Primary Care Otolaryngology

Rhinology, Nasal Obstruction, and Sinusitis

However, if the condition is severe ethmoid sinusitis with- out abscess, it may be treated with intravenous antibiotics and nasal flushes with decon- gestant nose drops. Severe eth- moid sinusitis will often resolve with nonoperative therapy, but if the patient’s condition wors- ens, then surgery is indicated. Sphenoid Sinusitis Sphenoid sinusitis can cause ophthalmoplegia , meningitis, and even cavernous sinus thrombosis . Cavernous sinus

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Figure 9.2. This axial MRI depicts a patient with fluid in his right frontal sinus. The infection has spread retrograde and he has developed a frontal abscess.

thrombosis is a complication with even more grave implications than meningitis or brain abscess, and it carries a mortality of approximately 50 percent. The veins of the face that drain the sinuses do not have valves, and they may drain posteriorly into the cavernous sinus. Infectious venous thrombophlebitis can spread into the cavernous sinus from a source on the face or in the sinus. The most common cause of this serious infection is rhinosinusitis. The nerves that run through the cavernous sinus are the oculomotor (III), trochlear (IV), and first and second divi- sions of the trigeminal (V) and the abducens (VI). A patient who has dou- ble vision and rhinosinusitis should be assumed to have cavernous sinus thrombosis until it is ruled out by a CT and/or MRI scan. The preferred treatment is high-dose intravenous antibiotics and surgical drainage of the paranasal sinuses . Anticoagulation is also a consideration in the treat- ment regimen. Fungal Sinusitis Although fungal elements are commonly found in the nasal cavity of nor- mal patients, some patients develop a sensitivity or immunoreactivity to fungi, resulting in allergic fungal sinusitis . This allergic disorder to fungi can result in severe symptoms of chronic sinusitis and significant inflam- mation in the sinonasal mucosa due to a preponderance of eosinophils. Effective treatment requires surgery to remove the offending fungal mucin. Fungal spores can also get trapped in a sinus, where they germi- nate and fill the sinus with debris, forming a “fungal ball” or mycetoma . Typically, mycetomas do not cause a significant inflammatory response, and they are easily cured by surgical removal. If a patient is immuno-

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