Rhinogenic orbital and intracranial complications
Rhinogenic orbital and intracranial complications are caused by the penetration of infection into the orbit and the cranial cavity by a contact, hematogenous, perineural, lymphogenous route, which is facilitated by the close location of the paranasal sinuses to the orbit and cranial cavity, a well-developed vascular connection, the presence of congenital defects, as well as common bony walls.
Rhinogenic orbital complications
Rhinogenic orbital complications often occur with ethmoiditis due to infectious diseases (flu, measles, scarlet fever, etc.). In early childhood, apparently, not diseases of the paranasal sinuses predominate, but osteomyelitis of the upper jaw, often occurring with orbital complications. The following forms of orbital complications are conventionally distinguished:
- Orbital periostitis
- Subperiosteal abscess
- Eyelid abscess
- Eyelid and orbital wall fistula
- Retrobulbar abscess
- Orbital cellulitis
- Retrorbital venous thrombosis
Orbital complications are often preceded by reactive edema, as well as diffuse non-suppurative inflammation of the tissue of the orbit and eyelids.
Orbital periostitis with inflammation of the paranasal sinuses develops again after inflammation of the bone of the orbital wall. This allows us to consider periostitis, not in isolation, but together with the process in the bone that caused it, i.e. talk about osteoperiostitis. The latter is observed both in an acute disease of the paranasal sinuses and during its exacerbation. With osteoperiostitis, which develops as a result of acute inflammation of the paranasal sinuses, the general reaction of the body is more often observed: an increase in body temperature, headache, general weakness. Typical clinical signs of inflammation of the walls of the orbit are swelling of the eyelids, exophthalmos with an eye displacement to the side opposite to the lesion. If the source of osteoperiostitis is inflammation of the ethmoid sinus, then swelling of the eyelids occurs, especially in the inner part of the eye. Inflammation of the maxillary sinus relatively rarely leads to osteoperiostitis. If the inflammation captures the lower edge of the orbit or its anterior part, the lower eyelid swells, the lower parts of the conjunctiva are swollen.
Subperiosteal abscesses are, as it were, the next stage in the development of purulent osteoperiostitis. Inflammatory changes in the eyelids and conjunctiva are characteristic. Fluctuation is not always determined, especially rarely with deep subperiosteal abscesses. If the cause of the latter is a disease of the ethmoid sinus, then the clinical picture depends on which cells were the source of the lesion (anterior, middle, or posterior). If the abscess is caused by a disease of the anterior cells of the ethmoid sinus, a typical picture of a marginal subperiosteal abscess develops: the abscess is located in the region of the upper inner corner of the orbit; in addition to a swelling of the eyelids, at the inner corner of the orbit at the initial stage of the formation of an abscess, one can find hyperemia of the inner half of the conjunctiva of the eyeball; further, the displacement of the eyeball outward and downward is noted. With subperiosteal abscesses emanating from the posterior cells of the ethmoid sinus, the leading symptom is a protrusion of the eyeball, and the displacement of the eye to the side and swelling of the eyelids are secondary signs. In this case, exophthalmos is often combined with impaired mobility of the eye and decreased visual acuity. With an increase in inflammatory edema in the depths of the orbit, paralysis of the abducens and oculomotor nerves may appear. Pain is also determined when pressure on the eyeball and its movements.
Eyelid abscess is rare in clinical practice.
Eyelid and orbital wall fistula
Fistulas of the upper eyelid and root of the nose are caused by inflammation of the ethmoid or frontal sinus. The formation of a fistula is the final stage of a breakthrough into the eyelid of exudate from the paranasal sinus. A fistula is, as a rule, a manifestation of chronic suppuration in the sinus. We are talking about the so-called primary orbital fistulas, flowing torpidly, without pronounced inflammation from the orbit and eyelids.
A retrobulbar abscess is a limited purulent focus in the orbital cell. Usually, it proceeds with a pronounced general reaction, high body temperature, chills, significant changes in the blood. Local symptoms vary depending on the mechanism of abscess formation. If the retrobulbar abscess develops from the subperiosteal, the symptoms of the latter are first observed, and then the main signs are pronounced protrusion of the eyeball and limitation of its mobility. In this case, the clinical picture is very similar to that with phlegmonous lesions of the orbit.
Orbital phlegmon is diffuse, without clear boundaries, progressive acute inflammatory process, accompanied by infiltration and purulent fusion of loose tissue of the orbit. In the picture of the disease, a violation of the general condition usually predominates high body temperature, chills, headache. Regardless of how orbital phlegmon develops (contact or vascular), its main symptom is a painful protrusion of the eyeball with a sharp impairment of mobility or complete immobility of the eye (ophthalmoplegia). The clinical picture is complemented by swelling of the eyelids without a tendency to suppuration and abscess formation.
Retrorbital venous thrombosis
Retrorbital venous thrombosis is rare in clinical practice.
Rhinogenic orbital complications treatment
It is necessary to influence the primary focus of the disease, i.e. on the inflamed paranasal sinus. Measures that target only the affected eyelids or orbit cavity are doomed to fail. Orbital complications in acute sinusitis do not always require surgical treatment. Therapy depends on the nature of the lesion in the orbit and paranasal sinuses.
Local treatment, especially at the onset of the disease, consists of sinus punctures, anemisation of the mucous membrane of the middle nasal passage (at least 4-5 times a day), and in young children, the suction of the contents from the nasal passages. Physiotherapeutic methods of treatment, anti-inflammatory therapy, broad-spectrum antibiotics (mycerin, etc.) are prescribed.
In case of damage to the frontal sinus, according to indications, it is performed trepanopuncture with the introduction of antibacterial agents, resection of hypertrophied, polyposis-altered nasal conchas, or endonasal opening of the ethmoid sinus cells, use UHF therapy. If conservative treatment is unsuccessful or the symptoms worsen, surgery is performed on the corresponding paranasal sinus.
Abscesses of the eyelids and subperiosteal abscesses of the orbit are opened with incisions running parallel to the palpebral fissure. At the same time, a radical operation is performed on the affected sinus.
With phlegmon of the orbit, a diagnostic puncture is performed, opening the affected paranasal sinus with the removal of the contents of the orbit. If a fistula is found in an unclothed periorbital, it is preferable to penetrate the orbit through it. In early childhood, with phlegmon of the orbit, the primary focus, as a rule, is the maxillary or ethmoid sinus. The latter is opened with an external approach, the maxillary - through the lower orbital wall. During the period of eruption of permanent teeth (at the age of 6-11 years), radical surgery on the maxillary sinus is undesirable, it is better to limit yourself to endonasal intervention. With urgent indications for radical sinusitis at this age, trepanation of the outer wall of the sinus is performed as high as possible, i.e. further from the alveolar ridge and near the edge of the pear-shaped opening. From the age of 12, the indications for surgical intervention in the maxillary sinus can be set wider.
An orbital abscess is drained with an external approach. If there is an abscess in the orbit and the cells of the ethmoid sinus are damaged, the latter must be opened only externally. With non-purulent lesions of the orbit and acute inflammation of the paranasal sinuses in children, especially young children, conservative therapy is mainly carried out. With non-purulent lesions of the orbit and chronic inflammation of the paranasal sinuses, sparing surgical interventions are necessary, taking into account the age-related characteristics of the development of these sinuses.
In case of a purulent process in the orbit and paranasal sinuses, a wide opening of the affected sinuses is performed with simultaneous drainage of the abscess in the orbit or through the operated sinus with additional orbitotomy against the background of massive anti-inflammatory therapy. Endonasal intervention in these cases is unacceptable. Decreased vision is a strict indication for urgent surgical intervention in the affected paranasal sinuses.
Rhinogenic intracranial complications
Rhinogenic intracranial complications: hydrocephalus, arachnoiditis, serous and purulent meningitis, meningoencephalitis, extra- and subdural brain abscess, thrombosis of the cavernous and superior longitudinal sinuses. Sometimes one form of complication turns into another. A combination of several forms at the same time is possible.
Hydrocephalus can be primary and secondary and is characterized by edema of the membranes of the brain with symptoms of cerebrospinal fluid hypertension, an increase in the amount of cerebrospinal fluid, an increase in cerebrospinal fluid pressure, and a decrease in the protein content with unchanged cytosis. The headache usually occurs in the forehead and temple area. Possible nausea, vomiting, visual disturbances, congestive nipples of the optic nerves, lesions of the abducens, oculomotor, trigeminal, and olfactory nerves, epileptiform seizures, paralysis.
Arachnoiditis is in the form of adhesive, cystic, and mixed forms. The characteristic localization is the anterior cranial fossa, optic-chiasmal region, less often the posterior cranial fossa, the convex surface of the brain. Hence, a variety of neurological symptoms in this disease.
If the inflammatory process is localized in the anterior cranial fossa, focal neurological symptoms are not observed; characterized by pain in the forehead, bridge of the nose. Optical-chiasmal arachnoiditis is accompanied by impaired visual acuity and visual fields, and later atrophy of the optic nerve; possible paroxysms, paralysis of the oculomotor, and (less often) abducens nerves, pain in the forehead, orbit. Basal arachnoiditis with the involvement of the trigeminal nerve is characterized by pain in one half of the face. For arachnoiditis of the posterior cranial fossa, coordination disorders in the form of ataxia, adiadochokinesis are typical. Rhinogenic arachnoiditis is not always accompanied by changes in the cerebrospinal fluid; moderate pleocytosis and a slight increase in protein are possible.
Serous meningitis is characterized by acute onset, mild meningeal symptoms, and increased cerebrospinal fluid pressure.
Purulent meningitis is more common than other forms of intracranial complications. It is characterized by acute onset, high body temperature, headache with nausea and vomiting, meningeal syndrome with high pleocytosis, sometimes seizures, positive symptoms of Babinsky, Rossolimo, Oppenheim, Gordon, the involvement of the cranial nerves in the process (usually VI, VII pairs) with psychomotor agitation, delirium, loss of consciousness. Cerebrospinal fluid already on the 1st day becomes purulent, flows out under high pressure, the number of cellular elements increases to several thousand in 1 mm3, the protein content sometimes reaches 1-3%, the amount of sugar decreases to 10-15 mg%, the chloride content - to 350-450 mg%.
Meningoencephalitis develops acutely, accompanied by headache, vomiting, meningeal signs, convulsions, impaired consciousness. The meningeal syndrome is complemented by focal symptoms: seizures appear, skin and tendon reflexes change against the background of pathological ones. Cerebrospinal fluid pressure and cytosis increase.
An epidural abscess often occurs by contact as a result of damage to the frontal, ethmoid, or sphenoid sinus. It can be asymptomatic and is discovered by chance during surgery. Sometimes there is a headache, vomiting, it is difficult to move the eyeball outwards, the corneal reflex is weakened, choking, nasal sounds occur.
A subdural abscess often appears hematogenous, less often - contact, especially in the presence of an extradural abscess. It is characterized by an increasing headache that cannot be relieved by medication. Convulsions, paresis of the extremities, and sometimes motor aphasia are possible with left-sided localization of the abscess (in right-handers). In the cerebrospinal fluid, the content of protein and cells increases.
A brain abscess is more often localized in the frontal lobe of the brain and is caused by an exacerbation of chronic purulent frontal sinusitis. Characterized by increased body temperature, headache, vomiting, lack of appetite, general weakness. Mental disorders, a violation of statics, the appearance of pathological reflexes (grasping and sucking), a decrease in intelligence and memory can be noted.
Sometimes in the behavior of patients appear rudeness, buffoonery, they commit ridiculous acts, gluttony, untidiness is noted. When the abscess is localized in the left frontal lobe of the brain (or temporal in right-handers), speech disorders may be observed. In the case of an encapsulated abscess, protein-cellular dissociation appears in the cerebrospinal fluid, the cerebrospinal fluid flows out under pressure. If a brain abscess is combined with meningitis, the symptoms of the latter prevail. Deterioration of the general condition, lagging of the pulse from body temperature after the disappearance of meningeal symptoms, and sanitation of the cerebrospinal fluid more often indicate an abscess.
Thrombosis of the cavernous and superior longitudinal sinuses can be observed with a purulent disease of the paranasal sinuses, trauma, nasal furuncle. Characterized by a severe general septic condition: high temperature of an intermittent nature, chills, headache, weakness, meningeal symptoms. Thrombosis of the cavernous sinus is manifested by swelling of the eyelids and conjunctiva, exophthalmos, paralysis of the eye muscles. Thrombosis of the superior longitudinal sinus in children is rare.
Rhinogenic intracranial complications diagnosis
Diseases of the paranasal sinuses are detected. The masking effect of antibiotics on both local and general symptoms is taken into account (bearing in mind that intracranial complications may be the first clinical signs of asymptomatic sinusitis). If the causative factor according to the lumbar puncture is cerebrospinal fluid hypertension, a diagnosis of hydrocephalus is made. Arachnoiditis often proceeds without clear neurological symptoms, gross focal phenomena are absent. For diagnostics, modern research methods are used: pneumo- and electroencephalography, angiography, etc. In the recognition of serous meningitis, the acute onset of the disease, symptoms from the meninges, the presence of sinusitis, the serous nature of the cerebrospinal fluid and a favorable clinical course are important.
Purulent meningitis develops acutely, with cerebral meningeal symptoms, against a background of high body temperature and the presence of sinusitis. High pleocytosis is found in the cerebrospinal fluid. Purulent meningitis is differentiated from a brain abscess and secondary meningitis. If during the rehabilitation of the cerebrospinal fluid, the patient's state of health remains heavy or worsens, he is indifferent to the environment, drowsy, this is characteristic of a brain abscess.
Meningoencephalitis is characterized by a combination of meningeal and focal symptoms. It is difficult, but it is necessary to distinguish it from a brain abscess since the doctor's tactics for these diseases are different. For the beginning of a brain abscess, high fever, meningeal symptoms, psychomotor agitation, and convulsions are atypical; this disease is characterized by a subacute onset with gradually increasing neurological symptoms, mental changes in the form of apathy, lethargy.
It is difficult to recognize extra- and subdural abscesses due to the low severity of focal neurological symptoms. Diagnosis of a brain abscess is based on a change in the psyche (with an abscess of the frontal lobe of the brain) and focal symptoms (a symptom of gaze paralysis to the side opposite to the localization of the process, statokinetic disorders, phenomena of grasping, resistance, and closing of the eyelids). With an abscess of the temporal lobe, there may be ataxia and a violation of the contralateral test. If the abscess is localized in the left temporal lobe of the brain, in addition to these symptoms, amnestic and sensory aphasia is noted.
When diagnosing, CT of the main brain, CT of the paranasal sinuses, MRI of the brain is used. Focal symptoms in rhinogenic brain abscess develop, as a rule, over several days (sometimes weeks), and in brain tumors, they grow gradually, over several months. Thrombophlebitis is characterized by a septic state in combination with discirculatory and neurological syndromes.
Diagnostic procedure - magnetic resonance imaging of the brain (MRI).
Rhinogenic intracranial complications treatment
Complex therapy depends on the nature of sinusitis, complications, age of the child and is reduced to the effect on the primary focus of the disease, i.e. directly on the inflammatory process in the paranasal sinuses. In the case of non-suppurative intracranial complications (hydrocephalus, arachnoiditis, serous meningitis) caused by an acute inflammatory process in the paranasal sinuses, conservative treatment is first performed. If within the next 2-3 days it does not bring success or the symptoms of intracranial complications increase, they resort to surgery on the paranasal sinuses. In this case, in the case of a non-suppurative intracranial complication and chronic sinus inflammation, a sanitizing operation is performed on it, and in case of a purulent intracranial complication, emergency surgery is indicated on the affected paranasal sinuses (in order to eliminate the intracranial complication) against the background of massive antibacterial, dehydration, desensitizing and general therapy.
An extradural abscess often occurs with frontitis. If during the operation it is found that the posterior wall of the frontal sinus is changed or there is a fistula, its wide resection is necessary. Even if an intracranial complication is suspected, surgical activity is justified. In the case of osteomyelitis of the frontal bone, the affected areas are removed. In the presence of a subdural abscess or suspicion of it, a wide exposure of the dura mater, its puncture, or dissection is necessary.
In the case of a brain abscess, the affected paranasal sinus is first widely opened. With frontal sinusitis, for the purpose of decompression, trepanation is performed, removing the posterior wall of the sinus, and the abscess of the anterior cranial fossa is drained.
Having exposed the dura mater, pay attention to its color, pulsation, thickness, the presence of granulations, and fibrinous plaque. Before puncturing the brain, sometimes a small incision is made in the dura mater. A special needle with a blunt end is inserted into the brain to a depth of about 3 cm. The abscess is drained using rubber strips inserted into the abscess cavity until the purulent discharge disappears.