Management of acute complicated sinusitis: A 5-year review

Management of acute complicated sinusitis: A 5-year review SEAN MORTIMORE, BSc(Med)(Hons), FCS(SA)ORL, FRCS(Ed), and PETER-JOHN WORMALD, FCS(SA)ORL, FRCS(Ed),

Cape Town, South Africa

Acute sinusitis is a relatively common problem; however, sinusitis associated with a complication is less frequent. Currently there is debate as to whether acute complicated sinusitis should be managed by frontal sinus trephine and sinus washout or by immediate frontoethmoidectomy/ functional endoscopic sinus surgery. To assess the effectiveness of frontal sinus trephine in the management of acute complicated frontal sinusitis, we reviewed all patients admitted to Groote Schuur Hospital with acute pansinusitis (includes frontal, maxillary, and ethmoid) from 1989 to 1993. Eightyseven patients were admitted, of whom 43 were treated medically and 44 were treated surgically. Of the surgical patients 38 had frontal trephines and management of associated complications. Thirty (80%) of the patients who received frontal trephines recovered without further surgery, and 8 required further sinus surgery for persistent disease. Frontal trephine with management of associated complications is an acceptable management option for patients with acute complicated pansinusitis. Frontoethmoidectomy or functional endoscopic sinus surgery can be held in reserve for those patients with persistent disease that does not resolve after the initial frontal trephine. (Otolaryngol Head Neck Surg 1999;121:639-42.)

Sinusitis has traditionally been classified anatomically according to the sinus affected. Sinusitis could be either isolated sinusitis if, for instance, only the frontal or maxillary sinuses were involved, or pansinusitis if more than 1 sinus was involved. Complications of sinusitis are classified into orbital, soft tissue, osteitis, and Department of Otolaryngology, Groote Schuur Hospital. Presented at the Annual Academic Meeting of the South African Society of Otorhinolaryngology Head and Neck Surgery, October 24-27, 1994. Reprint requests: Dr S. Mortimore, Department of Otolaryngology– Head and Neck Surgery, Fazakerley Hospital, Aintree University Hospitals NHS Trust, Longmore Lane, Liverpool, L97AL, UK. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/77/93866

intracranial.1-3 Orbital complications have been further classified by different authors according to the site of inflammation and presenting signs, for the purpose of describing and discussing the complication.4,5 Insertion of trocars with or without indwelling tubes into the maxillary sinuses has remained the mainstay of medical management,6,7 whereas the surgical management has consisted primarily of either frontal trephination and/or external ethmoidectomy.8 Two additional surgical options have been described recently. In 1980 Fry et al9 described frontal trephination with insertion of an indwelling catheter for repeated irrigation (Saldinger principle), and since 1985 functional endoscopic sinus surgery (FESS) has being used to manage acute complicated sinusitis.10,11 Several options are now available in treating acute complicated sinusitis: Lynch-Howarth frontoethmoidectomy, FESS, or frontal sinus trephination and insertion of indwelling catheters in both the frontal and maxillary sinuses. If intraorbital or periorbital purulence is present, it is drained through the Lynch incision, through a frontal trephination incision, or through endoscopy for intraorbital collections and craniotomy for intracranial sepsis. Each of these 3 techniques has its proponents. The traditional approach has been emergency frontoethmoidectomy,12,13 with the less invasive approach being frontal sinus trephine and maxillary sinus irrigation.2,14,15 With the popularization of FESS, it has been advocated not only as the least invasive approach but also as the most effective because not only can diseased ethmoid air cells be removed, but also intraorbital purulence can be drained.10,11 The aim of this article is to review the results of the management of acute noncomplicated and complicated sinusitis with our management protocol, in which the surgical option consists of frontal sinus trephination, sinus irrigation, and management of complications. METHODS All patients admitted to Groote Schuur Hospital for acute pansinusitis during a 5-year period from 1989 to 1993 were reviewed retrospectively. Patients were classified according to the orbital subclassification of Chandler et al,4 namely, preseptal cellulitis (inflammatory edema), orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus throm639

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Table 1. Chandler’s classification of the orbital complications of sinusitis Group

Site

I

Inflammatory edema

II

Orbital cellulitis

III

Subperiosteal abscess

IV

Orbital abscess

V

Cavernous sinu thrombosis

Fig 1. Flow chart detailing the management and outcome of medically treated sinusitis. Mx, Managed.

bosis (Table 1). Intracranial complications are subclassified into meningitis, epidural abscess, subdural empyema, and intracerebral abscess.16 All patients admitted were treated with intravenous antibiotics (ampicillin and metronidazole until a cultured organism and antibiotic sensitivity were available) and nasal and systemic decongestants. Bilateral antral irrigations were performed with a Tilley-Lichtwitz trocar and cannula (local anaesthetic) and with insertion of polyethylene tubes into the antra through the cannula, to facilitate bedside antral irrigations with warm isotonic saline solution once every 4 hours. Patients who had sinusitis with a clinically evident complication or in whom medical treatment had failed underwent a coronal and, if indicated, an axial CT scan. If the complication did not require immediate surgical intervention (eg, periorbital cellulitis without abscess formation), these patients were treated according to the medical protocol outlined above. If these patients had complications that required immediate surgery (eg, intraorbital abscess), they underwent frontal sinus trephination with insertion of indwelling catheters in the frontal and maxillary sinuses. Associated complications as identified on the CT scan were dealt with on merit (eg, drainage of intraorbital abscess). This surgical group also had medical treatment, which included antibiotics as above, systemic and topical decongestants, and maxillary sinus irrigation. Patients who had a history of previous sinusitis were treated as above but underwent CT scanning after 6 weeks and were booked for a subsequent definitive procedure if they remained symptomatic and had pathology identified on the CT scan (eg, functional endoscopic frontonasal duct clearance, ethmoidectomy, and middle meatal antrostomy).

Description

Edema of the eyelids (preseptal) ± slight proptosis; no limitation of ocular movements; normal visual acuity Diffuse edema of orbital contents; infiltration with inflammatory cells and bacteria ± reduced visual acuity Collection of purulence between periorbita and bony wall of orbit; globe usually displaced Collection of purulence within orbital tissues; marked proptosis and chemosis; ophthalmoplegia; visual impairment Extension of inflammation posteriorly into cavernous sinus; bilateral eye signs; meningism (neck stiffness) present

Orbital complications were treated in consultation with the ophthalmologists, who monitored recovery by performing daily funduscopy, visual acuity, eye movement, proptosis measurement, and pupil reaction. Intracranial complications were managed in consultation with the neurosurgeons. Irrigation tubes were removed from the maxillary sinuses once the return irrigation fluid was recorded as being clear for 24 hours and from the frontal sinuses once the patient could taste the saltiness of the normal saline irrigation, indicating that the frontonasal duct was patent. If after 5 days the frontonasal duct was still not patent, the catheters were removed. In this situation the patient’s symptoms and clinical condition determined further management (ie, either discharge if clinically well or frontoethmoidectomy if still symptomatic). Patients were discharged once clinically well and followed up on an outpatient basis until asymptomatic. RESULTS

There were 87 admissions during the 5-year period, including 64 males and 23 females (male/female ratio 2.6:1), with an average age of 25.0 years (range 8 to 76 years; SD = 12.3 years). Twenty-four patients had uncomplicated pansinusitis (average age 29.9 years, average hospital stay 4.0 days, SD = 1.5 days), whereas 63 patients (72.4%) had 1 or more orbital, intracranial, soft tissue, or bony complication (average hospital stay 9 days, SD = 10.3 days). The complications, according to the Chandler classification,4 are summarized in Table 2. The 87 patients can be divided into 2 groups; 1 group requiring medical treatment and the other requiring immediate surgical inter-

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Fig 2. Flow chart of the management (Mx) and outcome of patients treated with surgery.

vention (44 patients). Of the 43 patients treated medically, 4 preceded to surgery (frontal trephines). Figures 1 and 2 are flow charts that summarize how the medical and surgical groups were managed. The 2 patients who had primary frontoethmoidectomy had had previous admissions for acute frontal sinusitis, and at presentation had frontal osteitis with a frontocutaneous fistula. One patient, having previously undergone frontal sinus obliteration for recurrent frontal sinusitis, was admitted with an infected osteoplastic frontal bone flap, which was removed. Of the 39 patients who were treated with frontal sinus trephine and management of complications, 5 required further surgery during their initial hospital stay and 2 had a recurrence of acute frontoethmoiditis during the follow-up period and required frontoethmoidectomy. One of these patients was booked for an elective frontoethmoidectomy after a recurrent episode of frontoethmoiditis, which was managed medically during the acute admission. All patients were followed up 2 weeks after discharge with a varying follow-up thereafter of up to 2 years. DISCUSSION

Medical management is the accepted treatment of acute uncomplicated sinusitis, with surgery held in reserve should medical management fail. This study confirms the effectiveness of medical therapy for uncomplicated sinusitis and for complicated sinusitis when the complication does not require surgical intervention. It also confirms the effectiveness of frontal sinus trephine and insertion of indwelling catheters as the mainstay of the treatment for complicated sinusitis requiring immediate surgical management. Most patients (70%) with acute sinusitis did not have a history of sinus disease. It is logical to treat these patients, when possible, with minimal intervention. With this approach (frontal sinus trephine, irrigations, and drainage of

Table 2. Site and frequency of the complications of acute sinusitis Site

Orbital (total = 51) Preseptal cellulitis + abscess Subperiosteal abscess Orbital cellulitis Orbital abscess Intracranial (total = 8) Meningitis Extradural Subdural Cerebritis Brain abscess Soft tissue (total = 6) Abscess over maxilla Maxillary cellulitis Temporal abscess Osteitis (total = 13) Subperiosteal abscess Fistula

Frequency

28 17 5 1 4 1 2 1 0 4 1 1 11 2

purulence) 80% of the patients recovered without further surgery. Advocates of immediate frontoethmoidectomy suggest that the diseased ethmoidal cells are a potential source of continued formation of purulence, and incomplete removal of cells allows reseeding of the drained areas, prolonging the patient’s recovery.13 However, this and other studies show that an immediate frontoethmoidectomy subjects a significant number of patients to unnecessary surgery.2,14,15 Frontoethmoidectomy is not without risk to the supratrochlear nerve9 and the nasolacrimal duct (0.6%).17 Major complications include a 2% incidence of diplopia with long-term follow-up and a 5% incidence of cerebrospinal fluid leak.18,19 There is also a significant risk (30%) of frontonasal duct stenosis after frontoethmoidectomy.20 This can be reduced to less than 10%

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with the insertion of a Silastic tube as a stent.18,21 In one study 6% of patients were unhappy with the cosmetic appearance of the scar.18 Recently FESS has been advocated for the treatment of acute complicated sinusitis. However, the risk of major complications varies between 1% and 2%.22 These risks may increase when the surgery is performed on acutely inflamed sinuses when the increased vascularity and consequent hemorrhage may obscure the operative field. Added to this is the problem of having an anesthetist and theater staff unfamiliar with these procedures in emergency situations. Frontal sinus trephine is relatively simple and safe and allows both drainage of the acutely inflamed sinus and management of its associated complication. However, the trephine is not without risks because the incision is in region of the supratrochlear nerve. There is also a risk to the anterior cranial fossa, but this is less than for frontoethmoidectomy. If, after the frontal sinus trephine, definitive surgery is still required, this can be performed at a later date under more optimal conditions. Finally, an interesting feature is the unexplained demographic predominance in males during their second to fourth decades of life. This has been found by other authors2,14,23 but remains unexplained. REFERENCES 1. Pickard BH. The complications of sinusitis. In: Kerr AG, Groves J, editors. Scott-Brown’s otorhinolaryngology.5th edition. Vol 4. Oxford: Butterworths; 1987. p. 203-11. 2. Middleton WG, Briant TDR, Fenton RS. Frontal sinusitis—a 10 year experience. J Otolaryngol 1985;14:197-200. 3. Clayman GL, Adams GL, Paugh DR, et al. Intracranial complications of paranasal sinusitis: a combined institutional review. Laryngoscope 1991;101:234-9. 4. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970; 80:1414-28.

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5. Moloney JR, Badham NJ, McRae A. The acute orbit: preseptal (periorbital) cellulitis, subperiosteal abscess and orbital cellulitis due to sinusitis. J Laryngol Otol 1987;101(Suppl 12):1-18. 6. Goode RL. An antral catheter for maxillary sinusitis. Arch Otolaryngol Head Neck Surg 1970;91:302-6. 7. Sasaki CT, Kirchner C, Goodwin WJ. Self-retaining catheters for continuous frontal and maxillary sinus lavage. Otolaryngol Head Neck Surg 1987;97:419-20. 8. Lund VJ. Surgical management of sinusitis. In: Kerr AG, Groves J, editors. Scott-Brown’s otorhinolaryngology. 5th edition. Vol 4. Oxford: Butterworths; 1987. p. 180-202. 9. Fry TL, Biggers WP, Fischer ND, et al. Frontal sinus trephination: a new technique for office procedure. Laryngoscope 1980; 90:838-41. 10. Elverland HH, Melheim I, Anke IM. Acute orbit from ethmoiditis drained by endoscopic sinus surgery. Acta Otolaryngol 1992; 492(Suppl):147-51. 11. Turner WJ, Davidson TM. Endoscopic management of acute frontal sinusitis. Ear Nose Throat J 1994;73:594-7. 12. Goodwin WJ. Orbital complications of ethmoiditis. Otolaryngol Clin North Am 1985;18:139-47. 13. Hoyt DJ, Fisher SR. Otolaryngologic management of patients with subdural empyema. Laryngoscope 1991;101:20-4. 14. Du Preez SFM, Collard WM, Sellars SL. The surgery of frontal sinus infection. South African Med J 1975;49:1911-4. 15. Norante JD. Surgical management of sinusitis. Ear Nose Throat J 1984;63:155-62. 16. Wenig BL, Goldstein MN, Abrahamsom AL. Frontal sinusitis and its intracranial complications. Int J Paediatr Otorhinolaryngol 1983;5:285-302. 17. Lund VJ. Surgery of the ethmoids—past, present and future: a review. J R Soc Med 1990;83:451-5. 18. Rubin JS, Lund VJ, Salmon B. Frontoethmoidectomy in the treatment of mucoceles. Arch Otolaryngol Head Neck Surg 1986; 112:434-6. 19. Canalis RF, Zajtchuk JT, Jenkins HA. Ethmoidal mucoceles. Arch Otolaryngol Head Neck Surg 1978;104:286-91. 20. Schenck NL. Frontal sinus disease. III: Experimental and clinical factors in failure of the frontal osteoplastic operation. Laryngoscope 1975;85:76-92. 21. Neel HB, Whicker JH, Lake CF. Thin rubber sheeting in frontal sinus surgery: animal and clinical studies. Laryngoscope 1976; 86:524-36. 22. van der Merwe J. Functional endoscopic surgery—the South African experience. South African J Surg 1994;32:67-9. 23. Lebovics RS, Moisa II, Ruben RJ. Sex predilection in patients with acute frontal sinusitis. Ear Nose Throat J 1989;68:433-7.