SINUSITIS

In the clinical setting, patients and caregivers often lump upper respiratory infection (URI) and

“sinusitis” together. Indeed, the common cold virus is the most common infection associated with URI,

which concomitantly involves the nasal mucosa and paranasal sinuses. Rhinosinusitis is therefore a

better term than “sinusitis.” Rhinosinusitis is classified as acute, subacute, and chronic based on length

of duration: less than 4 weeks, 4 to 12 weeks, and greater than 12 weeks, respectively.8

Figure 41-5. The deep spaces of the neck are distinct but interconnected compartments. Infections in any one of these may spread

to involve other potential spaces and critical structures contained therein.

In the acute setting, it is important to differentiate between viral and bacterial rhinosinusitis, as both

will present with fever, facial pressure and/or pain, nasal obstruction, and purulent or discolored nasal

discharge. The American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice

Guideline for adult sinusitis notes that the vast majority of URIs are viral, and that bacterial

rhinosinusitis should be suspected when symptoms persist after 10 days or worsen after a period of

improvement.8

In the setting of presumed viral rhinosinusitis, patients should be treated with antipyretics and

analgesics, and decongestants may be considered. For acute bacterial rhinosinusitis, amoxicillin was

recommended as the first-line antibiotic in the 2007 guidelines; however, some now recommend

amoxicillin-clavulanate for 5 to 7 days due to the increasing prevalence of resistance. A fluoroquinolone

or doxycycline may be used as first-line treatment in patients with penicillin allergy.9

Surgery is not indicated for patients with acute sinusitis, unless orbital or intracranial involvement

occurs, or in the setting of an immunocompromised patient who fails to respond to medical treatment.

Similarly, imaging is recommended against, except in the aforementioned situations.8 However,

complicated acute bacterial rhinosinusitis (Table 41-3) should be suspected when visual, mental status, or

neurologic changes are present. Proptosis, chemosis, and periorbital edema may signify extension of

infection into the orbit (Fig. 41-6). Contrasted CT is useful to determine the extent of disease, and may

be complemented by MRI. Prompt consultation with ophthalmology and/or neurosurgery is warranted

for these cases.

Acute, severe, evolving sinonasal complaints in the immunocompromised should raise concern for

acute invasive fungal sinusitis, which is rapidly progressive and fatal if untreated. Patients with HIV,

organ transplant, chemotherapy-induced neutropenia, and even uncontrolled diabetes mellitus may be

susceptible. The organisms most commonly associated are from the Aspergillus, Rhizopus, Mucor,

Rhizomucor, and Absidia genera.10 Nasal endoscopy should be performed at the bedside, and which will

demonstrate pale or black, necrotic mucosa, typically involving the turbinates or septum. Frozen section

biopsy is performed, rather than fungal cultures, as immediate diagnosis is imperative. The patient

should be emergently and aggressively debrided to bleeding, vascularized tissue in the operating room,

and concomitant consultation of an Infectious Disease specialist with initiation of antifungal drugs is

advised. Reversal of the underlying immunocompromised state will improve prognosis, as well.

COMPLICATIONS

Table 41-3 Complications of Sinusitis

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SIALADENITIS

Patients with sialadenitis present with acute onset pain in the parotid or submandibular areas. Patients

who are debilitated, dehydrated, or have decreased salivary flow due to medications or other factors

(e.g., previous radiation) are predisposed to salivary gland infection. Sialadenitis is a clinical diagnosis,

based on reproducible pain with palpation of the affected gland(s), temporal course, and presence of

purulence in Warthin or Stensen duct. Sialadenitis may be viral or bacterial, viral infections (mumps,

HIV, etc.) having a tendency to affect multiple glands bilaterally. In acute bacterial sialadenitis,

symptoms tend to present quickly, with purulent salivary secretions, tense, erythematous skin, fever,

and leukocytosis. Most infections are caused by Staphylococcus aureus, although a variety of anaerobes

and other oral pathogens may be cultured.11

Figure 41-6. Contrasted coronal CT demonstrates a right-sided periorbital abscess (asterisk) arising in a child with acute bacterial

ethmoid sinusitis. Urgent ophthalmologic consultation was obtained, which revealed increased intraocular pressure. The child was

taken for endoscopic ethmoidectomy and orbital decompression.

Patients with uncomplicated sialadenitis should be treated with hydration, sialogogues, gland

massage, and broad spectrum antibiotics if bacterial pathogens are suspected. If purulent saliva is noted,

cultures may be sent. Worsening of symptoms after initiation of therapy should prompt consideration of

abscess development, and imaging with ultrasound or CT should be performed. Recurrent or chronic

salivary infections less often result from chronic infection, but rather structural or inflammatory

disorders are more common. Connective tissue disorders, such as Sjogren syndrome, rheumatoid

arthritis, and sarcoidosis may present with or develop salivary gland involvement, and should prompt

consultation with a rheumatologist if suspected. Alternatively, a history of repeated episodes of

sialadenitis or gland fullness can be due to sialolithiasis. Physical examination with palpation of the

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submandibular and parotid ducts will reveal a palpable mass in cases with large, distal stones. These are

best approached via intraoral cutdown on a lacrimal probe. However, smaller stones in the hilum or

gland parenchyma may require imaging for diagnosis.

Although parotidectomy or submandibular gland excision has long been the treatment for such stones

and strictures, improvements in fiberoptic technology have led to increasing adoption of sialendoscopy

to implement gland-sparing interventions. A recent meta-analysis demonstrated a high proportion of

success and low incidence in complications for patients undergoing sialendoscopy for obstructive

disease.12

Finally, it is important to rule out neoplasia in patients with repeated salivary complaints, as tumors

can cause transient obstruction, as well.

CYSTIC NECK INFECTIONS

2 A variety of head and neck infections may present atypically. While it is true that adult patients may

rarely manifest infectious, cystic neck lesions, they should be presumed malignant until proven

otherwise because of the high prevalence cystic lymph node metastasis in SCC, particularly the HPVrelated disease (Fig. 41-7). Large, necrotic lymph nodes may become painful and swollen if hemorrhage

or superinfection occurs, mimicking benign disease. It is important to note that incision and drainage of

cancerous lymph nodes can hinder cure due to widespread tumor seeding.

Figure 41-7. Contrasted axial CT demonstrates a large, rim-enhancing mass involving the right level III and IV neck. Image-guided

FNA was required to confirm HPV-related squamous cell carcinoma due to its cystic nature.

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Algorithm 41-1. Workup of a Neck Mass in an Adult Patient.

With the previous caveats, the infrequent adult patient may present with atypical suppurative

lymphadenitis or an infected, previously unrecognized branchial cleft cyst. If history and physical

examination are suspicious for this, a limited trial of antibiotics may be initiated for 1 to 2 weeks to

monitor for improvement. However, further workup, including complete physical examination,

imaging, and fine-needle aspiration should be simultaneously undertaken to prevent delays in diagnosis.

If a cystic neck mass is to be removed for diagnosis, a frozen section should be sent at the time of

surgery, with completion neck dissection planned if SCC is present. Algorithm 41-1 is a suggested

approach to the adult with a lateral neck mass.

HEAD AND NECK NEOPLASMS

3 Patients with diagnosed head and neck tumor should be referred to a center with a multidisciplinary

care team, including head and neck surgeons, radiation oncologists, medical oncologists, dentists,

pathologists, radiologists, speech therapy, and social work. Treatment of head and neck neoplasms,

whether surgical or nonsurgical, is likely to have an impact on speech, swallowing, and overall quality

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of life, and anticipation and aggressive treatments of these aspects are crucial.

Table 41-4 Salivary Tumors

SALIVARY

Salivary tumors, although rare, encompass a large number of benign and malignant pathologies (Table

41-4). The parotid is the most commonly involved gland, followed by minor salivary glands, the

submandibular gland, and the sublingual gland. The majority of parotid tumors (∼75%) are benign, the

most common type being pleomorphic adenoma.13,14 However, there is an inverse relationship between

frequency of gland involvement and rate of malignancy, with approximately 50% malignant pathology

in the submandibular gland and up to 86% in the sublingual gland. The most common malignant tumor

is mucoepidermoid carcinoma, followed by adenoid cystic carcinoma (ACC) and adenocarcinoma.13

Table 41-5 lists the T-staging for parotid malignancies according to the American Joint Committee on

Cancer.15 Additionally, the parotid gland contains lymph nodes that receive lymphatic drainage from

the scalp and face.

Salivary tumors commonly present with painless swelling, and the most typical location is in the

parotid tail. However, tumors that arise in the deep lobe of the parotid (deep to the plane of the facial

nerve) may extend into the parapharyngeal space and grow quite large before they are noticed, and

may cause trismus or a pharyngeal bulge. Warthin tumors are associated with male gender and

smoking, and may be bilateral or multifocal.16 Although most salivary tumors are benign, the presence

of pain, trismus, or facial weakness should raise the clinician’s suspicion of malignancy.

In the setting of a small tumor without atypical symptoms, routine imaging is not necessarily

required, as it is unlikely to change the surgical plan. When imaging is desired, CT is the mainstay of

imaging due to its widespread availability and ease to obtain, although MRI can be useful to further

delineate the extent of a mass and perineural invasion.17 Figure 41-8A,B demonstrates MRI

characteristics of a pleomorphic adenoma on contrasted MRI.

Table 41-5 Staging of Major Salivary Gland Tumors

Fine-needle aspiration may be performed prior to surgery, based on surgeon preference. In practice,

FNA may be useful for counseling patients in whom malignancy is found that a more aggressive surgery

will be performed, or to avoid surgery in patients with inflammatory disease or lymphoid malignancies.

However, the surgeon should be aware that the specificity for neoplasia and malignancy is high,

however the sensitivity is lower and more variable for both.18

For benign lesions, partial superficial parotidectomy, taking just the tissue immediately around the

tumor, is sufficient. Additionally, there is some evidence that, in experienced hands, extracapsular

dissection without facial nerve identification may be equally effective and less morbid than superficial

parotidectomy.19,20 Figure 41-9 demonstrates the steps performed in superficial parotidectomy with

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facial nerve dissection.

Although “total parotidectomy” is typically recommended for malignancy, tumors may not be found

to be malignant until final pathology.21 Furthermore, a total parotidectomy is very difficult to perform

en bloc with preservation of the facial nerve, which should always be attempted if it is functional. In

small tumors localized to the superficial lobe, a superficial parotidectomy with an ample cuff of normal

gland is adequate. Tumors in the deep lobe require superficial parotidectomy for nerve identification

and mobilization, which may cause a temporary paresis due to retraction. If tumor involvement

necessitates nerve sacrifice, it should be reconstructed with a nerve graft.

PATHOLOGY-SPECIFIC CONCERNS

Pleomorphic adenoma is typically a well-encapsulated, enhancing, round lesion with a tendency to recur

if incompletely excised or if there is tumor spillage. Malignant transformation occurs in approximately

6%, and increases with the length of observation.22 Although benign, up to 40% may have extension

beyond the capsule (“tumor pseudopodia”), and incomplete capsules have also been described.23

Therefore, it is generally recommended to take a cuff of parotid with the tumor, although the surgeon

frequently finds that it is necessary to dissect the tumor capsule directly off the facial nerve. In cases

that recur, surgical salvage is recommended, but radiation may aid in local control for patients who are

not surgical candidates.

The prognosis and treatment of mucoepidermoid carcinoma and ACC are largely affected by

histologic grade. Mucoepidermoid carcinoma is classified as low grade or high grade, and sometimes as

intermediate grade depending on the grading system used. High-grade tumors tend to be more

aggressive, recurring locally and metastasizing frequently. Similarly, ACC can be subdivided by

histologic type, tubular being the most indolent and solid being the least. ACCs have a great propensity

for perineural invasion, and therefore MRI should be performed to evaluate for nerve involvement, and

frozen sections should be taken to clear nerves when they are involved.

Figure 41-8. Precontrast (A) and postcontrast (B) T1 MRI demonstrate a lobulated, heterogeneous mass within the right parotid

gland just posterior to the retromandibular vein, consistent with a pleomorphic adenoma.

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Figure 41-9. Superficial parotidectomy. A: The standard Blair incision or the cosmetically superior rhytidectomy incision may be

employed. B: Branches of the facial nerve course between the superficial and deep lobes of the parotid. C: The main trunk of the

facial nerve is identified 8 mm deep to the tympanomastoid suture line and at the same level as the digastric muscle. D: The nerve

is then dissected distally, separating it from the substance of the parotid. E: Schematic representation of the relationship between

the parotid and surrounding structures.

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In general, ipsilateral neck dissection should be performed when lymphadenopathy is present, and in

the N0 neck when there is high-grade pathology (salivary duct carcinoma, high-grade MEC, SCC,

adenocarcinoma except for polymorphous low-grade adenocarcinoma, carcinoma ex-pleomorphic

adenoma). Postoperative radiation should be used for stage III/IV disease, high-grade pathology, and

perineural or extensive tissue invasion.

SINONASAL

Sinonasal tumors may present with vague symptoms, including nasal obstruction, epistaxis, decreased

smell, or nasal discharge. Sinonasal tumors are rare, the most common being the benign inverted

papilloma, with a yearly incidence between 0.2 and 0.6 per 100,000. However, there are over 70

pathologies that may involve the paranasal sinuses, over half of which are malignant.24 The maxillary

sinus is most commonly affected, followed by the ethmoid, sphenoid, and frontal sinuses.25

Rigid endoscopy is required to evaluate the patient with a possible sinonasal tumor. Imaging of the

sinuses and skull base with fine-cut CT is advisable prior to biopsy to evaluate for the integrity of the

orbits, vasculature, and skull base, and to rule out odontogenic origin for maxillary sinus pathology.

MRI is also valuable to assess for dural, intraorbital, and neural integrity. Figure 41-10 is a contrasted

T1 image of a sinonasal mucosal melanoma; MRI provides evidence that both the dura and the

periorbita are intact, allowing for an endoscopic resection without craniotomy or orbital exenteration.

When possible, inverted papilloma should be resected in its entirety with drilling of its site of

attachment to prevent recurrence, which may be as high as 70% without complete resection. The

specimen should be sent for pathologic evaluation due approximately 10% risk of concurrent or delayed

malignancy.26 However, when tumor involves critical structures (optic nerve, carotid artery, etc.), they

should be preserved and the patient followed closely.

For sinonasal malignancies, surgery is the mainstay for most lesions. SCC is the most common (40%

to 50%), followed by adenocarcinoma and ACC.27 “Round blue cell” tumors are less common, but

represent several different pathologies, including esthesioneuroblastoma, sinonasal undifferentiated

carcinoma (SNUC), neuroendocrine carcinoma, small cell carcinoma, mucosal melanoma, lymphoma,

and various sarcomas. Rhabdomyosarcoma is most common in the pediatric population, and should be

treated nonsurgically as primary therapy. Consultation with a head and neck pathologist is particularly

important in patients with small blue cell tumors because high-grade pathologies (SNUC, small cell)

tend to metastasize early and are also often treated with induction chemotherapy and radiation, or

concurrent chemoradiation.

Figure 41-10. Postcontrast T1 coronal image of a sinonasal mucosal melanoma. MRI allows for the distinction between the

vascular tumor and trapped secretions in the maxillary sinus (asterisk), and provides evidence that the periorbita is intact (arrow).

The widespread adoption of endoscopic sinus surgery in the 1990s has led to increasing comfort with

minimally invasive techniques for sinonasal tumors. For inverted papilloma, the endoscopic approach is

associated with a decrease in both recurrence rate and morbidity for inverted papilloma compared to

open approaches.26,28 Similarly, evidence is building that T1 and T2 sinonasal tumors may be safely and

effectively removed with the endoscopic approach, and that endoscopic resection may complement open

surgery in combined cases.29,30

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