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Pediatric Sinusitis-Related Intracranial Infections Identified
Although pediatric acute sinusitis is a common disease, the incidence of central nervous system (CNS) complications is rare. The rate of CNS involvement is much less common than orbital complications, which occur in the bony cavity surrounding the eye or inside the skull, and is present in three to four percent of patients admitted to the hospital for sinusitis. In fact, there is a higher rate of involvement of infection within the skull when orbital complications are present.
Potential symptoms of central nervous system complications include headache, fever, and focal neurological signs, although their absence does not preclude the presence of the disorder. Adolescents are more frequently affected than younger children presumably due to the more complete pneumatization of the paranasal sinuses.
This issue is explored more in depth in a new research study, Intracranial Complications of Pediatric Sinusitis, authored by Jonathan S. Glickstein, MD, Rakesh K. Chandra, MD, and Jerome W. Thompson, MD, MBA, all from the University of Tennessee Health Science Center in Memphis. 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.
A retrospective review was conducted of medical records of all patients discharged from LeBonheur Childrens Hospital Memphis from January 1995 through July 2004 with a diagnosis of acute sinusitis and intracranial complications, specifically meningitis, epidural abscess/subdural abscess, brain abscess, or thrombosis intracranial venous sinus. Patients were excluded if they were older than 18 years or they developed sinusitis subsequent to admission.
Twenty-one patients were included in the study. 13 males and eight females with an average age of 13.3 years (median 13; range two to 16). Seven of the patients had prior antibiotic therapy.
There was a total of 25 intracranial complications of acute sinusitis in 21 patients, with the most common being epidural abscesses, found in the fibrous membrane forming the outer covering of the central nervous system (10/21; 48 percent). The most common coincidental extracranial complication of sinusitis was Potts puffy tumor, or a swelling of the scalp indicating an underlying inflammation of the bone which was observed in seven cases. Five of these patients had a coexisting epidural abscess. Two patients had subperiosteal orbital abscesses, both of whom had concurrent subdural abscesses.
Fifty percent (15/30) of organisms cultured were oral flora, a diverse group of microorganisms that includes bacteria, funi, mycoplasmas, protozoa, and possibly a viral flora which may persist from time to time. Bacteria are the predominant group of microorganisms. Oral flora was present in 12/21 (57 percent) of patients. Patients were commonly treated empirically with a combination of vancomycin, a third or fourth generation cephalosporin, and flagyl or clindamycin. Patients received an average of five weeks of intravenous antibiotics.
Four patients were managed medically. There were 27 separate administrations of a general anesthetic to 17 patients for treatment of a complication of acute sinusitis. Thirty-eight procedures were performed on 17 patients. This included 20 craniotomies (an opening of the skull) in 13 patients, and 10 patients who had endoscopic sinus surgery (ESS) during the inpatient course. If planned outpatient ESS is included, 62 percent of patients ultimately underwent ESS. Overall, one third of patients required multiple returns to the operating suite during the inpatient course. The average length of stay was 14.7 days.
Intracranial complications of acute pediatric sinusitis often require surgical intervention in addition to long-term intravenous antibiotics. Craniotomy is often necessary, particularly in association with polymicrobial infection. Oral flora was prevalent in the present series and has been implicated in other recent studies as the most commonly cultured organisms. To the study authors knowledge this study is the largest reported group of cases of intracranial complications caused by Streptococcus abiotrophia. Without aggressive management, mortality is possible and permanent neurological morbidity remains a significant concern.