CASE REPORT
Simultaneous intracranial and orbital complications of acute rhinosinusitis in children

https://doi.org/10.1016/j.ijporl.2003.12.010Get rights and content

Abstract

Objective: To evaluate the frequency of intracranial and orbital complications occurring as simultaneous but separate complications of acute rhinosinusitis in the pediatric population. Methods: Records of children admitted to St. Louis Children’s Hospital between 1 January 1990 and 31 December 2002 were reviewed. Relevant literature was reviewed with the assistance of Medline. Results: We identified 74 patients with orbital complications related to acute rhinosinusitis. A bimodal age distribution was identified with one group above and one group below the age of 7 years. The frequency of intracranial complications in pediatric patients already admitted for orbital complications of acute rhinosinusitis was 0% for those less than 7 years of age and 9.3% (4/43) for patients 7 years and older. If surgery was required for orbital disease, these risks were 0 and 24% (4/17), respectively. The review found that patients with dual complications had a mean age of 15 years, 11 months, were male (100%), had subperiosteal abscesses located superiorly or superolaterally within the orbit, and presented with significant frontal sinus disease. All intraoperative cultures were polymicrobial. MRI was superior to CT for identification of intracranial extension. Conclusions: Simultaneous intracranial and orbital complications are rare but significant occurrences in acute pediatric rhinosinusitis. Because of the high incidence of intracranial findings, we recommend MRI in addition to CT scan along with aggressive management in children older than 7 years of age admitted with orbital complications of acute rhinosinusitis who also demonstrate risk factors for intracranial disease. These risk factors are discussed.

Introduction

On average, most children experience six to eight upper respiratory infections per year [1]. Rhinosinusitis complicates 5–10% of pediatric upper respiratory infections [2]. Most often related to infection in the frontal and ethmoid sinuses, suppurative extension involving the orbit or intracranial space represents the rarest and most severe presentation of acute rhinosinusitis. Estimated to occur once every 95,000 hospital admissions, suppurative complications can be both vision and life threatening if not diagnosed early and treated aggressively [3]. Maintaining a high index of suspicion and early surgical intervention are keys in the prevention of potential lifelong disability. Difficulty in obtaining a proper and timely diagnosis remains, however, when suppurative disease spreads simultaneously to both the orbit and cranial vault.

Diagnostic evaluations often include imaging studies because the information gathered from the history and physical examination may be limited by a child’s inability to accurately describe his/her symptoms as well as patient intolerance to the examination itself. In addition, the paranasal cavities, orbit, and cranial vault are themselves relatively inaccessible to direct evaluation. Imaging studies such as CT and MRI have revolutionized our ability to evaluate sinonasal disease, particularly in children. CT is preferred because of its superior ability to demonstrate bony detail, speed, and ease of examination. MRI, while providing outstanding soft tissue detail without radiation exposure, is slower and exquisitely sensitive to motion artifact, requiring monitored sedation for most children. While these modalities are complementary, their individual roles in the evaluation of complications arising from pediatric sinonasal disease are just now beginning to be elucidated. As our dependence on imaging has grown, so must our understanding of its limitations. Information provided by imaging studies must be evaluated in the context of the patient’s overall medical condition.

Although rare, acute rhinosinusitis has the potential to simultaneously spread through multiple routes. Failure to recognize two distinct complications can have dire consequences as these children are at significant risk for long-term morbidity if not managed appropriately. We present our pediatric experience with dual suppurative intracranial and orbital complications arising from frontoethmoid rhinosinusitis.

Section snippets

Methods

Medical records of patients admitted to St. Louis Children’s Hospital for acute rhinosinusitis from 1 January 1990 to 31 December 2002 were reviewed. Patients experiencing orbital and intracranial complications related to their acute rhinosinusitis were evaluated. Although cavernous sinus thrombosis is considered an intracranial complication, it often is a result of orbital extension. Because of this, patients with cavernous sinus thrombosis were excluded from consideration in order to evaluate

Results

Seventy-four patients were admitted to St. Louis Children’s Hospital with orbital infections due to acute rhinosinusitis between 1990 and 2002. Thirty of these patients underwent surgical procedures to treat the orbital complications of frontoethmoid sinusitis. Of these, seven patients were also found to have intracranial extension. Three patients with cavernous sinus thrombosis accompanying orbital complications of acute rhinosinusitis were excluded, leaving four patients with simultaneous

Discussion

Suppurative extension of pediatric frontoethmoid rhinosinusitis is a rare complication that often results from delays in diagnosis and/or inadequate treatment. Orbital complications arising from acute rhinosinusitis are well known and often involve the postseptal orbit due to its close proximity to the ethmoid sinuses. Spread of infection is usually through dehiscences in the lamina papyracea containing ophthalmic vessels supplying the paranasal sinuses. While most cases of preseptal and

Conclusion

Acute rhinosinusitis is a common pediatric infection that usually responds well to conservative therapy. Although rare, suppurative complications of acute rhinosinusitis can cause considerable morbidity if not properly diagnosed and treated. This is especially pertinent when patients present with multiple, simultaneous complications. Surgical drainage procedures in conjunction with aggressive medical management remain the standard of care for these critically ill patients.

This report reviews

References (15)

There are more references available in the full text version of this article.

Cited by (0)

View full text