What characterizes complicated sinusitis?

Characteristics of Complicated Sinusitis

Complicated sinusitis is characterized by the spread of infection beyond the paranasal sinuses, resulting in orbital or intracranial involvement that can cause significant morbidity and mortality if not promptly recognized and treated. 1

Orbital Complications

• Periorbital/preseptal cellulitis: Inflammation limited to the eyelid

  • Mild cases (eyelid <50% closed) may be treated as outpatients with high-dose amoxicillin-clavulanate 1
  • Requires daily follow-up until improvement is noted

• Postseptal (intraorbital) complications:

  • Medial orbital wall subperiosteal abscess
  • Orbital cellulitis
  • Ocular findings including:
    • Proptosis
    • Abnormal visual examination
    • Ophthalmoplegia
    • Impaired visual acuity 1

Intracranial Complications

• Most common sources: Frontal sinusitis, particularly in adolescent males 1

• Mechanisms of spread:

  • Progression of septic thrombi through valveless diploic veins
  • Direct intracranial extension of osteomyelitis 1

• Types of intracranial complications:

  • Meningitis
  • Encephalitis
  • Epidural and subdural empyema
  • Brain abscess
  • Dural sinus thrombophlebitis
  • Venous thrombosis 1

Clinical Warning Signs of Complicated Sinusitis

• Orbital complications:

  • Periorbital edema
  • Proptosis
  • Impaired extraocular movement
  • Visual disturbances
  • Severe ocular signs 1

• Intracranial complications:

  • Altered mental status
  • Severe headache
  • Seizures
  • Hemiparesis
  • Cranial nerve palsy
  • Pott's puffy tumor (osteomyelitis of frontal bone) 1

• Sphenoid sinusitis complications (rare but high mortality):

  • Vague, nonspecific symptoms
  • Severe headache
  • Ocular signs
  • Oculomotor palsy due to involvement of orbital apex/cavernous sinuses 1

Specific Sinus Involvement and Associated Complications

• Frontal sinusitis: Most commonly leads to intracranial complications 1
• Ethmoid sinusitis: Typically spreads through the lamina papyracea to the orbit 1
• Sphenoid sinusitis: Can lead to cavernous sinus thrombosis 1
• Maxillary sinusitis: Less commonly causes complications, but can be severe when of dental origin 1

Diagnostic Approach for Suspected Complications

• Imaging:

  • Contrast-enhanced CT scan (preferably coronal thin cut) of head, orbits, and sinuses is essential 1
  • MRI may be preferred in some cases for better soft tissue definition 1

• Laboratory evaluation:

  • Monitor inflammatory markers (CRP, ESR, WBC) 2

Management of Complicated Sinusitis

• Hospitalization is required for:

  • Any signs of orbital involvement beyond mild preseptal cellulitis
  • Any signs of intracranial involvement
  • Severe symptoms or clinical deterioration 1

• Consultations:

  • Otolaryngology
  • Ophthalmology (for orbital complications)
  • Infectious disease
  • Neurosurgery (for intracranial complications) 1

• Antimicrobial therapy:

  • Immediate intravenous antibiotics for suspected complications 1
  • For frontal, fronto-ethmoidal, or sphenoidal sinusitis (high risk of complications):
    • Consider fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) 1

Risk Factors for Complications

• Low socioeconomic status and poor access to healthcare 1
• Immunodeficiency
• Ciliary dysfunction
• Cystic fibrosis
• Anatomic abnormalities 1, 2

Key Pitfalls in Managing Complicated Sinusitis

• Failure to recognize warning signs of orbital or intracranial spread
• Delayed imaging in patients with concerning symptoms
• Inadequate antimicrobial coverage
• Failure to obtain appropriate specialist consultation
• Relying solely on clinical examination without appropriate imaging 2

Remember that while complications of acute bacterial sinusitis are uncommon, they can cause significant morbidity and mortality if not recognized and treated promptly and appropriately.