Management Strategy of Intracranial Complications of Sinusitis: OurExperience and Review of the Literature

The treatment of acute, recurrent, and chronic sinusitis remains controversial because of the presence of a wide variety of aerobic and anaerobic bacteria in the sinuses. This double-blind, randomized trial compared cefaclor with amoxicillin in the treatment of acute, recurrent, and chronic maxillary sinusitis using clinical evaluation, roentgenography, and microbiologic evaluation of antral aspirates. Outpatient office of five otorhinolaryngologists in Salt Lake City, Utah. One hundred eight adult patients with acute, recurrent, or chronic maxillary sinusitis. Oral treatment with cefaclor (500 mg) twice daily or amoxicillin (500 mg) three times daily for 10 days. Clinical response to treatment with cefaclor vs amoxicillin. Fifty-six patients with acute sinusitis, 25 with recurrent sinusitis, and 15 with chronic sinusitis were evaluable. Although multiple organisms were common in each group, patients with acute sinusitis were more likely to have Haemophilus influenzae or Streptococcus pneumoniae, and patients with recurrent or chronic sinusitis were more likely to have anaerobes in sinus aspirate. Whether treated with cefaclor or amoxicillin, clinical improvement occurred in 86% of patients with acute sinusitis and 56% of patients with recurrent sinusitis. Patients with chronic sinusitis were too few to allow statistical analysis of the differences in outcome between them and patients with recurrent or acute sinusitis. Resistance of the cultured organisms to the study drug used was unrelated to treatment outcome. The rate of clinical improvement was high in patients with acute sinusitis but was less favorable in those with recurrent and chronic disease regardless of the study drug used. The susceptibility of organisms isolated to the study drugs was unrelated to outcome.

On the basis of strong research evidence, the pathogenesis of sinusitis involves 3 key factors: sinusostia obstruction, ciliary dysfunction, and thickening of sinus secretions. On the basis of studies of the microbiology of otitis media, H influenzae is playing an increasingly important role in the etiology of sinusitis, exceeding that of S pneumoniae in some areas, and b-lactamase production by H influenzae is increasing in respiratory isolates in the United States. On the basis of some research evidence and consensus,the presentation of acute bacterial sinusitis conforms to 1 of 3 predicable patterns; persistent, severe, and worsening symptoms. On the basis of some research evidence and consensus,the diagnosis of sinusitis should be made by applying strict clinical criteria. This approach will select children with upper respiratory infection symptoms who are most likely to benefit from an antibiotic. On the basis of some research evidence and consensus,imaging is not indicated routinely in the diagnosis of sinusitis. Computed tomography or magnetic resonance imaging provides useful information when complications of sinusitis are suspected. On the basis of some research evidence and consensus,amoxicillin-clavulanate should be considered asa first-line agent for the treatment of sinusitis.

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

Sinusitis

Despite increasingly better diagnostic and therapeutic methods intracranial sinogenic complications, invariably pose a direct threat to the lives of patients and a challenge for otolaryngologists. The aim of the study was to analyze patients with intracranial sinogenic complications treated at the Department of Otolaryngology and Otolaryngological Oncology of Poznań University of Medical Sciences in the years 2000-2013. Analysis covered the period from January 2000 to December 2013. Twenty-one patients with intracranial sinogenic complications were treated at the Department of Otolaryngology in Poznan during that time. Material mainly included young men. Brain abscesses were the most common complications. Intracranial complications of sinusitis rarely occurred in isolation, often coexisting with other intracranial pathologies. A significant increase in the incidence was recorded in 2013. Treatment involved concurrently alleviating inflammation in the sinuses through implementation of broad-spectrum antibiotics for several weeks and decompressing the organized intracerebral abscesses, empyema, epidural and/or subdural abscesses under control of neuronavigation. There were no patient deaths recorded in the analyzed period. The risk of developing intracranial sinogenic complications is low but invariably present and should be included in the differential diagnosis. Since the incidence of intracranial complications may increase in the course of prevailing viral infection, it should raise diagnostic vigilance.

Aspergillus Sinusitis: A Radiologic Study

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

To provide an up-to-date review summarizing the pathophysiology and management of the most common orbital and intracranial complications of acute rhinosinusitis (ARS). A narrative literature review was conducted using the following search criteria in the PubMed database: "sinusitis" AND "complications" AND ("orbital" OR "intracranial" OR "osseous" OR "Pott's puffy tumor"). Titles and abstracts were screened for relevance. Additional articles were found by hand-searching references. Articles were chosen for inclusion based upon relevance, quality, full-text availability, and date of publication. Common or interesting radiographic findings were highlighted as figures using patient imaging data based on senior author expert opinion. ARS is one of the most common diagnoses made in the United States. While the vast majority of these cases resolve with oral antibiotics and conservative medical management, rare instances of ARS may be complicated by the spread of infection into orbital, intracranial, and osseous spaces. This review seeks to guide physician management with evidence-based recommendations. The pathophysiology of complex sinusitis is explored and risk factors, evaluation, and up-to-date prevention and management recommendations are discussed. This review of the literature highlights that when orbital, intracranial, and osseus complications are suspected, a multidisciplinary team should be assembled to consider both medical and surgical management options. In this way, outcomes of these complex infections can be optimized. ARS is common and self-resolving in most cases. However, clinicians should suspect orbital and intracranial complications in at-risk individuals with worsening symptoms that do not respond to standard therapies, and initiate early interventions as directed by multidisciplinary teams.

Background:Diagnosis and treatment of chronic and recurrent sinusitis in children is of potential importance and many factors can havean influence on it. This study assessed the chronic and recurrent sinusitis and affecting factors, as well as the role of allergy in its course and treatment in children.Materials and Methods:A total of 106 children with the diagnosis of chronic or recurrent sinusitis, referred to specialty clinics of otolaryngology and allergy of Tabriz Children Educational-Medical centres since 2010 to 2012, were enrolled. The history and physicalexamination findings were recorded for all patients and allergy Prick test was done for all. Response to treatment was evaluated during the follow-up visits.Results:The mean age of studied patients was 6.5 ± 2.9 years. Of all the patients, 54 (50.9%) were male and 52 (49.1%) were female. Skin Prick test was positive in 69.8%. Response to treatment was seen in 86.8% of the patients while 7.5% did not have any favourable outcome. Anti-allergic treatment caused better outcomes in patients with positive Skin Prick test than those with negative results.Conclusion:The prevalence of allergic disease in children with chronic or recurrent sinusitis is considerable and anti-allergic treatments can result infavourable therapeutic outcomes in children with sinusitis, especially with positive skin prick test results.

Ibuprofen as risk-factor for complications of acute anterior sinusitis in children

To summarize the follow-up outcomes of Draf IIb frontal sinusotomy and it's modified procedures, and to discuss the surgical indications and prognostic factors. Thirty-two patients treated between 2004 and 2010 were enrolled in this study. There were 15 patients for recurrent frontal inverted papilloma (IP), 6 for mucocele, 4 for recurrent frontal sinusitis, 3 for osteoma, 2 for meningoencephalocele with cerebrospinal fluid rhinorrhea, 1 for meningoencephalocele alone and 1 for acute frontal sinusitis. All patients underwent preoperative paranasal sinus computed tomography (CT) scans. Patients with tumor accepted magnetic resonance imaging (MRI). The patients with meningoencephalocele and cerebrospinal fluid rhinorrhea received magnetic resonance cisternography (MRC). The Draf IIb frontal sinusotomy and it's modified Draf IIb-1-3 procedures were applied endoscopically under general anesthesia mainly by high speed bur and power system. The postoperative CT scan was obtained as a base line for follow-up 1 week after the operation. Postoperative follow-up was performed under endoscope. Among 19 cases of Draf IIb, 12 were recurrent IP of frontal sinus, 4 were mucocele, 2 were recurrent frontal sinusitis and 1 were osteoma. Five cases received Draf IIb-1, 2 for each recurrent IP of frontal sinus and recurrent frontal sinusitis and 1 for osteoma. Six cases received Draf IIb-2, 3 for meningoencephalocele, 1 for each IP, acute frontal sinusitis and osteoma. Two cases received Draf IIb-3 were mucocele. The follow-up ranged from 8 to 73 months. Twenty-two cases of the frontal nepostium were widely opened, 7 were stenosis and 3 were closed. Revision surgery was seen in 2 cases with IP. All of them had no complications. The Draf IIb frontal sinusotomy and it's modified procedures are suitable for complex frontal sinus disease, which can be selected according to pathological and anatomical features, and have a good prospect for clinical application.

BackgroundTo compare the clinical features of two time cohorts of patients: “pre-COVID-19” and “COVID-19”—admitted as emergency with intracranial otogenic complications, with special regard to sigmoid sinus thrombosis (CVST).MethodsRetrospective analysis of patients documentation concerning urgent procedures of intracranial otogenic complications at tertiary-referral otolaryngology department. Analysed database—pre-COVID-19 cohort (January–February 2019/2020): 1434 otological outpatient visits, 509 planned otosurgeries and 17 urgent otological procedures; COVID-19 cohort (March–April 2020/2021): 1150, 566 and 20 respectively. Overall intracranial complications: 5 and 9 respectively. Analysed outcome measures: incidence proportion of otogenic intracranial complications in relation to planned and urgent otosurgical procedures; incidence proportion of intracranial complications in relation to the total number of emergency and planned outpatient consultations and the total number of planned surgical procedures.ResultsThere were 14 intracranial complications, 5 in the pre-COVID and 9 in the COVID cohort, including 1 and 5 sigmoid sinus thrombosis, respectively. Out of them, 3 and 5 patients reported a prior history of chronic otitis media, respectively. In COVID period, CVST was more prevalent, with 2 cases (22.2%) presenting solitary CVST, and 3 cases (33.3%) CVST and a simultaneous brain abscess or meningitis. CVST was much more frequent in the COVID period (p < 0.01).ConclusionsDespite the published data which suggest that CVST is a rare event associated with COVID-19 infection, based on our experience, CVST can be expected as a frequent component of intracranial otogenic complications during COVID-19 pandemic time.Trial registration This research study was conducted retrospectively from data obtained for clinical purposes. We consulted extensively with the Bioethics Committee at Poznan University of Medical Sciences who determined that our study did not need ethical approval. An official waiver of ethical approval was granted from the Bioethics Committee at Poznan University of Medical Sciences.Graphical abstract

The microbiology of 87 patients admitted to hospital, over a five-year period, with acute sinusitis was retrospectively analysed. Sixty-three patients had one or more of an orbital, intracranial, soft tissue or bony complication. Eighty-four patients had maxillary sinus washouts, while 48 required a surgical procedure to their sinuses, and 33, drainage of an empyema. Streptococcus milleri and Haemophilus influenzae were the commonest organisms isolated from sinus aspirates (44 per cent), with a noticeable absence of Streptococcus pneumoniae (10 per cent). Organisms cultured from intracranial, soft tissue or orbitral empyemas were predominantly Streptococcus milleri (50 per cent) and Staphylococcus aureus (25 per cent) with an absence of Haemophilus influenzae (four per cent) and Streptococcus pneumoniae (four per cent). Ampicillin is an appropriate first line antimicrobial agent in patients with acute complicated sinusitis with the addition of cloxacillin in cases with an empyema. Chloramphenicol or ceftriaxone is used in cases with an intracranial complication.

This study aimed to investigate the computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of bone remodeling in chronic maxillary sinusitis and assess their clinical significance. This retrospective study included patients with unilateral chronic maxillary sinusitis and bone remodeling who were admitted to our hospital from January, 2020 to December, 2022. A total of 31 patients were ultimately included. Imaging and clinical data analyses were conducted on the enrolled patients, including multislice spiral computed tomography (MSCT) examination and measurements, as well as plain and enhanced MRI scans. A comparative analysis was performed between the affected and healthy samples. The CT images were evaluated using the "LIAT" systematic assessment method, with a focus on lesion location, extrasinus wall invasion, density, and thickness. Furthermore, a comparative analysis between CT and MRI was carried out for various types of bone remodeling, emphasizing the imaging features of the surrounding soft tissues, including the mucosa and periosteum. Among the 31 patients with chronic sinusitis, CT revealed 26 cases of cortical-like bone remodeling and 5 cases of cancellous-like bone remodeling. For cortical-like bone remodeling, the thickest part of the posterolateral wall of the maxillary sinus was used to differentiate between mild and moderate-to-severe cases using a 3 mm threshold. Specifically, 15 mild cases exhibited sinus mucosa thickening and a normal blood supply outside the sinus wall on MRI, whereas 11 moderate-to-severe cases exhibited sinus mucosa separation, submucosal edema, and significant vessel proliferation outside the sinus wall on MRI. In cases of cancellous-like bone remodeling, MRI revealed uneven sinus mucosa thickening and mild vessel proliferation outside the sinus wall. Specifically, 21 patients exhibited cross-suture signs, 13 patients exhibited vascular tunnel signs, and 6 patients exhibited nerve canal perineural infiltration. Chronic maxillary sinusitis bone remodeling appeared in two forms on CT images: cortical-like bone remodeling and cancellous-like bone remodeling. MRI can detect morphological and signal alterations in the soft tissues around the remodeling site. Analyzing the imaging features of bone remodeling in chronic maxillary sinusitis patients can increase the understanding of disease progression and diagnostic accuracy.

Complicated acute pediatric bacterial sinusitis: imaging updated approach