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Periorbital and ocular pain, vision changes can indicate
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All optometrists should keep sinusitis in their differential diagnosis when evaluating patients with vision changes or periorbital and ocular pain. Paranasal sinus disease can be a serious cause of pain and vision loss, especially if the eye examination does not reveal an ocular etiology.
Serious ocular and nonocular consequences include benign reactive edema of the orbit, orbital cellulitis, orbital abscess, cavernous sinus thrombosis, intracranial involvement and death. Different levels of vision loss, including blindness, can occur from secondary optic nerve dysfunction.
Sinusitis is categorized based on its location and duration. Acute sinusitis is an infection with a duration of less than 2 weeks. The subacute form persists for 1 to 3 months, while sinus disease that lasts beyond 3 months is considered chronic.
Nonocular findings
Severe frontal sinusitis: This type produces pain and tenderness of the brow and forehead.
Aside from periorbital and ocular symptoms, patients with sinusitis often have other nonocular findings. Reviewing these other nonocular symptoms and signs with the patient will often help the clinician make the appropriate diagnosis. Nonocular symptoms and signs often vary between adults and children and whether the sinusitis is acute in onset or chronic.
Acute sinusitis in children is most often suspected when the typical symptoms and signs of a viral upper respiratory tract infection persist beyond the usual 7 to 10 days. Cough and nasal discharge are the most common symptoms of acute sinusitis, occurring in 80% of children. Acute sinusitis in adults is characterized by colored nasal discharge, unilateral face pain, headache and cough.
Chronic sinusitis can include many of the same findings as an acute infection, but the sinus pain is often referred to areas of the head other than the face and it is often worse in the morning.
Referred pain from sinusitis will be a constant, dull ache. There is no throbbing or pounding as seen in vascular headaches. Only rarely is sinusitis pain associated with nausea or vomiting. It may worsen if the patient bends over, coughs or strains.
The location of the patient's pain may also reveal which sinuses are involved. Infection of the frontal sinuses produces pain and tenderness of the brow and forehead. Ethmoid and sphenoid sinusitis produces retro-orbital pain. Maxillary sinusitis produces pain over the cheeks and, at times, downward into the teeth.
Transilluminate patients
Right-sided maxillary sinusitis: This type produces pain over the cheeks and, at times, downward into the teeth.
Although the diagnosis of sinusitis and its ophthalmic manifestations can often be made by history alone, in-office transillumination and palpation can help confirm the clinician's suspicions. Comparative transillumination can provide information about the maxillary and the frontal sinuses, but not about the other sinuses.
The examiner must be completely dark-adapted and evaluate the patient in a completely darkened room. Transillumination of the maxillary sinuses may be performed by two different methods. The transilluminator light source can be positioned over the infraorbital rim, shielding the light source from the observer's eye, and then judging light transmission between sides through the hard palate.
An alternative method is to place a light source in the patient's mouth and have the patient make a tight seal around the transilluminator. This technique has the advantage of being able to simultaneously compare both sides.
The examiner should note the red pupillary reflex, the crescent of light on the lower eyelid and the patient's sense of light in the eyes when they are closed. Inspection over the anterior wall of the maxillary sinus is not dependable because of variations in the thickness of the anterior sinus wall. The roof of the maxillary sinus (orbital floor) is more uniform in thickness, so that the transmission of light into the orbital tissues is a better basis for comparison.
Transillumination of the frontal sinuses is performed by placing the light source up and in, beneath the medial border of the supraorbital ridge. The frequency of asymmetry and poor development of the frontal sinus limits the value of transillumination.
Palpate, then treat
| Determining Sinus Involvement | |
|---|---|
| Location of pain | Involved sinus |
| Brow and forehead | Frontal |
| Retro-orbital | Ethmoid and sphenoid |
| Cheeks, teeth | Maxillary |
Sinus pain can further be confirmed by palpation. Increased pain on palpation is consistent with sinus infection. Specialized testing to confirm sinusitis may include sinus series x-rays, nasal cytology, anterior rhinoscopy, ultrasonography, CT scanning or MRI and sinus aspirations or biopsy.
Treatment of sinusitis may include antibiotics, decongestants, antihistamines, mucoregulators, mucoevacuants, topical steroid nasal sprays, steam inhalation, saline or surgery for cases that do not respond to conventional therapy.
For Your Information:
- Leonid Skorkin Jr., OD, DO, practices in a multispecialty group in Dixon, Ill., and writes and lectures on disease and neuro-ophthalmic disorders. He underwent fellowship training in neuro-ophthalmology. He may be contacted at the Medical Arts Center, 1620 Sauk Road, Dixon, IL 61021; (815) 288-7711, Ext. 2830; fax: (815) 288-5077. Dr. Skorkin has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.