Aggressive evaluation, treatment urged for sinusitis with other complications

Hicks CW. Pediatr Infect Dis J. 2011;30:222-226.

Pediatric patients admitted to medical facilities for acute sinusitis with accompanying neurological problems should be treated early and aggressively to avoid more serious sequelae, according to a recent study.

Researchers with the Cleveland Clinic Foundation reported on results of a retrospective chart review of all pediatric patients admitted for intracranial complications of sinusitis during a 10-year period.

Of the 13 children profiled, eight demonstrated some degree of neurological complications and required rehabilitation after their hospital stay, the researchers said. Epidural and subdural empyema was commonly noted. One child had a brain abscess. All of the children showed signs of a bacterial infection.

Most of the 13 children had elevated C-reactive protein values, leukocytosis and erythrocyte sedimentation rates. Physical examinations showed Pott’s puffy tumor orbital cellulitis, new-onset seizures, nuchal rigidity, hemiparesis and visual disturbances in many patients, the researchers wrote in the online edition of The Pediatric Infectious Disease Journal.

The researchers said these symptoms “may prove useful in screening patients who are at greater risk of intracranial complications of sinusitis.”

Although rare and difficult to diagnose, intracranial complications of sinusitis “can result in devastating consequences,” they said. “It is critical that clinicians remain alert for clinical signs and symptoms that may indicate the onset of this potentially serious disease.”

Disclosure: The researchers reported no relevant financial disclosures.

The most common suppurative complications of acute bacterial sinusitis involve the orbit and the central nervous system in that order. Orbital complications of acute sinusitis have been divided into 5 categories: sympathetic effusion, subperiosteal abscess, orbital cellulitis, orbital abscess and cavernous sinus thrombosis. Although sympathetic effusion (inflammatory edema), is categorized as an orbital complication, the site of infection remains confined to the sinus cavities; eye swelling is due to the impedance of venous drainage secondary to congestion within the ethmoid sinuses. The remaining “true” orbital complications are best visualized by CT scanning. Intracranial complications of acute sinusitis, which are substantially less common than orbital complications, are more serious, with higher morbidity and mortality than those involving the orbit. Intracranial complications include subdural empyema, epidural empyema, brain abscess and meningitis.

There have been no head-to-head comparisons of the diagnostic accuracy of CT scanning to MRI in the evaluation of orbital and intracranial complications of sinusitis in children. In general, the CT scan has been the preferred image when complications of sinusitis are suspected. However, there are documented cases in which a CT scan has not disclosed the pathology responsible for the clinical presentation and the MRI has, especially for intracranial complications and rarely for orbital complications. Accordingly, the most recent Appropriateness Criteria from the American College of Radiology, endorses MRI and CT as complementary examinations in complications of sinusitis. The availability and speed of obtaining the CT are desirable, albeit, there is increasing concern regarding exposure to radiation; nonetheless, it should be the first study to be performed. The MRI, although very sensitive, takes longer than the CT and often requires sedation in young children. MRI should be performed when there is persistent clinical concern or incomplete information has been provided by the CT scan.

– Ellen R. Wald, MD

Professor and Chair, Department of Pediatrics,
University of Wisconsin School of Medicine and Public Health

Disclosure: Dr. Wald reports no relevant financial disclosures.

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