SAN DIEGO — Children with intracranial complications of sinusitis are significantly older, and have longer hospitalizations and more neurologic sequelae, compared with children who have intraorbital complications of sinusitis, Dr. Veronica K. Goytia reported at the annual meeting of the Infectious Diseases Society of America.
Recognition of clinical features suggestive of either intraorbital extension or intracranial extension is critical to initiating medical and surgical interventions that optimize outcome, said Dr. Goytia, a pediatric infectious diseases fellow at Baylor College of Medicine and Texas Children's Hospital, both in Houston.
In a study that is among the largest of its kind, Dr. Goytia and her mentors, Dr. Carol J. Baker and Dr. Morven S. Edwards, described the features of illness in 58 children under the age of 18 years who were admitted to Texas Children's Hospital with sinusitis complicated by intraorbital and/or intracranial extension from 1997 through 2006.
They defined sinusitis as paranasal sinus opacification on diagnostic imaging performed within 72 hours of admission. Intraorbital extension (IOE) was defined as an infection within or involving the bony confines of the orbit, whereas intracranial extension (ICE) was defined as an infection of sinusitis beyond the confines of the sinuses and orbit.
Of the 58 children, 26 had IOE and 32 had ICE. Intracranial complications consisted of dural enhancement (17 patients), subdural empyema (15), epidural abscess (14), frontal bone osteomyelitis (9), brain abscess (4), and sinus thrombosis (1). Some patients had more than one complication.
Children with ICE were significantly older than children with IOE (a mean of 11 years vs. 6 years, respectively). There was no difference in ethnicity between the two groups, and males outnumbered females by nearly two to one.
Prior to hospital admission, a majority of children with IOE had been seen by their primary care physicians, whereas children with ICE “were more likely to have come to a community hospital for evaluation, and had significantly more preadmission encounters than [did] those with IOE,” Dr. Goytia said.
There were no significant differences between the ICE and IOE groups in history of allergic rhinitis, dental surgery, otitis media, or trauma, but children in the ICE group were more likely than their IOE counterparts to have a history of acute or chronic sinusitis.
The most common presenting features for both groups were fever, headache, and vomiting. There were no differences between groups in the level or duration of fever, but children in the ICE group were more likely to have longer duration of headache, compared with children in the IOE group (a mean of 11 days vs. 3 days).
Dr. Goytia reported that broad-spectrum antibiotics were initiated in all children within 48 hours of admission. “The most common combination of antibiotics was vancomycin, cefotaxime, and metronidazole,” she said. “The most common regimens contained vancomycin, a third-generation cephalosporin, and either metronidazole or clindamycin for anaerobic organisms.” The duration of intravenous therapy was longer for children in the ICE group, compared with those in the IOE group (a mean of 35 days vs. 15 days).
The most common organisms isolated were streptococcus and staphylococcus, including both methicillin-susceptible Staphylococcus aureus and methicillin-resistant S. aureus. Gram-negative aerobic organisms were isolated occasionally in both groups, but anaerobic organisms were isolated exclusively in ICE patients.
In the ICE group, 31 patients underwent surgical procedures, compared with 20 patients in the IOE group. Endoscopic sinus surgery was common in both groups of patients. “More than half of ICE children underwent neurosurgical intervention,” Dr. Goytia said.
All children survived. Neurologic sequelae were seen in five children (16%) in the ICE group, and included one case each of the following: diplopia, hemiparesis, loss of vision, expressive aphasia, and cognitive and speech deficit. No children in the IOE group experienced neurologic sequelae. Frontal sinuses were undeveloped significantly more often in the IOE group, compared with the ICE group (58% vs. 22%).
“We speculate that undeveloped frontal sinuses in younger patients may provide a protective effect from developing intracranial extension of sinusitis,” Dr. Goytia said.
A cranial CT scan of a 12-year-old patient shows orbital abscess (red arrow) in the setting of ethmoid and sphenoid sinusitis. Courtesy Dr. Veronica K. Goytia