Section 7

8-year-old presents with a history of recent nasal obstruction, rhinorrhea and now right sided eye swelling, erythema and pain.


What type of scan is this (modality, axis, use of contrast)?

  • CT scan of brain and orbit
  • Axial
  • With contrast

 

Describe four abnormal features of the scan above

  • Opacification of right ethmoidal sinuses
  • right subperiosteal abscess
  • right eye preseptal oedema 
  • right eye  proptosis 

 

Describe a common classification for this condition?

Chandler’s classification

Which stage is the patient in this case?

Stage 3 – subperiosteal abscess

Describe how you would manage this patient?

  • Ophthalmology review
  • IV antibiotics 
  • Analgesia
  • Nasal steroids and decongestants
  • Surgery to drain abscess – either open or endoscopic

Supporting Information

Sinusitis – blockage in the drainage pathway – stasis of secretions – infection. 

Causes:

  • Polyps
  • Anatomical variation
  • Mucocilliary disorders- Kartagener’s and CF
  • Rhinitis
  • URTI

Acute sinusitis – mostly maxillary. Strep pneumonia, H influenzae. Possibly fungal. 

  • Presentation – facial pain, pyrexia, pus in middle meatus. 
  • Treatment – broad spectrum abx and decongestant. 
  • Local treatment with cocaine soaked pledget may be tried
  • If no response–> surgery:
    • FESS
    • Frontal sinus trephine
    • Antrostomy – done for washing out and treating but also to obtain samples of cells/pus.
      • Tilley Lichtwitz Antral trocar and cannula.
      • 2cm posterior to the anterior-most part of inferior turbinate, directed toward outer canthus on same side (superolaterally). 
      • Complications- bleeding, infection, misplacing cannula into cheek (pain, swelling, cheek emphysema) or orbital floor (proptosis, swelling, bleeding), damage to nasolacrimal duct leading to epiphora. 
    • Anterior sphenoidotomy
    • Ethmoidectomy
  •  

Chronic sinusitis– symptoms weeks to months. Causes granulation tissue, ulceration of epithelium and mucosal thickening may become irreversible. Initially treat as above. If no effect must have FESS. 

Fungal sinusitis – 4 categories:

  1. Allergic fungal sinusitis – associated with asthma and nasal polyps- steroids and itraconazole should be used. 
  2. Mycetoma – masses of fungal debris – surgical removal is necessary
  3. Acute invasive – immunocompromised- debridement
  4. Chronic indolent – due to aspergillosis- surgical debridement required

Periorbital cellulitis– complication of sinusitis. Normally in children. 

  • Presentation– pain, erythema, vision loss, colour first, restricted eye movements, sepsis. 
  • Organisms– Strep. pneumoniae, Haemophilus influenzae
  • Chandler classification
    • Group 1: Preseptal
    • Group 2: Orbital cellulitis
    • Group 3: Subperiosteal collection
    • Group 4: Orbital abscess
    • Group 5: Cavernous sinus thrombosis
  • Investigations – CT brain and orbit. May show:
    • Proptosis
    • Preseptal oedema
    • Subperiosteal abscess
    • Intracranial complications
    • Obstructed sinuses
  • Treatment
    • Medical– stabilisation ABCDE, fluids, analgesia
    • Antibiotics broad spectrum covering staph A and Strep- co-amoxiclav or ceftriaxone/metronidazole
    • Nasal treatment: Nasal decongestants/steroids
    • Drainage
      • External – Modified Lynch-Howarth incision to external ethmoidectomy + bilateral antral washouts
      • endoscopic
    • Swabs for MC&S
    • Eye observations, ophthalmology review 
  • Complications – epidural empyema, subdural empyema, meningitis, venous sinus thrombosis and osteomyelitis.
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