orbital complications of sinusitis
TRANSCRIPT
ORBITAL COMPLICATIONS
OF SINUSITIS- N. ARAVINTHO
Epidemiology• 80 – 90% of cases.• Peak incidence between 5 - 10 years• 80% of patients <18 Y/O ( Younis et al 2002)• Sinus infections are the most common cause of
unilateral proptosis in children and the 3rd most common cause in adults following Graves’ orbitopathy and pseudotumor
• Ethmoid sinusitis is most common cause , followed by Maxillary
Orbital Complications Of Sinusitis
Etiology• Direct extension of ethmoid sinusitis through thin
lamina papyracea• Retrograde bacterial phlebitis with intact lamina
papyracea via:1. The anterior & posterior ethmoidal neurovascular
foramina2. The ophthalmic venous system, the superior and inferior
ophthalmic veins, are valveless, allowing for free-flowing communication of infection from the nose and ethmoid sinus to the orbit.(Chandler et al., 1970)
RELATION OF SINUSES TO ORBIT
Anatomy• Orbital septum is a thin fibrous tissue continuation of orbital rim
periostium which extends to the tarsal plates• Deep to posterior orbicularis fascia• Anterior extent of orbit & Posterior extent of eyelid• A Fascial barrier against the spread of periorbital infections into the
orbit proper
GRADING OF ORBITAL CELLULITIS
• G 1 : PRE SEPTAL CELLULITIS• G 2: POST SEPTAL CELLULITIS• G 3: SUBPERIOSTEAL ABSCESS• G 4: ORBITAL ABSCESS• G 5: CAVERNOUS SINUS THROMBOSIS• SUPERIOR ORBITAL FISSURE SYNDROME • ORBITAL APEX SYNDROME
Optic globe and septum divides the orbit into anterior and Optic globe and septum divides the orbit into anterior and posterior compartmentsposterior compartments
Localizing orbital disease to compartment helps generate a Localizing orbital disease to compartment helps generate a differential diagnosis.differential diagnosis.
Orbital CompartmentsOrbital Compartments
PRE SEPTAL CELLULITIS• NO MARKED ERYTHEMA AND
TENDERNESS OF THE LIDS• ONLY OEDEMA OF THE LIDS• OCCULAR MOVEMENTS AND VISION NOT
AFFECTED• UPPER LID INVOLVED IN FRONTAL ,
LOWER IN MAXILLARY AND BOTH IN ETHMOIDAL CELLULITIS
Orbital Cellulitis Pre-septal cellulitis
9
Orbital Cellulitis Post-septal (Orbital) Cellulitis
10
. Axial CE fat-suppressed T1-W MRI obtained in a 40-. Axial CE fat-suppressed T1-W MRI obtained in a 40-Y/O man demonstrates right exophthalmos and Y/O man demonstrates right exophthalmos and heterogeneous enhancement of orbital (arrows) and heterogeneous enhancement of orbital (arrows) and periorbital (arrowhead) fat.periorbital (arrowhead) fat.
Christina A. LeBedis, Osamu Sakai. Christina A. LeBedis, Osamu Sakai. RSNA, 2008 RSNA, 2008 •• radiographics.rsnajnls.orgradiographics.rsnajnls.org
SUBPERIOSTEAL ABSCESS• ETHMOID SINUSES- UNDER PERIOSTEUM
OF LAMINAPAPYRACEA• PUSHES THE EYEBALL OUTWARD,
LATERALLY, AND DOWNWARDS• FRONTAL SINUSE- DOWNWARDS AND
LATERALLY• MAXILLARY SINUSES- UPWARD AND
FORWARDS
Subperiosteal AbcessSubperiosteal Abcess
Subperiosteal abscess due to ethmoid sinusitis. Axial Subperiosteal abscess due to ethmoid sinusitis. Axial (a) (a) and coronal and coronal (b) (b) nonenhanced CT images obtained in a 24-year-old man depict a subperiosteal nonenhanced CT images obtained in a 24-year-old man depict a subperiosteal abscess (arrow) along the medial wall of the right orbit,adjacent to the opacified abscess (arrow) along the medial wall of the right orbit,adjacent to the opacified ethmoid air cells, with resultant lateral displacement of the medial rectus ethmoid air cells, with resultant lateral displacement of the medial rectus muscle.muscle.. .
Christina A. LeBedis, Osamu Sakai. Christina A. LeBedis, Osamu Sakai. RSNA, 2008 RSNA, 2008 •• radiographics.rsnajnls.orgradiographics.rsnajnls.org
ORBITAL ABSCESS• SUBPERIOSTEAL ABSCESS BURSTS INTO
ORBIT CAUSING ORBITAL ABSCESS• HIGH FEVER• OEDEMA OF THE LIDS • PROPTOSIS • CHEMOSIS OF CONJUNTIVA• EYEBALL MOVEMENTS RESTRICTED• VISION AFFECTED
Orbital Abscess
Post-Septal Orbital AbscessChild with an intraorbital abscess Child with an intraorbital abscess 2ry to ethmoid sinusitis2ry to ethmoid sinusitis
SUPERIOR ORBITAL FISSURE SYNDROME
• INFECTION OF SPHENOID SINUSES • DEEP ORBITAL PAIN, FRONTAL
HEADACHE• PROGRESSIVE PARALYSIS OF
CRANIAL N 4, 3 AND 6 IN THAT ORDER
ORBITAL APEX SYNDROME
SUP ORBITAL FISSURE SYNDROME + INVOLEMENT OF OPTIC NERVE AND MAXILLARY DIVISION OF TRIGEMINAL NERVE
1.1. Periorbital (Pre-Septal) cellulitisPeriorbital (Pre-Septal) cellulitis2.2. Orbital (Post-Septal) cellulitisOrbital (Post-Septal) cellulitis3.3. Subperiosteal AbscessSubperiosteal Abscess4.4. Orbital abscessOrbital abscess5.5. Cavernous Sinus ThrombophlebitisCavernous Sinus Thrombophlebitis
Orbital Complications Of SinusitisOrbital Complications Of SinusitisClassificationClassification
Pre-Septal• More common• Anterior to the septum• Erythema/Edema eyelids• No proptosis• No Pain• Normal vision • No restriction of ocular
movements/Painless• No aff. Pupillary defect• No abscess• ±Fever
Post-Septal• Less frequent <5y• Posterior to the septum• Massive eyelid swelling • Proptosis• Severe Pain• Diminution of vision • Restriction of ocular
movements/Painful • Afferent pupillary defect• An abscess may form • ‡Fever
CLINICAL PRESENTATION• CHILDREN AND YOUNG ADULT COMONLY
INVOLVED• ORBITAL COMPLICATION MOSTLY ARISE AS
COMPLICATION OF ACUTE ETHMOIDAL SINUSITIS OR RARELY ACUTE EXACERBATION OF CHRONIC SINUSITIS
• SWELLING AROUND EYE WITH H\O UPP. RESPIRATORY INFECTION
• EYEBALL MOVEMENTS AND VISION DEPENDS ON THE GRADING (G 3 ONWARDS)
• VISUAL ACUITY AND COLOUR VISION – MEASURE OF OPTIC NERVE
EXAMINATION• DIAGNOSTIC NASAL ENDOSCOPY• FULL RANGE OF EYE MOVEMENTS• DEGREE OF PROPTOSIS• LIGHT REFLEX• VISUAL ACUITY• COLOUR VISION• FUNDUS EXAMINATION
INVESTIGATION• TO DEFINE THE EXTENT AND SITE OF THE
DISEASE• CT SCAN OF ORBIT, PNS AXIAL AND
CORONAL VIEW• HEMATOLOGY : TC , DC , RBC COUNT , Hb • URINE ANALYSIS : DIABETES MELLITUS
TREATMENT MEDICAL MANAGEMENTFIRST LINE OF TREATMENT
IV ANTIBIOTICS- BROAD SPECTRUM Like 3rd GENERATION CEPHALOSPORIN,
CEFOTAXIME CEFTRIAXONE
SURGICAL MANAGEMENT AIM IS TO TREAT COMPLICATION AND SINUSITIS
• SURGERY FOR ALL CASES WITH PROPTOSIS IRRELAVENT OF EYEBALL MOVEMENTS AND VISUAL ACUITY
• ENDOSCOPIC APPROCH: • EXTERNAL APPROCH: LYNCH HOWARTH
SURGERY
LYNCH HOWARTH SURGERY
DRAINAGE OF ABSCESS DRAINAGE TUBE EITHER INTO
NASAL CAVITY OR DRAINED EXTERNALLY
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