Sinus infection
- Viral rhinosinusitis
- For first 10 days of rhinosinusitis, etiology is viral in 60%–90% of cases.
- Antibiotics are indicated only after day 10 of routine sinusitis symptoms or a “double worsening” of the symptoms during the first 10 days.
- Acute bacterial rhinosinusitis (ABRS)
- Can lead to preseptal cellulitis, orbital cellulitis, subperiosteal abscess, or orbital abscess (Bilyk, Curr Opin Ophthalmol 2007)
- Most common organisms: Staphylococcus, Streptococcus, H influenza
- Location important in guiding management of subperiosteal abscess (Garcia, Ophthalmology 2000)
- Ethmoid (most common): often responds to IV antibiotics, especially in younger children
- Subperiosteal abscess originating from other sinuses more likely to require surgical drainage
- Chronic rhinosinusitis (CRS)
- 12 weeks or more of sustained sinus symptoms, confirmed with radiographic or endoscopic evidence of sinus disease
- Divided broadly into polyp or non-polypoid sinusitis
- Considered more immunologic driven than ABRS
- Steroids are fundamental treatment modality.
- Antibiotics are used secondarily.
- Common contributing comorbidities: asthma, environmental allergies, tobacco use
- Fungal sinus disease
- Invasive fungal
- Potentially devastating condition; high risk of orbital involvement, vision loss, or death
- Occurs in immunocompromised patients
- Organisms
- Mucormycosis (Mucorales or Rhizopus) (Schwartz, Surv Ophthalmol 1977)
- Large non-septate hyphae
- Chelating agents helpful for treatment
- Aspergillus (Levin, Surv Ophthalmol 1996)
- Similar clinical picture to mucormycosis
- Chelating agents not helpful
- Treatment
- Debridement of involved tissue
- Antifungals: systemic and intraorbital
- Reversal of immunocompromised state
- Chronic invasive/granulomatous
- Endemic to Middle East
- Potentially vision threatening
- Much slower clinical progression than invasive fungal sinusitis
- Fungus ball
- Benign, does not involve mucosa
- Does not involve orbit
- Treatment is removal
- Allergic fungal (Chang, OPRS 2000)
- Complex interaction of allergy, bacterial biofilm, altered immune response, and genetic expression
- Can cause significant bony remodeling of orbit that self-corrects after functional endoscopic sinus surgery (FESS)
- Treatment is multimodal:
- Control of comorbidities
- Topical treatment of mucosa
- Immunosuppression
- Aggressive FESS
Tumors
- Benign
- Mucocele
- Commonly from frontal sinus
- Inverting papilloma
- Malignant transformation possible
- Fibrous dysplasia/ossifying fibroma
- Meningioma
- Malignant (Frazell, Cancer 1963)
- Squamous cell carcinoma
- Most common epithelial sinus malignancy (60%)
- 80% arise from maxillary sinus
- Adenoid cystic carcinoma, adenocarcinoma
- Aggressive, poor prognosis
- Lymphoma
- 90% B‑cell origin
- Natural killer T‑cell lymphoma: predilection for nasopharynx
- Also known as lethal midline granuloma (Parker, Am J Otolaryngol 2010)
- Esthesioneuroblastoma (olfactory neuroblastoma)
Inflammations
(Weber, Radiol Clin N Am 1987)
- Sarcoidosis
- Granulomatosis with polyangiitis (Wegener’s granulomatosis) (Harman, Surv Ophthalmol 1996)
- Necrotizing granulomatous vasculitis, highly destructive
- Can invade orbit from sinuses or involve orbit primarily
- Other sites of involvement: upper respiratory tract, lungs, kidneys
- Diagnosis: C-ANCA, biopsy
- Treatment: steroids, immunosuppressants
- Polyarteritis nodosa
- Churg Strauss disease
Trauma and structural abnormalities
- Orbital blowout fractures
- Floor and medial wall most commonly involved due to thinness
- Floor fractures most often occur medial to infraorbital canal
- Infraorbital hypoesthesia often associated with floor fractures
- Medial wall fractures often limited to a few ethmoid air cells
- Ethmoid-maxillary suture (inferomedial strut) provides strong structural support at the junction of the two sinuses (Figure 1)
- Fracture of strut requires significant energy
- Repair of floor and medial wall more difficult due to loss of implant support
- Often requires “wraparound” implant or single shaped implant to span entire defect (Cho, Craniomaxillofacial Trauma Reconstr 2013)
Figure 1. Combined left orbital floor and medial wall fractures (two separate cases). Inferomedial strut (white arrow) is intact in A, but fractured and inferiorly displaced in B. Reprinted (need permission) from Cho RI, Craniomaxillofac Trauma Reconstr 2013.
- Indications for repair (Burnstine, Ophthalmology 2002)
- Extraocular muscle entrapment (urgent)
- Diplopia within 30 degrees of primary gaze or visually significant
- Aesthetically unacceptable enophthalmos or globe malposition
- More likely to occur if fracture involves > 50% of surface area
- Frontal sinus fractures (Doonquah, Oral Maxillofacial Surg Clin N Am 2012)
- Frontal bone very strong, significant energy required to cause fracture
- Often associated with traumatic brain injury
- Potential sequelae:
- Frontal sinus outflow obstruction causing sinusitis and/or mucocele
- Traumatic orbital cephalocele (large orbital roof defect)
- Facial deformity
- Management controversial
- Observation
- Exenteration
- Cranialization
- Obliteration
- Traumatic optic neuropathy (Warner, Curr Opin Ophthalmol 2010)
- Typically caused by severe trauma, often associated with frontal sinus or orbital roof fractures
- Energy can be directed from forehead along orbital roof to optic canal (with or without fracture)
- Sphenoid fractures sometimes detectable on CT scan
- Treatment controversial
- High-dose steroids advocated by some
- Optic canal decompression can be attempted through trans-sphenoidal approach
- International Optic Nerve Trauma Study (IONTS) showed no definitive benefit from either high-dose steroids or optic nerve decompression
- Silent sinus syndrome (Annino, Curr Opin Otolaryngol Head Neck Surg 2008)
- Maxillary sinus atelectasis caused by impaired outflow through the ostiomeatal complex
- Chronic fluid accumulation and resorption causes negative pressure
- Collapse of orbital floor causes enophthalmos and globe dystopia
- CT findings: maxillary sinus hypoplasia and opacification, orbital expansion, lateralization of uncinate process
- Treatment
- Restoration of normal sinus outflow
- Enophthalmos/hypoglobus can spontaneously resolve after several months
- Consider orbital floor augmentation if malposition persists following period of observation