Orbital Complications of Chronic Sinusitis

: *Done By Emad AL-Matar

*Supervised by: Dr.Kamal Abou-ElhamdDr.Usama Mohamed Rashad

Introduction

* Chronic sinusitis is an inflammation of the sinuses lasting more than six weeks.

1- Nasal polyps or tumors .2- Allergic reactions.3- Deviated nasal septum.4- Trauma to the face.5- Respiratory tract infections.6- Allergies such as hay fever.

Common Causes of Chronic Sinusitis

7- Immune system cells. (eosinophils can cause sinus inflammation).8- Other medical conditions. The

complications of cystic fibrosis, gastroesophageal reflux, or HIV and other immune system diseases may result in nasal blockage.

Complications of Chronic Sinusitis

Sinonasal disease accounts for the majority of orbital infections (up to 85%).

- The frontal, maxillary, ethmoid and sphenoid sinuses sit immediately above, below, between and behind the eyes, respectively.

For this reason, infections of any of the sinuses may spread to the orbit, causing a wide spectrum of complications from mild inflammation of the eyelid to abscesses with possible blindness.

- Most of the complications follow infection of ethmoids as they are separated from the orbit only by a thin lamina of bone~ lamina papyracea. - Infection travels from these sinuses either by osteitis or as thrombophlebitic process of ethmoidal veins.

Symptoms of Orbital Disease

Erythema or edema of the eyelids (common to all orbital infections), proptosis and ophthalmoplegia (suggestive of orbital cellulitis or orbital or subperiosteal abscess), decreased visual acuity (associated with advanced infection.)

Orbital complications as staged by Chandler (1970) are: preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis (dural thrombophlebitis).

Chandler classification of orbital complications

• Inflammatory Oedema of Lids .• Subperiosteal Abscess .• Orbital Cellulitis .• Orbital Abscess .• Superior Orbital fissure syndrome .

Inflammatory Oedema of Lids - There is no erythema or tenderness of the lids whichcharacterises lid abscess.- It involves only preseptal space.- Eyeball movements and vision are normal.- Generally, upper lid is swollen in frontal, lower lid in maxillary, and both upper and lower lids in ethmoid sinusitis.

Subperiosteal Abscess

- Pus collects outside the bone under the Periosteum.- A subperiosteal abscess from ethmoids forms on the medial wall of orbit and displaces the eyeball forward, downward and laterally.

- From the frontal sinus, abscess is situated just above and behind the medial canthus and displaces the eyeball downwards and laterally.

- From the maxillary sinus, abscess forms in the floor of the orbit and displaces the eyeball upwards and forwards.

Orbital Cellulitis

- When pus breaks through the periosteum and finds its way into the orbit, it spreads between the orbital fat, extraocular muscles, vessels and nerves.

- Clinical features will include oedema of lids, exophthalamos, chemosis of conjunctiva and restricted movements of the eye ball.

- Vision is affected causing partial or total loss which is sometimes permanent. - Patient may run high fever. - Orbital cellulitis is potentially dangerous because of the risk of meningitis and cavernous sinus thrombosis.

Orbital Abscess

- Intraorbital abscess usually forms along lamina papyracea or the floor of frontal sinus.

- Clinical picture is similar to that of orbital cellulitis.

- Diagnosis can be easily made by CT scan or ultrasound of the orbit.

- Treatment is i.v. antibiotics and drainage of the

abscess and that of the sinus (ethmoidectomy or trephination of frontal sinus).

Superior Orbital fissure syndrome

Infection of sphenoid sinus can rarely affect structures of superior orbital fissure. Symptoms consist of deep orbital pain, frontal headache and progressive paralysis of CN VI, III and IV, in that order.

Orbital Apex Syndrome

It is superior orbital fissure syndrome with additional involvement of the optic nerve and maxillary division of the trigeminal.

Evaluation

It should include a thorough ophthalmologic examination and thin cut CT with contrast of the orbits and paranasal sinuses.

Treatment

- Local and systemic decongestion play an important role.

- Surgical intervention is frequently required and should be considered as indicated.

- Frank abscesses should be evacuated urgently.

- Small subperiosteal abscesses with normalvision, normal EOMI, mild proptosis may be treated conservatively with IV antibiotics. - All patients with orbital complications managed medically should be closely observed with frequent visual checks.

- Patients who experience a decrease in visual acuity, worsening extraocular muscle function or failure to improve in 48-72 hours should undergo surgical sinus drainage.