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Rhinology, Nasal Obstruction, and Sinusitis

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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

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-

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.