Complications of

Rhinosinusitis
Synopsis of Critical Sequelae

(http://www.smbc-comics.com)

All images obtained via Google search unless otherwise

specified. All images used without permission.
 Outline

Standring S, ed. Gray's Anatomy, 40th Ed.

 Anatomy

Spain: Churchill Livingstone, 2008.

 Rhinosinusitis
 Acute
 Chronic
 Complications
 Orbital
 Intracranial
 Bony
 Conclusion
 Anatomy
Maxillary Sinus

 Largest and first sinus to develop

Kennedy DW, Bolger WE, Zinreich SJ, eds.

Management. Hamilton: BC Decker, 2001.

 At 3 months gestation

Diseases of the Sinuses – Diagnosis and

 Volume 6-8cm3 at birth
 Volume 15cm3 by adulthood
 Biphasic periods of rapid growth
 First 3 years and between 7-18 years
 Coincides with dental development
 Natural ostium drains into ethmoidal infundibulum
 Accessory ostia in 15-40%
 Haller cell can impair drainage

Notes: The anterior wall forms the facial surface of the maxilla,
the posterior wall borders the infratemporal fossa, the medial
wall constitutes the lateral wall of the nasal cavity, the floor of
the sinus is the alveolar process, and the superior wall serves
as the orbital floor.
 Anatomy
Maxillary Sinus

 Innervation via V2 distribution

 Infraorbital nerve
 Dehiscent intraorbital canal
in 14%
 Vasculature
 Maxillary artery and vein
 Facial artery
 First and second
molar roots dehiscent
in 2%
NOTES: Haller cell is an ethmoidal cell that
pneumatizes between maxillary sinus and
orbital floor.
Bailey, et al. 2006. pp 10.
 Anatomy
Ethmoid Sinus
Nasolacrimal
Duct
 First seen at 5 months gestation
 Five ethmoid turbinals Infundibulum
 Agger nasi
Uncinate Process
 Uncinate
Hiatus Semilunaris
Ethmoid bulla

Kennedy, et al. 2001



 Ground/basal lamella Ethmoid Bulla

 Posterior wall of most posterior ethmoid cell
Basal Lamella
 Between 3-4 cells at birth
 Adult size by 12-15 years
Retrobulbar Recess
 Between 10-15 cells
 Volume 2-3cm3 by adulthood

Hansen JT, ed. Netter’s Clinical

Anatomy, 2nd Ed. Philadelphia:
Saunders, 2010.
 Anatomy
Ethmoid Sinus
Nasociliary Nerve

Ophthalmic
 Drainage Nerve
 Anterior cells via ethmoid infundibulum
 Posterior cells via sphenoethmoid recess
 Innervation via V1 distribution
 Branches from nasociliary nerve
 Anterior and posterior ethmoids
 Vasculature
 Ophthalmic artery
 Maxillary and ethmoid veins
Anterior Ethmoidal Artery

Posterior cells drain into superior meatus

Ophthalmic artery provides anterior and posterior
ethmoidal arteries
Cavernous sinus gives off maxillary and
ethmoidal veins Posterior Ethmoidal Artery
Ophthalmic
artery
 Anatomy
Frontal Sinus

Tollefson TT, Strong EB. Frontal Sinus Fractures.

 Not present at birth
 Starts developing at 4 years

eMedicine 13 Jul 2009.

 Radiographically visualized at 5-6 years
 Development not complete until 12-
20 years
 Volume 4-7cm3 by adulthood
 No or poor pneumatization in 5-10%
 Drainage via frontal recess Frontal Sinus
 Anterior: posterior agger nasi
Frontal
 Lateral: lamina papyracea
Recess
 Medial: middle turbinate

Kennedy, et al. 2001

NOTES:The anterior table of the frontal sinus is twice as thick
as the posterior table, which separates the sinus from the
anterior cranial fossa. The floor of the sinus also functions as
the supraorbital roof, and the drainage ostium is located in the
posteromedial portion of the sinus floor
A markedly pneumatized agger nasi cell or ethmoidal bulla can
obstruct frontal sinus drainage by narrowing the frontal recess.
Drainage of the frontal sinus also depends on the attachment of Posterior
the superior portion of the uncinate process Ethmoid Basal Infundibulum
Uncinat
Lamella e
 Anatomy
Frontal Cell Types

 Type 1: single cell superior to agger nasi

 Type 2: > 2 cells superior to agger nasi
 Type 3: single cell from agger nasi into sinus NOTES:Type 3 cell
attaches to anterior table.

 Type 4: isolated cell within sinus

Type 1 Type 2 Type 3 Type 4

Sold arrow – Frontal cell type DelGaudio JM, et al. Multiplanar computed tomography analysis of
Dashed arrow – Agger nasi cell frontal recess cells. Arch Otolaryngol Head Neck Surg 2005; 131:230-5.
 Anatomy
Frontal Sinus
Supratrochlear
Nerve

 Vasculature
 Supraorbital artery and vein Supraorbital
Nerve
 Supratrochlear artery
Supratrochlear
 Ophthalmic vein Artery

 Foramina of Breschet Supraorbital

Artery
 Innervation via V1 distribution
 Supraorbital
 Supratrochlear

NOTES:Foramina of Breschet: small venules that

drain the sinus mucosa into the dural veins
 NOTES: Approximately 25% of bony capsules separating the

Anatomy
internal carotid artery from the sphenoid sinus are partially
dehiscent. An optic nerve prominence is present in 40% of
individuals with dehiscence in 6%.

Sphenoid Sinus
In most cases, the posteroinferior end of the superior
turbinate was located in the same horizontal plane as the
floor of the sphenoid sinus. The ostium was located medial to
the superior turbinate in 83% of cases and lateral to it in 17%.

 Evagination of nasal mucosa into sphenoid bone

 First seen at 4 months gestation
 Pneumatization begins in middle childhood
 Minimal volume at birth
 Volume 0.5-8cm3 by adult
 Reaches adult size by 12-18 years
 Sellar type (86%)
 Presellar (11%)
 Conchal (3%)
 Anatomy
Sphenoid Sinus

 Innervation via sphenopalatine nerve

 V2 distribution
 Parasympathetics
 Vasculature via maxillary artery and vein
 Sphenopalatine artery
 Pterygoid plexus
 Acute Rhinosinusitis (ARS)
 Inflammation of the nasal mucosa and lining of the
paranasal sinuses
 Obstruction of sinus ostia
 Impaired ciliary transport
 Viral etiology in majority of cases
 Superimposed bacterial infection in 0.5-2%
 Symptoms for at least 7-10 days or worsening
after 5-7 days
 Symptoms present for < 4 weeks
 “Recurrent ARS” with > 4 episodes, lasting > 7-10
days

NOTES: Most viral upper respiratory tract infections are caused by rhinovirus,
but coronavirus, influenza A and B, parainfluenza, respiratory syncytial virus,
adenovirus, and enterovirus are also causative agents.
 Acute Rhinosinusitis (ARS)
 Major symptoms
 Facial pain/pressure  Hyposmia/anosmia
 Facial congestion/fullness  Purulence on exam
 Nasal obstruction  Fever (ARS only)
 Nasal discharge/purulence
 Minor symptoms
 Headache  Dental pain
 Fever (non-ARS)  Cough
 Halitosis  Ear pain/pressure/fullness
 Fatigue
 Diagnosis with two major or one major and two minor
factors
 Acute Rhinosinusitis (ARS)
Microbiology
Children
Streptococcus pneumoniae (30-43%)
Haemophilus influenzae (20-28%)
Moraxella catarrhalis (20-28%)
Other Streptococcus species
Anaerobes
Adults
Streptococcus pneumoniae (20-45%)
Haemophilus influenzae (22-35%)
Other Streptococcus species
Anaerobes
Moraxella catarrhalis
Staphylococcus aureus
 Chronic Rhinosinusitis (CRS)
 Symptoms present for > 12 consecutive weeks
 “Subacute” for symptoms between 4-12 weeks
 Chronic inflammation
 Bacterial, fungal, and viral
 Allergic and immunologic
 Anatomic
 Genetic predisposition
 No clear consensus on pathophysiology

NOTES: One of the major problems with identifying the pathogenesis of CRS is that neither symptoms, findings, nor radiographs,
taken independently, are sufficient basis for the diagnosis. One study showed that current symptom-based criteria had only a 47%
correlation with a positive CT scan result.
Stankiewicz JA, Chow JM: A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity. Am J Rhinol 2002;
16:199-202.
 Chronic Rhinosinusitis (CRS)
Microbiology

Children
Anaerobes
Other Streptococcus species
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Adults
Anaerobes
Other Streptococcus species
Haemophilus influenzae
Staphylococcus aureus
Streptococcus pneumoniae
Moraxella catarrhalis
 Complications of Sinusitis
 Incidence has decreased with antibiotic use
 Three main categories
 Orbital (60-75%)
 Intracranial (15-20%)
 Bony (5-10%)
 Radiography
 Computed tomography (CT) best for orbit
 Magnetic resonance imaging (MRI) best for intracranium

Siedek et al, 2010

 Complications of Sinusitis
Orbital

 Most commonly involved complication site

 Proximity to ethmoid sinuses
 Periorbita/orbital septum is the only soft-tissue barrier
 Valveless superior and inferior ophthalmic veins
 Continuum of inflammatory/infectious changes
 Direct extension through lamina papyracea
 Impaired venous drainage from thrombophlebitis
 Progression within 2 days
 Children more susceptible
 < 7 years – isolated orbital (subperiosteal abscess)
 > 7 years – orbital and intracranial complications

NOTES:
-- close proximity of the orbit to the paranasal sinuses, particularly the ethmoids, make it the most commonly
involved structure in sinusitis complications; rarely from frontal or maxillary sinuses
-- pediatric population difference likely related to age-related sinus development
* pain and deterioration is not necessarily always present
* increase in WBC only found in 50%
 Orbital Complications
Microbiology

Children Adults
Streptococcus species Streptococcus pneumoniae
Staphylococcus aureus Hemophilus influenzae
Anaerobes (Bacteroides and Moraxella catarrhalis
Fusobacterium species) Staphylococcus aureus
Gram-negative bacilli Anaerobes
Staphylococcus epidermidis
 Orbital Complications
Chandler Criteria

 Five classifications
 Preseptal cellulitis
 Orbital cellulitis
 Subperiosteal abscess
 Orbital abscess
 Cavernous sinus thrombosis
 Not exclusive, can occur concurrently

Bailey, et al. 2006.

 Orbital Complications
Preseptal Cellulitis

 Symptomatology
 Eyelid edema and erythema

Bailey, et al. 2006.

 Extraocular movement intact
 Normal vision
 May have eyelid abscess
 CT reveals diffuse thickening of lid and
conjunctiva
 Orbital Complications
Preseptal Cellulitis

 Medical therapy typically sufficient

 Intravenous antibiotics
 Head of bed elevation

Ramadan et al, 2009

 Warm compresses
 Facilitate sinus drainage
 Nasal decongestants
 Mucolytics
 Saline irrigations
 Orbital Complications
Orbital Cellulitis
NOTES: Patients may complain of pain and
diplopia and a history of recent orbital trauma
 Symptomatology or dental surgery.:

 Post-septal infection
 Eyelid edema and erythema
 Proptosis and chemosis

Bailey, et al. 2006.

 Limited or no extraocular movement limitation
 No visual impairment
 No discrete abscess
 Low-attenuation adjacent to lamina
papyracea on CT

Ramadan et al, 2009

 Orbital Complications
Orbital Cellulitis

 Facilitate sinus drainage

 Nasal decongestants
 Mucolytics
 Saline irrigations
 Medical therapy typically sufficient
 Intravenous antibiotics
 Head of bed elevation
 Warm compresses

Harrington JN. Orbital cellulitis.

 May need surgical drainage

eMedicine, 25 Oct 2010.

 Visual acuity 20/60 or worse
 No improvement or progression
within 48 hours
 Orbital Complications
Subperiosteal Abscess
 Symptomatology
 Pus formation between periorbita and lamina papyracea
 Displace orbital contents downward and laterally
 Proptosis, chemosis, ophthalmoplegia
 Risk for residual visual sequelae
 May rupture through septum and present in eyelids

Bailey, et al. 2006.

 Rim-enhancing hypodensity with mass effect
 Adjacent to lamina papyracea
 Superior location with frontal
sinusitis etiology
 Diagnostically accurate 86-
91%
NOTES: Patients will complain of diplopia,
ophthalmoplegia, exophthalmos, or reduced visual
acuity. The patient has limited ocular motility or pain
on globe movement toward the abscess.; may have
normal movement early on. Orbital signs include
proptosis, chemosis, and visual impairment.
Ramadan et al, 2009
 Orbital Complications
Subperiosteal Abscess

 Surgical drainage
 Worsening visual acuity or extraocular
movement
 Lack of improvement after 48 hours
 May be treated medically in 50-67%
 Meta-analysis cure rate 26-93% (Coenraad 2009)
 Combined treatment 95-100%
 Orbital Complications
Subperiosteal Abscess

 Open ethmoids and remove lamina

papyracea
 Approaches
 External ethmoidectomy (Lynch incision)
is most preferred
 Endoscopic ideal for medial abscesses
 Transcaruncular approach
 Transconjunctival incision
 Extend medially around lacrimal caruncle

Bailey, et al. 2006.

 Orbital Complications
Orbital Abscess

 Symptomatology
 Pus formation within orbital tissues

Bailey, et al. 2006.

 Severe exophthalmos and chemosis
 Ophthalmoplegia
 Visual impairment
 Risk for irreversible blindness
 Can spontaneously drain through eyelid

infection imaging. eMedicine, 24 Mar 2010.

Drain abscess and sinuses

Kirsch CFE, Turbin R, Gor D. Orbital



Lafferty KA. Orbital infections. eMedicine, 22 Sep 2009.

 Orbital Complications
Orbital Abscess

 Incise periorbita and drain intraconal abscess

 Similar approaches as with subperiosteal abscess
 Lynch incision
 Endoscopic

NOTES:Transcaruncular approach allegedly does not utilize a facial incision.

 Orbital Complications
Cavernous Sinus Thrombosis

 Symptomatology
 Orbital pain

Bailey, et al. 2006.

 Proptosis and chemosis
 Ophthalmoplegia
 Symptoms in contralateral eye
 Associated with sepsis and meningismus
 Radiology
 Poor venous enhancement on CT
 Better visualized on MRI

Contralateral involvement is distinguishing feature of cavernous

sinus thrombosis
MRI findings of heterogeneity and increased size suggest the
diagnosis
 Orbital Complications
Cavernous Sinus Thrombosis

 Mortality rate up to 30%

 Surgical drainage
 Intravenous antibiotics
 High-dose
 Cross blood-brain barrier
 Anticoagulant use is
controversial
 Prevent thrombus propagation
Agayev A, Yilmaz S. Cavernous sinus thrombosis.
 Risk intracranial or intraorbital N Engl J Med 2008; 359:2266.

bleeding
MRI better especially if suspecting intracranial involvement, too.
 Cavernous Sinus Thrombosis
Anticoagulation

Beneficial Harmful
 Southwick et al (1986)  Bhatia et al (2002)
 Reduction in mortality
 Not recommended for other dural
 Fatal hemorrhagic cerebral
sinus thrombosis infarction
 Levine et al (1988)  Subarachnoid hemorrhage
 No change in mortality reversed with protamine
 Mortality reduction with added early
 Bhatia et al (2002)
 PTT ratio 1.5-2.5
 INR 2-3
 Anticoagulate for 3 months

NOTES: 1980s were retrospective reviews

Bhatia was a literature review
 Complications of Sinusitis
Intracranial
 Occurs more commonly in CRS
 Mucosal scarring, polypoid changes
 Hidden infectious foci with poor antibiotic penetration
 Male teenagers affected more than children
 Direct extension
 Sinus wall erosion
 Traumatic fracture lines
 Neurovascular foramina (optic and olfactory nerves)
 Hematogenous spread
 Diploic skull veins
 Ethmoid bone
NOTES: Teenagers affected more because of developed frontal and sphenoid sinuses, and
because they are more prone to URI’s than adults.
Thrombophlebitis originating in the mucosal veins progressively involves the emissary veins of
the skull, the dural venous sinuses, the subdural veins, and, finally, the cerebral veins. By this
mode, the subdural space may be selectively infected without contamination of the intermediary
structure; a subdural empyema can exist without evidence of extradural infection or osteomyelitis.
 Intracranial Complications
Types

 Five types (not exclusive)

 Meningitis
 Epidural abscess
 Subdural abscess
 Intracerebral abscess
 Cavernous sinus, venous sinus thrombosis
 Common signs and symptoms
 Fever (92%)  Seizure (31%)
 Headache (85%)  Hemiparesis (23%)
 Nausea, vomiting (62%)  Visual disturbance (23%)
 Altered consciousness (31%)  Meningismus (23%)
NOTES: Not exclusive, can occur concurrently. Percentages in children (Hicks et al, 2011)
 Intracranial Complications
Meningitis

 Most common intracranial complication of sinusitis

 Symptomatology
 Headache
 Meningismus
 Fever, septic
 Cranial nerve palsies
 Sinusitis is unusual cause of meningitis
 Sphenoiditis
 Ethmoiditis
 Usually amenable with medical treatment
 Drain sinuses if no improvement after 48 hours
 Hearing loss and seizure sequelae

NOTES: Also incidence of neurologic sequelae such as hearing loss and seizure disorder.
 Meningitis
Microbiology

Children Adults
Streptococcus pneumoniae Streptococcus pnuemoniae
Staphylococcus aureus Hemophilus influenzae
Other Streptococcus species
Anaerobes (Bacteroides and
Fusobacterium species)
Gram-negative rods
 Intracranial Complications
Epidural Abscess

 Second-most common intracranial complication

 Generally a complication of frontal sinusitis

Bailey, et al. 2006.

 Symptomatology
 Fever (>50%)  Papilledema
 Headache (50-73%)  Hemiparesis
 Nausea, vomiting  Seizure (4-63%)
 Crescent-shaped hypodensity on CT

Ramachandran TS, et al, 2009.

 Intracranial Complications
Epidural Abscess

 Lumbar puncture contraindicated

 Prophylactic seizure therapy not necessary
 Antibiotics
 Good intracerebral penetration
 Typically for 4-8 weeks
 Drain sinuses and abscess
 Frontal sinus trephination
 Frontal sinus cranialization
 Stereotactic-guided drainage

NOTES: Will likely need antibiotics for 4-8 weeks;

usually vancomycin and 3rdrd or 4th
th generation

cephalosporin
Prophylactic seizure therapy not necessary unless
there’s an associated subdural abscess.
 Intracranial Complications
Subdural Abscess

 Generally from frontal or ethmoid sinusitis

 Symptomatology

Bailey, et al. 2006.

 Headaches
 Fever
 Nausea, vomiting
 Hemiparesis
 Lethargy, coma
 Third-most common intracranial
complication, rapid deterioration
 Mortality in 25-35%
 Residual neurologic sequelae in 35-55%
 Accompanies 10% of epidural abscesses
 Intracranial Complications
Subdural Abscess

 Lumbar puncture potentially fatal

 Aggressive medical therapy
 Antibiotics
 Anticonvulsants
 Hyperventilation, mannitol
 Steroids
 Drain sinuses and abscess
 Medical therapy possible if < 1.5cm
 Craniotomy or stereotactic burr hole
 Endoscopic or external sinus drainage

NOTES:Need antibiotics with good intracerebral penetration, typically 3-6 weeks

Craniotomy is favored over burr hole placement due to better exposure
 Intracranial Complications
Intracerebral Abscess
 Uncommon, frontal and frontoparietal lobes
 Generally from frontal sinusitis

Bailey, et al. 2006.

 Sphenoid
 Ethmoids
 Symptomatology
 Headache (70%)  Nausea, vomiting
 Mental status (40%)
change (65%)  Seizure (25-35%)
 Focal neurological  Meningismus (25%)
deficit (65%)
 Papilledema (25%)
 Fever (50%)
 Mortality 20-30% NOTES: May have mood swings
and behavioral changes with
 Neurologic sequelae 60% frontal lobe involvement
Worsening headache with
meningismus suggests possible
rupture of the abscess.
 Intracranial Complications
Intracerebral Abscess

 Lumbar puncture potentially fatal

 Aggressive medical therapy
 Antibiotics
 Anticonvulsants
 Hyperventilation, mannitol
 Steroids
 Drain sinuses and abscess
 Medical therapy possible if abscess < 2.5cm
 Excision or aspiration
 Diagnostic aspiration if < 2.5cm or cerebritis
 Stereotactic-guided aspiration
 Endoscopic or external sinus drainage
NOTES: Antibiotic regimen is typically 6-8 weeks; typically ceftriaxone, vancomycin or nafcillin, and metronidazole
Corticosteroid use is controversial. Steroids can retard the encapsulation process, increase necrosis, reduce antibiotic penetration into the
abscess, increase the risk of ventricular rupture, and alter the appearance on CT scans. Steroid therapy can also produce a rebound effect
when discontinued. If used to reduce cerebral edema, therapy should be of short duration. The appropriate dosage, the proper timing, and
any effect of steroid therapy on the course of the disease are unknown. The procedures used are aspiration through a bur hole and complete
excision after craniotomy. Aspiration is the most common procedure and is often performed using a stereotactic procedure with the guidance
of CT scanning or MRI.
 Intracranial Abscesses
Microbiology

Children Adults
Anaerobes (anaerobic Streptococcus, Bacteroides, Fusobacterium
species)
Staphylococcus aureus
Other Streptococcus species (Streptococcus milleri)
Gram-negative bacilli (Hemophilus influenzae)
Staphylococcus epidermidis
Eikenella corrodens
Polymicrobial
NOTES: Incidence of anaerobes in
suppurative intracranial complications
range from 60-100%
 Intracranial Complications
Venous Sinus Thrombosis

 Sagittal sinus most common

 Retrograde thrombophlebitis from
frontal sinusitis
 Extremely ill
 Subdural abscess
 Epidural abscess
 Intracerebral abscess
 Decreased cavernous carotid
artery flow void on MRI
 Elevated mortality rate
 Intracranial Complications
Venous Sinus Thrombosis

 Aggressive medical therapy

 Antibiotics
 Steroids
 Anticonvulsants
 Anticoagulation controversial
 Heparin inpatient, warfarin outpatient
 Thrombus resolution by 6 weeks
(Gallagher 1998)
 Increased intracranial pressure
outweighs bleeding risk (Gallagher 1998)
 Drain sinuses
 External
 Endoscopic
 Complications of Sinusitis
Bony
 Pott’s puffy tumor
 Frontal sinusitis with acute osteomyelitis

Sabatiello M, et al. The Potts puffy tumor: an unusual complication of

frontal sinusitis, methods for its detection. Pediatr Dermatol 2010;
 Subperiosteal pus collection leads to “puffy” fluctuance
 Rare complication
 Only 20-25 cases reported in post-antibiotic era (Raja 2007)
 Less than 50 pediatric cases in past 10 years (Blumfield 2010)
 Symptomatology
 Headache
 Fever
 Neurologic findings
 Periorbital or frontal swelling
 Nasal congestion, rhinorrhea

27:406-8.
NOTES: Sir Percivall Pott described Pott's Puffy tumor in 1768 as a
local subperiosteal abscess due to frontal bone suppuration
resulting from trauma. Pott reported another case due to frontal
sinusitis.
 Complications of Sinusitis
Bony

Upadhyay S. Recurrent Pott's puffy tumor, a rare

 Associated with other abscesses in 60%

clinical entity. Neurol India 2010; 58:815-7.

 Pericranial
 Periorbital
 Epidural
 Subdural
 Intracranial
 Cortical vein thrombosis
 Frontocutaneous fistula

Blumfield, et al. 2010.

NOTES: Sir Percivall Pott described Pott's Puffy

Bailey, et al. 2006.

tumor in 1768 as a local subperiosteal abscess due
to frontal bone suppuration resulting from trauma.
Pott reported another case due to frontal sinusitis.
 Pott’s Puffy Tumor
Microbiology

Children Adults
Streptococcus species (Streptococcus milleri)
Staphylococcus aureus
Anaerobes (Bacteroides species)
Gram-negative bacilli (Proteus species)
Polymicrobial
 Complications of Sinusitis
Bony

 Cooperative effort
 Otolaryngology
 Neurosurgery
 Infectious disease

Diaz PM, et al. Tumor hinchado de Pott. Recidiva tras 10 anos

asintomatico. Rev Esp Cirug Oral y Maxilofac 2007; 29(5).
 Surgical and medical therapy
 Drain abscess and remove infected bone
 Intravenous antibiotics for six weeks
 May obliterate frontal sinus to prevent
recurrence
 Conclusions
 Complications are less common
with antibiotics
 Orbital
 Intracranial
 Bony
 Can result in drastic sequelae
 Drain abscess and open involved

(http://www.smbc-comics.com)
sinuses
 Surgical involvement
 Ophthalmology
 Neurosurgery
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literature. J Laryngol Otol 2002; 116:667-76.
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