 2nd Ed. San Diego: Plural Publishing, 2006. pp 2-6.Rahbar R, Petersen RA, DiCanzio J, et al. Management of orbital subperiosteal abscess in children. Arch Otolaryngol Head Neck Surg 2001; 127:281-6.Raja V, Low C, Sastry A, Moriarty B. Potts puffy tumor following an insect bite. J Postgrad Med 2007; 53:114-6.Ramachandran TS, Ramachandran A. Intracranial epidural abscess. eMedicine 9 Sep 2009. Accessed 10 Apr 2011 .Ramadan HH, Tewfik TL, Talavera F, et al. Pediatric sinusitis, medical treatment. eMedicine, 22 Apr 2009. Accessed 2 Apr 2011 .Remmler D, Boles R. Intracranial complications of frontal sinusitis. Laryngoscope 1980; 90:1814-24.Rosenfeld EA, Rowley AH. Infectious intracranial complications of sinusitis, other than meningitis, in children: 12-year review. Clin Infect Dis 1994; 18:750-4.Schramm VL, Myers EN, Kennerdell JS. Orbital complications of acute sinusitis: Evaluation, management, and outcome. Otolaryngology 1978;86:221-30.Souliere CR Jr, Antoine GA, Martin MP, et al. Selective non-surgical management of subperiosteal abscess of the orbit: computerized tomography and clinical course as indication for surgical drainage. Int J Pediatr Otolarynol 1990; 19:109-19.Southwick FS, Richardson EP Jr, Swartz MN. Septic thrombosis of the dural venous sinuses. Medicine (Baltimore) 1986; 65:82-106.Stankiewicz JA, Chow JM. A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity. Am J Rhinol 2002; 16:199-202.Vazquez E, Creixell S, Carreno JC, et al. Complicated acute pediatric bacterial sinusitis: imaging updated approach. Curr Probl Diagn Radiol 2004 MayJun; 33:127-45.Wald E. Microbiology of acute and chronic sinusitis in children. J Allergy Clin Immunol 1992; 90:452-60.Wald E. Sinusitis in children. N Engl J Med 1992; 326:319-23.

ReferencesWallace MR, Rana A, Yadavalli GK. Epidural abscess. eMedicine 20 Apr 2009. Accessed 10 Apr 2011 .Yogev R, Bar-Meir M. Management of brain abscesses in children. Pediatr Infect Dis J 2004; 23:157-9.Younis RT, Lazar RH, Anand VK, Intracranial complications of sinusitis: A 15-year review of 39 cases. Ear Nose Throat J 2002; 81:636-44.Younis RT, Lazar RH, Bustillo A, et al. Orbital infection as a complication of sinusitis:aAre diagnostic and treatment trends changing? Ear Nose Throat J 2002; 81:7715.

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.Haller cell is an ethmoidal cell that pneumatizes between maxillary sinus and orbital floor.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 roof. The ethmoid roof articulates with the cribriform plate at the lateral lamella of 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).Posterior cells drain into superior meatusOphthalmic artery provides anterior and posterior ethmoidal arteriesCavernous sinus gives off maxillary and ethmoidal veinsThe 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 processType 3 cell attaches to anterior table.Foramina of Breschet: small venules that drain the sinus mucosa into the dural veinsApproximately 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%.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. 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-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%Patients may complain of pain and diplopia and a history of recent orbital trauma or dental surgery.Patients will complain of diplopia, ophthalmoplegia, exophthalmos, or reduced visual acuityThe patient has limited ocular motility or pain on globe movement toward the abscess.; may have normal movement early onOrbital signs include proptosis, chemosis, and visual impairment. Transcaruncular approach allegedly does not utilize a facial incisionContralateral involvement is distinguishing feature of cavernous sinus thrombosisMRI findings of heterogeneity and increased size suggest the diagnosisMRI better especially if suspecting intracranial involvement, too.1980s were retrospective reviewsBhatia was a literature reviewTeenagers 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. Not exclusive, can occur concurrentlyPercentages in children (Hicks et al, 2011)Also incidence of neurologic sequelae such as hearing loss and seizure disorder.Will likely need antibiotics for 4-8 weeks; usually vancomycin and 3rd or 4th generation cephalosporinProphylactic seizure therapy not necessary unless theres an associated subdural abscess.Generally unilateralNeed antibiotics with good intracerebral penetration, typically 3-6 weeksCraniotomy is favored over burr hole placement due to better exposureMay have mood swings and behavioral changes with frontal lobe involvementWorsening headache with meningismus suggests possible rupture of the abscess.Antibiotic regimen is typically 6-8 weeks; typically ceftriaxone, vancomycin or nafcillin, and metronidazoleCorticosteroid 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.Incidence of anaerobes in suppurative intracranial complications range from 60-100%.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.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.