Intracranial complications of sinusitis: a 15-year review of 39 cases. (Original Article).
Despite improvements in antibiotic therapies and surgical techniques, sinusitis still carries a risk of serious and potentially fatal complications. We examined the charts of 82 patients who had been admitted to the University of Mississippi Medical Center between Jan. 1, 1985, and Dec. 31, 1999,for treatment of complications of sinusitis. Of these 82 patients, 43 had orbital complications and 39 had intracranial complications. In this article, we describe our findings in those patients who had intracranial complications (our findings in patients with orbital complications will be reported in a future article). The most common intracranial complication was meningitis; others were epidural abscess, subdural abscess, intracerebral abscess, Pott's puffy tumor, and superior sagittal sinus thrombosis. Most patients with meningitis were treated with drug therapy only; patients with abscesses were generally treated with intravenous antibiotics and drainage of the affected sinus and the abscess. Advancements in antib iotic therapy, endoscopic surgery, imaging studies, and computer-assisted surgery have helped improve outcomes. Management of these patients should be undertaken immediately and is best achieved via a multidisciplinary approach, involving the otolaryngologist, neurosurgeon, radiologist, anesthesiologist, infection disease specialist, pediatrician, internist, and others.
Affecting one in eight persons in the United States, sinusitis has become the most common chronic illness in this country, surpassing arthritis and hypertension. (1) Sinus infections are usually not limited to the sinuses; in fact, they frequently originate in the nose and spread to the sinuses. (2) As a result, the term rhinosinusitis has gained popularity in the literature. Most sinus infections are secondary to an upper respiratory tract infection or an allergy. (3) The widespread practice of sending children to day-care facilities has led to an increase in the incidence of rhinosinusitis among children. (3,4)
Whenever a sinus infection extends beyond the confines of the sinonasal complex, the risk of an associated complication increases. Sinusitis has been classified into four different categories (acute, subacute, chronic, and recurrent), depending on the duration of the infection (table 1). Complications of sinusitis are generally classified as either local or distant (table 2), and they are usually seen in patients with acute sinusitis or acute recurrences of chronic sinusitis. (5) Local complications are further classified as intracranial, orbital, and mucocele-related.
Complications of sinusitis vary in their characteristics and severity according to their location, duration, and specific symptoms. The spectrum of complications ranges from relatively benign orbital cellulitis to potentially fatal intracerebral abscess or cavernous sinus thrombosis. (6) Only occasionally do patients experience more than one complication at a time--for example, meningitis and orbital cellulitis or intracranial abscess and subperiosteal abscess.
Although the incidence and seriousness of these complications has steadily decreased, orbital and/or central nervous system complications still pose a challenge. (6-8) Among children, periorbital cellulitis is the most common complication of acute sinusitis. (9) Even with the liberal use of potent antibiotics and with newer surgical and diagnostic techniques, blindness, permanent hearing loss, seizures, hemiplegia, and death still occur as sequelae to orbital or central nervous system complications. (6,10,11) In the preantibiotic era, 17% of patients with orbital infections died of meningitis and 20% became blind in the affected eye. (6,12) In 1991, Patt and Manning reported that the incidence of blindness had fallen to 10%--still a relatively high percentage. (13)
The incidence of morbidity and mortality among patients with intracranial complications of sinusitis has been reported to range between 5 and 40%. (10,11) The incidence of intracranial extension in hospitalized patients with sinusitis ranges from 3.7 to 11 %. (6,14,15) In this article, we report the findings of our review of intracranial complications. which include meningitis, epidural abscess, subdural abscess, intracerebral abscess, Pott's puffy tumor (frontal bone osteomyelitis), superior sagittal sinus thrombosis, and cavernous sinus thrombosis. (5)
Patients and methods
We conducted a retrospective review of the charts of 82 adults and children who had been admitted to the University of Mississippi Medical Center in Jackson between Jan. 1, 1985, and Dec. 31, 1999, for treatment of complications of sinusitis. Of this group, 39 patients had intracranial complications (47.6%) and the remaining 43 had orbital complications (52.4%). In this article, we describe our findings in those patients who had intracranial complications (our findings in patients with orbital complications will be reported in a future article).
The group of 39 patients with intracranial complications was made up of 32 males and 7 females. There were 23 adults and 16 children, ranging in age from 1 to 60 years. Individual follow-up ranged from 6 months to 15 years.
The most common intracranial complication was meningitis, which was seen in 21 patients (53.8%). Six other patients had an epidural abscess alone (15.4%), five had a subdural abscess (12.8%), four had an intracerebral abscess (10.3%), one had both an epidural abscess and Pott's puffy tumor (2.6%), one had Pott's puffy tumor alone, and one had superior sagittal sinus thrombosis (table 3).
Meningitis. All 21 patients who had meningitis received medical treatment; five of them eventually required endoscopic sinus surgery. Six of the 21 patients had acquired immunodeficiency syndrome (AIDS), and all six had cryptococcal meningitis; two of them died. The most common bacterial isolate was Streptococcus pneumoniae, which was found in 12 of the 21 patients. Other isolated organisms included staphylococci, meningococci, and Citrobacter spp., which were seen in one patient each. Three of the 21 patients had a history of trauma to the head, with skull and sinus fractures but no rhinorrhea. The most common sequelae to meningitis were seizure disorder in four patients and hearing loss in two.
Computed tomography (CT) revealed that the ethmoid and sphenoid sinuses were affected in all 21 patients--nine had unilateral ethmoid, sphenoid, frontal, and maxillary sinusitis; seven had pansinusitis; two had unilateral ethmoid and sphenoid sinusitis; two had bilateral ethmoid and sphenoid sinusitis; and one had unilateral ethmoid, sphenoid, and frontal sinusitis. Overall, 12 of the 21 patients had unilateral disease.
Abscesses. Pansinusitis was the predominant finding in the 16 patients who had intracranial abscesses. Seven patients had an epidural abscess (including the one patient with concomitant Pott's puffy tumor), five had a subdural abscess, and four had an intracerebral abscess.
Of the seven patients who had an epidural abscess, six underwent craniotomy for drainage; four underwent standard external-approach sinus surgery, one had endoscopic sinus surgery, and one had computer-assisted endoscopic sinus surgery. The remaining patient did not undergo drainage craniotomy at the recommendation of the neurosurgery service, and this patient's abscess resolved completely within 3 weeks of draining the affected sinuses.
All five patients who had a subdural abscess underwent drainage through a craniotomy; three underwent functional endoscopic sinus surgery (one of which was computer assisted) and two underwent standard external-approach sinus surgery.
Of the four patients who had an intracerebral abscess, three underwent a drainage craniotomy and one underwent CT-guided needle aspiration of the abscess. Two underwent standard sinus surgery and two functional endoscopic sinus surgery.
Involvement of the right frontal sinus was seen in 11 of these 16 patients--five of the seven with an epidural abscess, four of the five with a subdural abscess, and two of the four with an intracerebral abscess. Six of these 16 patients underwent frontal sinus cranialization. There were no deaths. The most common sequelae were residual seizure disorder in three patients and unilateral hemiplegia in one; CT and magnetic resonance imaging (MRI) were obtained for all four of these patients.
Other complications. The patient with Pott's puffy tumor alone underwent an open procedure, and the patient with superior sagittal sinus thrombosis was managed with endoscopic sinus surgery, intravenous medical therapy, and observation.
An infection in the sinus cavity can easily spread to the orbit or to the orbital or intracranial cavity because the anatomy is so closely interrelated. The maxillary, ethmoid, sphenoid, and frontal sinuses all share thin bony walls with the orbit and the cranium. Any bony dehiscence or defect, whether it be congenital or traumatic, can lead to the direct spread of infection. Direct spread can also take place through the bone suture via a neurovascular foramen. Another direct route is through the heavily vascularized venous system that connects these three anatomic regions.
For example, the superior ophthalmic vein connects with the angular, supraorbital, and supratrochlear veins, and it crosses over the optic nerve through the superior orbital fissure and drains into the cavernous sinus. (6) The inferior ophthalmic vein passes through the inferior orbital fissure under the optic nerve and communicates with the pterygoid plexus; there it either joins the superior ophthalmic vein or empties into the cavernous sinus. Superior ophthalmic vein thrombosis is a diagnostic radiographic finding in patients with cavernous sinus thrombosis (figure 1).
Likewise, the ethmoid veins communicate with the superior ophthalmic veins, and one or more of them pierce the cribriform plate and join the veins of the frontal lobe. The ophthalmic venous system is devoid of valves, which allows for the easy spread of infection either through infected emboli or through a thrombophlebitic phenomenon. Moreover, the lack of a lymphatic system in the orbit facilitates the spread of infection through the valve-less venous channels. The cranial dura and galea derive their blood supply from the same system. Also, the diploic Breschet's veins are valveless, which allows blood and infected emboli to flow easily from the extracranial orbital and sinus area to the intracranial cavity. (6) Children have more diploic veins in the cranium than do adults, which allows infections to spread more deeply and more rapidly; this explains why sinus complications in children are more common and more severe. Intracranial complications of sinusitis are even more common in adolescents than in childr en, and there is a male preponderance. (6,16,17)
Because intracranial complications can evolve into major infections, they are potentially life-threatening and immediate attention is critical. Management is best carried out via a teamwork approach that includes the involvement of not only the otolaryngologist and neurosurgeon, but the radiologist, anesthesiologist, infection disease specialist, pediatrician, internist, and others, as well. Broad-spectrum IV antibiotics and surgical drainage of the sinuses is the mainstay of therapy. In addition, drainage of associated abscesses is frequently required. The neurosurgical and otolaryngologic procedures are usually performed during the same anesthesia when the patient's condition permits. (6,11)
Meningitis. The most common intracranial complication of sinusitis is meningitis. (5,6,18) It is frequently the result of sphenoiditis or ethmoiditis. The cranial arachnoid in adults is relatively resistant to bacterial invasion, but the immature brains of children transmit infection more freely. (6,19) Initial symptoms usually include headache, neck stiffness, and a high fever superimposed on the sinusitis complaints; some patients are also toxic. Cranial nerve palsy is frequently present, the most common abnormality being a dysfunction in extraocular movement. (6) It is necessary to obtain CT before performing a lumbar puncture.
The initial treatment of meningitis is administration of a broad-spectrum IV antibiotic that crosses the blood-brain barrier. Surgery can be performed if no improvement is noted within 48 hours, provided that the patient has been stabilized. Neurologic sequelae are common in patients with meningitis, primarily seizure disorders and sensorineural deficits. Hearing loss has been reported in as many as 25% of patients. (5) Mortality from meningitis is rare in our era. In our series, only two patients died, and their deaths were primarily attributable to their underlying AIDS.
Epidural abscess. The second most common intracranial complication of sinusitis is epidural abscess. (5) This type of infection is seen almost exclusively in patients with frontal sinusitis, probably because of the high degree of venous communication and loosely adherent dura in that particular site. The most common organisms are Staphylococcus aureus and streptococci. (6) Initial symptoms include fever, headache, and local pain and tenderness. The diagnosis can be made on MRI or CT (figure 2).
Treatment of epidural abscess includes a high-dose IV antibiotic and drainage of the sinuses and the abscess, although a neurosurgeon will occasionally recommend that drainage of the abscess not be performed because of its small size. (20) In our series, epidural abscess was the second most common intracranial complication. Drainage of the abscess was not performed in one of the seven patients. No sequela was noted.
Subdural abscess. Subdural abscess is the third most frequently seen complication, although it is by no means common. When it does occur, mortality has been reported to be as high as 25 to 35%. (17,18,21) Approximately 30% of patients who survive a subdural abscess are left neurologically impaired. (22) Again, this type of abscess is usually precipitated by a frontal sinus infection; because there are no anatomic barriers, empyema can spread rapidly over the cortex and into the interhemispheric region. (6) Subdural abscesses of sinus origin often arise over the frontal lobe convexity; they are usually unilateral. (6,16) Streptococci are the usual causative organisms. (6)
Clinically, a subdural abscess can constitute a life-threatening emergency because patients usually deteriorate quickly. Headache, fever, and lethargy followed by seizures and coma is a common occurrence. Signs of meningitis are usually present; the degree of focal neurologic deficits depends on the precise site of the abscess. CT is helpful in making the diagnosis (figure 3), although it occasionally does not detect the abscess formation. (6) MRI with gadolinium enhancement usually allows for a better evaluation of the brain. Treatment involves a high-dose IV antibiotic along with surgical drainage of the sinuses and the abscess. Steroid and anticonvulsant medications are routinely administered, as well.
Intracerebral abscess. Intracerebral abscesses are also an uncommon complication of sinusitis. (5,6,23) When they do occur, they usually involve the frontal and frontoparietal lobes. The most common site of the precipitating infection is the frontal sinus, although involvement of the ethmoid and sphenoid sinuses has been reported in many cases.6 Fever, headache, vomiting, and lethargy are the common symptoms of intracerebral abscess. Seizures and focal neurologic deficits can also occur, and the presence of these ominous signs is associated with an increased incidence of hospitalization, long-term morbidity, and mortality. (6,5) Abscesses localized to the frontal lobe are associated with more subtle symptoms, such as mood and behavioral changes. MRI and CT are diagnostic (figure 4). Lumbar puncture can be life-threatening in these patients, and its risk outweighs any diagnostic benefit. Aerobic and/or anaerobic organisms can be cultured. The most common aerobic pathogens are S. aureus and hemolytic streptococ ci, and the most common anaerobic organisms are Fusobacterium spp. and streptococci. (6)
The treatment of choice for intracerebral abscess is a high-dose IV antibiotic and surgical drainage of the sinuses and the abscess. Steroids and anticonvulsants are also used. Despite optimum therapy, brain abscesses are associated with a mortality rate as high as 20 to 30%. (9) Approximately 60% of children who survive an intracerebral abscess develop neurologic and developmental sequelae. (23)
Pott's puffy tumor. The indolent circumscribed tumor that bears his name was first recognized by Percival Pott on the forehead of a patient in 1760. (5,6) The precipitating infection originates in the frontal sinus and causes a progressive osteomyelitis of the bone, eventually culminating in an anterior subperiosteal pericranial abscess, a periorbital abscess, or an epidural abscess. The subperiosteal collection of pus in the forehead produces the fluctuant swelling that Pott called "puffy."
CT is the diagnostic modality of choice for Pott's puffy tumor (figure 5). MRI is more reliable for detecting any intracranial complications, and bone scanning is superior for the early detection of osteomyelitis. (24) The most common offending organisms are S. aureus, streptococci, and oral anaerobics. (6,24) Treatment involves an IV antibiotic, drainage of the abscess, and, if necessary, debridement of the bone. In some cases, frontal sinusotomy is required. (25) IV antibiotics are continued for 3 weeks. Thereafter, the patient should be switched to an oral antibiotic for an additional 3 to 5 weeks.
Table 1 Types of sinusitis Type Duration of symptoms Acute 30 days or fewer Subacute 31 to 90 days Chronic 91 days or more Recurrent Chronic with acute exacerbations Table 2 Types of local and distant complications of sinusitis Local Intracranial complications Meningitis Epidural abscess Subdural abscess Intracerebral abscess Pott's puffy tumor Superior sagittal sinus thrombosis Cavernous sinus thrombosis Orbital complications Periorbital cellulitis} Extraconal Orbital cellulitis} (preseptal) Subperiosteal abscess Orbital abscess} Intraconal Cavernous sinus thrombosis} (postseptal) Mucocele Distant Pulmonary (exacerbations of) Asthma Bronchitis Chronic obstructive pulmonary disease Cystic fibrosis Systemic diseases Sepsis Toxic shock syndrome Table 3 Incidence of intracranial complications in this study Complication n (%) Meningitis 21 (53.8) Epidural abscess alone 6 (15.4) Subdural abscess 5 (12.8) Intracerebral abscess 4 (10.3) Pott's puffy tumor alone 1 (2.6) Epidural abscess plus Pott's puffy tumor 1 (2.6) Superior sagittal sinus thrombosis 1 (2.6) Cavernous sinus thrombosis 0 Total 39 (100)
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From the Division of Otolaryngology, Department of Surgery, University of Mississippi Medical Center, Jackson.
Reprint requests: Ramzi T. Younis, MD, Chief, Pediatric ENT, Department of Otolaryngology, University of Miami, Bascom Palmer Eye Institute, 900 N.W. 17th St., Ground Floor, Miami, FL 33136. Phone: (305) 326-6332; fax: (305) 326-6003; e-mail: email@example.com
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|Author:||Anand, Vinod K.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Sep 1, 2002|
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