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COMPLICATED ACUTE SINUSITIS

Overview
While most cases of acute sinusitis resolve spontaneously or with medical therapy, consults to evaluate potential complications of sinusitis are common. Acute sinusitis typically develops from a viral or bacterial infection of the paranasal sinuses leading to inflammation, edema, and ultimately obstruction of the sinus outflow tracts. Acute sinusitis is typically managed medically with topical and sometimes systemic medications. This guide will focus on the management of the complications of untreated or progressive acute sinusitis.  For this guide, the complications of sinusitis are distilled into orbital and intracranial complications. The presentation and management of invasive fungal sinusitis are discussed in a separate consult guide.

Orbital Complications

Overview
Acute sinusitis can involve the orbit through direct extension, generally through a thin or dehiscent lamina papyracea. In advanced disease, infection can involve the cavernous sinus through propagating thrombophlebitis of the valveless orbital venous system. Orbital complications of sinusitis can present with a wide range of symptoms including periorbital edema, vision changes, ophthalmoplegia, chemosis or proptosis. Any of these signs on history and examination warrant emergent imaging. In cases of early orbital involvement, exam findings may be subtle and include periorbital edema and erythema. The Chandler classification categorizes orbital involvement into five groups:

            Group I            Preseptal Cellulitis

            Group II           Orbital Cellulitis

            Group III          Subperiosteal Abscess

            Group IV         Orbital Abscess

            Group V          Cavernous Sinus Thrombosis

For reference, the orbital septum is a fibrous membrane that extends from the periosteum of the orbit as the arcus marginalis and lies just deep to the orbicularis oculi muscle. Transgression of the orbital septum by infection constitutes post-septal involvement. Postseptal infection can lead to optic neuritis, thrombophlebitis, and pressure or traction on the optic nerve leading to blindness. Surgery is indicated for patients in most cases of Chandler Group III-V, but also may be considered for Chandler Groups I-II. While a trial of intravenous antibiotics is appropriate in many cases, surgical treatment should not be delayed in the case of a defined orbital abscess, ophthalmoplegia, or vision loss. An ophthalmology consultation serves as a great resource for management of these orbital complications.

Key Supplies for Consultation

  • Appropriate PPE including mask, eye protection, gloves, and gown

  • Headlight

  • Nasal Speculum

  • Flexible scope or rigid endoscope (with monitor & tower, if possible)

  • Antifog solution (Fred)

  • Culture trap or swab

  • Oxymetazoline

  • Flashlight for pupil exam (or can use headlight)

  • Snellen eye chart for visual acuity

 Management

  • History and detailed head and neck physical exam with attention to the cranial nerve and ophthalmic exam; always test visual acuity and color vision, extraocular movements (while asking if movement is painful), pupillary response to light, and globe position (evaluate for proptosis)

  • If there is no evidence of sinus disease or inflammation on CT, then one must consider other causes of orbital disease. Ensure ophthalmology is consulted if suspicion of any disease beyond preseptal cellulitis

  • Initiate empiric broad spectrum antibiotics with coverage of common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella sp., and more rarely Staphylococcus aureus. Polymicrobial infection is more common in adults and in immunosuppressed patients

  • Consider obtaining sinus cultures (middle meatus)

    • Blood cultures indicated if the patient exhibits signs /symptoms of systemic illness

  • Basic laboratory analysis (CBC, CMP, and CRP)

  • If IV antibiotics are used, patients can generally be de-escalated to oral antibiotics, guided by culture data when available. In cases with osteomyelitis, a longer course may be necessary, and involvement of Infectious Disease may be beneficial

 Chandler Group I: Preseptal cellulitis

  • Characteristic findings on ocular exam: periorbital erythema, edema, and tenderness without ophthalmoplegia or decreased visual acuity (suspect post-septal disease if these are present)

  • Consider high dose amoxicillin-clavulanate if outpatient vs ampicillin-sulbactam (Unasyn) if admitted

  • Additional treatments include head of bed elevation, heat packs to affected eye, topical decongestant (typically Afrin for 3 days), saline irrigations and mucolytics such as guaifenesin 

  • Mild preseptal cellulitis in a reliable adult without signs of orbital cellulitis may be followed closely as an outpatient; any signs of systemic disease or eyelid abscess warrant admission

  • Rarely, may require drainage of eyelid abscess at bedside

Chandler Group II: Orbital Cellulitis

  • Characteristic findings on ocular exam: diffuse periorbital edema, chemosis, proptosis, intact extraocular movements, intact vision, ophthalmoplegia in severe cases 

  • Admit patient for observation

    • Initiate parenteral antibiotics: consider ampicillin-sulbactam vs ceftriaxone 

    • Additional acute sinusitis medical treatment (i.e. mucolytics, nasal decongestant, saline sinus irrigations)

    • Can consider corticosteroids, may defer to ophthalmology

    • Disease is typically responsive to medical management, however, sinus surgery may play a role in refractory disease. If surgery is required, it typically consists of endoscopic sinus surgery (ESS) of affected sinuses in proximity to the lamina papyracea, most notably a maxillary antrostomy and total ethmoidectomy

Chandler Group III: Subperiosteal abscess 

  • Characteristic findings on exam: proptosis, impaired extraocular movements, periorbital edema, vision intact unless large abscess 

  • Admit patient

    • Initiate parenteral antibiotics: ceftriaxone or ampicillin-sulbactam, consider adding vancomycin if risk of MRSA or intracranial disease extent 

    • Surgery generally indicated if defined abscess present, no improvement with 24-48 hours of antibiotics, or vision loss

      • Surgery typically consists of ESS of the affected sinuses in proximity to the lamina papyracea, as well as an endoscopic drainage of the subperiosteal abscess through the lamina papyracea 

      • In select situations, consideration of a combined surgery with oculoplastic surgery may be undertaken

    • Additional medical management (i.e. head of bed elevation, warm compress to eye, mucolytics, nasal decongestant, saline sinus irrigations) 

    • Parenteral antibiotics transitioned to oral after symptomatic improvement usually minimum of 24 hours after surgery

Chandler Group IV: Orbital Abscess

  • Characteristic findings on exam: severe proptosis, ophthlamoplegia, periorbital edema, chemosis, vision impairment

  • Admit patient

    • Initiate parenteral antibiotics: ceftriaxone or ampicillin-sulbactam, consider adding vancomycin if risk of MRSA or intracranial disease extent

    • Surgery is usually indicated, in conjunction with ophthalmology

      • Open or endoscopic drainage of the abscess with ESS of the involved sinuses

    • Additional medical management (i.e. head of bed elevation, warm compress to eye, mucolytics, nasal decongestant, saline sinus irrigations) 

 Chandler Group V: Cavernous Sinus Thrombosis

  • Characteristic findings include bilateral symptoms including ophthalmoplegia, proptosis, decreased visual acuity, multiple cranial nerve palsies III, IV, V, VI

  • MRI/MRV with contrast for diagnosis confirmation

  • Ensure hemodynamic stability, evaluate for associated sepsis or meningitis

  • Initiate parenteral antibiotics: Consider ceftriaxone, vancomycin, metronidazole at meningitis dosages

  • ESS may be useful for source control and culture data

  • Ophthalmology & Neurosurgery consultations          

  • Consider anticoagulation

  • Admit to ICU

Intracranial Complications

Overview
Intracranial complications of sinusitis occur more commonly in children and are classically associated with adolescent males with spread of frontal sinus disease through the veins of Breschet which communicate directly with the dura. However, disease can also spread intracranially from other sites such as the ethmoid or sphenoid sinuses. Extension of the disease intracranially can lead to meningitis, superior sagittal sinus thrombosis, epidural abscess, subdural empyema or abscess, cerebral abscess, or frontal bone osteomyelitis (i.e., Pott’s puffy tumor). Signs and symptoms suggestive of intracranial extension of disease include persistent headache, nuchal rigidity, nausea and vomiting, altered mental status, cranial neuropathies, and focal neurologic deficits. Signs of complicated sinusitis such as frontal swelling or periorbital edema are common prior to intracranial spread of disease. Imaging, most commonly CT with contrast, is indicated although MRI with and without contrast better differentiates subdural empyema or intracranial abscess from adjacent cerebritis and inflammation. Sampling from an involved sinus with endoscopic visualization or trephination (preferable in some cases of isolated frontal sinusitis in order to not disturb the mucosa of the outflow tract or when the degree of infection/inflammation makes endoscopic visualization challenging) can be helpful for identification and susceptibility of the responsible pathogen. ESS may also allow for better source control of the disease. Consultation with infectious disease specialists and neurosurgery is warranted.

Management

  • Complete head and neck physical exam including rhinoscopy/endoscopic nasal examination with neurologic and cranial nerve exam 

  • Neurosurgical consultation

  • Obtain cultures from sinus and blood. Lumbar puncture may be required in some cases 

  • Obtain labs: CBC, CMP, CRP

    • Initiate broad spectrum antibiotics at meningitis dosages that are age and weight based; an optional regimen would usually include vancomycin, ceftriaxone, and metronidazole

    • Continue IV antibiotics usually for 4-6-week course in conjunction with infectious disease recommendations 

  • Consider corticosteroids if significant cerebral edema is present

  • Prophylactic antiepileptics usually indicated

  • Surgery is indicated in almost all cases and involves ESS with or without craniotomy dependent on intracranial disease extent. Goal of surgery is infection source control and culture collection

  • Close follow up and serial imaging with MRI is typically required

References

  1. Benninger, M.S., et al (2020). Acute Rhinosinusitis: Pathogenesis, Treatment, and Complications. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 643-648). Philadelphia, PA: Elsevier.

  2. Giannoni, C.M. (2013). Complications of Rhinosinusitis. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 573-585). Baltimore, MD: Lippincott Williams & Wilkins.

  3. Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Ashok Kumar, K., Kramper, M., … Corrigan, M. D. (2015). Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery, 152(2_suppl), S1–S39.https://doi.org/10.1177/0194599815572097