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NASAL FOREIGN BODIES

Overview
Most commonly seen in pediatric patients, the presence of a nasal foreign body should be suspected in the young patient who presents with unilateral foul-smelling rhinorrhea, epistaxis, and nasal pain. Most often, however, the patient presents asymptomatically with witnessed or confessed placement. While some foreign bodies can be removed by Pediatricians or Emergency Physicians, Otolaryngologists are typically consulted for deep foreign bodies, chronic foreign bodies with resultant inflammation, or corrosive or sharp objects that render removal difficult. While some foreign bodies can be easily removed at bedside, young patients or those with developmental delay more frequently require sedation for removal. Additionally, in cases of wedged or corrosive objects, such as button batteries, evaluation in the OR may be necessary for removal and to assess for local tissue damage. Button batteries should be removed urgently as injury to the nasal mucosa can occur in <1 hour, resulting in harmful sequelae including mucosal scarring, synechiae, and septal perforation.

 

Key Supplies for Nasal Foreign Body Consultation

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

  • Headlight

  • Rigid or flexible endoscope and tower for recording

  • Antifog solution (Fred™)

  • Topical anesthetic/decongestant spray

  • 12 French Frazier tip suction

  • Nasal speculum

  • Alligator forceps with large mouth

  • Bayonet forceps

  • Silver nitrate application sticks

  • Blunt right angle hook, large ear loop

  • Small Foley catheter and 5cc syringe may be helpful in some cases

 

Management

  • Patience, good patient rapport, and atraumatic nasal exam and foreign body removal are often the most important facets of nasal foreign body removal.

  • Imaging is indicated only if the foreign body is embedded in tissue or the diagnosis is uncertain, as in the case of rhinolith formation.

  • Unless the foreign body is very anterior and easily visualized and removed, apply topical anesthetic/decongestant spray; for button batteries, generally attempt to avoid nasal sprays and excess moisture as this can increase tissue damage.

  • If the foreign body is anterior and not sharp, it may be removed using anterior rhinoscopy and nasal instruments.

  • For more posterior foreign bodies, rigid endoscopy should be used for visualization and to ensure foreign body is not pushed back into the airway.

  • Larger sized ear curettes or right angle hooks can be useful for rounded objects.

  • For objects that are unable to be grasped, such as marbles, one may place a Foley or Fogarty balloon catheter just distal to the object, inflate a few cc’s, and gently pull the Foley. Many pediatric patients may not be able to tolerate this, requiring that the object be removed in the OR.

 

Example Procedure Note
Procedure: Nasal foreign body removal
After discussion of risks and benefits, written consent was obtained for foreign body removal. The child was restrained by the mother/father/family member, and visualization was obtained with a straight endoscope. The foreign body was seen to be resting in ___ anterior middle meatus. A right angle hook was gently passed just distal to the object and the object was gently extracted. After removal, the nasal cavity was visualized again with the endoscope and confirmed to have no active epistaxis and no septal perforation. The patient tolerated the procedure well.

 

References
1. Baranowski, K., Al-Aaraj, M.S., Sinha, V. (2020). Nasal Foreign Body. In: StatPearls. Treasure Island, FL: StatPearls Publishing; July 8.
2. Friedman, E.M. (2016). Videos in Clinical Medicine. Removal of Foreign Bodies from the Ear and Nose. N Engl J Med. 374(7):e7.

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ACUTE SINUSITIS, COMPLICATED

Overview
While most cases of acute sinusitis resolve spontaneously or with medical therapy, consultations 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 chapter details the management of the complications of untreated or progressive acute sinusitis, distilled into orbital and intracranial complications. The presentation and management of invasive fungal sinusitis are discussed in a later chapter.

 

Key Supplies for Acute Sinusitis (Complicated) Consultation

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

  • Headlight

  • Nasal speculum

  • Flexible scope or rigid endoscope (with monitor and 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

 

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 exam 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.

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 postseptal involvement. Postseptal infection can lead to abscess, optic neuritis, thrombophlebitis, and pressure or traction on the optic nerve leading to blindness. Surgery is indicated for most cases of Chandler Group III-V but also may be considered for Chandler Groups I-II. While a trial of IV 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 is a great resource for management of these orbital complications.

 

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 spp., 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 lab analysis including CBC and CMP, with consideration of CRP.

  • If IV antibiotics are used, patients can generally be de-escalated to oral antibiotics as symptoms improve, 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 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 versus ampicillin-sulbactam if admitted.

  • Additional treatments include head of bed elevation, topical decongestant (typically oxymetazoline for 3 days), saline sinus 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 (“Postseptal Cellulitis”)

  • Characteristic findings on exam: Diffuse periorbital edema, chemosis (billowing or blister-like conjunctival edema from irritation), proptosis, usually intact extraocular movements, usually intact vision, ophthalmoplegia in severe cases.

  • Admit the patient for observation.

  • Initiate parenteral antibiotics: Consider ampicillin-sulbactam versus ceftriaxone; consider adding vancomycin if risk of MRSA.

  • 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 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 the patient.

    • Initiate parenteral antibiotics: Consider 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 endoscopic sinus surgery 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, 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, ophthalmoplegia, periorbital edema, chemosis, vision impairment.

  • Admit the 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; may involve open or endoscopic drainage of the abscess with endoscopic sinus surgery of the involved sinuses.

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

 

Chandler Group V: Cavernous Sinus Thrombosis

  • Characteristic findings on exam: Bilateral symptoms including ophthalmoplegia, proptosis, decreased visual acuity, multiple cranial nerve involvement, potentially including III, IV, V, and 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.

  • Endoscopic sinus surgery may be useful for source control and culture data.

  • Ophthalmology and 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, dural 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 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. Endoscopic sinus surgery may also allow for better source control of the disease. Consultation with Infectious Disease and Neurosurgery is warranted.

 

Management

  • Complete head and neck physical exam including rhinoscopy or endoscopic nasal exam with neurologic and cranial nerve exam.

  • Neurosurgery consultation.

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

  • Obtain labs: CBC, CMP, CRP.

  • Initiate broad spectrum antibiotics at meningitis dosages that are age- and weight-based; an optional regimen often includes vancomycin, ceftriaxone, and metronidazole.

  • Continue IV antibiotics usually for a 4-6-week course in conjunction with Infectious Disease recommendations.

  • Consider corticosteroids if significant cerebral edema is present.

  • Prophylactic antiepileptics often indicated based on input from Neurosurgery or Neurology.

  • Surgery is indicated in almost all cases and involves endoscopic sinus surgery 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 are typically required.

 

References
1. Benninger, M.S., Roxbury, C.R., Stokken, J.K. (2020). Acute Rhinosinusitis: Pathogenesis, Treatment, and Complications. In Flint, P.W., 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 Johnson, J.J., Rosen, C.A. (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., et al. (2015). Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery, 152(2_suppl), S1–S39.

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EPISTAXIS

Overview
One of the most common consultation requests for the Otolaryngologist is nosebleeds. Over 90% are anterior bleeds that typically stem from Kiesselbach’s Plexus in Little’s Area, but true posterior bleeds or sinonasal tumor bleeding will be encountered on occasion. While the etiology of epistaxis is most commonly related to factors such as digital trauma, mucosal dryness, and anticoagulants, the underlying pathology including autoimmune conditions, foreign bodies, masses, intranasal drug use, familial blood dyscrasias, or various coagulopathies must be considered. The management of epistaxis from the simple common variety to the more complex or urgent is discussed here. These consultations are usually received after a non-Otolaryngologist provider has attempted some intervention that has failed to stop the bleeding. These patients are therefore frequently frustrated, anxious, and in pain. Thorough investigation of the location and cause of the epistaxis can lead the provider to a solution that stops the bleed in the most comfortable and efficient way for the patient. There are many ways to treat epistaxis, and with time, personal preferences will develop in how to address different types of bleeds.

 

Key Supplies for Epistaxis Consultation

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

  • Chux pad, emesis basin, tissue for patient

  • Headlight

  • Nasal speculum

  • 10 or 12 French Frazier tip suction

  • Oxymetazoline (Afrin®), tranexamic acid (TXA) spray (if available)

  • 2% lidocaine, 4% cocaine, or combination anesthetic/decongestant spray (e.g., lidocaine/oxymetazoline spray); avoid topical cocaine in patients with cardiovascular risk factors

  • Cotton pledgets

  • Bayonet forceps

  • Nasal clamp

  • Rigid endoscope, flexible scope may be sufficient if diagnostic visualization is all that is required

  • Silver nitrate application sticks

  • Absorbable and nonabsorbable packing

  • Surgicel®/Fibrillar™

  • Merocel®/Rhino Rocket®

  • Gauze

  • Vaseline® gauze

  • Double balloon system such as Epistax™

 

Management

  • Always ensure cardiopulmonary stability of the patient first following the ABCs (Airway, Breathing, Circulation).

  • In case of significant bleeding:

  • Protection of the airway and hemodynamic resuscitation are of primary concern.

  • Ensure large bore IV access and that vitals are being monitored.

  • Consider labs including CBC, type and screen, and coagulation panel.

  • Ask the consulting provider to have the patient sit up and lean forward, liberally spray oxymetazoline in both nostrils, clamp the anterior nose for at least 15 minutes, and get the patient normotensive. This will resolve some nosebleeds and help manage the epistaxis while you gather supplies.

  • Complete a history and head and neck physical exam, although this may be delayed until after hemorrhage control depending on the situation. Investigate personal and family history of coagulopathy, anticoagulant medications, previous personal history of epistaxis (and what worked before), recent nasal trauma, previous or current nasal/nasopharyngeal malignancy, history of nasal/skull base surgery.

  • Patient’s nose will likely be filled with blood and clot. Either have the patient gently blow their nose or use headlight, speculum, and Frazier tip suction to carefully suction blood and clot.

  • Apply topical anesthetic, either lidocaine 2% or 4% or cocaine soaked pledgets if available.

    • 4% cocaine is an excellent vasoconstrictor and anesthetic, but it is important to use only in patients without cardiovascular risk factors

    • Alternatively, lidocaine/oxymetazoline can be used for combination anesthetic/decongestant.

  • Locate the bleed. Most nose bleeds occur on the anterior septum and can be identified using a headlight, nasal speculum, and suction.

  • If the bleeding is still too heavy to complete a proper exam, can repeat the process below up to 3 times.

    • Have patient blow their nose, apply oxymetazoline spray to bleeding side, and apply pressure for 10 minutes without any breaks (may complete a more thorough history and physical exam during this time). A nasal clip applied over the anterior soft part of the nose may be useful to some patients.

    • After 10 minutes, release pressure and determine if bleeding continues.

    • Tranexamic acid (TXA) can be a useful adjunct.

    • If unable to localize the bleed with anterior rhinoscopy, 0-degree rigid nasal endoscopy will be helpful both for localization of the site and to allow for directed treatments.

 

Nasal Packing

  • If a site is visualized with slow bleeding or an area of denuded mucosa, consider covering with absorbable packing (like Surgicel®/Fibrillar™) gently sprayed with oxymetazoline +/- tranexamic acid (TXA) to help them adhere to the mucosa. If the area of bleeding is very localized, consider silver nitrate cauterization, although this is usually more painful and there is risk of further damage to the nasal mucosa and even septal perforation with liberal or indiscriminate use, particularly if used bilaterally.

  • Patients not requiring packing or in whom only absorbable packing is used do not require follow-up for uncomplicated epistaxis. If there is knowledge or suspicion of an underlying process, follow-up should be scheduled.

  • If a more profuse bleeding site is seen or arterial bleeding present, consider expandable packing (e.g., Merocel®, Rhino Rocket®), gauze, or Vaseline® gauze (packed in a ribbon/accordion fashion).

  • Electrocautery can be attempted but is painful if not adequately anesthetized and can be difficult if bleeding is too brisk. There is also a risk of causing septal perforation.

  • Rarely, Epistax or double balloon packing may be necessary, ensure proper placement and monitoring to prevent alar necrosis.

  • Rarely, bilateral packing for bilateral sources may be necessary.

    • Necessitates admission and pulse oximetry monitoring.

    • Remove packing from less severe side of bleeding as soon as possible.

  • Merocel® and Rhino Rocket® are easier to place in awake patients and can tamponade bleeding. Vaseline® gauze (the entire 6’ x ½”) can be placed and is very effective at controlling difficult bleeds (hereditary hemorrhagic telangiectasia, trauma, etc.) but is even more uncomfortable for patients.

  • Keep in mind that alar necrosis can occur in <24 hours; minimize pressure on nasal ala.

    • Prescribe antibiotics for patients with non-absorbable nasal packing. Although risk of toxic shock has been called into question by recent studies, the increased risk of sinusitis and mucostasis justify their use. Recommend twice a day saline irrigation of non-absorbable packing to prevent denuding of nasal mucosa upon removal.

    • Secure nonabsorbable packing so that it is easily removed. Taping the ties or a suture passed through the gauze/Merocel® to the cheek is effective.

    • Nonabsorbable packing is often left in place for 3-5 days in patients without coagulopathy and for 5-7 days in patients more prone to bleeding.

    • Apply oxymetazoline (Afrin®) or a combination spray to the packing prior to removal to prevent denuding and improve comfort.

    • Upon removal of nonabsorbable packs, it is important to re-examine the nose for responsible nasal anatomic abnormality (e.g., septal perforation) or pathologic processes (malignancy, juvenile angiofibroma, granulomatous disease, hereditary hemorrhagic telangiectasia, etc.)

    • Unilateral packing is usually all that is required; in the rare case that bilateral packing is placed, many centers use inpatient admission with pulse oximetry especially if history of obstructive sleep apnea or cardiopulmonary risk factors.

  • After you have stopped the bleed, a period of observation is warranted, depending on patient/situation and volume of the bleed. It is reasonable to watch the patient for an hour in the Emergency Department and encourage them to ambulate to ensure adequate hemostasis before discharge.

 

Posterior Epistaxis

  • Posterior epistaxis is uncommon but almost always arterial (sphenopalatine artery [SPA] or, less commonly, anterior/posterior ethmoid arteries) and difficult to control. If a very significant bleed is present that you cannot control with topical sprays and cannot localize anteriorly with headlight, speculum, and suction, you may suspect a posterior bleed. A 0-degree rigid endoscope and 10 French Frazier tip suction can often help identify the source. If a posterior arterial bleed is present, place a posterior nasal pack.

  • Options include nasal Foley catheter to block the nasopharynx followed by packing the nasal cavity with Vaseline® gauze or use of a double balloon catheter system; the anterior balloon may induce alar necrosis if too full and should be managed carefully.

    • In many institutions, patients receiving posterior nasal packing require hospital admission. These patients often require a trip to the OR to control bleeding and perform SPA ligation or treatment through embolization.

      • If the source is suspected to be the sphenopalatine artery, endoscopic SPA ligation is often the preferred intervention given its efficacy and safety profile.

      • Embolization is a good option for patients who are medically unstable or cannot tolerate general anesthesia.

      • If the source is suspected to be the anterior/posterior ethmoid arteries, surgical intervention is preferred over embolization due to the risk of blindness/stroke or other complications (the anterior and posterior ethmoid arteries arise from the ophthalmic artery, a branch of the internal carotid system).

 

Aftercare Instructions

  • Aftercare/moisturizing recommendations to decrease frequency of nosebleeds:

  • Saline sprays/rinses.

  • Nightly application of Vaseline® or Polysporin® to anterior nares.

  • Room humidification.

  • Avoidance of nasal cannula if possible (use face tent, nasal cup, or facemask).

  • Management of medical conditions contributing to epistaxis (coagulopathy, hypertension, etc.).

  • Humidification of continuous positive airway pressure appliance if applicable.

  • It is useful to leave instructions in case of rebleeding for providers (inpatients) or the patient themselves if being discharged home:

    • Apply Afrin® liberally to both nostrils.

    • Apply pressure over the soft part of the nose for 15 minutes (clip or digital pressure, important to have pressure over soft part).

    • Lean forward, avoid swallowing blood. This can cause nausea and vomiting.

    • Can repeat steps 1-3 up to 3 times.

    • Consult Otolaryngology or return to the nearest Emergency Department if this is unsuccessful.

 

Example Procedure Notes
Procedure: Chemical cauterization
After obtaining consent from the patient, topical anesthetic was applied (oxymetazoline and 2% lidocaine in 1:1 mixture). Silver nitrate was applied to the ___ anterior nasal septum for 3 seconds in affected areas. The patient tolerated the procedure well. The septal mucosa appeared gray as expected without active bleeding at the end of the procedure.

 

Procedure: Anterior/posterior nasal packing
After obtaining consent from the patient, topical anesthetic was applied (oxymetazoline and 2% lidocaine in 1:1 mixture). An active bleed was identified at the ___. A ___ nasal pack was placed to stop the bleed. At the conclusion of the procedure, no active bleeding around the nasal pack was seen.

 

References
1. Bleier, B.B., Schlosser, R.J. (2013). Epistaxis. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 501-508). Baltimore, MD: Lippincott Williams & Wilkins.
2. Kuan, E.C., Palmer, J.N. (2020). Epistaxis. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 733-744). Philadelphia, PA: Elsevier.
3. Tunkel, D.E., Anne, S., Payne, S.C., et al. (2020). Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery, 162(1_suppl), S1–S38.

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ACUTE INVASIVE FUNGAL RHINOSINUSITIS

Overview
While fortunately still a relatively rare disease, the increasing incidence, fulminant course, and need for emergent management of acute invasive fungal sinusitis make this a diagnosis that cannot be missed. Seen almost exclusively in immunocompromised patients (most commonly due to hematologic malignancy, transplant patients on immunosuppressive medications, or poorly controlled diabetes), consultations to rule out invasive fungal sinusitis can be relatively common in tertiary care centers. Fever of unknown origin, sinusitis symptoms, or incidentally discovered abnormality on sinus imaging most commonly trigger this consultation. It is important to maintain a high index of suspicion to identify cases as early as possible. The diagnosis of invasive fungal sinusitis is based primarily on history and physical exam findings with histopathological confirmation. While diagnosis is clinical, imaging can be helpful in determining extent of disease. CT of the sinuses may show non-specific unilateral mucosal thickening, but bony destruction may be evident in more advanced disease. An MRI of the face and head with gadolinium is preferred to evaluate the extent of soft tissue involvement, intracranial extension, and potential loss of nasal mucosa hyperintensity due to angioinvasion.

Presenting signs and symptoms are variable, ranging from asymptomatic or mild sinus mucosal involvement to vision changes and cranial nerve deficits. In cases of delayed treatment, patients may experience nasal or palatal anesthesia, restricted extraocular movements, diplopia, proptosis, or even mental status changes. Physical exam most commonly reveals necrosis or insensate pale mucosa of the head of the middle turbinate; however, less commonly the inferior turbinate, septum, nasal floor, or palate may be involved. The most common fungal pathogens are species of Aspergillus among patients with poorly controlled diabetes and Mucormycosis in patients with hematologic malignancy. When suspected, biopsy should be taken at the border of the abnormal tissue (including both normal and abnormal tissue) and sent to the lab for immediate frozen section and fungal staining. If suspected, emergent treatment includes IV antifungals, wide surgical resection, and, if possible, treatment or reversal of the underlying immunosuppressive disease process is necessary to reduce morbidity and mortality for this once universally fatal condition. Even in cases of early diagnosis and treatment, invasive fungal sinusitis has a high mortality rate, especially in patients with a non-reversible underlying disease process.

 

Key Supplies for Invasive Fungal Sinusitis Consultation

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

  • Headlight

  • Nasal speculum

  • Rigid endoscope (with monitor and tower)

  • Antifog solution (Fred™)

  • 9 or 10 French Frazier tip suction

  • Bayonet forceps, alligator forceps, or other grasping instruments

  • Cup forceps

  • Specimen cup, sterile saline

  • Oxymetazoline for hemostasis after biopsy

  • Pledgets for hemostasis after biopsy

  • Absorbable and nonabsorbable packing in case persistent bleeding ensues after biopsy

 

Management

  • See patient emergently and obtain history with attention to symptom progression, presence of fever, sinusitis symptoms (facial pressure, nasal congestion, rhinorrhea, hyposmia, etc.), vision changes, and potential causes of immunosuppression.

  • Physical exam should include a detailed cranial nerve nasal and sinus exam with endoscopy. Importantly, if a patient has significant crusting, this should be debrided to allow for exam of the mucosa. Mucosal sensation of the middle turbinate, palate, or any suspicious areas should be assessed.

  • Basic labs should include CBC, CMP, and blood cultures.

  • A sinus CT without contrast is usually obtained prior to consultation but should be ordered emergently in all suspected cases. This may also be useful for stereotactic navigation in the OR, if needed. If obvious disease is present and obtaining imaging studies would delay emergent intervention, imaging may be delayed allowing for timely operative debridement.

  • If abnormal tissue is identified, a sizable biopsy should be taken of the border of the abnormal tissue with cup forceps and placed in saline and sent (or personally delivered) for immediate frozen section and fungal staining; a second biopsy for cultures should be considered.

    • Negative biopsy result: If suspicion for invasive fungal sinusitis is very high, consider taking a second biopsy, following with frequent, serial endoscopic exams, or proceed to the OR for thorough exam, biopsy, and resection if indicated.

    • Positive biopsy result: A positive biopsy with fungal invasion requires surgical resection of all involved tissues with cleared margins intraoperatively. Imaging should be reviewed to determine resectability in the case of intracranial or major vessel involvement. In cases of advanced disease requiring large soft-tissue resections, goals of care should be discussed with the patient and family prior to proceeding.

  • Consider involvement of Ophthalmology or Neurosurgery depending on extent of disease.

  • Initiation of systemic antifungals with involvement of Infectious Disease specialists.

    • Liposomal amphotericin B is an option, although the toxicity of this drug requires close monitoring.

    • Early fungal identification may allow treatment with less toxic or more efficacious antifungals such as posaconazole or voriconazole (if susceptible Aspergillus species are identified).

  • Reversal of immunosuppression when feasible.

  • Typically requires multidisciplinary input and care.

    • Patients in diabetic ketoacidosis require aggressive parenteral hydration and correction of acidosis with close electrolyte monitoring (generally managed by Medicine or ICU teams).

    • Neutropenic patients may require white blood cell transfusions and granulocyte colony stimulating factors such as filgrastim (generally managed by Hematology). Despite treatments, reversal in these patients may not be adequate.

  • Consider topical sinus rinse with amphotericin B. Although there is not strong evidence for the efficacy of topical antifungal medications, it may be considered in this disease.

  • Patient should be admitted to the ICU with serial endoscopic exams, and potentially serial surgical resections in the case of disease progression. Close monitoring continues until disease is controlled and patient’s underlying disease is addressed, if possible.

 

Example Procedure Note
Procedure: Nasal biopsy
After obtaining written and verbal consent from the patient, topical anesthetic was applied (Afrin® and 2% lidocaine in 1:1 mixture). The rigid 0-degree endoscope was used to examine the bilateral nasal passages. The nasal mucosa appeared ___. An area that was concerning for invasive fungal sinusitis, located at the ___, was biopsied using a cup forceps. The biopsy was sent for frozen section pathology and fungal staining. Bleeding from the biopsy site was managed with ___. The patient tolerated the procedure well.

 

References
1. Adelson, R.T., Marple, B.F., Ryan, M.W. (2013). Fungal Rhinosinusitis. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 557-572). Baltimore, MD: Lippincott Williams & Wilkins.
2. Benninger, M.S., Roxbury, C.R., Stokken, J.K. (2020). Acute Rhinosinusitis: Pathogenesis, Treatment, and Complications. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 643-648). Philadelphia, PA: Elsevier.
3. Ergun, O., Tahir, E., Kuscu, O., et al. (2017). Acute invasive fungal rhinosinusitis: Presentation of 19 cases, review of the literature, and a new classification system. J Oral Maxillofac Surg. 75(4):767.e1-767.e9.

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FRONTAL BONE FRACTURES

Overview
Fractures of the frontal bones can be broadly categorized based on sites of fracture, anterior or posterior table involvement, frontal sinus outflow tract involvement, and degree of displacement. When fractures involve the anterior table of the frontal sinus alone, the primary concerns relate to frontal sinus function and outflow as well as facial deformity secondary to a posteriorly displaced or impacted fracture. Chronic obstruction of the frontal outflow tract may lead to chronic sinusitis or mucocele formation, potentially with intracranial or intraorbital extension as late sequelae. These complications are avoided by careful exploration and management of the frontal sinus outflow tract. Fracture of the posterior table of the frontal sinus can affect not only sinus function if displaced but, as with any skull fracture, is frequently associated with intracranial injury. This type of fracture is usually managed in concert with Neurosurgery. Non-displaced posterior table fractures can be managed with observation alone, although herniation of brain or dura into the sinus or CSF leak should be ruled out before consideration of conservative management. Traumatic anosmia is also relatively common through shearing of the olfactory neurons as they pass through the cribriform plate. Various classification systems have been devised for fractures involving the frontal sinus including Stanley and Becker’s system for prediction of frontal sinus outflow tract obstruction, although no system is consistently used in clinical practice. Supraorbital rim involvement or orbital roof involvement of the fracture can present with various orbital concerns such as reduced ocular motility or injury to the supratrochlear or supraorbital nerves leading to forehead hypoesthesia. Additionally, fractures of the orbital rim as well as the nasoethmoidal complex have high association with lacrimal system obstruction.

 

Key Supplies for Frontal Bone Fracture Consultation

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

  • Headlight

  • Nasal speculum

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

  • Antifog solution (Fred™)

  • Oxymetazoline

  • Flashlight for pupil exam (or can use headlight)

 

Management

  • Full head and neck exam beginning with ABCs (Airway, Breathing, Circulation) and with attention to associated lacerations, sensation to forehead, presence of bony step off along orbital rims/frontal sinuses, facial contour over the frontal sinuses and glabella, extra ocular movements and visual acuity, presence of rhinorrhea or post nasal drip (may indicate CSF leak especially if clear and salty) and consideration of sinus evaluation with rigid endoscopy.

  • High resolution maxillofacial CT is the imaging modality of choice with attention to involvement of the anterior and posterior tables, frontal sinus outflow tract, intracranial findings (pneumocephalus, epidural/subdural/subarachnoid hemorrhage, meningocele, or encephalocele), fracture extension into the naso-orbito-ethmoidal (NOE) complex, supraorbital rims, or anterior skull base.

  • Make recommendation for appropriate consultations to include Ophthalmology if orbital involvement and Neurosurgery for significant posterior table fractures with associated pneumocephalus or intracranial injury or hemorrhage.

  • Antibiotics are often considered for all posterior table fractures with coverage of common sinus organisms (e.g., amoxicillin/clavulanate or clindamycin), although their usage is not uniform.

  • Initial non-operative CSF leak management options:

    • Over 50% of traumatic CSF leaks will spontaneously resolve in 1 week with conservative management.

    • Less likely to spontaneously resolve if posterior table displaced >5 mm.

    • Conservative management: Bedrest, head elevation, stool softeners, avoid Valsalva and nose blowing.

    • CSF diversion (lumbar drain or external ventricular drain) may be added through Neurosurgery if conservative management is not effective.

    • Antibiotics: Prophylactic antibiotics have not been shown to reduce risk of meningitis; data suggest surgical repair after 7 days without spontaneous resolution minimizes risk of meningitis.

  • Isolated anterior table fracture without high risk of outflow obstruction or facial contour deformity can be managed conservatively with observation and radiographic follow-up. If forehead contour deformity is appreciated once the overlying soft tissue edema dissipates, this can be repaired secondarily.

  • Depressed anterior table fracture with high risk of frontal sinus outflow tract obstruction (NOE fractures, fontal sinus floor fractures, inferior medial anterior table displaced fractures) or forehead contour deformity are usually managed with surgery.

    • For contour deformity, open reduction internal fixation (ORIF) with plates, autologous bone from the outer table of the calvarium or iliac crest, mesh, or a custom implant.

    • Most common approach is the coronal incision while other options include extension of an existing overlying laceration, bilateral brow incision (mid-forehead, pretrichial, etc.), or less commonly an upper blepharoplasty incision or gullwing/spectacle incision.

    • For sinus outflow tract obstruction, this can be managed with functional endoscopic sinus surgery or frontal sinus obliteration if severely comminuted (see the AO Foundation Surgery Reference for management specifics).

      • If sinus outflow obstruction occurs without CSF leak, most can be managed with endoscopic sinus surgery. Cranialization is rarely indicated and obliteration is rarely, if ever, used due to the high risk of late sequelae as outlined below.

  • For isolated anterior table fractures that may impinge on the frontal outflow tract without cosmetic deformity, consideration may be given to observation with serial imaging. If obstruction develops radiographically, endoscopic management may be considered to re-establish normal outflow and preserve sinus function. This is often accomplished via a unilateral Draf IIB or Draf III frontal sinusotomy.

  • Displaced posterior table fractures or patients with persistent CSF leak through the involved sinus are usually managed with cranialization of the sinus; frontal sinus obliteration has fallen out of favor at most centers secondary to the risk of late complications including mucocele formation, mucopyocele formation, and chronic infection of obliteration material.

  • Usually approached jointly with Neurosurgery with a coronal incision and frontal craniotomy.

    • Posterior table bony fragments are removed.

    • Dura is inspected and any tears repaired primarily or with a fascia lata graft sutured to dura.

    • Removal of all sinus mucosa including mucosal invaginations into the remaining bone (this is vital to reduce the risk of mucocele development as a late complication) smoothing of the bony surface of the frontal table (brain gradually fills the void left in the anterior cranial fossa).

    • A pericranial flap is often used as a second layer over the repaired dura or fascia lata graft.

 

Follow-up

  • Short- and long-term follow-up is important because complications can develop; there is no strong consensus on timing of follow-up.

  • CT can be used for surveillance unless the frontal sinus is obliterated, in which case MRI is needed.

    • Fat: T1 bright, T2 dark.

    • Scar: T1 and T2 intermediate to dark.

    • Mucosa/Mucocele: T1 hypo- to intermediate intensity and T2 intermediate to hyperintense (depending on the relative fluid content of the mucocele), but T1 gadolinium bright peripherally in surrounding mucosa but hypointense centrally within the mucocele.

 

References
1. Fokkens, W.J., Harvey, R. (2020). Management of the Frontal Sinuses. In Flint, P.W., et al. (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 719-732). Philadelphia, PA: Elsevier.
2. Fusetti, S., Hammer, B., Kellman, R., et al. Skull Base and Cranial Vault. AO Foundation Surgery Reference, https://surgeryreference.aofoundation.org/cmf/trauma/skull-base-cranial-vault.
3. Strong, E.B. (2013). Frontal Sinus Fractures. In Johnson, J.J., Rosen, C.A. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 1255-1271). Baltimore, MD: Lippincott Williams & Wilkins.

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