Clinical and Endoscopic Findings

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Patients with acute rhinosinusitis commonly complain of nasal obstruction, rhinorrhea, headache, facial pain, and dysosmia.

The occurrence of an orbital complication may be suspected when fever, exacerbation of headache, and ocular symptoms appear (Younis et al. 2002a). In the presence of preseptal cellulitis, erythema and edema of the eyelid without ophthalmoplegia or visual loss are observed. When proptosis, chemosis, and impairment of extraocular movement occur, a subperiosteal or intraorbital abscess must be suspected. When the patient complains of a unilateral impairment or loss of visual acuity, a compression of the optic nerve or the ophthalmic artery or the small retinoic vessels must be excluded. Acute headache, fever, and painful paresthesia in the distribution of the trigeminal nerve are the early symptoms of cavernous sinus thrombosis; they can be followed by afferent pupillary defect, extraocular motility palsy, and hyperes-thesia of the cornea as a consequence of trigeminal nerve inflammation (Lusk 1992). An ominous sign is the appearance of bilateral orbital involvement, which indicates a propagation of the infection to the opposite side through the cavernous sinus plexus (ShAhiN et al. 1987).

Whenever an orbital complication is observed, ophthalmologic consultation is mandatory to disclose any possible sign (optic disc pallor, papilledema, decreased venous pulsation) suggesting an impairment of blood flow.

In a patient with acute rhinosinusitis, the onset of an acute or gradually worsening headache is the most important symptom indicating an intracranial complication. Nausea, vomiting, alteration of mental status, affective changes, seizures, lethargy, and coma may also be observed. If the frontal lobe is involved,

Rhinorrhea Middle Turbinate
Fig. 6.1. Acute bacterial rhinosinusitis. At nasal endoscopy (0° rigid endoscope), whitish, purulent secretion covers the right middle turbinate (MT). Nasal septum, NS; inferior turbinate, IT

signs and symptoms may be absent, with only mild personality changes until the infection spreads.

Nasal endoscopy shows an inflamed, congested mucosa covered by purulent secretions, flowing from the ostiomeatal complex and the sphenoethmoidal recess when the entire ethmoid is affected by the infection (Fig. 6.1). Isolated involvement of the anterior or posterior compartment of the ethmoid is suggested by the presence of purulent discharge into the middle or superior meatus, respectively. Sometimes, a micropolyposis secondary to the infection can be appreciated. There are no peculiar endoscopic findings which differentiate an uncomplicated from a complicated acute rhinosinusitis; therefore, only an accurate clinical evaluation may alert the physician.

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