Complicated acute sinusitis

The incidence of complications of paranasal sinusitis have been progressively decreasing since the advent of antibiotics. Most of the complications that have occurred are secondary to sub-acute or chronic sinusitis. A few patients, however, still present with a complication of an acute sinusitis infection. Four cases are presented in detail and 14 cases are summarized which presented with an acute complication as the primary presenting complaint. Sinusitis was not an obvious component in most of these cases, and none of the 18 patients had any previously known sinus disease. The paper was limited to a discussion of complications involving the orbit, the tissues surrounding the sinuses, and the intracranial cavity. Basic information regarding these topics was reviewed. The first case report described a young boy with cellulitis of the orbit and cheek secondary to a maxillary sinusitis. Neither the cellulitis nor the sinusitis responded to the medical treatment until trephine and irrigation of the sinus was performed. The second case report described a young man with a frontal subperiosteal abscess and orbital cellulitis secondary to frontal sinusitis. His treatment consisted of drainage of the abscess and performance of a frontal sinus trephine. The third case described a young man with maxillary, ethmoid and sphenoid sinusitis and a secondary cavernous sinus thrombosis. The maxillary sinuses were drained and the patient was given high doses of intravenous antibiotics and decongestants but he was not anticoagulated. Apart from the central retinal artery thrombosis resulting in the left eye, recovery was complete. The fourth case report described a young lady who had undergone a renal transplant and was maintained on immunosuppressant medications. She developed a meningitis secondary to maxillary sinusitis. Complete recovery occurred on medical treatment alone. The other 14 cases were summarized in a table. These cases were then discussed and recommendations were made regarding management of these complications. It was concluded that with antibiotics in adequate closes, it is now safe to perform a sinus trephine much earlier in the course of the disease than has previously been advocated. Eight of the 18 were drained in the acute phase and there was no evidence of osteomyelitis or other sequella secondary to this procedure. Indeed, six of these patients required surgical drainage before the fever or the complications would respond to therapy. It is suggested that immediate surgical drainage and irrigation is indicated when sinusitis does not respond or becomes clinically worse after 24-48 hours of treatment with systemic antibiotics and decongestants; or when acute suppurative local infection or septic intracranial complications are present. The sinuses should be irrigated frequently with saline until the return remains clear for 48 hours. The majority of the organisms isolated were staphylococci, coagulase negative and coagulase positive. Four cultures grew no organisms but since routine cultures for anaerobic organisms were not performed these could not be eliminated as a factor in the infection. The majority of cases were treated with high doses of intravenous antibiotics and these were only given intramuscularly 24 to 48 hours after the fever had subsided and the clinical symptoms were resolving. The total duration of antibiotic treatment varied considerably within this series. It is recommended that complicated acute sinusitis should be treated as though an osteomyelitis is actually present. The systemic antibiotics should be continued for a full week after fever disappears before changing to oral antibiotics. The total duration of antibiotic therapy should be for four to six weeks. In treating meningitis, high doses of broad spectrum antibiotics were used until culture sensitivities were available. Examination of cerebrospinal fluid was emphasized. On adequate treatment the C.S.F. sugar levels should rise above the initial values and no demonstrable micro-organism should be present after 24 hours. It was noted that intracranial abscesses can occur with minimal symptoms and that fever is not necessarily present. If any doubt exists an arteriogram or other investigations should be performed.