1

Introduction

Rhinosinusitis is one of the most common medical problems in both the adult and pediatric populations. The prevalence of chronic sinusitis has been estimated as high as 1 in 8 individuals in the United States , making it the most common chronic disease at the present. Acute sinusitis is likely a universal experience for Americans at some point in their lives. In fact, one study reported that 87% of patients with uncomplicated upper respiratory tract infection showed sinus mucosal changes on computed tomography (CT) . However, serious complications of sinusitis do occur, though their incidence has substantially decreased in the era of antibiotics .

Infection in the paranasal sinuses can potentially spread to any surrounding structures, including the orbital and intracranial cavity. Orbital complications are more common , but intracranial complications of sinusitis (ICS) are clearly the most serious and life-threatening. Potential intracranial complications include epidural abscess, subdural abscess, intracerebral abscess, meningitis, and cavernous or superior sagittal sinus thrombosis .

Even with proper use of broad-spectrum antibiotics and surgical intervention, there remains significant morbidity and mortality associated with ICS. Reported mortality rates in the past 20 years range from 0% to 7% . The patients who died in these studies commonly had a delayed diagnosis and presented in a comatose state . Persistent morbidity is seen in 10% to 25% of patients with ICS . The most common persisting problem is epilepsy, followed by dysphasia and focal paresis. The incidence of morbidity after intracranial complications of sinusitis is not related to the severity of neurologic deficits at the time of presentation .

Intracranial complications of sinusitis are typically a complication of acute (ARS) rather than chronic rhinosinusitis (CRS) and usually involve indirect spread through hematogenous routes rather than direct spread intracranially through bony defects. Although endoscopic sinus surgery (ESS) is well accepted in the treatment of medically refractory CRS, ESS in the setting of ARS is not typically indicated. In the setting of patients with ARS and ICS, it is sometimes presumed that surgically addressing the sinuses is necessary to avoid progression or in conjunction with neurosurgical drainage of the intracranial process. We retrospectively reviewed our series of patients with ICS to evaluate the role of ESS in the setting of ARS and to try to assess whether medical treatment alone with or without early ESS could affect the ultimate need for neurosurgical intervention.

2

Methods

We retrospectively reviewed the records at Emory Healthcare in Atlanta, GA, for patients with any intracranial infection between January 1, 2001 and December 31, 2006. Institutional review board approval was obtained from each institution. Charts were reviewed for a diagnosis of epidural abscess, subdural abscess, brain abscess, bacterial meningitis, cavernous sinus thrombosis, or superior sagittal sinus thrombosis. There were a total of 118 patients found meeting these criteria. The medical records of these patients were reviewed to determine if the intracranial infection was a complication of sinusitis. Criteria used for this determination included sinus opacification on imaging studies during the pertinent hospital admission, no other apparent source of intracranial infection, and the assessment of the attending otolaryngology staff that the intracranial infection resulted from sinusitis. Patients were excluded if they were immunocompromised. Data collected included basic demographic information; comorbidities including sinus history, medications, presenting symptoms, pertinent laboratory, and imaging studies; antibiotics used; surgeries performed; and follow-up information.

2

Methods

We retrospectively reviewed the records at Emory Healthcare in Atlanta, GA, for patients with any intracranial infection between January 1, 2001 and December 31, 2006. Institutional review board approval was obtained from each institution. Charts were reviewed for a diagnosis of epidural abscess, subdural abscess, brain abscess, bacterial meningitis, cavernous sinus thrombosis, or superior sagittal sinus thrombosis. There were a total of 118 patients found meeting these criteria. The medical records of these patients were reviewed to determine if the intracranial infection was a complication of sinusitis. Criteria used for this determination included sinus opacification on imaging studies during the pertinent hospital admission, no other apparent source of intracranial infection, and the assessment of the attending otolaryngology staff that the intracranial infection resulted from sinusitis. Patients were excluded if they were immunocompromised. Data collected included basic demographic information; comorbidities including sinus history, medications, presenting symptoms, pertinent laboratory, and imaging studies; antibiotics used; surgeries performed; and follow-up information.

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Results

Twenty-three patients were found to have ICS. These complications included 8 epidural abscesses (35%), 10 subdural abscesses (43%), 3 cases of meningitis (13%), and 2 intracerebral abscesses (9%). There were no cases of cavernous or superior sagittal sinus thrombosis resulting from sinusitis. Orbital complications were also found in 4 of the 23 patients. All had orbital subperiosteal abscesses that were incised and drained during the course of treatment. Of these patients, 2 had additional extrasinus complications including osteomyelitis of the frontal bone along with epidural abscess because of frontal sinusitis and necrotizing fasciitis of the scalp involving the galea, periosteum, and temporalis muscle.

Males were much more commonly affected than females, with 20 males and 3 females. The age range was 5 to 77, with a median of 14. There were 3 elderly patients (ages 63, 74, and 77), whereas all other patients were age 21 or younger. No patient possessed any congenital or acquired anatomical anomaly that would predispose them to direct spread of infection from the sinuses to the intracranial cavity.

Of the 23 patients, 2 had a documented history of sinusitis at least 1 month before their admission for ICS. There was no history of sinus surgery in any patient. Ten patients were taking oral antibiotics for acute sinusitis, and 1 patient had received intravenous antibiotics for orbital cellulitis before being admitted to the hospital at our institution.

The most common presenting symptoms included headache (20) and altered mental status (14). The 14 patients with altered mental status ranged from lethargic but oriented (7 patients), lethargic and confused (5 patients), to obtunded (2 patients). Other presenting symptoms included seizures (7), fever (8), nasal congestion (4), vomiting (5), photophobia (5), orbital edema (5), neck stiffness (2), and cranial nerve weakness (1).

Noncontrast CT of the head and sinuses was performed on all patients. Opacification of one or more sinuses was present in every patient. Of 23 patients, 22 (96%) had CT evidence of frontal sinusitis at the time of presentation. Prefrontal lobe and frontal lobe intracranial disease was present in 22 of 23 patients. Each of these 22 patients also had CT evidence of frontal sinus disease. In one patient without anterior cranial fossa (ACF) disease, the intracranial complication was a subfalcine subdural abscess. This patient had isolated left-sided maxillary and ethmoid sinus disease.

Six patients had CT scans that were negative for any intracranial process. These 6 patients had a subsequent magnetic resonance imaging (MRI) that confirmed ICS. Of 6 patients, 3 had an epidural abscesses less than 1 cm and the other 3 patients had evidence of dural enhancement only. The 3 patients with dural enhancement on MRI had lumbar punctures that confirmed bacterial meningitis. Six additional patients had an MRI that confirmed their CT findings.