Complications of Inflammatory Diseases of the Sinuses

Maxillary Postsurgical Ciliated Cysts (PSCCs): A Series of Three Cases

Introduction

A postsurgical ciliated cyst (PSCC) is an epithelial cyst that usually develops in the maxilla, although in rare cases, it can affect the mandible or other facial bones. The typical age of diagnosis is 40-50 years, with no gender prevalence, and the mean cyst development occurs approximately 10-15 years following a surgical or traumatic event. Some epithelial respiratory cells can be trapped into the bone tissue during maxillary surgical procedures or maxillary fractures. The pathogenetic mechanism can be attributed to an inflammatory process that stimulates epithelial proliferation, leading to cyst expansion caused by osmotic pressure difference.

Methods

This study presents case series involving three surgical ciliated cysts located in the left maxilla, affecting two female patients (aged 49 and 55 years) and one male patient (aged 39 years). In all three cases, symptoms such as pain or swelling were mild and not consistently present. Two cases showed cyst development 10 and 15 years after implant placement, while one case was not associated with any surgical or traumatic event. CT scan identified well-defined unilocular lesions in the maxillary bone in each patient.

Results

Histopathological examination of the surgical specimens confirmed the suspected diagnosis of a PSCC of maxilla. The cystic walls consisted of fibrous connective tissue with chronic inflammatory infiltrate, lined exclusively by a thin layer of ciliated pseudostratified columnar epithelium. In the third patient, it was not possible to rule out an unusual radicular cyst.

Conclusions

Although PSCCs are not commonly encountered in daily practice, clinicians should consider this possibility including it in the differential diagnosis of odontogenic jaw cysts and benign jaw tumors, particularly in patients who have undergone previous surgeries in the maxillary area.

Orbital Apex Syndrome Secondary to Huge Primary Ethmoidal Sinus Mucocele: A Case Report

Ethmoidal sinus mucoceles are benign expansile lesions that may progressively invade the orbit causing optic nerve compression and its nearby structures. We report a rare case of primary ethmoidal sinus mucocele instigating orbital apex syndrome. A 40-year-old man presented with right eye (RE) progressive blurring of vision with diplopia for 2 weeks. It was preceded by right-sided facial pain for 3 months. Clinical examination revealed RE proptosis with multiple cranial nerves palsy involving right cranial nerves II, III, IV, V, and VI, suggestive of right orbital apex syndrome. Magnetic resonance imaging (MRI) demonstrated right eye proptosis and right ethmoidal mucocele with intracranial and right intraorbital extension compressing the right medial rectus and optic nerve. The patient underwent an uncomplicated endoscopic sinus surgery resulting in a return to normal appearance and function post-operation. Thus, ethmoidal mucoceles are benign and curable with early recognition and intervention.

Frontal pyomucocoele as forehead swelling in a five-year-old girl

Mucocoeles are slow-growing, locally aggressive, mucus-containing cysts, lined by epithelium, which, when infected, are called pyomucocoeles. We present the case of a five-year-old girl who presented with a frontal pyomucocoele requiring decompression and adequate antibiotics.

A South African first: Congenital absence of the cartilaginous nasal septum

Congenital absence of the cartilaginous nasal septum has been reported just once in the literature. We present a case of a young child, diagnosed by exclusion, with complete agenesis of the cartilaginous septum. We believe it is only the second case worldwide, and the first in South Africa, to be reported.

Neurological Complications of Acute and Chronic Sinusitis

PURPOSE OF REVIEW

Acute and chronic sinusitis can give rise to a wide array of intracranial and orbital complications. These complications include brain abscess, subdural empyema, epidural abscess, meningitis, venous sinus thrombosis, frontal bone osteomyelitis, and orbital cellulitis and abscess. Despite numerous medical advances, these complications carry a risk of mortality and significant morbidity.

RECENT FINDINGS

Recent studies have shown improvement in both the mortality and the morbidity associated with the neurologic complications of acute and chronic sinusitis. However, there are still a large portion of patients with long-term sequelae, and the literature reports a morbidity rate of approximately 30%. The most common post-treatment morbidities include permanent changes in vision, seizures, and hemiparesis. Although the overall incidence of neurologic complications from a sinogenic source are rare, the potential long-term complications can be devastating making prompt diagnosis and treatment vital to improving outcomes.

Giant ethmoid mucocele presenting as an orbital mass

Mucocele is a benign and expansile cystic lesion lined with respiratory mucosa of pseudo stratified columnar epithelium. Mucocele most commonly produces bone destruction within the paranasal sinuses. It mostly involves the frontal sinus followed by ethmoid and rarely sphenoid and maxillary sinuses. We report a case of giant ethmoid mucocele who presented with history of progressive unilateral protrusion of eye since 5 years. CT scan revealed a large mucocele of the ethmoid sinus with orbital extension on the same side. He was successfully treated with endoscopic sinus surgery.

Intracranial mucocele formation in the context of longstanding chronic rhinosinusitis: A clinicopathologic series and literature review

Chronic rhinosinusitis (CRS) can lead to serious long-term adverse sequelae, particularly if left untreated. The aim of this study was to describe a series of intracranial mucoceles (ICMs) that arose in the context of longstanding CRS combined with a review of the pertinent literature. A retrospective chart review was performed on all patients who developed ICMs in association with CRS between 2003 and 2012. The clinical presentation, radiographic features, surgical approach, intraoperative findings, and patient outcome were examined in the context of a literature review. Sixty-five cases of mucoceles were identified in patients with a history of CRS, of which seven (10.8%) were intracranial. Five patients were men and two were women with a mean age of 42.1 years. Headache, facial pressure, retro-orbital pain, and visual disturbances were the most common presenting symptoms. Five of the seven had previously undergone sinonasal surgery. Imaging studies showed ICMs involving the anterior cranial fossa, two of which were bilateral. Latency between onset of CRS and ICM detection ranged from 3 to 19 years (mean, 9.4 years). All patients underwent endoscopic transnasal drainage with three also requiring a concurrent, open neurosurgical procedure to access the intracranial component. There were no postoperative complications, and no recurrences were observed after a mean follow-up of 2.7 years. ICMs presenting as delayed complications of CRS are uncommon and constitute a surgical challenge. Open, external skull base approaches used in conjunction with transnasal endoscopic drainage procedures may be necessary to achieve successful management of this rare condition.

Primary mastoid cyst

Objective:

To report an unusual case of a primary mastoid cyst (congenital or developmental) in a patient without otological symptoms.

Method:

Case report and review of the English language literature.

Results:

Primary mastoid cyst is a newly reported and very rare pathological entity. Mastoid cysts usually occur secondary to chronic infection, inflammation or trauma. Review of the medical literature highlights the rarity of this condition.

Conclusion:

This report describes the experience gained by the diagnosis and management of this patient. It emphasises the importance of clinical vigilance so that proper treatment may be instituted in a timely manner.

Postoperative maxillary cyst: a case report

Postoperative maxillary cyst is a quite rare delayed complication of surgical intervention associated with maxillary sinuses. It occurs many years after surgery. This paper describes a 54-year-old woman presenting with swelling of left cheek for seven-years duration. The orthopantomograph revealed a unilocular cystic radiolucency with well-defined margins in left maxillary sinus. In the computerized tomography, the cyst had a sclerotic wall with bony condensations. Aspiration cytology revealed many neutrophil leukocytes. Cyst was drained and enucleated. Histopathologically, it had a fibrous wall with inflammation and focal reactive bone formation and lined by a respiratory-type epithelium. In the clinical history, it is learned that she had a maxillary sinus surgery 8 years ago and the diagnosis was made considering the clinical and histopathological findings.

Acute bacterial rhinosinusitis and its complications in our pediatric otolaryngological department between 1997 and 2006

OBJECTIVE

A retrospective survey of the number, age, gender, month of admission, type of persistent acute bacterial rhinosinusitis and case history of pediatric patients who did not respond to conservative therapy, and of those who suffered from complications of acute sinusitis.

METHODS

The case charts of all children (<19 years of age) admitted to our department between January 1, 1997 and December 31, 2006 with persistent acute bacterial rhinosinusitis that within 14-26 days against the course of appropriate conservative therapy have not recovered and complications of acute sinusitis were subjected to a retrospective review.

RESULTS

Of the 339 patients 182 were admitted with persistent acute bacterial rhinosinusitis and did not respond to conservative therapy and 157 children were diagnosed with secondary complications of acute sinusitis. Males predominated overall (54.8%). The most endangered age range was between 3 and 6 years. The highest number of admissions occurred in March. The maxillary sinus was most frequently involved. Orbital complications were observed in 150 patients: 126 cases of preseptal cellulitis, 9 of orbital cellulitis, 4 of subperiosteal abscess, and 11 of orbital abscess. Further two children were diagnosed with intracranial complications, four patients presented with osteomyelitis and the remaining one exhibited mucocele. Streptococcus pneumoniae was the most commonly cultured pathogen. There were no mortalities, and morbidity occurred in only two cases. The topicality and importance of this subject are illustrated by taking into account of two cases.

CONCLUSIONS

The complications of acute rhinosinusitis are challenging, but the prognosis can be favorable. Early diagnosis and surgical drainage procedures in conjunction with aggressive medical management remain the standard of care for these critically ill patients.

Acute and Chronic Bacterial Sinusitis

Sinusitis is one of the most common complaints resulting in physician visits in the United States. An antecedent viral infection of the upper respiratory tract is the most common presentation. Despite its prevalence, most cases resolve spontaneously. Only a small proportion develops a secondary bacterial infection that will benefit from antimicrobial therapy. This article discusses the microbiology and pathogenesis of acute and chronic bacterial sinusitis. The role anaerobic bacterial in chronic and recurrent sinusitis is emphasized, and appropriate antimicrobial regimens are discussed.

Intracranial Complications of Sinusitis: A 15-Year Review of 39 Cases

Despite improvements in antibiotic therapies and surgical techniques, sinusitis still carries a risk of serious and potentially fatal complications. We examined the charts of 82 patients who had been admitted to the University of Mississippi Medical Center between Jan. 1, 1985, and Dec. 31, 1999, for treatment of complications of sinusitis. Of these 82 patients, 43 had orbital complications and 39 had intracranial complications. In this article, we describe our findings in those patients who had intracranial complications (our findings in patients with orbital complications will be reported in a future article). The most common intracranial complication was meningitis; others were epidural abscess, subdural abscess, intracerebral abscess, Pott's puffy tumor, and superior sagittal sinus thrombosis. Most patients with meningitis were treated with drug therapy only; patients with abscesses were generally treated with intravenous antibiotics and drainage of the affected sinus and the abscess. Advancements in antibiotic therapy, endoscopic surgery, imaging studies, and computer-assisted surgery have helped improve outcomes. Management of these patients should be undertaken immediately and is best achieved via a multidisciplinary approach, involving the otolaryngologist, neurosurgeon, radiologist, anesthesiologist, infection disease specialist, pediatrician, internist, and others.

Complicações orbitárias em pacientes com sinusite aguda

Introdução: As complicações orbitárias das sinusites permanecem como tópico importante dentro da otorrinoloringologia, a despeito do decréscimo de sua prevalência observado após o advento da antibioticoterapia. Objetivo: Tendo por objetivo determinar as características clínicas e terapêuticas nos casos de sinusites complicadas. Forma de estudo: Clínico prospectivo randomizado. Material e método: Realizamos um estudo retrospectivo de 128 pacientes internados nos últimos 15 anos na Divisão de Clínica Otorrinolaringológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A maior parte destes pacientes eram crianças ou adultos jovens (82,81% dos pacientes tinham menos de 30 anos de idade) e 57,81% eram do sexo masculino. Todos os pacientes apresentaram evolução satisfatória, sem seqüelas tardias. Conclusão: Observamos que o diagnóstico precoce destas patologias é importante, bem como o é a instituição de terapêutica adequada e agressiva (clínica ou cirúrgica). É a ação conjunta destes dois fatores que irá promover uma diminuição da morbimortalidade destas afecções.

Giant frontal mucocele extending into the anterior cranial fossa

The authors report a patient with a huge frontal mucocele presenting with transient left hemiparesis. Magnetic resonance imaging and computed tomography showed the huge frontal mucocele arising from the frontal sinus extending to the anterior cranial fo ssa. Right middle cerebral artery stenosis was seen on the carotid angiography. The mucocele was treated with Killian's surgery. On the postoperative seventh day, the patient showed massive cerebrospinal fluid leakage that ceased with conservative management. The patient was discharged from the hospital without any neurological deficit. We discuss the clinical symptoms and postoperative course of the huge frontal mucocele with intracranial extension.

Complications of Acute Otitis Media and Sinusitis

Otitis media and sinusitis are clinically identifiable infections of the middle ear and sinuses. Both conditions should be regarded as dynamic processes with a clinical spectrum, which may extend from a self-limiting condition to a prolonged and sometimes complicated disease. With the advent of antibiotics, the natural course of these diseases has changed significantly. Severe complications once characterized by high mortality and morbidity have become rare. This has led to a generation of general practitioners, otolaryngologists, and pediatricians trained in an atmosphere of complacency in the treatment of otitis media and sinusitis. However, several recent publications report an increasing incidence of serious complications associated with otitis and sinusitis, probably due to rising antibiotic resistance. A high index of suspicion, based on clinical grounds, is therefore warranted. The ultimate goal in the approach of these conditions is pharmacotherapeutic management, resorting to surgery for the restoration of function rather than for the eradication of the infectious disease. As new information becomes available on the etiology, pathogenesis, and bacteriology of these conditions, new strategies are being used to improve treatment and to prevent complications. These measures should include a more appropriate choice of antibiotics, the determination of the role of adjuvant therapy and surgical procedures, and the development of new vaccines.

Type A immunoglobulin deficiency presenting as a mixed polymicrobial brain abscess: case report

OBJECTIVE AND IMPORTANCE

We present a case report of a patient with a left frontal brain abscess. Cultures obtained from the abscess at the time of surgery were identified as dental flora known to establish a synergistic relationship in polymicrobial infections. This type of synergistic relationship makes the clearance of an infection more difficult for an intact immune system. A serum immunoglobulin (Ig) Type A deficiency was identified postoperatively. This immunodeficiency may have contributed to the development of the abscess.

CLINICAL PRESENTATION

The patient presented with headaches and photophobia. Computed tomography of the head performed with intravenously administered contrast demonstrated a left frontal brain abscess.

INTERVENTION

The patient was operated on through a left frontal approach, carefully avoiding the frontal sinus. The abscess was aspirated, and the patient was treated with intravenous antibiotics for several weeks. Postoperatively, the patient did well. There were no signs of enhancement on follow-up computed tomographic scans at 7 and 12 months postoperatively.

CONCLUSION

Through a comprehensive immunological workup, an IgA deficiency was identified postoperatively. Although the deficiency of a single type of Ig may be asymptomatic, complications from recurrent or chronic bacterial infections may occur. The deficiency of IgA, combined with a synergistic polymicrobial infection, contributed to the development of an intracranial abscess. A patient presenting with a brain abscess without any predisposing medical history should be evaluated for an underlying immune deficiency.

Epidural and pericranial abscesses complicating frontal sinusitis in a comatose child

Most complications of sinusitis have a significant risk of severe morbidity and possibly mortality. Therefore a keen awareness of the subtle signs and symptoms of bacterial spread beyond the paranasal sinuses must be maintained. This increased awareness is especially important in mentally retarded and psychomotor handicapped children because they can develop a rapidly fatal course despite the absence of any warning signs.

Intracranial complications of sinusitis: a pediatric series

Intracranial complications of sinusitis (ICS) (cerebral, epidural, and subdural abscesses, meningitis, and dural sinus thrombophlebitis) remain a challenging and contemporary topic. The progressive pneumatization and continued development of the sinuses after birth and the late appearance of the frontal and sphenoid sinuses imply that some infections would not appear until later childhood. We reviewed the records at a large pediatric hospital between 1986 and 1995 and found 10 children with 13 ICS (cerebral abscess, 5; extra-axial empyema, 5; and meningitis, 3). Of 43 children with cerebral abscess and 16 with extra-axial abscesses treated in this period, 12% of cerebral and 63% of extra axial abscesses were due to a sinogenic source. Multiple intracranial and extracranial complications of sinusitis in a single patient were common. The average age of children with ICS was 12.2 years old. We present these 10 cases and discuss their presentation, microbiology, and clinical course. Although the majority presented with a classic picture of headache, altered mental status, and fever, a few had symptoms that were more subtle. One child had recurrent meningitis, believed to be due to skull base dehiscence after endoscopic sinus surgery (ESS). He has required multiple otolaryngologic and neurosurgical procedures in an effort to prevent further episodes of meningitis. Ultimately, nine of 10 patients survived with an average hospital stay of 27.8 days (median of 17 days). The diagnosis of ICS requires a high index of suspicion, imaging of the brain and paranasal sinuses, and aggressive intervention.

Ethmoid metastasis of endometrial carcinoma causing mucocoele of maxillary antrum

We report a case of an antral mucocoele secondary to the obstruction of its ostium by metastatic endometrial carcinoma. This is the first report of such a cause for a mucocoele, and for a metastasis from such a tumour in the head and neck.

Sinusitis-associated epidural abscess presenting as posterior scalp abscess--a case report

Complications of paranasal sinusitis constitute true surgical and medical emergencies. These complications appear to be more prevalent and seem to present in a more fulminant manner in the pediatric age group. The most common complication of paranasal sinusitis is orbital cellulitis followed collectively by all the intracranial complications. These include meningitis, subdural empyema, intracerebral abscess, epidural abscess and rarely cavernous or superior sagittal sinus thrombosis. We report the case of a 7-year old boy who presented with posterior scalp cellulitis and abscess as a complication of minimally symptomatic paranasal sinusitis. A combined neurosurgical and otolaryngologic approach was required to treat a unilateral ethmoid and frontal sinusitis associated with an epidural abscess abutting the length of the superior sagittal sinus and a posterior subgaleal abscess. The pertinent anatomy allowing for the development of this disease process is discussed. The danger of neurologic sequellae resulting from thrombosis of the superior sagittal sinus is emphasized. Aggressive treatment utilizing a multi-disciplinary surgical approach as well as broad spectrum antibiotics is paramount to obtain the best chance for a full recovery.

The Groote Schuur hospital classification of the orbital complications of sinusitis

The complications of sinusitis have been well described. The most common classifications used for orbital complications have been that of Chandler et al. (1970) and Moloney et al. (1987). With the ready availability of high-resolution computed tomography (CT) scanners, limitations of these classifications have become apparent. The aims of this study were to determine the relative frequency of the various complications associated with acute sinusitis, to determine which groups of sinuses were most frequently involved and to correlate the orbital signs with a new proposed classification of orbital complications. Over a five-year period, 87 consecutive patients were admitted with acute sinusitis. Sixty-three patients (72.4 per cent) had one or more complications. When orbital complications were classified under the proposed classification, all patients with proptosis and/or decreased eye movement had post-septal infection. Visual impairment occurred only in the post-septal group. Most complications had a combination of sinus involvement with the maxillary/ethmoid/frontal combination being the most common. The authors propose a modification of Moloney's classification for orbital complications of acute sinusitis that allows a clear differentiation between pre- and post-septal infection and a radiological differentiation to be made between cellulitis/phlegmon and abscess formation. The latter is of importance when a decision is made on whether surgical intervention is appropriate or not.

Intracranial complications of sinusitis

Intracranial suppurative complications of sinusitis remain a challenging and contemporary topic. To determine the prevalence of sinogenic sources in intracranial infectious complications, we reviewed the records at a large public hospital between 1985 and 1995. There were 203 patients with 212 suppurative intracranial infections. Sinogenic sources were identified in 12 patients with 19 infections. Most patients had ethmoid or frontal sinusitis. We discuss the presentation, microbiology, diagnosis, treatment, and clinical course of these 12 cases. The diagnosis of intracranial complications of sinusitis requires a high index of suspicion and radiographic imaging of the head and paranasal sinuses. The mean hospital stay was 31.4 days and all 12 patients survived, although three patients had significant neurologic sequelae.

Orbital complications of sinusitis in the aspirin triad syndrome

Orbital complications are uncommon in adult sinusitis. In contrast, the sinusitis of the aspirin triad syndrome is often fulminate, expansive, and recurrent, and complications may be more frequent. Of 81 patients with aspirin triad who were treated surgically, 7 patients (8.6%) had orbital complications, including sinus mucoceles in 3 patients, lacrimal gland extension in 2 patients, inflammatory orbital mass in 1 patient, and proptosis from expansile sinonasal polyposis in 1 patient. All complications manifested within 2 years of prior surgery. Two patients suffered blindness. In a group of 120 consecutively treated sinus surgery patients without aspirin triad syndrome (51 of whom were followed for more than 2 years), no patient manifested nonoperative orbital complications. The results of this study suggest that aspirin triad patients are at significant risk for orbital complications and therefore should have long-term follow-up with aggressive treatment of persistent disease.

Ptosis associated with sinusitis

An adolescent male developed eye pain and a drooping lid. Imaging revealed adjacent pansinusitis and a swollen levator palpebrae and superior rectus muscle. Compression of a branch of the oculomotor nerve is the postulated cause because vertical eye movements were normal.