Complications of

Rhinosinusitis

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

Synopsis of Critical Sequelae

All images obtained via Google search unless otherwise

specified. All images used without permission.

Anatomy
Rhinosinusitis

Complications

Acute
Chronic
Orbital
Intracranial
Bony

Conclusion

Standring S, ed. Gray's Anatomy, 40th Ed.

Spain: Churchill Livingstone, 2008.

Outline

Anatomy
Maxillary Sinus
Largest and first sinus to develop

Biphasic periods of rapid growth

At 3 months gestation
Volume 6-8cm3 at birth
Volume 15cm3 by adulthood
First 3 years and between 7-18 years
Coincides with dental development

Natural ostium drains into ethmoidal

Accessory ostia in 15-40%

Haller cell can impair drainage

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.

infundibulum

Kennedy DW, Bolger WE, Zinreich SJ, eds.

Diseases of the Sinuses Diagnosis and
Management. Hamilton: BC Decker, 2001.

Anatomy
Maxillary Sinus

Innervation via V2 distribution

Vasculature

Infraorbital nerve
Dehiscent intraorbital canal
in 14%
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.

Anatomy
Ethmoid Sinus
First seen at 5 months gestation

Five ethmoid turbinals

Between 3-4 cells at birth

Adult size by 12-15 years

Infundibulum

Agger nasi
Uncinate Process
Uncinate
Hiatus Semilunaris
Ethmoid bulla
Ethmoid Bulla
Ground/basal lamella
Posterior wall of most posterior ethmoid cell

Between 10-15 cells

Volume 2-3cm3 by adulthood

Kennedy, et al. 2001

Nasolacrimal
Duct

Basal Lamella

Retrobulbar Recess

Hansen JT, ed. Netters Clinical

Anatomy, 2nd Ed. Philadelphia:
Saunders, 2010.

Anatomy
Ethmoid Sinus
Nasociliary Nerve

Drainage

Anterior cells via ethmoid infundibulum

Posterior cells via sphenoethmoid recess

Innervation via V1 distribution

Ophthalmic
Nerve

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

Anatomy
Not present at birth

Development not complete

20 years

Starts developing at 4 years

Radiographically visualized at 5-6 years

until 12-

Volume 4-7cm3 by adulthood

No or poor pneumatization in 5-10%

Frontal Sinus

Drainage via frontal recess

Anterior: posterior agger nasi

Lateral: lamina papyracea
Medial: middle turbinate

Frontal
Recess
Kennedy, et al. 2001

Tollefson TT, Strong EB. Frontal Sinus Fractures.

eMedicine 13 Jul 2009.

Frontal Sinus

NOTES: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 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

Posterior
Ethmoid

Basal
Lamella

Uncinat
e

Infundibulum

Anatomy
Frontal Cell Types

Type 1: single cell superior to agger nasi

Type 2: > 2 cells superior to agger nasi
Type 3: single cell from agger nasi into sinus
Type 4: isolated cell within sinus

Type 1
Sold arrow Frontal cell type
Dashed arrow Agger nasi cell

Type 2

Type 3

NOTES:Type 3 cell
attaches to anterior table.

Type 4

DelGaudio JM, et al. Multiplanar computed tomography analysis of

frontal recess cells. Arch Otolaryngol Head Neck Surg 2005; 131:230-5.

Anatomy
Frontal Sinus
Supratrochlear
Nerve

Vasculature

Supraorbital artery and vein

Supratrochlear artery
Ophthalmic vein
Foramina of Breschet

Innervation via V1 distribution

Supraorbital
Supratrochlear

NOTES:Foramina of Breschet: small venules that

drain the sinus mucosa into the dural veins

Supraorbital
Nerve
Supratrochlear
Artery
Supraorbital
Artery

Anatomy
Sphenoid Sinus

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

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%.

Minimal volume at birth

Volume 0.5-8cm3 by adult

Reaches adult size by 12-18 years

Sellar type (86%)

Presellar (11%)
Conchal (3%)

Anatomy
Sphenoid Sinus

Innervation via sphenopalatine nerve

V2 distribution
Parasympathetics

Vasculature via maxillary artery and vein

Sphenopalatine artery
Pterygoid plexus

Acute Rhinosinusitis (ARS)

Inflammation of the nasal mucosa and lining of the

paranasal sinuses

Viral etiology in majority of cases

Obstruction of sinus ostia

Impaired ciliary transport
Superimposed bacterial infection in 0.5-2%
Symptoms for at least 7-10 days or worsening
after 5-7 days

Symptoms present for < 4 weeks

Recurrent ARS with > 4 episodes, lasting > 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.

Acute Rhinosinusitis (ARS)

Major symptoms

Hyposmia/anosmia
Purulence on exam
Fever (ARS only)

Minor symptoms

Facial pain/pressure
Facial congestion/fullness
Nasal obstruction
Nasal discharge/purulence
Headache
Fever (non-ARS)
Halitosis
Fatigue

Dental pain
Cough
Ear pain/pressure/fullness

Diagnosis with two major or one major and two minor

factors

Acute Rhinosinusitis (ARS)

Microbiology
Children
Streptococcus pneumoniae (30-43%)
Haemophilus influenzae (20-28%)
Moraxella catarrhalis (20-28%)
Other Streptococcus species
Anaerobes

Adults
Streptococcus pneumoniae (20-45%)
Haemophilus influenzae (22-35%)
Other Streptococcus species
Anaerobes
Moraxella catarrhalis
Staphylococcus aureus

Chronic Rhinosinusitis (CRS)

Symptoms present for > 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;
16:199-202.

Chronic Rhinosinusitis (CRS)

Microbiology
Children
Anaerobes
Other Streptococcus species
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa

Adults
Anaerobes
Other Streptococcus species
Haemophilus influenzae
Staphylococcus aureus
Streptococcus pneumoniae
Moraxella catarrhalis

Complications of Sinusitis

Incidence has decreased with antibiotic use

Three main categories

Orbital
Intracranial
Bony

(60-75%)
(15-20%)
(5-10%)

Radiography

Computed tomography (CT) best for orbit

Magnetic resonance imaging (MRI) best for intracranium

Siedek et al, 2010

Complications of Sinusitis
Orbital

Most commonly involved complication site

Continuum of inflammatory/infectious changes

Proximity to ethmoid sinuses

Periorbita/orbital septum is the only soft-tissue barrier
Valveless superior and inferior ophthalmic veins
Direct extension through lamina papyracea
Impaired venous drainage from thrombophlebitis
Progression within 2 days

Children more susceptible

< 7 years isolated orbital (subperiosteal abscess)

> 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%

Orbital Complications
Microbiology
Children
Streptococcus species
Staphylococcus aureus
Anaerobes (Bacteroides and
Fusobacterium species)
Gram-negative bacilli
Staphylococcus epidermidis

Adults
Streptococcus pneumoniae
Hemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Anaerobes

Orbital Complications
Chandler Criteria

Five classifications

Preseptal cellulitis
Orbital cellulitis
Subperiosteal abscess
Orbital abscess
Cavernous sinus thrombosis

Not exclusive, can occur concurrently

Bailey, et al. 2006.

Orbital Complications
Preseptal 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.

Orbital Complications
Preseptal 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

Orbital Complications
Orbital Cellulitis

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.

Symptomatology

Ramadan et al, 2009

NOTES: Patients may complain of pain and

diplopia and a history of recent orbital trauma
or dental surgery.:

Orbital Complications
Orbital Cellulitis
Facilitate sinus drainage

Medical therapy typically sufficient

Nasal decongestants
Mucolytics
Saline irrigations
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.

Orbital Complications
Subperiosteal 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
sinusitis etiology
Diagnostically accurate
91%

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.

frontal
86-

Ramadan et al, 2009

Bailey, et al. 2006.

Orbital Complications
Subperiosteal 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%

Combined treatment 95-100%

(Coenraad 2009)

Orbital Complications
Subperiosteal 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.

Orbital Complications
Orbital Abscess

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

Lafferty KA. Orbital infections. eMedicine, 22 Sep 2009.

Bailey, et al. 2006.

Symptomatology

Kirsch CFE, Turbin R, Gor D. Orbital

infection imaging. eMedicine, 24 Mar 2010.

Orbital Complications
Orbital Abscess

Incise periorbita and drain intraconal abscess

Similar approaches as with subperiosteal abscess

Lynch incision
Endoscopic

NOTES:Transcaruncular approach allegedly does not utilize a facial incision.

Orbital Complications
Cavernous 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

Contralateral involvement is distinguishing feature of cavernous

sinus thrombosis
MRI findings of heterogeneity and increased size suggest the
diagnosis

Bailey, et al. 2006.

Orbital Complications
Cavernous 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

MRI better especially if suspecting intracranial involvement, too.

Agayev A, Yilmaz S. Cavernous sinus thrombosis.

N Engl J Med 2008; 359:2266.

Cavernous Sinus Thrombosis

Anticoagulation

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

Harmful
Bhatia et al (2002)

Fatal hemorrhagic cerebral

infarction
Subarachnoid hemorrhage
reversed with protamine

Complications of Sinusitis
Intracranial

Occurs more commonly in CRS

Male teenagers affected more than children

Direct extension

Mucosal scarring, polypoid changes

Hidden infectious foci with poor antibiotic penetration

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.

Intracranial Complications
Types

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)

Intracranial Complications
Meningitis

Most common intracranial complication of sinusitis

Symptomatology

Sinusitis is unusual cause of meningitis

Headache
Meningismus
Fever, septic
Cranial nerve palsies
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.

Meningitis
Microbiology
Children
Streptococcus pneumoniae
Staphylococcus aureus
Other Streptococcus species
Anaerobes (Bacteroides and
Fusobacterium species)
Gram-negative rods

Adults
Streptococcus pnuemoniae
Hemophilus influenzae

Intracranial Complications
Epidural Abscess

Fever (>50%)
Headache (50-73%)
Nausea, vomiting

Bailey, et al. 2006.

Second-most common intracranial complication

Generally a complication of frontal sinusitis
Symptomatology
Papilledema
Hemiparesis
Seizure (4-63%)

Crescent-shaped hypodensity on CT

Ramachandran TS, et al, 2009.

Intracranial Complications
Epidural 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;

rd or 4th
th generation
usually vancomycin and 3rd
cephalosporin
Prophylactic seizure therapy not necessary unless
theres an associated subdural abscess.

Intracranial Complications

Generally from frontal or ethmoid sinusitis

Symptomatology

Third-most common intracranial

complication, rapid deterioration

Headaches
Fever
Nausea, vomiting
Hemiparesis
Lethargy, coma

Mortality in 25-35%
Residual neurologic sequelae in 35-55%

Accompanies 10% of epidural

abscesses

Bailey, et al. 2006.

Subdural Abscess

Intracranial Complications
Subdural Abscess

Lumbar puncture potentially fatal

Aggressive medical therapy

Antibiotics
Anticonvulsants
Hyperventilation, mannitol
Steroids

Drain sinuses and abscess

Medical therapy possible if < 1.5cm

Craniotomy or stereotactic burr hole
Endoscopic or external sinus drainage

NOTES:Need antibiotics with good intracerebral penetration, typically 3-6 weeks

Craniotomy is favored over burr hole placement due to better exposure

Intracranial Complications

Uncommon, frontal and frontoparietal lobes

Generally from frontal sinusitis

Symptomatology
Headache (70%)

Mental status

change (65%)

Focal neurological
deficit (65%)

Fever (50%)
Mortality 20-30%
Neurologic sequelae 60%

Sphenoid
Ethmoids
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.

Bailey, et al. 2006.

Intracerebral Abscess

Intracranial Complications
Intracerebral Abscess

Lumbar puncture potentially fatal

Aggressive medical therapy

Antibiotics
Anticonvulsants
Hyperventilation, mannitol
Steroids

Drain sinuses and abscess

Medical therapy possible if abscess < 2.5cm

Excision or aspiration

Diagnostic aspiration if < 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.

Intracranial Abscesses
Microbiology
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
NOTES: Incidence of anaerobes in
suppurative intracranial complications
range from 60-100%

Intracranial Complications
Venous 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

Intracranial Complications
Venous 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

Complications of Sinusitis
Bony
Potts puffy tumor

Rare complication

Frontal sinusitis with acute osteomyelitis

Subperiosteal pus collection leads to puffy fluctuance
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

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.

Sabatiello M, et al. The Potts puffy tumor: an unusual complication of

frontal sinusitis, methods for its detection. Pediatr Dermatol 2010;
27:406-8.

Complications of Sinusitis

Pericranial
Periorbital
Epidural
Subdural
Intracranial

Cortical vein thrombosis

Frontocutaneous fistula

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.

Bailey, et al. 2006.

Associated with other abscesses in 60%

Blumfield, et al. 2010.

Upadhyay S. Recurrent Pott's puffy tumor, a rare

clinical entity. Neurol India 2010; 58:815-7.

Bony

Potts Puffy Tumor

Microbiology
Children
Streptococcus species (Streptococcus milleri)
Staphylococcus aureus
Anaerobes (Bacteroides species)
Gram-negative bacilli (Proteus species)
Polymicrobial

Adults

Complications of Sinusitis
Bony
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).

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)

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