Acute symptomatic seizures as a complication of rhinosinusitis in children

Abstract

When an otorhinolaryngologist thinks of acute seizures in children, what comes to mind are intracranial complications of infection within the sinuses or the temporal bone. Complications of rhinosinusitis, both in children and adults, may involve the orbit, soft tissues surrounding the nose and sinuses, and intracranial spread of the infection. Intracranial complications secondary to rhinosinusitis, intracranial abscesses and/or thrombophlebitis, occur sporadically and, although it appears that they cannot be prevented, early recognition and treatment are essential to reduce any subsequent morbidity or mortality [1]. The commonest presenting symptoms of intracranial complications are headaches (80%) followed by vomiting (45%) and swelling of the forehead (45%), an altered mental state, fever, seizure, unilateral weakness or hemiparesis, or a cranial nerve sign [1,2]. Exact pathogenesis of intracranial abscesses remains unclear [3]. Apart from rhinosinusitis, congenital cyanotic heart disease was identified as a predisposing factor, likewise otitis media or mastoiditis, dental abscesses and immunodeficiency [3]. The diagnosis of cerebral abscess is often difficult. The classical intracranial hypertension associated to high fever is usually incomplete and sometimes absent [4]. In most cases (60%), it is from the frontal sinus that the infection spreads intracranially [2]. In patients with intracranial complications of rhinosinusitis, frequency of seizures reaches 10–25% [1,3,5]. Epilepsy caused by intracranial complications is usually a long-term morbidity [1]. Above enumerated presenting symptoms justify an urgent magnetic resonance imaging (MRI) or computed tomography (CT) scan. The importance of imaging before a lumbar puncture cannot be overemphasized [1,6]. Since the availability of CT, both diagnostic delay after hospital admission and mortality were substantially reduced: mean delay from 8 to 3 days, andmortality from 25% to almost 0% [3]. In patients with intracranial complications, acute symptomatic seizures are usually accompanied by other neurological symptoms: fever in 50% of cases, headache in 75% of cases, and intracranial hypertension syndrome in 25% of cases [4]. The condition requires sinus surgery in order to drain the primary focus of the infection [2,7]. At the same time, prompt and aggressive medical and neurosurgical intervention is required, aiming tominimize the morbidity and mortality and to maximize the favorable outcome in those children [2]. The neurosurgical procedures aim to drain the abscess and include burr whole drainage or aspiration of abscess, craniotomy and evacuation of empyema, or craniotomy [2]. Central nervous system scars with subsequent seizures can be sequels of intracranial abscess therapy and are more common after excision of the brain abscess when compared to patients treated by aspiration and/or antibiotics alone [2,3,7]. Therefore, excision of brain abscess should be avoided *Address for correspondence: Olaf Zagolski, ENT, St. John Grande’s Hospital, Krakow, Poland. Tel.: +48 12 3797377; Fax: +48 12 4305491; E-mail: olafzag@poczta.onet.pl. Journal of Pediatric Epilepsy 1 (2012) 73–74 DOI 10.3233/PEP-2012-012 IOS Press 73