Paranasal sinus infections and ear infections are the most common causes of intracranial abscesses, a complication from sinusitis and mastoiditis that have decreased dramatically in this post-antibiotic era. However, the reduced incidence of these complications means that they can go unrecognized, untreated, or undertreated, resulting in serious illness and possibly death for a young child.
A new study set out to determine the incidence, describe the clinical presentation, and management of pediatric intracranial complications associated with sinusitis and mastoiditis. The authors of Pediatric Intracranial Complications from Sinusitis and Mastoiditis, are Maria Pena, MD, from the George Washington University Medical Center; and Robert P. Keating, MD, and George Zalzal, MD, from the Childrens National Medical Center, all in Washington, D.C. Their findings are to be presented at the 109th annual meeting and OTO EXPO of the American Academy of OtolaryngologyHead and Neck Surgery Foundation, being held Sept. 25-28, 2005 in Los Angeles.
The medical records of all patients admitted to Childrens National Medical Center in Washington, D.C., with a diagnosis of meningitis, epidural abscess, subdural abscess, cerebral abscess, otitic hydrocephalus, and dural sinus thrombophlebitis from Jan. 1, 1996 to Dec. 31, 2004 were reviewed. Ninety-six children with 122 intracranial complications were identified. These medical records were further analyzed for concurrent sinusitis and/or mastoiditis. Age, gender, clinical presentation, intracranial complication, therapeutic interventions, and outcomes were recorded.
Ninety-six patients with 122 intracranial complications were found. Twenty-one children (22 percent) had 30 intracranial complications associated with sinusitis. Subdural empyemas were most often found in this group (46 percent), followed by epidural abscesses (20 percent), cerebral abscesses (13 percent), meningitis (seven percent), cavernous sinus thrombosis, (7 percent) and sagittal sinus thrombosis (three percent). Four of 21 patients had other concomitant suppurative complications from sinusitis including three frontal subperiosteal abscesses and one right orbital abscess. Eight of 21children had frontal sinus involvement and 13 had pansinusitis, inflammation of all the paranasal sinusues on one or both sides.
Six children (six percent) had 13 complications associated with mastoiditis. Lateral sinus thrombosis (45 percent) was the intracranial complication most often seen with mastoiditis, followed by epidural abscess (18 percent), cerebellar abscess (nine percent), meningitis (nine percent), and otitic hydrocephalus (9 percent). One patient had a concomitant post auricular subperiosteal abscess. None was associated with chronic otitis media or cholesteatoma.
The average age of patients in the sinusitis group was 12.8 years (range 2-17 years), and the ratio of males to females was 9.5 to 1. Headache and fever were the most common symptom, with more than 70 percent of the children exhibiting at least one neurologic symptom or sign. Fifty two percent of these patients were diagnosed with sinusitis and treated with antibiotics prior to admission.
Children with intracranial complications of mastoiditis had an average age of children in this group was 6.8 years (range 2-11 years), and the ratio of males to females was one to five. Fever and otalgia were the most common presentation in this group of patients, with 67 percent exhibiting at least one neurologic symptom or sign. Approximately 83 percent of these children were diagnosed with otitis media and treated with antibiotics prior to admission.
A total of 28 neurosurgical procedures were carried out on the patients with intracranial complications of sinusitis. Thirteen patients had 22 craniotomies, with seven of these children requiring repeat procedures to drain a recurrent intracranial infection. In addition, one patient required another two craniectomies, three burr holes, and a lumbar laminectomy to address recollections of abscesses along the entire neuraxis. Sinus drainage procedures included cranialization of the frontal sinuses, endoscopic ethmoidectomies, endoscopic sphenoidotomies,, endoscopic frontal sinusotomy, maxillary antrostomies, and frontal sinus trephinations.
Seven complete mastoidectomies were performed in the group of children with mastoiditis with one patient requiring bilateral procedures. All six patients had myringotomy and tube. One child required craniotomy to address three cerebellar abscesses. Two patients underwent drainage of epidural abscesses via mastoidectomy.
The mean length of hospitalization was 21 days for the patients with intracranial complications of sinusitis. The mean length of hospitalization for the patients in the mastoiditis group was 10 days. There were no mortalities in either group. Three patients with intracranial complications of sinusitis had permanent neurological deficits resulting from the abscesses.
In this series of patients, 19 of 35 children with an intracranial abscess had a sinogenic source, and three had an origin resulting from inflammation of the ear, making the overall incidence of intracranial abscesses associated with sinusitis and mastoiditis 63 percent.
The researchers believe that diagnosing pediatric intracranial complications from sinusitis and mastoiditis can be challenging due to the clinical presentation and low incidence of the disorder. They suggest a high index of suspicion based on clinical presentation; serial examinations including appropriate imaging, and aggressive intervention are necessary for successful outcomes.