Abscess of the clivus in an adolescent with complicated acute rhinosinusitis: a case report

Lorenzo Solimeno,Lorenzo Pignataro,Elisabetta Iofrida,Claudio Guastella,Paola Marchisio,Claudia Tagliabue,Samantha Bosis,Giada Maria Di Pietro,Sara Torretta

doi:10.1186/s13052-020-00863-y

Abstract

BackgroundComplications of acute sinusitis affecting multiple sites are very uncommon, and generally develop for a delayed diagnosis of the primary infection, with possible severe and life-threatening evolution. Patients can have variable presentations according to the site and extent of the infection. Multiple forms generally include the coexistence of orbital manifestations and intracranial infections. We here present a case with unusual multiple sites locations (i.e.: intraorbital intraconic abscess, sigmoid sinus thrombosis, preclival abscess, multiple splanchnocranium osteomyelitic processes).Case presentationA 13-year-old male presented at our hospital with right progressive orbital oedema with eyesight worsening and signs of meningitis. Computed tomography and magnetic resonance (MRI) demonstrated right intraorbital intraconic abscess, left sphenoidal sinusitis, transverse and sigmoid sinus thrombosis. Ophthalmologic evaluation documented a right optic nerve sufferance. Endoscopic and superior right trans-palpebral surgical decompression was performed, and the abscess was drained. Microbiological analysis revealed the presence of multi-sensitive Streptococcus Intermedius. Subsequent prolonged antibiotic and anti-thrombotic treatments were started. In the following two-weeks the sinusal and ophthalmologic clinical conditions improved, whereas the patients complained of mild to moderate cervical pain and suffered from intermittent pyrexia. Control MRI documented clival abscess extending up to preclival soft tissues posterior to the nasopharynx, associated with mandible osteomyelitis, occipital condyles and anterior part of the temporal bone hyper intensity. Endoscopic trans-nasal surgical approach to the clival compartment with neurosurgery navigation-guided achieved preclival abscess drainage. Complete clinical and radiological recovery was achieved after 45 days of medical treatment.ConclusionsMultiple sites complicated rhinosinusitis is uncommon, and its management is challenging. A proper history and thorough clinical examination along with a radiological evaluation are key factors in the final diagnosis of patients with complicated multiple sites acute rhinosinusitis. A quick multidisciplinary approach is always necessary to avoid unwanted life-threatening complications.

Highlights

Complications of acute sinusitis affecting multiple sites are very uncommon, and generally develop for a delayed diagnosis of the primary infection, with possible severe and life-threatening evolution
Sinonasal-related orbital infection (SROI) are characterised by various clinical manifestations that may develop anteriorly or posteriorly to the orbital septum, a thin fibrous membrane extending from the orbital rims to the eyelids that acts as a barrier against the spread of external infections to the deep orbit
Sub-periosteal abscess (SPA) accounts for 9–28% of all SROIs [3] and is generally secondary to ethmoiditis; it is more frequently located in the medial portion of the orbit [3], but other less frequent locations include superior and superomedial SPA generally due to frontal sinusitis [3]

Summary

Conclusions

Multiple sites complicated rhinosinusitis is uncommon, and its management is challenging. A proper history and thorough clinical examination along with a radiological evaluation are key factors in the final diagnosis of patients with complicated multiple sites acute rhinosinusitis. A quick multidisciplinary approach is always necessary to avoid unwanted life-threatening complications

Findings

Background

Discussion and conclusions