Intracranial Complications of Sinusitis in Children and Adolescents and Their Outcomes

Abstract

Germiller JA, Monin DL, Sparano AM, Tom LWC. Arch Otolaryngol Head Neck Surg. 2006;132:969–976 PURPOSE OF THE STUDY. To evaluate the presentation, imaging, microbiology, treatment, and outcome of intracranial complications of sinusitis in children. STUDY POPULATION. The study included 25 consecutive children and adolescents treated for intracranial complications of sinusitis over a 5-year period. METHODS. This was a retrospective chart review of patients who were identified by screening admission diagnoses for central nervous system infections including intracranial abscesses, meningitis, encephalitis, and dural sinus thrombophlebitis. These records were cross-referenced for both procedure codes for external and endoscopic sinus surgery and diagnosis of acute or chronic sinusitis. RESULTS. Twenty-five consecutive patients were identified, with ages ranging from 4 to 18 years; 19 patients were male and 6 were female. There were 35 intracranial complications: 13 epidural abscesses, 9 subdural empyemas, 6 meningitis, 2 dural sinus thromboses, and 1 middle cerebral artery ischemia. Nine patients (36%) had >1 intracranial complication. Ten patients (44%) also had at least 1 extracranial complication: 5 with orbital cellulites, 4 with orbital/periorbital abscess, 1 with forehead abscess, and 1 with forehead edema. Seventy percent of the patients with extracranial complications had epidural abscess as their intracranial complication. In addition, 12 patients (48%) presented with neurologic signs and symptoms, most commonly change in mental status (9 patients) or hemiparesis (5 patients). Of the 13 who presented without neurologic signs and symptoms, 9 (69%) had epidural abscess as their only intracranial complication. Fifteen patients had computed tomography imaging with contrast, identifying 12 (63%) of 19 complications in those patients. MRI was performed in 19 patients, identifying 26 (93%) of 28 complications in those patients. Cultures grew multiple organisms in more than one half of the patients, 53% of which were Streptococcus species. Outcomes were divided into 3 groups. No patient in group 1 (14 patients) had neurologic deficits or events. All the patients in group 1 underwent endoscopic sinus surgery (100%), and 7 (50%) underwent a neurosurgical procedure. By definition, there were no short-term or long-term sequelae for the children in group 1. Group 2 included 8 patients who experienced short-term neurologic sequelae only. Seven patients of group 2 underwent endoscopic sinus surgery (88%), and 5 (63%) underwent a neurosurgical procedure. Group 3 included 3 patients who experienced permanent neurologic deficits (bilateral sensorineural hearing loss for one and hemiparesis, expressive aphasia, and seizures for the other) or death. Two patients in group 3 underwent endoscopic sinus surgery (67%), and 1 (33%) underwent a neurosurgical procedure. CONCLUSIONS. Intracranial complications of sinusitis in children present diagnostic challenges, because many patients lack a history of sinusitis and present with vague, nonlocalizing signs and symptoms. Aggressive medical and surgical management may limit morbidity and improve outcomes. Early imaging is crucial to diagnosis, and MRI is the most useful test. REVIEWER COMMENTS. Intracranial complications of sinusitis remain uncommon; even in this review from a tertiary pediatric center only 5 patients per year were identified. A high index of clinical suspicion, particularly in adolescent boys, should lead to early imaging for diagnosis. Medical therapy combined with neurosurgical and otolaryngological surgical interventions may improve outcomes and reduce short-term and long-term sequelae.