Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Update on Pediatric Complications of Acute Sinusitis Pediatric complications of acute rhinosinusitis can be divided into two categories: orbital complications and intracranial complications. I will discuss each of those separately. It is important when considering the orbital complications to keep in mind the close proximity of the orbit to the sinuses and that there can be dehiscenses in the lamina papyracea. In addition, another route of spread is direct extension through neurovascular foramina. Also, very commonly there is a septic thrombophlebitis of the valveless superior and inferior ophthalmic veins, which have communication with the nose, the ethmoids, and the cavernous sinus. The periorbita, which is the periosteum of the orbit, is the only soft tissue barrier between the sinuses and the orbit. Chandler classified orbital complications of sinusitis into preseptal cellulitis, which is depicted here on the slide drawing, which consists of eyelid edema; orbital cellulitis, which is demonstrated here; subperiosteal abscess; orbital abscess; and cavernous sinus thrombosis, and I will discuss each of these in turn. These complications should be considered separately rather than as a continuum. One does not necessarily progress to the next step, although this certainly can happen. Multiple complications can occur in the same patient. Preseptal cellulitis is often a complication of ethmoid sinusitis, although it can have other causes, such as trauma or a foreign body. It is manifested by eyelid swelling, erythema, and tenderness. There is no limitation of extraocular movements and no impairment of visual acuity. It can progress from lid abscess or postseptal edema, namely orbital celluitis. This CT scan demonstrates the preseptal cellulitis of the eyelid. Orbital cellulitis is postseptal edema without formation of a discrete abscess, and that occurs in this area here. It is manifested by eyelid edema, erythema, proptosis, and chemosis. There is limited or no impairment of the extraocular movements, and there is normal visual acuity. This is more concerning because it can evolve into an orbital abscess. A subperiosteal abscess forms between the periorbita and the lamina papyracea right here. This is discrete abscess, and you can see again, the medial rectus muscle. It can start as a phlegmon, as was discussed in our case, and it can displace the orbital contents and globe downward and laterally. There is normal mobility in the early stages and normal visual acuity. Orbital abscess occurs when an orbital cellulitis coalesces into a discrete collection of pus in the orbital tissues and that is demonstrated here on this line drawing. There is severe exophthalmos, chemosis, complete ophthalmoplegia, and visual impairment, and this is serious because of the risk for progression to irreversible blindness. Cavernous sinus thrombosis can be considered both an orbital and intracranial complication. It occurs when phlebitis extends posteriorly to the cavernous sinus with symptom progression in the opposite eye, and this is pathognomonic of cavernous sinus thrombosis. So, there is bilateral orbital pain, chemosis, proptosis, and ophthalmoplegia. Evaluation of the patient includes obtaining a complete history, including that of a recent upper respiratory tract infection, trauma, or swimming with forced water into the nose that is contaminated. Dental surgery or infection can cause maxillary sinusitis, which in turn can cause ethmoiditis and complications. The examination consists of decongesting the nose, anterior rhinoscopy, and nasal endoscopy. In addition, it is recommended that we also perform ophthalmologic examination by opening the eye, which is generally swollen shut to examine it for extraocular movements and at least gross visual acuity. Ophthalmologic consultation is obtained and then the patient is followed closely in order to determine their response to treatment. Conventional plain films of the sinuses are of limited value in complications of sinusitis. CT scanning is considered the gold standard, and the study of choice is a contrast-enhanced axial and coronal thin cut study of the sinuses and orbits. The indications for imaging are considered post-septal infection that is suspected on exam, consisting of proptosis, gaze restriction, or changes in visual acuity when there are suspected intracranial complications or symptoms of preseptal inflammation that progress despite 24 to 48 hours of appropriate medical treatments. Cultures can be obtained from the middle meatus or intraoperatively. The most common organisms that cause intraorbital complications are strep species, such as Strep pneumoniae; and recently Strep milleri has been found to cause both intraorbital and intracranial complications; anaerobes such as bacteroides and fusobacterium and staph species such as Staph aureus. In general, the treatment of most orbital infections is medical. Many of them respond to medical treatment, and this consists of broad-spectrum antibiotics followed by oral therapy, the duration being individualized for the patient depending upon the severity of their infection. In addition, we usually will recommend topical or oral nasal decongestants, mucolytics, and saline irrigations. The indications for surgery would include CT evidence of an abscess, visual acuity that is 20/60 or worse on initial evaluation, severe orbital complications such as blindness, progression of orbital signs and symptoms despite appropriate medical treatment, and lack of improvement within 48 hours despite aggressive medical management. The treatment of preseptal and orbital cellulitis is generally medical. Occasionally, an abscess will form in the eyelid that requires incision and drainage. The treatment of subperiosteal abscess is evolving somewhat and it is becoming more accepted to perform medical treatment first and surgery is performed if the abscess is large, progressing, or if it is not improving with appropriate medical management. Treatment of an orbital abscess generally involves drainage of the involved sinuses and the abscess. Cavernous sinus thrombosis carries with it a very grim prognosis, and the treatment is high-dose IV antibiotics. Consideration can be given to anticoagulating a patient and also surgery can be considered in order to obtain cultures and to drain the affected sinuses. However, again, the treatment is primarily medical. Surgical techniques have been evolving over the recent time. Endoscopic sinus surgery has become more common for draining the sinuses, although this can be technically difficult due to inflammation and bleeding that can occur at the time of surgery due to the infection. Conventional open surgery continues to be used, including frontal sinus trepination. External ethmoidectomy is used for abscess drainage, such as a subperiosteal abscess or an orbital abscess, and neuro-oculoplastic techniques have improved the cosmesis for drainage of subperiosteal abscesses. These drawings here demonstrate a transcaruncular incision or approach that is made by making the incision in soft tissues right here rather than an external incision and then dissecting along the periorbita and then making an incision in the periorbita in order to drain the abscess. Intracranial complications occur due to both acute and chronic sinusitis. There has been a decreased incidence of intracranial complications due to the widespread use of antibiotics, improved imaging techniques, earlier recognition of complications, and more aggressive treatment. The most common route of spread is hematogenous, through the diploic veins of the skull and the ethmoid sinuses and also direct extension can occur due to the proximity of the frontal and sphenoid sinuses to the brain. Intracranial complications can be classified as meningitis; epidural abscess, which is shown in this line drawing with the dura being here; subdural abscess, which is demonstrated here with the dura and the skull being here and the abscess here; and also intracerebral abscess; cavernous sinus and venous sinus thrombosis. Multiple complications, again, can occur in the same patient during the course of treatments. The evaluation includes a complete history, including sinonasal complaints. These are complications that can be asymptomatic until late in their course, and so a high index of suspicion is required for their diagnosis. Seizures, hemiparesis and other focal findings have a poor prognosis. An MRI with contrast is the study of choice in order to diagnosis an intracranial complication, and the management is multidisciplinary consisting of critical care physicians, neurosurgery, otolaryngology, and infectious disease. Meningitis is one of the most common complications of sinusitis, but sinusitis is an unusual cause of meningitis, therefore, it is not necessary to get a sinus CT on every patient who develops meningitis, but it is something to keep in mind. It results from sphenoiditis or ethmoiditis. The symptoms include headache, neck stiffness, high fever in association with sinus complaints. An epidural abscess is generally a complication of frontal sinusitis. The symptoms consist of a headache, fever, or local pain and tenderness, and the diagnosis is made with MRI or CT. Subdural abscesses are less common. They have high morbidity and mortality and generally complicate frontal sinusitis. They are generally unilateral, and this can be a life-threatening emergency due to the rapid deterioration of the patient. The symptoms include headaches, fever, and lethargy followed by coma. Intracerebral abscesses are uncommon, and they usually involve the frontal and frontoparietal lobes. They are most commonly due to frontal sinusitis and less commonly caused by ethmoiditis and sphenoiditis. The symptoms can be subtle consisting of mood swings and behavioral changes. Venous sinus thrombosis or sagittal sinus thrombosis can be caused by a retrograde thrombophlebitis from frontal sinusitis, and it is generally associated with other intracranial complications. These patients are extremely ill and the diagnosis is usually made by obtaining an MRI with gadolinium that reveals focal defects of enhancement and then this can be further delineated by obtaining an MR angiogram and MR venogram, and so the diagnosis is usually made when the MRI is done to look for intracranial complications and then further studies are generally obtained. Meningitis is most commonly caused by Strep pneumoniae. Abscesses are most commonly polymicrobial consisting of anaerobes, usually anaerobic strep or bacteroides, Staph aureus. Other strep species or H. flu are the most common causes of intracranial complications. The general treatment includes obtaining neurosurgical consultation, treatment with broad-spectrum antibiotics with intracerebral penetration, surgical drainage of the affected sinuses, and drainage of the intracranial abscess. IV antibiotics are generally continued for four to six weeks, and re-imaging is performed during the treatment and at hospital discharge in order to verify that the abscess has responded to treatment and that no other complications have arisen. The initial treatment of meningitis is medical and if the patient is not improving, drainage of the affected sinuses can be performed within 48 hours. Steroids and anticonvulsants can be used and neurologic sequelae, such as sensorineural hearing loss and seizures are common. Epidural, subdural, and intracerebral abscesses are treated with high-dose IV antibiotics and drainage of the affected sinuses. Generally, the abscesses are drained by the neurosurgical services, although occasionally they will monitor the abscess if it is small. Steroids and anticonvulsants can be used, and there is a high incidence of morbidity and mortality. Venous sinus thrombosis is treated with high-dose IV antibiotics and drainage of the involved sinuses. The use of anticoagulants is controversial, and it has been suggested that treatment be continued until there is radiologic evidence of resolution of the thrombus. In summary, diagnosing complications of sinusitis requires a high index of suspicion and the orbit is the most common structure involved. CT with contrast of the sinuses and orbits is the study of choice for orbital complications, and MRI with contrast of the brain and orbits is the study of choice for intracranial complications. The treatments consist of generally medical for preseptal and orbital cellulitis. Rarely, do these require surgery. Subperiosteal abscess is treated medically with or without surgery. Orbital abscesses generally require surgery. Cavernous sinus thrombosis is treated with aggressive medical management and possible sinus drainage. Meningitis is initially treated medically. Intracranial abscess is often medical and surgical treatment to drain the sinuses and the abscess. Venous sinus thrombosis is generally treated medically and surgically, and anticoagulation is controversial. Case Presentation: J.W. is an 11-year-old African-American female who was referred to the Texas Children’s Hospital Emergency Department by her pediatrician with a four day history of fever and nasal congestion. Three days prior to her presentation she had been diagnosed with a viral upper respiratory infection. Two days prior to her presentation she developed progressive left eye swelling. She denies facial pain, pain with eye movement, headaches, or trauma. She denies vision changes. She denies recurrent episodes of sinusitis or allergies. She had persistent fever at home. She has no other significant past medical or past surgical history. She has no drug allergies and was not taking any medications prior to admission. Her physical examination was remarkable for a temperature of 101˚F and left upper and lower eyelid edema and erythema. She was able to open her eye with effort and demonstrated intact extraocular movements and vision. There was mild conjunctival injection without proptosis. There was no purulent orbital or nasal discharge. She was admitted to the hospital and treated with intravenous Clindamycin. She demonstrated minimal improvement and on hospital day two an ophthalmology consultation was obtained which confirmed the diagnosis of preseptal cellulitis. She demonstrated a mild abduction deficit, however, and a CT scan of the sinuses and orbits was recommended. It was also recommended broadening her antibiotic coverage by adding Cefotaxime. CT of the orbits and sinuses revealed bilateral pansinusitis and a small left subperiosteal phlegmon. An otolaryngology consultation was requested. At that time she was afebrile with only mild eyelid edema and mild impairment of abduction. A left middle meatal culture was obtained and fluticasone, saline sprays and a three day course of oxymetazoline were added to her regimen. Gram stain revealed gram positive cocci in pairs and cultures grew coagulase negative staphylococcus. She received eight days of intravenous Cefotaxime and ten days of Clindamycin. Repeat CT scan revealed resolution of the subperiosteal phlegmon . She was discharged home on a two week course of oral Clindamycin, saline sprays and fluticasone. On subsequent clinic follow-up she had complete resolution of her symptoms. Bibliography: Bhattacharyya N, Jones DT, Hill M, Shapiro NL. The diagnostic accuracy of computed tomography in pediatric chronic rhinosinusitis. Arch Otolaryngol Head Neck Surg 2004;130:1029-1032. 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