0:01

I'd like to talk now about the potential complications

0:05

of sinusitis

0:06

and these complications may be in the setting

0:09

of either acute or chronic sinusitis.

0:13

In general, when we're looking at the perinasal sinuses and

0:16

after we've described the findings in the perinasal sinuses,

0:19

we wanna look at these different sites.

0:22

We wanna look at the orbit

0:23

to make sure there are no orbital complications,

0:25

the intracranial or intrathecal portion of the study,

0:29

in which case we'd looking for any type of brain lesions

0:32

or evidence of meningitis.

0:34

The vascular complications in which I've described several

0:38

times, the cavernous sinus, which is just adjacent

0:42

to the posterior ethmoid

0:43

and sphenoid science that can be involved

0:45

and anything going on.

0:47

Extra cy nasal in the soft tissues.

0:50

Remember that the perianal fat is one area

0:52

where we're most concerned with looking at in order

0:55

to find whether or not there is invasive fungal sinusitis

0:59

that may be spreading through the bony walls.

1:02

So we're about to talk about these various entities, which

1:06

represent some of the complications of sinusitis.

1:10

Alright, so orbital complications.

1:12

With orbital complications.

1:14

You usually are talking about a patient who shows evidence

1:18

of ethmoid sinusitis.

1:20

As we look at this opacified right ethmoid sinus,

1:23

we also notice that there is soft tissue,

1:26

which is in the extra conal fat on the right side compared

1:30

to the left side.

1:31

Identifying an inflammatory collection that has spread

1:35

through the wall of the ethmoid science.

1:37

Remember that the medial wall

1:39

of the orbit is also called the lamina pap ratio,

1:43

and that it means that it's very thin bone

1:47

that has some elements of openings to it, including

1:51

where the anterior

1:52

and posterior ethmoidal arteries go in and out.

1:55

And from these different locations, you may have spread

1:58

of ethmoid sinusitis into the orbit.

2:02

On the right image, we have a more flagrant collection.

2:06

In this case, we can see the dehiscence

2:08

through the ethmoid sinus.

2:10

We see the ethmoid sinusitis,

2:12

and we see the deviation of the medial rectus muscle

2:16

by this inflammatory collection, a subperiosteal abscess.

2:20

So even though we may not see on a non-contrast study,

2:25

a fluid density with the collection

2:29

and on a post contrast scan, a peripheral rim

2:33

of enhancement, we would still call these subperiosteal

2:37

abscesses in the orbit.

2:40

Here is an MRI scan of a similar case.

2:43

Here we see the ethmoid sinus infection.

2:47

Little bit concern

2:48

because it has dark signal on a T two weighted image.

2:52

That might imply the presence of fungal sinusitis.

2:55

It might imply in spec secretions, but the

2:58

Pertinent finding here is this collection of fluid,

3:02

which is in the subperiosteal region,

3:05

displacing the medial rectus muscle.

3:07

Very characteristically in this case

3:09

with gadolinium enhancement.

3:11

We do see a peripheral rim to this collection,

3:14

identifying it as an abscess.

3:16

If I don't see the peripheral rim of enhancement

3:19

and yet it still has some mass effect

3:21

but doesn't have low density on ct.

3:24

I may use the term aleman, which is on the spectrum

3:28

from the sinus infection to the abscess

3:32

where we're not having a well-defined collection.

3:35

Now here to four, these were treated with surgery

3:40

and sometimes that surgery was along the medial orbit.

3:44

Nowadays it's treated initially with IV antibiotics.

3:47

If it doesn't respond quickly,

3:49

then they will do the endoscopic sinus surgery,

3:51

even in the acute phase in order to drain the orbit,

3:54

particularly if there's any potential ischemic effect

3:58

that may be involving the ophthalmic artery

4:02

or the vessels in the orbit.

4:04

So this is a uh, diagram given to me

4:06

by Azero Khorsandi at Mount Sinai in New York.

4:09

You see that there is the periorbital,

4:12

which is basically the periosteum of the orbital wall

4:15

that is still defining this collection

4:18

and preventing pus from just

4:22

going throughout the orbit.

4:24

So there is this confining periorbital, which is creating

4:29

that bend, if you will, and the mass effect,

4:32

and still constraining its infiltration of the orbit.

4:36

That said, there are times

4:37

where you will get orbital cellulitis secondary

4:41

to the ethmoid infection, breaching the periorbital.