Intracranial complications of paranasal sinusitis: a combined institutional review

Impact of COVID-19 on nationwide pediatric complicated sinusitis trends throughout 2018-2022

OBJECTIVES

To describe and analyze the trends of pediatric sinusitis cases from 2018 to 2022 across the country utilizing the Pediatric Hospital Information System (PHIS) database focusing on volumes, socioeconomics, and severity of cases.

STUDY DESIGN

Retrospective Cohort Study.

METHODS

A retrospective cohort study using the Pediatric Health Information System (PHIS) database, which consists of 50 children's hospitals was performed. Regions were defined according to PHIS guidelines. We evaluated percentage of sinusitis cases demographic and socioeconomic information and subgrouped by region throughout 2018-2022.

RESULTS

In all regions there were a greater number of sinusitis cases post-COVID compared to pre-COVID, with notable increases in major and extreme severity. The years 2020 and 2021 saw a decrease in total sinusitis cases in all locations. Both surgical intervention and severity of sinusitis were significant factors affecting length of stay. Age and severity were the most significant predictors regarding the odds of having sinus surgery. Age and insurance type were significant predictors of severity, with increasing age and government insurance associated with higher odds of major or extreme severity of sinusitis.

CONCLUSIONS

There appears to be a trend of both increased number and worsening severity of acute sinusitis cases in the post-COVID era compared to pre-COVID. There was a decrease in cases in 2020-2021 during the pandemic, consistent with trends of other communicable diseases.

Paranasal sinus occupancy assessed from magnetic resonance images-associations with clinical indicators in patients with systemic lupus erythematosus

OBJECTIVES

Nasal, paranasal sinus and mucosal disorders are common symptoms in autoimmune rheumatic diseases. Soft tissue changes and fluid accumulation in the osteomeatal complexes and paranasal sinuses manifest as opaqueness on radiological images which can be assessed using visual scoring and computational methods on CT scans, but their results do not always correlate. Using MRI, we investigate the applicability of different image analysis methods in SLE.

METHODS

We assessed paranasal sinus opaqueness on MRI from 51 SLE patients, using three visual scoring systems and expert-delineated computational volumes, and examined their association with markers of disease activity, inflammation, endothelial dysfunction and common small vessel disease (SVD) indicators, adjusting for age and sex-at-birth.

RESULTS

The average paranasal sinus volume occupation was 4.55 (6.47%) [median (interquartile range) = 0.67 (0.25-2.65) ml], mainly in the maxillary and ethmoid sinuses. It was highly correlated with Lund-Mackay (LM) scores modified at 50% opaqueness cut-off (Spearman's ρ: 0.71 maxillary and 0.618 ethmoids, P < 0.001 in all), and with more granular variations of the LM system. The modified LM scores were associated with SVD scores (0: B = 5.078, s.e. = 1.69, P = 0.0026; 2: B = -0.066, s.e. = 0.023, P = 0.0045) and disease activity (anti-dsDNA: B = 4.59, s.e. = 2.22, P = 0.045; SLEDAI 3-7: 2.86 < B < 4.30; 1.38 < s.e. < 1.63; 0.0083 ≤ P ≤ 0.0375). Computationally derived percent opaqueness yielded similar results.

CONCLUSION

In patients with SLE, MRI computational assessment of sinuses opaqueness and LM scores modified at a 50% cut-off may be useful tools in understanding the relationships among paranasal sinus occupancy, disease activity and SVD markers.

Hospitalizations and severe complications following acute sinusitis in general practice: a registry-based cohort study

OBJECTIVES

To investigate complication rates of acute sinusitis in general practice, and whether antibiotic prescribing had an impact on complication rate.

METHODS

All adult patients diagnosed with sinusitis in Norwegian general practice between 1 July 2012 and 30 June 2019 were included. GP consultation data from the Norwegian Control and Payment for Health Reimbursements Database were linked with antibiotic prescriptions (Norwegian Prescription Database) and hospital admissions (Norwegian Patient Registry). Main outcomes were sinusitis-related hospitalizations and severe complications within 30 days. Logistic regression was used to estimate associations between antibiotic prescriptions, prespecified risk factors, individual GP prescribing quintile, and outcomes.

RESULTS

A total of 711 069 episodes of acute sinusitis in 415 781 patients were identified. During the study period, both annual episode rate (from 30.2 to 21.2 per 1000 inhabitants) and antibiotic prescription rate (63.3% to 46.5%; P < 0.001) decreased. Yearly hospitalization rate was stable at 10.0 cases per 10 000 sinusitis episodes and the corresponding rate of severe complications was 3.2, with no yearly change (P = 0.765). Antibiotic prescribing was associated with increased risk of hospitalization [adjusted OR 1.8 (95% CI 1.5-2.1)] but not with severe complications. Individual GP prescribing quintile was not associated with any of the outcomes, whereas risk factors such as previous drug abuse, or head injury, skull surgery or malformations, and being immunocompromised were significantly associated with increased risk of both outcomes.

CONCLUSIONS

Severe complications of acute sinusitis were rare and no protective effect of high prescribing practice among GPs was found. Recommendations to further reduce antibiotic prescribing are generally encouraged, except for high-risk groups.

A Systematic Review of Intracranial Complications in Adults with Pott Puffy Tumor over Four Decades

The purpose of this study is to investigate the risk factors of intracranial complications in adult patients with Pott Puffy Tumor (PPT). A systematic review was conducted of clinical studies from January 1983 to December 2022 that reported on PPT adult patients. The full-text articles were reviewed for the patients’ ages, sex, cultured organisms, surgical procedures, clinical sequalae, and underlying diseases that may affect the onset of intracranial complications in PPT adult patients. A total of 106 studies were included. Medical data were reviewed for 125 patients (94 males, 31 females). The median age was 45 years. A total of 52% had comorbidities, mostly head trauma (24.5%), sinus/neurosurgical operations (22.4%), immunosuppression conditions (13.3%), diabetes mellitus (9.1%), cocaine use (7.1%), or dental infections (6.1%). A total of 28 cultures revealed Streptococcus (22.4%), 24 contained staphylococci (19.2%), and 22 cultures contained other pathogens (17.6%). An amount of 30.4% developed intracranial complications, with the most common being epidural abscesses or empyemas (55.3%), as well as subdural (15.7%) and extradural lesions (13.2%). Age, DM, and immunosuppression conditions are significantly associated with intracranial complications (p < 0.001, p = 0.018 and p = 0.022, respectively). Streptococcus infection is associated with intracranial complications (p = 0.001), although Staphylococcus and other microorganisms are not. Surgical intervention, mainly ESS, and broad-spectrum antibiotics remain the cornerstones of treatment.

Intracranial empyema complicating sinusitis in childhood: Epidemiology, imaging findings and outcome

BACKGROUND

To describe clinical presentations of intracranial sinusitis complications in childhood, their pitfalls and imaging findings.

MATERIEL AND METHODS

This retrospective IRB-approved single-center study included infants diagnosed with sinusitis and empyema and/or other intracranial complications who underwent imaging between September 2008 and September 2019. Three radiologists individually reviewed clinical charts and imaging findings, including sinusitis complications and at-risk anatomical variations.

RESULTS

21 children (76% males and 24% females, mean age 13±3.1 years) with imaging pansinusitis were included. Headache (95%) and fever (90%) were the main clinical nonspecific signs. Ten (48%) children presented an extradural empyema, nine (43%) children had a subdural empyema and two (10%) children had both. Frontal location sinusitis was the most common (76%). In MRI, all empyema presented as a hypo intensity on pre-contrast T1-WI, a hyperintensity on T2-WI, a reduced apparent diffusion coefficient (ADC) on diffusion weighted imaging (DWI) and a peripheral contrast enhancement on post-contrast T1-WI. CT or MRI revealed intracranial complications such as a collection size increase (52%), a midline shift (62%), intraparenchymal abscesses (24%), a cerebral venous thrombosis (29%), an intracranial pressure increase (29%), cerebral ischemia (43%) and Pott's Puffy Tumor (10%). Imaging highlighted sinus anatomical abnormalities in 52% of cases. All children were treated with sinus drainage and/or neurosurgery. Long-term follow-up was favorable in 14 cases (67%).

CONCLUSION

Complications of sinusitis are life threatening in the studied population. Empyema and cerebral complications may be misleading. Brain contrast-enhanced CT covering sinuses and orbits, is mainly the first examination done but MRI is mandatory.

Systemic corticosteroids for orbital complications of pediatric rhinosinusitis: A systematic review

OBJECTIVES

Determine if systemic corticosteroids administration is associated with reduced length of stay, surgical intervention, and abscess formation in pediatric patients with orbital complications of rhinosinusitis.

METHODS

Systematic review and meta-analysis were performed utilizing the PubMed and MEDLINE databases to identify articles published between January 1990 and April 2020. Retrospective cohort study of the same patient population over the same time period at our institution.

RESULTS

Eight studies, 477 individuals, met criteria for inclusion in the systematic review. 144 patients (30.2%) received systemic corticosteroids, while 333 patients (69.8%) did not. Meta-analyses of frequency of surgical intervention and subperiosteal abscess showed no difference between those who did and did not receive systemic steroids ([OR = 1.06; 95% CI: 0.46 to 2.48] and [OR = 1.08; 95% CI: 0.43 to 2.76], respectively). 6 articles evaluated hospital length of stay (LOS). 3 of these reported enough data to perform meta-analysis, which showed patients with orbital complications who received systemic corticosteroids had shorter mean hospital LOS when compared with those who did not receive systemic steroids (SMD = -2.92, 95% CI: 5.65 to -0.19).

CONCLUSION

While available literature was limited, systematic review and meta-analysis suggests systemic corticosteroids decrease length of stay for hospitalized pediatric patients with orbital complications of sinusitis. Further research is needed to more clearly define the role of systemic corticosteroids as an adjunctive treatment.

[Pott's Puffy Tumor: a need for interdisciplinary diagnosis and treatment. German Version]

Der Pott-Puffy-Tumor (PPT) stellt als bakterielle Infektion des Sinus frontalis mit subperiostaler und intrakranieller Abszessbildung eine seltene Erkrankung in der Pädiatrie dar. Nachfolgend präsentieren wir vier Fälle eines PPT, die bei zwei Kindern (6 und 9 Jahre) und bei zwei jungen Erwachsenen (17 und 19 Jahre) auftraten. Alle Patienten wurden interdisziplinär von einem Team aus Neurochirurgie, Pädiatrie, HNO-Heilkunde, Neuroradiologie und Mikrobiologie betreut. Die Antibiotikabehandlung wurde in einem Fall mit einer endoskopischen Nasennebenhöhlenoperation (FESS) und in den anderen drei Fällen zusätzlich mit einem offenen transkraniellen Zugang zur Drainage der intrakraniellen Abszessbildung kombiniert. Da der PPT im Kindesalter mit dem Befund einer intrakraniellen Abszessbildung einhergehen kann, ist eine enge interdisziplinäre Zusammenarbeit für eine erfolgreiche Behandlung dieser seltenen Erkrankung erforderlich.

The Endoscopic Management of Different Pediatric Frontal Sinus Pathologies

Background.The paranasal sinuses in pediatrics can harbor a wide variety of pathologies. With the present literature being composed of case studies only, this entity is quite understudied. Objectives. This article aims to study the clinical presentation, diagnosis, and endoscopic management of six different rare frontal sinus pathologies in pediatrics, which include extensive allergic fungal sinusitis, mucoceles, osteoma, superior sagittal sinus thrombosis, CSF leak, and subdural empyema. Methods. We retrospectively studied all pediatric patients with frontal sinus pathologies presenting to our center, King Fahad Specialist Hospital, Dammam, Saudi Arabia, from the period of 2006 to 2020. Results. A total of 8 patients presented to our hospital with different frontal sinus pathologies. 5 of them were males, and 3 were females with an age of presentation ranging from 7 to 17 years. The diagnosis and localization were performed through computerized tomography without contrast and magnetic resonance imaging, when indicated. All cases were primarily managed with endonasal endoscopic approaches successfully without complications and with no recurrence evident upon follow-up. Conclusion. In this case series, six different frontal sinus pathologies were managed by an endoscopic approach, with excellent recovery and no recurrence upon follow-up demonstrated. This approach enabled excellent visualization of the pathologies, accurate localization, adequate drainage, and repair or grafting when needed.

Sex Disparities in Pediatric Acute Rhinosinusitis: A National Perspective

OBJECTIVE

This study aims to provide an age-stratified analysis of associations with patient sex in pediatric inpatients with acute rhinosinusitis (ARS).

STUDY DESIGN

Retrospective cohort study.

SETTING

National administrative database.

METHODS

The 2016 Kids' Inpatient Database was queried for pediatric inpatients (<21 years old) with ARS (ICD-10 J01). Orbital and intracranial sequelae were selected via ICD-10 codes. Statistical associations by sex were determined via univariate and multivariable analyses. Weighted measures are reported to provide national estimates.

RESULTS

Of the 5882 patients identified with ARS, 2404 (40.9%) were female and 3478 (59.1%) were male. Male patients were younger than female patients (mean, 9.3 vs 9.9 years; P < .001). Multivariable analysis indicated that males and females had similar total charges ($71,094 vs $66,892, P = .464) and length of stay (5.8 vs 6.1 days, P = .263). However, male patients underwent more procedures (1.8 vs 1.5, P < .001). Mortality was similar between male and female patients (odds ratio [OR], 0.91; P = .664). Male patients also had increased odds for having orbital (OR, 1.58; P < .001) and intracranial (OR, 1.99; P < .001) complications. Differences in sex-dependent sequela risk were starkest in patients aged 14 to 20 years, with male patients being more likely to have orbital (OR, 2.91; P < .001) and intracranial (OR, 3.86; P < .001) complications.

CONCLUSION

In a cohort of pediatric inpatients with ARS, males have increased odds for orbital and intracranial sequelae and undergo more procedures than females. However, males and females have similar charges and length of stay. Our study highlights age-stratified differences in ARS across patient sex.

Suboccipital extracranial and intracranial abscess of a neonate: an exceedingly rare occurrence

Intracranial abscess is a life-threatening disease that is uncommon in paediatric populations. Although there have been few reports in the literature, some aetiologies, such as mastoiditis and sinusitis, have been proposed. The pathophysiology is not completely known, and there are no data regarding the long-term follow-up of these patients. Herein, we present a case of a newborn affected with a mass in the suboccipital region due to an extracranial and intracranial abscess that had no clear association with infections except for a transient fever episode 1 month earlier. Isolation of Staphylococcus aureus from an open-surgery sample identified the cause of the mass. The patient achieved excellent recovery with no recurrence even after 8 years of follow-up. To our knowledge, this rare pattern of infection highlights the importance of early diagnosis in combination with a surgical approach as an effective diagnosis and treatment approach that provided a good outcome.

The Relationship Between an Accessory Maxillary Ostium and Variations in Structures Adjacent to the Maxillary Sinus without Polyps

Introduction  The maxillary sinus and its variations are very important to dentistry and rhinology.

Objective  To investigate the effect of the accessory maxillary ostium (AMO) on the variations of adjacent structures of the maxillary sinus.

Methods  The computed tomography (CT) images of 400 patients were retrospectively evaluated. The prevalence of AMO was calculated. The relationship between morphological variations of adjacent structures of maxillary sinus such as agger nasi cell (ANC), Haller cell (HC), nasal septum deviation (NSD), hypertrophy of inferior concha (HIC), pneumatization of middle concha (PMC), mucus retention cyst (MRC), mucosal thickening (MT), and maxillary sinusitis (MS), as well as the presence of AMO, were investigated.

Results  Presence of AMO was diagnosed in 42 patients (10.5%), having been found in 4.5% of the patients only on the right side, in 1.25% of the patients only on the left side, and in 4.75% of the patients on both sides. There is an increasing incidence of ANC, HC, NSD, HIC, and PMC in the presence of AMO and MS. There is a decreasing incidence of MRC in the presence of AMO. Furthermore, AMO does not affect the incidence of MT.

Conclusion  This study showed that most parameters, except for MRC and MT, had increasing incidence in the presence of AMO. It is important for radiologists and rhinologists to have knowledge about the location of AMO and the presence of variations of MS adjacent structures to avoid surgical complications.

Pott’s puffy tumor: a need for interdisciplinary diagnosis and treatment

Pott’s puffy tumor (PPT) is an infection of the frontal sinus with subperiosteal and intracranial abscess formation and one of the rare entities in pediatrics. We present a series of four cases of PPT that occurred in two children (6 and 9 years) and in two young adults (17 and 19 years). All patients were treated by an interdisciplinary team of pediatric, neurosurgical, ENT, radiological, and neuroradiological specialists. Antibiotic treatment was combined with single endoscopic surgery in one case and combined endoscopic sinus surgery with an open transcranial approach to drain intracranial abscess formation in three cases. It is important to be aware that PPT occurs in children with the finding of intracranial abscess formation. Therefore, a close interdisciplinary cooperation for successful treatment is needed in this rare disease.

Management Strategy of Intracranial Complications of Sinusitis: Our Experience and Review of the Literature

Objective

Sinusitis or rhinosinusitis is a very common disease worldwide, and in some cases, it leads to intracranial complications (ICS). These are more common in immunocompromised patients or with underlying comorbidities, but even healthy individuals, can be affected. Nowadays, ICS have become less common thanks to improved antibiotic therapies, radiological diagnostic methods, surgical techniques and skills. Nonetheless, they can still cause significant morbidity and mortality. For this reason, management of these complications requires a multidisciplinary approach to plan and customize treatment options. This paper presents our strategy in the management of a series of intracranial complications induced by acute sinusitis and compares our experience and outcomes with the literature.

Study design

Single institute experience, retrospective analysis of cases series and literature review.

Methods

Adult and child patients who were treated for ICS in the Department of Otorhinolaryngology at Sion Hospital, in Switzerland from 2016 to 2020 were included. Their symptoms, medical history, clinical and radiological findings, treatment, and outcome were documented.

Results

Eight patients (6 males- 2 females) aged from 14 to 88 y.o., were enrolled. None had any previous history of chronic, or recurrent sinusitis. Moreover, very few presented specific rhinological symptoms, but with neurological or other symptoms. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) were used to confirm the diagnosis of all ICS. All types of known intracranial complications were observed in our cohort with a wide range of extension and severity of sinusitis. A multidisciplinary approach with individual treatments was tailored to each patient. Outcomes were favorable in almost all patients with neither recurrence, nor neurological sequels being observed in the follow-up. Only one patient was lost due to fatal complications of advanced lung cancer.

Conclusion

ICS remain a challenging clinical problem due to substantial associated morbidity and mortality. The incidence of these complications is relatively low. Therapeutical management guidelines are lacking. Early detection and multidisciplinary approach are key to successful treatment.

Streptococcus Intermedius as the cause of sphenoid sinusitis & associated extensive skull base and neck thrombophlebitis & thrombosis

Acute bacterial sinusitis may be complicated by orbital and intracranial involvement and by thrombophlebitis. Its spread across multiple anatomic compartments is facilitated by the interconnected venous anatomy of the head and neck and the virulence of the primary pathogen. We present a rare case of Streptococcus Intermedius (S. Intermedius) acute bacterial sinusitis complicated by extensive skull base involvement including cavernous sinuses and neck vein thrombophlebitis and thrombosis.

Parenchymal Brain Abscess as an Intracranial Complication After Sinusitis

Brain abscesses caused by sinusitis are rare in the antibiotic era. The purpose of the current manuscript was to report a rare case of a brain abscess located mainly in the frontal lobe after sinusitis, which was initially thought to be meningitis or encephalitis. A 39-year-old man was transferred to our hospital from another neighbouring hospital with tonic-clonic seizures, severe headache, and purulent nasal secretions. For one week, he was taking antibiotics for sinusitis. The computed tomography indicated lesions in the right sinuses but not in the parenchymal brain and thus antibiotics along with antiepileptic drugs were given. However, due to the deterioration of symptoms, magnetic resonance imaging was executed, which revealed an abscess in the frontal lobe. Afterward, an anterior ethmoidectomy and middle maxillary antrostomy were performed in order to drain the purulent content from the right sinuses. Ten days later, the patient presented disorientation and thus an open craniotomy for successful removal of the parenchymal abscess was performed. One month later, the patient was discharged with mild irritability, which was eliminated gradually over the next two months. Conclusively, brain abscesses can be caused by local spread from an infection of the paranasal sinus. The contribution of imaging modality is very significant not only for the early diagnosis but also for the therapeutic management of such cases. Frequently antibiotic treatment is insufficient and surgery may be required.

Efficacy of endoscopic sinus surgery alone versus in combination with neurosurgical intervention for the treatment of pediatric subdural empyema

OBJECTIVES

To compare treatment outcomes for sinogenic subdural empyema (SE) between those managed with initial endoscopic sinus surgery (ESS) alone versus those treated with a combination of ESS and craniotomy over the last decade at our institution. To better characterize subdural empyema with regard to presentation, causative pathogens, and treatment course.

METHODS

Retrospective single-center chart review to identify and evaluate pediatric SE patients between 2009 and 2019. Patients meeting inclusion criteria were classified in one of two groups: those who initially underwent ESS or frontal trephination without concurrent neurosurgical procedure and those who underwent craniotomy or burr hole in addition to a sinus procedure. Presenting characteristics and treatment outcomes were compared between the two groups.

RESULTS

Eighteen patients met inclusion criteria. The ESS alone and the ESS + craniotomy subgroups each had 9 patients with similar baseline characteristics. The ESS + craniotomy group was more likely to present with neurological symptoms (p = 0.039) and have multiple intracranial fluid collections (p = 0.046). 74.1% of patients presented to the Emergency Department (ED) or to their primary medical doctor and were treated with outpatient management prior to hospitalization with definitive surgical management. The most common presenting symptoms were fever, headache and nausea/vomiting. There were no differences between treatment groups in rate of return to the operating room (OR) (p = 1.00), length of stay (LOS) (p = 0.553), or adverse neurological outcomes (p = 0.456). 44.4% of patients in the ESS alone group eventually required neurosurgical intervention.

CONCLUSIONS

Surgical SE patients often present to medical professionals in the primary care setting or ED and are managed with outpatient treatment before admission with definitive treatment. In this small retrospective cohort patients who underwent sinus intervention alone had similar rates of return to OR, LOS and adverse neurological outcomes use as those who underwent a sinus procedure in coordination with a neurosurgical intervention. There may be a group of patients with SE who may be managed with endoscopic procedures alone and further studies should seek to determine the characteristics of this population.

When is a multidisciplinary approach required in management of intracranial complications of sinonasal inflammatory disorders?

Intracranial complications of sinonasal inflammatory disorders are relatively unusual but can cause significant morbidity and mortality. They often occur in patients with comorbid disorders and immunocompromised but also people without risk factors can be affected. Intracranial complications of acute rhinosinusitis are rare, probably due to oral antibiotics availability, but are less predictable as they often occur in immunocompetent patients without comorbidity. Their management requires a multidisciplinary approach to plan and customize the therapeutic treatment. Intracranial complications of chronic rhinosinusitis are more predictable as they occur often in immunocompromised patient with particularly risk factors. For this reason, a multidisciplinary approach it’s important for treatment and mostly for prevention. The aim of this paper is to present an overview of different multidisciplinary management of intracranial complications of sinonasal inflammatory disorders according to their etiology and severity.

Simultaneous Orbital and Intracranial Abscesses in 17 Cases

PURPOSE

To describe the demographics, clinical presentation, treatment, and outcomes of a rare cohort with simultaneous orbital and intracranial abscesses.

METHODS

A historical cohort study of 17 patients with simultaneous orbital and intracranial abscesses between 2010 and 2018 was performed. The demographics, location of abscesses, treatment, and outcomes of these patients were analyzed.

RESULTS

The mean age was 26.9 years (range 5-83 years). Fourteen patients (82%) were male. In this cohort, the most common orbital abscess location was the superior orbit, involved in 14 patients (82%). The most common site of intracranial abscess was the frontal lobe, involved in 16 patients (94%). Concurrent sinus disease was present in 16 patients (94%). Surgical evacuation was the standard of treatment, with 94% of patients undergoing at least one surgical procedure. Streptococcus species were the most common, isolated from 6 sinus cultures (43%), 3 orbitotomy cultures (21%), and 4 craniectomy cultures (36%). Staphylococcus species were also common. Most patients (94%) had stable or improved mental status and visual function at the conclusion of their treatment.

CONCLUSIONS

Simultaneous orbital and intracranial abscesses are rare. Local invasion from the orbit into the intracranial space may occur from direct spread, thus superior orbital abscesses pose the greatest risk for intracranial spread. Additional factors such as infection with Streptococcus and Staphylococcus species as well as male sex appear to be risk factors for intracranial spread. For those who develop intracranial abscesses, young age and absence of seizures or altered mental status at presentation may be associated with favorable outcomes.

Distinct Histopathologic Features of Complicated Sinusitis

BACKGROUND

Sinusitis complicated by intracranial or orbital extension can be life-threatening and require emergent intervention. Histologic features of complicated sinusitis have yet to be determined and may have significant implications for understanding pathophysiology.

METHODS

A structured histopathology report was utilized to analyze sinus tissue extracted during functional endoscopic sinus surgery (FESS). A total of 13 histopathology variables were compared between patients with complicated sinusitis (CS), CRS without nasal polyps (CRSsNP), and CRS with nasal polyps (CRSwNP).

RESULTS

About 24 CS, 149 uncomplicated CRSsNP, and 191 uncomplicated CRSwNP patients were analyzed. Nasal tissue from CS and CRSwNP patients demonstrated similar levels of overall inflammation (66.7% vs. 69.6% with moderate/severe inflammation, P = .466). Relative to CRSsNP, CS patients showed significantly greater overall inflammation (66.7% vs. 41.6%, P = .019). CS patients demonstrated significantly fewer eosinophils per high power field (eos/HPF) and eosinophil aggregates compared to CRSwNP patients (20.8% vs. 70.7% with 5+eos/HPF, P < .0001; 4.2% vs. 33.5%, P < .0001). Relative to CRSsNP patients, CS patients demonstrated enhanced neutrophil infiltration (45.8% vs. 28.0%, P = .011). About 91.7% of CS patients demonstrated a lymphoplasmacytic predominant inflammatory infiltrate, compared to 69.8% of CRSsNP and 62.8% of CRSwNP patients (P < .0001).

CONCLUSION

Significant histopathological differences were evident in patients with CS, CRSsNP, and CRSwNP. CS patients did not perfectly fit either a CRSsNP or CRSwNP profile, underscoring the importance of delineating the histopathological features of CS. This study offers insight into the histologic aspects of CS, providing initial evidence that it is an aggressive neutrophilic inflammatory process.

Risk Factors for Brain Abscess: A Nationwide, Population-Based, Nested Case-Control Study

BACKGROUND

Knowledge on risk factors for brain abscess is limited and relies on single-center cohort studies.

METHODS

We accessed nationwide medical registries to conduct a population-based, nested case-control study of risk factors for brain abscess. We applied risk-set sampling for the selection of population controls (1:10), who were individually matched by age, sex, and area of residence. Conditional logistic regression was used to compute adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Population-attributable fractions were calculated.

RESULTS

We identified 1384 brain abscess patients in Denmark from 1982 through 2016, and 13 839 matched population controls. The median age of patients was 50 years (interquartile range 33-63) and 37% were female. Cases often had Charlson comorbidity scores >2 (16%), compared with controls (3%). Our calculated aORs were 2.15 (95% CI 1.72-2.70) for head trauma; 19.3 (95% CI 14.3-26.0) for neurosurgery; 4.61 (95% CI 3.39-6.26) for dental infections; 2.57 (95% CI 1.71-3.84) for dental surgery; 3.81 (95% CI 3.11-4.67) for ear, nose, and throat infection; 2.85 (95% CI 2.21-3.70) for ear, nose, and throat surgery; 15.6 (95% CI 9.57-25.4) for congenital heart disease; 1.74 (95% CI 1.33-2.29) for diabetes mellitus; 2.22 (95% CI 1.58-3.11) for alcohol abuse; 2.37 (95% CI 1.53-3.68) for liver disease; 2.04 (95% CI 1.30-3.20) for kidney disease and 8.15 (95% CI 3.59-18.5) for lung abscess or bronchiectasis. The aORs were 4.12 (95% CI 3.37-5.04) for solid cancer; 8.77 (95% CI 5.66-13.6) for hematological cancer; 12.0 (95% CI 6.13-23.7) for human immunodeficiency virus; and 5.71 (95% CI 4.22-7.75) for immunomodulating treatments. Population-attributable fractions showed were substantial contributors to the occurrence of brain abscess neurosurgery (12%); solid cancer (11%); ear, nose, and throat infections (7%); and immunomodulating treatments (5%).

CONCLUSIONS

Important risk factors included neurosurgery; cancer; ear, nose, and throat infections; and immunomodulating treatments.

Septic cavernous sinus thrombosis: A review

Septic cavernous sinus thrombosis (SCST) is a rare, yet severe, process typically arising from infections of the paranasal sinuses (predominately ethmoid and/or sphenoid sinusitis) and less commonly, otogenic, odontogenic, and pharyngeal sources. Clinical symptoms of SCST arise from obstruction of venous drainage from the orbit and compression of the cranial nerves within the cavernous sinus. In the preantibiotic era SCST was considered universally fatal (80-100%); however, with the introduction of antibiotics the overall incidence, morbidity, and mortality of SCST have greatly declined. In spite of dramatic improvements, morbidity and mortality remain high, with the majority of patients experiencing neurological sequalae, highlighting the severity of the disease and the need for prompt recognition, diagnosis, and treatment. Here we review of the literature on SCST with a focus on the current recommendations and recent evidence for diagnostic and medical management of this condition.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Risk factors of orbital complications in outpatients presenting with severe rhinosinusitis: A case-control study

OBJECTIVES

We assessed associations of potential factors with orbital complications in acute rhinosinusitis (ARS) patients.

DESIGN

An unmatched case-control study.

SETTING

A tertiary referral hospital in Thailand.

PARTICIPANTS

Consecutive outpatients of any age with severe ARS (visual analog scale ≥ 7) with and without orbital complications.

MAIN OUTCOME MEASURES

Patients were enrolled from January 2013 to December 2018. Forty-three ARS patients (55.8% female, median age 45.6, (range 2.0-93.0) years) were included, with 19 patients in the complicated group and 24 in the uncomplicated group. Patient characteristics (gender, age, diabetes, immune status), symptoms and signs, site of infection and type of pathogenic bacteria were recorded and assessed their associations with orbital complications by univariable and multivariable logistic regression analyses. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

The most common orbital complication was subperiosteal abscess (42.1%), followed by orbital cellulitis (15.8%) and cavernous sinus thrombosis (10.5%). Multivariable logistic regression analysis demonstrated a positive association with orbital complications (pseudo R² 0.4) for ethmoid sinusitis (OR 31.1, 95% CI [2.3-430.6]) and a short duration of symptoms (OR 0.9, 95% CI [0.8-0.9]).

CONCLUSIONS

Orbital complications were associated with ethmoid sinusitis with a short duration of ARS symptoms.

Incidence of Odontogenic Disease in Patients With Pott's Puffy Tumor

PURPOSE

Osteomyelitis with subperiosteal abscess of the frontal bone, or Pott's puffy tumor (PPT), is a rare but life-threatening condition. The relationship of concurrent dental disease to PPT has not been well described. This study sought to delineate the incidence of odontogenic disease in PPT, especially in cases where there is no history of facial trauma or prior frontal sinus surgery.

METHODS

A retrospective chart review of patients diagnosed with PPT between 2010 and 2019 was carried out. Demographics, pertinent medical history, surgical procedures performed, and microbial cultures and antibiotics used were extracted for analysis. Maxillofacial computed tomography scans were reviewed for presence of odontogenic disease.

RESULTS

A total of 17 patients were identified. Four had documented history of frontal bone trauma; 3 had previous frontal sinus surgery. Seven (41%) had documented odontogenic disease on initial radiology reports; however, upon dentist review, 16 (94%) had various pathology visible on their computed tomography scans. Twelve of these 16 patients had no previous frontal sinus trauma or surgery. Eight patients (47%) had only ipsilateral maxillary or ethmoid inflammation respective to PPT on computed tomography. Seventy-six percent of patients underwent endoscopic sinus surgery. Of 14 patients with cultures collected at the time of surgery, 7 (50%) had polymicrobial growth and 6 (43%) had anaerobic growth.

CONCLUSIONS

The incidence of odontogenic disease in this population of PPT was 94%. In the absence of a history of frontal bone trauma or frontal sinus surgery, underlying dental origin should be suspected in cases of PPT. Initial radiology reports may not document all identifiable dental pathology. Therefore, patients presenting with PPT should undergo comprehensive evaluation, including an oral cavity and dental examination, and potential referral to dental colleagues.

Frontal sinusitis in adult beef bulls: 18 cases (1999-2014)

OBJECTIVE

To characterize frontal sinusitis unrelated to standard dehorning procedures in adult beef bulls.

ANIMALS

18 beef bulls > 2 years of age treated for frontal sinusitis at a veterinary medical teaching hospital between May 1999 and May 2014.

PROCEDURES

Medical records were reviewed. Information obtained for each bull included signalment, history, findings from physical examination and diagnostic procedures, treatment, and survival to discharge. Long-term follow-up (≥ 1 year) was obtained from owners by telephone.

RESULTS

18 bulls were included, and 17 were bucking bulls. Median age and duration of signs were 4.5 years and 23 days, respectively. The most common owner complaints were nonspecific signs (eg, separation from the herd, hypo- or anorexia, and weight loss; n = 10) and suspected horn or sinus infection (7). Only 8 bulls had nasal discharge, and only 7 of the 17 bulls for which the rectal temperature was recorded were febrile. Results of radiography indicated frontal sinusitis in 12 of 13 bulls, with increased opacity of the affected sinus (n = 11) noted most commonly. Seventeen bulls were discharged from the hospital alive. Long-term follow-up was obtained for 14 bulls, including 13 bucking bulls. All 14 bulls recovered fully, and 9 of the 13 bucking bulls performed well after treatment.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that frontal sinusitis should be considered as a differential diagnosis in beef cattle examined for nonspecific clinical signs and that, with appropriate treatment, the prognosis is good for long-term survival in affected beef cattle.

Our experience in the management of orbital complications in acute rhinosinusitis

BACKGROUND AND OBJECTIVE

The spread of an infection from the paranasal sinuses is rare but severe. Between 4% and 20% of all rhinosinusitis can become complicated, orbital involvement being the most frequent (60-75%). Orbital complications are more common in children but more severe in adults. We aim to analyse the epidemiological characteristics of these patients and to propose a management algorithm.

MATERIALS AND METHODS

We carried out a retrospective review of 21 patients with orbital complications of acute rhinosinusitis diagnosed in the same institution from 2005 to 2018. The diagnosis was based on clinical history, endoscopic examination and imaging tests. All patients received an intravenous antibiotic and were assessed by ophthalmology. An immediate surgical treatment was performed in the case of an abscess or poor response to medical management.

RESULTS

The average age was 24 years. Fifty-two percent were males and 48% females. According to Chandler's classification, 43% (9/21) had preseptal cellulitis (7 adults and 2 children), 10% (2/21) orbital cellulitis (one adult and one child), 43% (9/21) subperiosteal abscess (2 adults and 7 children), there was one case of orbital abscess in an adult and there were no cases of cavernous sinus thrombosis. A CT scan was performed in all patients and the cases of subperiosteal or orbital abscess were treated surgically, except 2 paediatric patients (<4 years) with a small and medial subperiosteal abscess (<4mm) who responded well to medical treatment. The surgical approach is performed by endonasal endoscopy, perforating the lamina papyracea in cases of subperiosteal abscess and also opening the periorbita in orbital abscess. It was combined with an external palpebral approach in the 4 cases that presented a superior or lateral abscess. Two young adults (10%) presented an intracranial complication concomitantly.

CONCLUSION

Orbital complications of acute rhinosinusitis are rare but potentially severe. It is important to be aware of and suspect them in order to act quickly. It is essential to define the location and extension of the infection for correct management, as well as multidisciplinary treatment. The surgical approach is performed by endonasal endoscopy. It is limited by abscesses located on the roof of the orbit or on the lateral wall, when a combined external palpebral approach is required.

Management Patterns in Pediatric Complicated Sinusitis

OBJECTIVES

Sinusitis is a common pediatric illness that can be complicated by periorbital or intracranial extension. Patients can be managed with antimicrobials alone or in conjunction with surgical intervention. This article examines management patterns and outcomes in pediatric patients presenting with complicated sinusitis.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

An evaluation of 168 pediatric patients with complicated sinusitis with periorbital complications presenting at a single institution from 2008 to 2018 was performed. Demographics, disease characteristics, in-hospital management, and outcomes were recorded and analyzed.

RESULTS

The most common complication was orbital cellulitis, seen in 49% of children. Surgical intervention occurred in 49% of patients, with 36% receiving medical therapy followed by surgery (MTS). Chandler I patients underwent surgical intervention 30% of the time, Chandler II patients 29%, and Chandler III patients 83%. Nineteen percent of initially nonoperative patients started on ampicillin-sulbactam required MTS vs 57% of those started on other antibiotic regimens (P = .01). Twelve percent of initially nonoperative Chandler I to II patients started on ampicillin-sulbactam needed MTS vs 40% started on other antibiotic regimens. Hospital charges for operative patients were $45,056 vs $14,311 for nonoperative patients (P < .01). Hospital charges for patients with surgery followed by medical therapy (SMT) were $45,563 vs $44,393 for MTS (P = .92).

CONCLUSION

Nonoperative early stage patients started on ampicillin-sulbactam had a lower risk of MTS. MTS did not cost significantly more than SMT, and there were no significant outcome differences seen.

Trends in complications of pediatric rhinosinusitis in the United States from 2006 to 2016

OBJECTIVES

1) Evaluate the changing prevalence of complications from pediatric acute bacterial rhinosinusitis and 2) elucidate factors associated with the development of complicated acute rhinosinusitis in this population.

STUDY DESIGN/SETTING

Cross-sectional analyses of the Kids' Inpatient Database.

SUBJECTS AND METHODS

Children <20 years with a diagnosis of acute rhinosinusitis were included. Diagnosis codes pertaining to acute rhinosinusitis-related complications were then queried for each subject. All patients were ultimately categorized into one of four groups: uncomplicated acute rhinosinusitis, orbital complications, intracranial complications, or both orbital and intracranial complications. Weighted measures were applied to provide national estimates.

RESULTS

Over the decade studied, national estimates for children admitted with acute rhinosinusitis decreased from 8,312 cases in 2006 to 5,592 in 2016. There was an increase in the rate of orbital complications from 8.9% to 19.3% and intracranial complications from 2.2% to 4.3%. Children with both complications increased from 0.5% to 1.0% of cases. Children with orbital complications were significantly younger (8.6 years) compared to those with intracranial complications (12.4 years) and both complication types (12.2 years) (p < 0.001).

CONCLUSION

Despite an overall decrease in cases of acute rhinosinusitis, rates of orbital and intracranial complications continued to increase over a ten-year period. Antibiotic prescribing patterns, vaccination effects, and evolving practice patterns may help explain these observations. Further studies warrant investigation into the cause of these trends.

LEVEL OF EVIDENCE

4.

Neuronavigation-Guided Endoscopic Endonasal Drainage of Pediatric Anterior Cranial Base Epidural and Subdural Empyema

In children, epidural and/or subdural intracranial empyema can complicate frontal sinusitis or pansinusitis. The standard transcranial approach used to treat epidural or subdural empyema has many drawbacks, but these can be avoided with an endoscopic expanded endonasal approach (EEA). To support the feasibility and advantages of this approach, we report the successful drainage through endoscopic EEA of a bifrontal empyema caused by an intracranial extension of pansinusitis. Our case and the ones previously reported in the literature establish well that endoscopic EEA offers several advantages over the standard craniotomy. Hence, EEA should be considered as an alternative to the transcranial approach when surgically draining anterior skull base empyema resulting from pansinusitis in children.

Management of Orbital Complications of Acute Rhinosinusitis in Pediatric Patients: A 15-Year Single-Center Experience

BACKGROUND

The major clinical dilemma managing acute rhinosinusitis (ARS) in pediatric population is distinguishing uncomplicated rhinosinusitis from a complicated bacterial ARS and orbital complications, the latter requiring antimicrobials and surgical intervention. However, factors associated with severe orbital complications and the optimum management strategy remains controversial. The objectives of this study were to characterize the clinical outcomes of children with orbital complications of ARS and to identify risk factors associated with disease severity.

METHODS

This retrospective cohort analysis evaluated the clinical outcomes of 61 children admitted for orbital complications between January 1, 2002 and December 31, 2017. Descriptive statistics were performed to examine the demographics and clinical findings. We compared groups using Mann-Whitney U test for continuous variables and χ for categorical variables.

RESULTS

Although two-thirds of children had received prehospital antibiotics, half of the cohort presented with post-septal orbital complications. While 83% of isolates obtained from the same patients were susceptible to the prehospital antibiotics given, the majority of those who received prehospital antibiotics nevertheless required surgical intervention. We observed significant association between the age of presentation and disease severity. Children >5 years of age presented with more severe orbital complications despite prehospital antibiotics and were more likely to require surgical intervention (P < 0.001).

CONCLUSIONS

In this study, stage II/III orbital complications at presentation and older age were the most important determinants of medical treatment failure. Early referral to eye, nose and throat (ENT) should be considered for children >5 years with ARS due to worse orbital complications despite prehospital antibiotics.

Outcomes of endoscopic sinus surgery for sinusitis-induced intracranial abscess in patients undergoing neurosurgery

OBJECTIVE

Although sinusitis-induced intracranial complications rarely occur in the current era of antibiotics, they can induce neurological symptoms or death. The authors of this study investigated the association between endoscopic sinus surgery (ESS) and outcomes in patients who had undergone neurosurgical procedures for sinusitis-induced intracranial abscess.

METHODS

The authors obtained data on patients with sinusitis-induced intracranial abscess from the Japanese Diagnosis Procedure Combination inpatient data for the period from 2010 to 2017. They excluded patients with fungal sinusitis, orbital complications, immunodeficiency, and malignant disease. They also excluded patients who had received antifungal agents, chemotherapy, immunosuppressants, and antidiabetic drugs. Eligible patients were divided into those with and those without neurosurgical procedures. Propensity score-adjusted regression analyses were performed to examine the association between ESS within the same hospitalization and outcomes (mortality, blood transfusion, readmission, revision neurosurgery, and length of stay).

RESULTS

Of the 552 potentially eligible patients, 255 were treated with neurosurgical procedures, including 104 who underwent ESS within the same hospitalization and 151 who did not. ESS was not significantly associated with mortality (OR 0.54, 95% CI 0.05-5.81, p = 0.61), blood transfusion (OR 1.95, 95% CI 0.84-4.51, p = 0.12), readmission (OR 0.86, 95% CI 0.34-2.16, p = 0.75), revision neurosurgery (OR 0.65, 95% CI 0.24-1.74, p = 0.39), or length of stay (percent difference -10.8%, 95% CI -24.4% to 5.1%, p = 0.18).

CONCLUSIONS

The present study suggests that ESS may not have significant benefits with respect to reducing mortality, blood transfusion, readmission, revision neurosurgery, or length of stay.

Innovations in Endonasal Sinus Surgery in Children

Although there have been many advances in new tools and procedures for endonasal sinus surgery in children, the management and care for pediatric chronic rhinosinusitis has remained relatively unchanged. However, there have been advances in skull base surgery and tumor removal and new knowledge about perioperative concerns in children. This article discusses the role and risks of endoscopic sinus surgery, the use of balloon sinuplasty in children, management of complicated rhinosinusitis, and advances in skull base tumors and choanal atresia repair.

Non-Traumatic Pneumocephalus and Sub-Dural Empyema as a Complication of Chronic Sinusitis

Infectious sinusitis is extremely common in children, and persistent infection can lead to many complications. The most dangerous and commonly reported complications are intracranial. These intracranial complications include pneumocephalus, cerebral abscess, subdural empyema, meningitis, cellulitis, orbital abscess, and cavernous sinus thrombosis. Pneumocephalus is the presence of air in the cranium and sometimes it can lead to intracranial infection and localized pus collection in the potential space between meninges. Herein, we report a case of a 12-year-old girl who presented to a pediatric emergency in a confused and disoriented state. The cerebrospinal fluid (CSF) analysis provided a picture of bacterial meningitis, but her CT scan showed pneumocephalus and subdural empyema. This case report will help clinicians overcome this diagnostic challenge using the appropriate imaging and treatment modalities to prevent neurological sequelae.

Pneumocephalus as a Rare Presentation of Acute Sinusitis with Intracranial Extension – Two Cases and a Review of Literature

Pneumocephalus is a rare presentation of sinusitis. The purpose of this case series and literature review is to highlight the critical importance of recognizing pneumocephalus on initial brain imaging, since it may serve as the first sign of acute sinusitis with intracranial complication. Although sinusitis is a treatable condition with appropriate and timely antibiotic therapy, failure to recognize intracranial extension and delays to prompt surgical drainage could lead to a dire clinical course.

The Microbiology of Complicated Acute Sinusitis among Pediatric Patients: A Case Series

OBJECTIVE

The microbiology of pediatric complicated acute rhinosinusitis (ARS) has evolved, and our current understanding of pathogenic organisms is limited. The objectives of this study are to describe the incidence of pathogens causing complicated ARS requiring surgical intervention at our institution over a 10-year period as well as their associated treatment outcomes.

STUDY DESIGN

Retrospective cohort study.

SETTING

A single tertiary care children's hospital.

SUBJECTS AND METHODS

Data were reviewed from all patients who underwent surgery for complicated ARS and had positive culture data from 2006 to 2016. Associations among pathogens, complications, and outcomes were analyzed with Pearson χ² and Wilcoxon rank-sum tests.

RESULTS

Eighty-nine patients met criteria. Complications included orbital infections (78%), intracranial infections (48%), Pott's puffy tumor (13%), and cavernous sinus thrombosis (9.0%). Bacterial isolates were majority polymicrobial (55%) and included Streptococcus species (58%), Staphylococcus species (49%; including methicillin-resistant S aureus [MRSA], 11%), and anaerobic bacteria (35%). S pneumoniae (9.0%), Haemophilus species (4.5%), and Moraxella catarrhalis (1.1%) were relatively uncommon. Bacterial isolates were similar among patients with all types of complications.

CONCLUSION

Among a large cohort of pediatric patients with complicated ARS, most bacterial isolates were polymicrobial, with Streptococcus and Staphylococcus species contributing to the majority of cases. S aureus species, including MRSA and anaerobic pathogens, were common. The pattern of bacterial isolates was similar among patients with all types of complications of ARS. We suggest treatment for complicated ARS with broad-spectrum antibiotics with coverage for Streptococcus species, Staphylococcus species including MRSA, and anaerobic bacteria.

Correlation of imaging and intraoperative findings in Pott’s puffy tumour

Introduction

Pott’s puffy tumour is characterised by frontal bone osteomyelitis accompanied by subperiosteal abscess. It can be further complicated by intracranial extension of the infectious process.

Case presentation

A 12-year-old boy initially presented with signs and imaging findings of pan-sinusitis. Despite antibiotic therapy, there was progressive swelling of the forehead region. Subsequent imaging studies revealed osteomyelitis of frontal bone, subcutaneous abscess and extension into intracranial space. The abscesses were surgically drained, and craniectomy for osteomyelitis was carried out.

Conclusion

The initial symptoms of Pott’s puffy tumour can be subtle, and antibiotic use may mask the underlying sinister involvement of intracranial structures. Imaging plays an important role both in diagnosis and detection of possible intracranial complications.

Intracranial complications of pediatric sinusitis: Identifying risk factors associated with prolonged clinical course

OBJECTIVE

Intracranial extension is one of the most serious and morbid complications of pediatric sinusitis. Managing this complication continues to be challenging even after widespread pneumococcal vaccination adoption. We aim to identify risk factors associated with complicated clinical courses, and to assess for altering microbial communities and increased antibiotic resistance.

METHODS

A retrospective review was conducted of sinus procedures performed at a single institution for acute sinusitis with intracranial extension, and 16 cases were identified. Variables collected included patient demographics, vaccination status, laboratory results, imaging data, antibiotic therapy, sinus and intracranial cultures, perioperative and surgical reports, and hospital course.

RESULTS

The average patient age was 11.9 years, and 75% were male. The dominant microbial organisms were gram positive in 93.8% (15/16) of cases and 37.5% (6/16) were anaerobic. There were no cases of resistant bacterial growth, and only one case of Streptococcus pneumoniae. Increased antibiotic therapy duration was associated with anaerobic and polymicrobial sinus cultures. A significant increase in length of hospital stay was identified in polymicrobial sinus cultures and frontal sinus involvement. Intracranial abscess re-accumulation was associated with sinus cultures positive for fusobacterium (p = 0.036), polymicrobial infections (p = 0.034), and involvement of brain parenchyma (p = 0.036). Patients with frontal sinus involvement required a greater number of surgical procedures for abscess drainage (p = 0.046). An anaerobic intracranial culture was associated with an increased number of revision craniotomies (p < 0.001). Parenchymal involvement of the infection was associated with an increased number of surgical complications.

CONCLUSIONS

Frontal sinus involvement, and anaerobic and polymicrobial sinus cultures were predictive of a more severe infection requiring more surgical interventions, prolonged intravenous antibiotic treatment and overall hospital length of stay. Streptococcus pneumoniae was not prevalent in our series, and there seems to be a shift in the microbial profile of this patient subset, compared to previous studies, which can likely be attributed to the adoption of pneumococcal vaccinations. Sinus cultures were more predictive of a complicated clinical course compared to intracranial cultures, suggesting the importance of a thorough sinus debridement and obtaining directed sinus cultures.

Prognosis of septic cavernous sinus thrombosis remarkably improved: a case series of 12 patients and literature review

Purpose

Septic cavernous sinus thrombosis (CST) is a rare complication of infections in the head and neck area. CST is notorious for its bad prognosis, with high mortality and morbidity rates described in literature. However, these rates are based on old series. We question whether the prognosis of CST is currently still as devastating. The primary purpose of this study is to assess the mortality and morbidity of CST.

Methods

Using the databases of all relevant specialties in our tertiary referral hospital, we collected all the patients treated for CST in the period 2005–2017. In addition, a PubMed search, using the mesh term ‘cavernous sinus thrombosis’, was performed.

Results

We found 12 patients with CST in the study period. Of the 12 patients, 11 survived and 9 recovered without any permanent deficits. Seven patients were treated with anticoagulation, and in none of the patients we saw hemorrhagic complications. In literature, older articles describe higher mortality rates (14–80%), but more recent articles report mortality and morbidity rates similar to our results.

Conclusions

The prognosis of CST nowadays is more favorable than previously described. Anticoagulation seems to be a safe addition to antibiotic and surgical treatment, at least in patients without central nervous system infection.

Intracranial Complications of Pediatric Sinusitis

"Headache and fever" is a common presentation to the urgent care and emergency department setting and can have many etiologies. We present a case of a 10-year-old girl who presented with headache and fever and was found to have intracranial extension of sinusitis despite lack of typical sinus or chronic upper respiratory tract infection symptoms. This case illustrates the need in the emergency department or urgent care to keep a broad differential diagnosis for pediatric headache, especially when initial interventions are unsuccessful. We also review the epidemiology of pediatric sinusitis, age at sinus development, and associated intracranial complications.

Intracranial complications of acute sinusitis in children: The role of endoscopic sinus surgery

OBJECTIVE

To study the role of endoscopic sinus surgery (ESS) in the management of intracranial complications of children with acute rhinosinusitis METHODS: Retrospective chart review at a tertiary care pediatric hospital MAIN OUTCOMES: Demographics, intracranial complications, length of hospital stay (LOS), neurological sequelae, ESS, neurosurgical procedures RESULTS: Twenty-four children with a mean age (SD) of 12.9 years (+/-3.2) with an intracranial complication(s) of acute rhinosinusitis were identified between 2005-2016. A total of 22 were included and 15 (68%) of these were males. The most common complications were: subdural abscess (n=10), epidural abscess (n=10), meningitis (n=5), intraparenchymal abscess (n=5), and cavernous sinus thrombosis (n= 2). Neurologic symptoms included headache (n=12), hemiparesis (n=5) and aphasia (n=3). Average length of stay was 16 (+/- 9.2) days. Average follow up was 7 (+/-5.6) months. One patient had residual seizures and 1 had recurrent rhinosinusitis. Aphasia and hemiparesis resolved in all patients within 1 year. Nineteen (86%) patients had ESS within 4 days of admission. Fourteen patients (63%) had a neurosurgical procedure, 6 (27%) required more than 1 neurosurgical procedure. Six patients (27%) had concurrent neurosurgical drainage and ESS. Four patients (17%) had neurosurgical procedure followed by ESS and 3 patients (13%) were treated only by a neurosurgical procedure. Patients who underwent ESS prior to a neurosurgical procedure had significantly less risk of needing a neurosurgical intervention (OR = .02, p < .01). There was a significantly higher proportion of neurosurgical patients with positive Strep anginosus cultures compared to the ESS only group (85.7% vs 37.5%, p = .02). Studies with larger patient populations are needed to determine the role of ESS in the management of intracranial complications of children with acute rhinosinusitis.

DISCUSSION

Early ESS may be associated with less need for neurosurgical procedures.

Simultaneous treatment of intracranial complications of paranasal sinusitis

PURPOSE

The objective of this study was to analyse 51 patients with intracranial complications of sinusitis treated in the Department of Otolaryngology and Laryngeal Oncology at Poznań University of Medical Sciences from 1964 to 2016.

MATERIALS AND METHODS

Males made up a significant portion of study participants at 70.5%. Treatment included simultaneous removal of inflammatory focal points in the paranasal sinuses and drainage of cerebral and epidural abscesses and subdural empyemas under the control of neuronavigation preceded by the implementation of broad-spectrum antibiotics continuously for 4 weeks. Seventy-three intracranial complications were found among 51 patients. Of the 51 patients, 25 had frontal lobe abscesses (including multiple abscesses). Other complications included the following: 16 epidural abscesses, 9 subdural empyemas, 15 meningitis cases, 3 intracerebral abscesses, 3 sinus thrombosis cases and 2 patients with cerebritis. Co-occurrence of these complications worsened the state of the patient and increased the duration of treatment. Patients with frontal lobe abscesses had a better prognosis and less pronounced neurological symptoms in recent years versus earlier treatment approaches.

CONCLUSIONS

Simultaneous treatment of intracranial complications of sinusitis is an effective treatment method that has minimal burden for the patient. From 1964 to 1978, three deaths (17%) were reported among patients with these complications. Since 1978, no deaths were reported in the clinic.

Intracranial Complications of Pediatric Frontal Rhinosinusitis

Background

The aim of this study was to review the presentation and management of children admitted for intracranial complications arising from frontal rhinosinusitis. We performed a retrospective case series review at two academic tertiary care children's hospitals.

Methods

This study consisted of children <18 years old who presented with intracranial complications from frontal rhinosinusitis between January 1, 1990 and December 31, 2002. Relevant literature was reviewed with the assistance of Medline. Presentation, type of intracranial complication, radiographic evaluations, response to treatment, and prognosis were evaluated.

Results

Sixteen patients were identified with intracranial complications due to frontal rhinosinusitis. Patients were usually older (mean age, 14 years and 3 months), of male gender (M/F, 4.3:1.0), and African American (AA/W, 3.0:1.0). Headache, nasal congestion, and visual changes were the most common early symptoms and neurological findings indicated advanced disease. Subdural (56%), epidural (44%), and cerebral abscesses (19%) were the most common complications. Meningitis alone was identified in 13% and was associated with another intracranial complication in 6%. Multiple intracranial complications were noted in 31%. Polymicrobial cultures were obtained in 50% of patients. Although CT was excellent in identifying orbital pathology, MRI was superior for characterization of intracranial disease.

Conclusion

Intracranial complications of frontal rhinosinusitis are rare in children. Early symptoms often are nonspecific, with neurological findings more commonly seen in advanced disease. Adolescent African American male patients were found to be at highest risk for intracranial complications from frontal rhinosinusitis. Headache and orbital complaints associated with rhinosinusitis in older children failing to respond to initial therapy should prompt an aggressive evaluation including MRI.

Complications of Sinusitis

From 1982 to 1992, 65 patients presented to our service with sinusitis complications. In this report we will analyze our clinical material with emphasis on the type of complications, clinical presentations, and radiologic findings. The most common complication was orbital (83.1%), followed by intracranial (18.5%) and bony (7.7%). There was a higher incidence of complications in the second decade of life (44.6%), and 83.2% of the cases occurred in the third decade of life. The main complaints were orbital swelling (63.1%), fever (33.8%), headache (32.3%), and rhinorrhea (21.5%). The predominant signs were eyelid swelling (73.8%) and rhinorrhea (64.6%). The most frequent radiologic findings (x-ray, CT, MRI) were pansinusitis (40%), maxilloethmoidal sinusitis (24.6%), and maxillary sinusitis (13.8%). All patients were treated with intravenous antibiotics, and surgery was performed in 50.8% of the patients. Almost all patients (98.5%) had a good outcome, and one patient died (cavernous sinus thrombosis). Complicated sinusitis can be a life-threatening condition. CT and MRI are a great aid in the diagnosis of these complications.