Subdural empyema complicating acute frontal sinusitis. Four cases report

OBJECTIVE: Subdural empyema is a collected cranioencephalic suppuration between arachnoid and dura meninge space. Subdural empyema occurring after sinusitis is an uncommon but serious complication of paranasal sinus infections. The purpose of this study is to aware the clinician about this condition. MATERIAL ET METHOD: Four young male children had been admitted with expressed fronto-ethmoid sinusitis. The intracranial infection was confirmed by computed tomography scan of brain and sinus. Both drainage of the sinus and intracranial suppuration was performed at the same time surgical procedure and antibiotics administered during 4 weeks. RESULTS: The subdural empyema was localized in the right temporoparietal region in 1 case, in the frontal lobe in the others cases. In 1 case, the frontal subdural empyema was associated with an inerhemispherique collection. One patient underwent a second drainage. Immediate post-operative outcomes were temporally complicated with convulsions and focal neurological deficit, in 1 case. This symptoms had regressed spontaneously. There was no case of death. The functional prognosis was bad, marked by lost vision in 2 cases, which was bilateral in 1 case. CONCLUSION: A high index of suspicion of intracranial extension of sinus infection must recommended neuroradiological investigations. When suppurative collection is confirmed, an appropriated management of the infection between otorhinolaryngologists and neurosurgeons is necessary.     

The prevalence of intracranial complications in pediatric frontal sinusitis

OBJECTIVE: Intracranial extension of infection represents a serious complication of sinusitis but with no clearly documented prevalence. The frontal sinus with its unique anatomical characteristics, has been singled out as a catalyst for intracranial spread, but without solid evidence. Our objective was to determine the prevalence of intracranial complications in pediatric acute frontal sinusitis and to test the claimed association. METHODS: A retrospective chart review of all children (相似文献   

Bilateral subdural empyemas with meningitis secondary to acute barosinusitis

IntroductionIntracranial complications of acute rhinosinusitis are rare, but may turn life-threatening.Case summaryWe report a healthy 30-year-old male who complained of frontal headache, which developed while on a plane. A brain CT showed a low-density lesion on the left frontal convexity with right maxillary and ethmoid sinusitis. Despite receiving intravenous antibiotics, a follow-up brain CT showed two lesions with adjacent dural and leptomeningeal enhancement. A paranasal sinus CT revealed aggravated left frontal sinusitis and right maxillary sinusitis. The patient underwent craniotomy and brain abscess removal along with endoscopic sinus surgery. Seventeen days after the surgery, the patient was discharged with no neurological sequelae.ConclusionTo the best of our knowledge, this case is the first report regarding the association between barotrauma and intracranial complications of acute rhinosinusitis. A high index of suspicion and well-timed surgical evacuation may ensure a full recovery.     

Subdural empyema as a complication of sinusitis in the pediatric population

OBJECTIVE: Sinusitis is a rare cause of intracranial infection in children. While intracranial complications of sinusitis are rare, the morbidity and mortality remain high. Subdural empyema is recognized as the most common sinogenic intracranial complication. We undertook a review of our cases of subdural empyema and other intracranial complications of sinusitis over the past 8 years at a busy inner city hospital. Our intent was to identify factors that may predispose children to these serious complications. METHODS: A retrospective chart review was conducted using ICD-9 codes to identify pediatric patients treated for complications of sinusitis at University Hospital (UH) from 1996 to 2004. Only patients age 18 or younger at the time of admission were included in this study. The following data were collected from hospital medical records: age, gender, past medical and social history, presenting symptoms, history of present illness, microbiology, surgical and medical intervention, and outcome. RESULTS: Twelve patients were identified that fit the criteria for this study. The mean age of these patients was 14.1 years, and 10 of our 12 patients were male (83.3%). The most common presenting complaints were fever, headache, altered mental status, orbital cellulitis, nasal symptoms, nausea and vomiting, and photophobia. In the week prior to admission for intracranial complications, nine patients were seen by a physician: five patients were seen in the ER and four by a primary care physician. Subdural empyema was the most commonly observed intracranial complication in this series. Microaerophilic and anaerobic organisms were most commonly identified in this series. Most sinus procedures consisted of endoscopic ethmoid and maxillary sinus drainage. There was a long-term morbidity rate of 16% and a mortality rate of 8%. CONCLUSIONS: Three conclusions may be drawn from this study. First, the morbidity and mortality of intracranial complications of sinusitis remain high in the pediatric inner-city population despite adequate access to medical care. Second, subdural empyema appears to arise in the setting of subacute rather than acute frontal sinusitis. Lastly, there may be an under-diagnosis and delay in treatment of patients with frontal sinusitis, resulting in subsequent intracranial complications.     

Intracranial complications of paranasal sinusitis: a combined institutional review

Intracranial complications of paranasal sinusitis constitute true surgical and medical emergencies. The charts of all patients (n = 649) admitted for acute or chronic sinusitis to the University of Minnesota Hospital and to the University of Michigan Medical Center during a 13-year period (1975 to 1988) were retrospectively reviewed to determine the incidence of complications. The clinical presentation, bacteriology, involved sinuses, influencing host factors, white blood cell count on presentation, length of hospitalization, and postinterventional complications are presented. Twenty-four patients with intracranial complications from paranasal sinusitis are studied for an incidence of 3.7%. Aggressive medical and semi-emergent surgical intervention are required to prevent excessive morbidity and/or mortality. Intracranial complications included subdural empyema, frontal lobe abscesses, intrahemispheric abscesses, cavernous and superior sagittal sinus thrombosis, and osteomyelitis.     

The expression of somatostatin receptors 3, 4 and 5 in laryngeal pathology

Even though being a rare condition in the era of antibiotic treatment, complications of acute frontal sinusitis still pose a potentially life-threatening problem. We present a clinical case series using a combined surgical approach. Within a 7 year period, all patients with a suppurative complication of an acute frontal sinusitis were included into this retrospective study and evaluated concerning histories, diagnostic and therapeutic procedures and achieved outcomes. Twelve patients (11–74 years) were identified; this corresponds to 0.3% of all patients that have undergone paranasal sinus surgery and 15.4% of all patients with infectious complications of sinusitis. The cases could be subdivided as follows: intracranial complications (4/12), osteomyelitis of the frontal bone (4/12), frontal/orbital soft tissue involvement (3/12) and endoluminal empyema (1/12). These were all correctly diagnosed by CT and (especially in the cases of intracranial complications) MRI. The microbiological spectrum comprised mostly non-multiresistant Staphylococci and Streptococci. All patients received aggressive antibiotic and combined surgical treatment. Within a mean follow up period of 32 months, the disease-related mortality and the rate of severe long-term ailment was 0%. If detected and treated early, both long-term morbidity and mortality can be minimised. A close cooperation with the related specialties (neurosurgery, ophthalmology, radiology) is thereby of utmost importance.     

Subdural empyema and blindness due to cavernous sinus thrombosis in acute frontal sinusitis

In this era of antibiotics, the complications of acute sinusitis are much less frequently encountered. Although orbital complications are most common, intracranial complications carry a high rate of mortality and morbidity. We describe a case of acute frontal sinusitis with subdural empyema and blindness due to cavernous sinus thrombosis and carotid artery thrombosis with a discussion of treatment of these complications and the etiology of blindness in sinusitis.     

The endoscopic management of chronic frontal sinusitis associated with frontal sinus posterior table erosion

Expansile inflammatory diseases of the frontal sinuses may produce erosion of the posterior table of the frontal sinus. In these instances, the bone between sinus mucosa and intracranial dura is absent. Over the past decade, endoscopic frontal sinusotomy has emerged as the preferred technique for the treatment of refractory chronic frontal sinusitis. Endoscopic approaches also have a role in the most advanced instances of frontal sinusitis. A retrospective chart review of patients who were treated for frontal sinusitis with erosion of the frontal sinus posterior table was performed. Eight patients were identified. All patients underwent endoscopic frontal sinusotomy; some patients required multiple endoscopic procedures. Complete frontal recess dissection with identification of the frontal ostium was achieved for all involved frontal sinuses. In all cases, this postoperative result was monitored by CT scans (where indicated) and serial nasal endoscopy, which demonstrated good frontal sinus aeration and normal mucociliary clearance. Antibiotics were administered for culture-documented bacterial exacerbations, and systemic steroids were given for management of allergic fungal sinusitis and sinonasal polyposis associated with asthma. No patient underwent frontal sinus obliteration or cranialization. No suppurative intracranial complications were noted during the postoperative period. Endoscopic frontal sinusotomy can be used safely for the definitive management of frontal sinusitis associated with posterior table erosion. In fact, endoscopic techniques may represent the preferred approach for the treatment of this problem. Such an approach avoids the morbidity of more destructive alternatives (such as obliteration), and serves to create a frontal sinus with normal mucociliary clearance.     

Complicated acute sinusitis

The incidence of complications of paranasal sinusitis have been progressively decreasing since the advent of antibiotics. Most of the complications that have occurred are secondary to sub-acute or chronic sinusitis. A few patients, however, still present with a complication of an acute sinusitis infection. Four cases are presented in detail and 14 cases are summarized which presented with an acute complication as the primary presenting complaint. Sinusitis was not an obvious component in most of these cases, and none of the 18 patients had any previously known sinus disease. The paper was limited to a discussion of complications involving the orbit, the tissues surrounding the sinuses, and the intracranial cavity. Basic information regarding these topics was reviewed. The first case report described a young boy with cellulitis of the orbit and cheek secondary to a maxillary sinusitis. Neither the cellulitis nor the sinusitis responded to the medical treatment until trephine and irrigation of the sinus was performed. The second case report described a young man with a frontal subperiosteal abscess and orbital cellulitis secondary to frontal sinusitis. His treatment consisted of drainage of the abscess and performance of a frontal sinus trephine. The third case described a young man with maxillary, ethmoid and sphenoid sinusitis and a secondary cavernous sinus thrombosis. The maxillary sinuses were drained and the patient was given high doses of intravenous antibiotics and decongestants but he was not anticoagulated. Apart from the central retinal artery thrombosis resulting in the left eye, recovery was complete. The fourth case report described a young lady who had undergone a renal transplant and was maintained on immunosuppressant medications. She developed a meningitis secondary to maxillary sinusitis. Complete recovery occurred on medical treatment alone. The other 14 cases were summarized in a table. These cases were then discussed and recommendations were made regarding management of these complications. It was concluded that with antibiotics in adequate closes, it is now safe to perform a sinus trephine much earlier in the course of the disease than has previously been advocated. Eight of the 18 were drained in the acute phase and there was no evidence of osteomyelitis or other sequella secondary to this procedure. Indeed, six of these patients required surgical drainage before the fever or the complications would respond to therapy. It is suggested that immediate surgical drainage and irrigation is indicated when sinusitis does not respond or becomes clinically worse after 24-48 hours of treatment with systemic antibiotics and decongestants; or when acute suppurative local infection or septic intracranial complications are present. The sinuses should be irrigated frequently with saline until the return remains clear for 48 hours. The majority of the organisms isolated were staphylococci, coagulase negative and coagulase positive. Four cultures grew no organisms but since routine cultures for anaerobic organisms were not performed these could not be eliminated as a factor in the infection. The majority of cases were treated with high doses of intravenous antibiotics and these were only given intramuscularly 24 to 48 hours after the fever had subsided and the clinical symptoms were resolving. The total duration of antibiotic treatment varied considerably within this series. It is recommended that complicated acute sinusitis should be treated as though an osteomyelitis is actually present. The systemic antibiotics should be continued for a full week after fever disappears before changing to oral antibiotics. The total duration of antibiotic therapy should be for four to six weeks. In treating meningitis, high doses of broad spectrum antibiotics were used until culture sensitivities were available. Examination of cerebrospinal fluid was emphasized. On adequate treatment the C.S.F. sugar levels should rise above the initial values and no demonstrable micro-organism should be present after 24 hours. It was noted that intracranial abscesses can occur with minimal symptoms and that fever is not necessarily present. If any doubt exists an arteriogram or other investigations should be performed.     

Brain abscess secondary to rhinosinusitis. Therapeutical modalities. Exposition of one case

Brain abscess (BA) as complication of sinusitis represent around 3% of the cases. Other suppurative intracraneal complications such as epidural abscess, subdural empyema and meningitis are more common than BA. The frontal and ethmoid sinuses form an integral part of anterior and to a lesser extent middle skull base to which the dura is intimately related. Thrombophlebitis of veins associated with paranasal sinuses is considered to be the main route of intracraneal spread of infection. However, osteitis is an uncommon mechanism that typically involves frontal sinus. Chronic sinusitis more than fulminant course of acute sinusitis is often responsible for BA. Epidemiology of BA has changed with the increasing incidence of this infection in inmunocompromised patient and the decreasing incidence related to sinus infection. Mortality rate of BA were around 35-55% before CT scan era and with surgical excision as the rule of surgical treatment.     

经鼻内镜额窦脑脊液鼻漏修补术初探

目的探索额窦脑脊液鼻漏修补术的进路、修补方法和手术技巧。方法对9例额窦后壁和4例额隐窝后外侧壁脑脊液鼻漏患者进行手术修补，其中首次手术行鼻内镜下修补术12例，联合进路1例；术后观察手术疗效及并发症情况。结果13例患者中12例一次修补成功，1例二次修补成功。出现并发症2例，其中1例为术后颅内感染，行鼻外引流、额窦填塞术治愈；另1例为阻塞性额窦囊肿，行鼻内镜下额窦开放术治愈。结论经鼻内镜可以成功修补可视的额窦后壁脑脊液鼻漏，但要注意额窦口及漏口大小，防止术后额窦阻塞，诱发阻塞性额窦囊肿、额窦炎和颅内感染；对于额窦内不可视的脑脊液鼻漏和额窦口扩大困难的病例，建议行联合进路修补术。     

The modified endoscopic Lothrop procedure in the treatment of complicated chronic frontal sinusitis

The purpose of this study was to evaluate the modified endoscopic Lothrop procedure in the management of complicated frontal sinus disease which has breached the confines of the sinus walls and extended into the cranial cavity or orbit. Fourteen patients with radiological evidence of 17 complications of frontal sinus disease presented over a 23-month period. CT scan and MRI scans revealed the presence of posterior table erosion and extension of the frontal sinus disease into the anterior cranial fossa in 10 patients. In addition, seven patients had intraorbital complications, with three patients having both intracranial and orbital complications. All patients underwent a modified endoscopic Lothrop procedure as part of the management of the complication. In addition, one patient required an orbital abscess drainage and repair of an encephalocele, with a second patient requiring drainage of an orbital subperiosteal abscess. At follow-up, all patients were asymptomatic and had patent frontal sinus ostia. Follow-up ranged from 8 months to 38 months with a median of 25 months. Three patients required a revision of their frontal ostium. Two patients had allergic fungal sinusitis with aggressive polyp recurrence and ostial re-stenosis while one patient developed recurrent orbital infections from a retained frontal sinus cell. Currently, all have patent ostia, with an average size of 14.6 x 11 mm. The modified endoscopic Lothrop procedure is an effective form of treatment in the management of complicated frontal sinus disease. The results are comparable to those achieved with other surgical approaches such as the osteoplastic flap with obliteration.     

Subdurales Empyem und Zerebritis als Folge einer dentogenen, eitrigen Pansinusitis

BACKGROUND: Complications and local extension of dentogenous and paranasal sinus infections most often involve the periorbit and frontal cranium. Because of the widespread use of antibiotics, intracranial extension of maxillofacial sinusitis is rarely seen today. Nevertheless, the clinician must be aware of the potential for these complications, because late recognition of this condition and delay in treatment can increase morbidity and mortality rates. CASE REPORT: A case report of sinogenic intracranial complications is presented, with sinogenic empyema, cerebritis, and subdural empyema. The mechanisms and potential for intracranial spread of infection from the frontal, sphenoid, and ethmoid sinuses are discussed. The management of complications is outlined, including the use of computed tomography and the role of surgical drainage.     

Ostre izolowane zapalenie zatoki klinowej – opis 4 przypadków

Introduction

Isolated acute sphenoid sinusitis is an uncommon sinus infection, frequently misdiagnosed and not usually considered in the differential diagnosis of acute severe headache, with the potential of serious neurologic complications.

Aim

Describe four patients with acute sphenoid sinusitis who presented with acute onset of severe headache and consider the role of medical or surgical management. Two patients do not required surgical intervention and medical treatment was sufficient. One patient had sphenoidotomy due to meningitis. One patient was performed surgical intervention after fail of medical therapy. Acute isolated sphenoid sinusitis appears to be difficult to diagnose. It is important to be aware of acute sphenoid sinusitis in the setting of new onset severe headache, when imaging studies are unrevealing for intracranial pathology. Medical therapy focused on infection, inflammation, and obstruction may be adequate for resolution, but surgical intervention may be required in certain situations.     

Intracranial complications of frontal sinusitis

Frontal sinus infections can spread to the intracranial space so fast that the clinical situation often becomes far advanced before a complication is recognized. Retrograde septic thrombophlebitis is the most common pathway of extension. A review of recent experiences with fulminating frontal sinusitis and its intracranial complications such as subdural empyema, brain abscess, epidural abscess, and meningitis is presented. Neurologic features of intracranial invasion are interpreted. Good results have been achieved by immediate and aggressive surgical and medical measures.     

Rhino-frontal sinuseptotomy (RFS): a combined intra-extra nasal approach for the surgical treatment of severely diseased frontal sinuses

OBJECTIVES: Frontal sinus surgery is a challenge to those involved in the treatment of recurrent frontal sinusitis. The purpose of this report is to describe the technique and to present the results of a combined endoscopic and external approach to the frontal sinus (rhino-frontal sinuseptotomy [RFS]). MATERIAL: RFS was performed in 45 patients by the author; 41 of these patients had a follow-up over 12 months and were included in this series. Indications for RFS were severe chronic frontal sinusitis (n = 23), mucoceles (n = 12), in two cases each with osteoma, inverting papilloma, and malignant tumors of the frontal sinus, respectively. The surgical technique is started with an external approach according to Jansen-Ritter and includes the resection of the interfrontal septum, partial resection of the nasal septum, bilateral subtotal resection of the middle turbinates, bilateral endoscopic ethmoidectomy, and resection of the frontal sinus floor. The nasofrontal communication is epithelialized with free mucosal grafts and fixed with fibrin clue. RESULTS: After a mean follow-up of 62 months, 40 patients (98%) had a widely patent epithelialized nasofrontal communication. Ninety-one percent of the patients with chronic frontal sinusitis or mucoceles noted complete relief of their frontal discomfort within 1 week after RFS. No patient required revision surgery of the nasofrontal outflow tract after RFS. Only one severe complication was recognized (cerebrospinal fluid leakage). CONCLUSION: The results reported here with the RFS technique are superior to those reported on external procedures and endoscopic drill-out procedures. The key to successful management is the creation of a large nasofrontal communication, and direct epithelialization with free mucosal grafts obtained from the septum and turbinates.     

Subdural empyema of sinus origin caused by Gemella morbillorum,a strange etiology

We present a case of frontal sinusitis complicated with a subdural empyema, in which the identified microorganism was Gemella morbillorum, a frequent host of the aerodigestive tract and occasionally related to infections. The problem was resolved successfully using endoscopic surgery and an external approach of the sinus. Afterwards it was completed with a subdural drainage through craniotomy. Subdural empyema is a rare complication of sinusitis although very severe. We want to emphasize the importance of early diagnosis of intracranial complications, the need of a detailed microbiology test the method used to obtain samples, and the convenience of a combined approach by the otolaryngologists and the neurosurgeons for its complete drainage.     

Surgical treatment of subperiosteal abscess of the orbit: Sendai's ten-year experience

OBJECTIVE: One of the common complications of acute infection of the paranasal sinus is cellulitis of the orbit. This is secondary to the spread of infection through the very thin bony wall between the ethmoid sinuses and the orbit, the roof of the orbit in frontal sinusitis, and the floor of the orbit in maxillary sinusitis. When the infection does not penetrate the periorbita, it dissects under the periosteum and forms subperiosteal abscess. METHODS: We experienced 10 patients with subperiosteal abscess for 10 years from 1992 to 2002 that required surgical drainage. The age of the patients ranged from 4 to 76 years including five males and five females. RESULTS: Successful and safe drainage of the abscess with endoscopic sinus surgery was obtained in four patients while six patients required external surgery. The selection of the surgical approach depended upon the localization of abscess in the orbit. Five of the seven patients with visual disturbance resulted in a complete recovery of vision after surgery. However, there was no improvement of visual acuity in the other two patients who had already shown severe damage of vision prior to treatment. CONCLUSION: Ocular symptoms such as exophthalmos, double vision, and ptosis subsided completely in all patients. It is suggested that prompt diagnosis and surgical drainage before severe loss of visual acuity rescue or recover the vision.     

Do you need to operate following recovery from complications of pediatric acute sinusitis?

Objectives

There are many studies that evaluate the role of surgery in the treatment of complications of pediatric acute sinusitis; however there are few studies, if any that report the incidence of surgery following recovery from acute complicated sinusitis. The goal of this study was to report the incidence and indications for surgical intervention after recovery from complications of pediatric acute sinusitis.

Methods

We reviewed the records of all children admitted to a tertiary care children's hospital between January 2005 and September 2010 with a diagnosis of sinusitis and an orbital or intracranial complication. Eighty-six patients met inclusion criteria. Charts were reviewed for type of complication, initial treatment (medical or surgical), type of procedure, secondary procedures, age, and comorbidities. Statistical analysis was completed using independent samples student t-tests and Mann–Whitney tests.

Results

A total of 86 patients with a mean age of 6.38 years (2 months to 18 years) were identified. Eighty patients had orbital complications while six presented with intracranial complications. Twenty-seven patients (31%) underwent sinus surgery during the acute phase of their illness whereas 59 patients (69%) were treated medically. After hospitalization and recovery for acute complicated sinusitis, surgery was performed on nine patients (mean age 4.86 years) within 1 month to 2 years post hospitalization. Of the nine patients who required secondary surgery following resolution of the initial complicated sinusitis, four patients were following initial surgical intervention and five patients had initially resolved their complication with medical therapy alone. Indications for subsequent surgery included failure of medical therapy for persistent rhinosinusitis (8 patients) and second complication (1 patient).

Conclusions

This study suggests that following resolution of complicated pediatric rhinosinusitis, very few patients may need further surgical intervention. Subsequent intervention is best guided by clinical judgment, symptoms during outpatient clinic visits, and failure of medical therapy.     

Frontal sinus obliteration with autologous calvarial bone graft: indications and results

Despite increasing advances in endonasal frontal sinus surgery, frontal sinus obliteration (FSO) is sometimes necessary after failure of other surgical techniques. This procedure has been reported with autologous tissue or synthetic material, but few studies have reported results with autologous calvarial bone graft. The aim of this study was to report our experience with osteoplastic FSO calvarial bone graft. A retrospective review was performed on 11 patients operated upon for FSO with autologous calvarial bone graft from 2005 to 2011. Obliteration was indicated for chronic symptomatic frontal sinusitis with nasofrontal duct stenosis in five cases of nasal polyposis with a history of endoscopic sinus surgery, two cases of frontal trauma, two of surgery for frontal inverted papilloma and two of chronic frontal purulent sinusitis. Ten patients had a history of one or two previous functional endoscopic sinus surgery (FESS) procedures. On outcome assessment, eight patients had no residual complaints after FSO and all patients showed improvement in symptoms. Frontal sinus obliteration with autologous calvarial bone graft showed low donor site morbidity and good aesthetic results. This procedure should be considered in severe frontal sinusitis after repeated FESS procedures have failed.