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. 


  • 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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