Complications of Pediatric Rhinosinusitis

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Complications of Pediatric Rhinosinusitis

Pediatric Otolaryngology
Author Credentials 

Original Author:
David E. Tunkel, MD
Associate Professor of Otolaryngology and Pediatrics
Johns Hopkins University School of Medicine
Director of Pediatric Otolaryngology
Johns Hopkins Outpatient Center, Room 6231
601 North Caroline Street
Baltimore, MD 21287-0910
Email: dtunkel@jhmi.edu

Updated by:
Kathleen R. Billings, MD
Associate Professor of Pediatric Otolaryngology-Head & Neck Surgery
Ann & Robert H. Lurie Children’s Hospital of Chicago
225 E Chicago Ave Box 25
Chicago, IL 60611-2991
Email: kbillings@luriechildrens.org

Module Summary

Complications of sinusitis in children are unusual but serious. Appropriate diagnosis involves knowledge of sinus and orbital anatomy. Radiographic imaging should be directed at the sinus source of infection as well as the area of suspected extension of infection (orbit, intracranial, or both). Multidisciplinary evaluation is critical, and broad spectrum antibiotics combined with timely surgical drainage is necessary for cure without sequelae.

Module Learning Objectives 
  1. Review the pathophysiology of orbital and intracranial complications of sinusitis in children.
  2. Recognize the signs and symptoms of impending complications of sinusitis.
  3. Review the surgical indications and surgical approaches for treatment of complicated sinusitis.
  4. Distinguish between the different types of orbital infections associated with sinusitis.
  5. List the different intracranial complications of sinusitis.
  6. Describe the local complications of sinusitis, including mucocele formation, frontal bone osteomyelitis, and lacrimal duct obstruction.
  7. Explain the aggressive nature of fungal sinusitis in immunocompromised children.

Anatomy

Learning Objectives 
  1. Understand the relationship between the ethmoid sinus and the orbit and recognize the anatomic features that allow extension of ethmoid infection into the orbit.
    1. Describe the valveless veins that communicate between the ethmoid sinus and the orbit.
    2. Identify the foramina that provide preformed pathways for infection across the lamina papyracea.
    3. Know that the thin medial orbital wall can allow infection to spread into the orbit.
  2. Describe the importance of the orbital septum with regard to classification of orbital complications, clinical signs and symptoms, and need for surgical intervention.
  3. Know the relationships of the optic nerve to other bony and soft tissue orbital landmarks.
  4. Understand the anatomic factors that allow intracranial extension of frontal sinus infection across the posterior table of this sinus.
    1. Describe the diploic veins that communicate from the frontal sinus to the dura.
References 
  1. Goodwin, WJ. Orbital complications of ethmoiditis. Otolaryngol Clin North Am.1985;18:139-47.
  2. Lange EE, Curran AJ, Patil N, et al. Intracranial complications of acute frontal sinusitis. Clin Otolaryngol. 2001;26:452-57.
  3. Weisman RA. Surgical anatomy of the orbit. Otolaryngol Clin North Am. 1988;21:1-12.
  4. Grischkan JM, Elmaraghy CA, Garrett MR, et al. Radiographic findings and clinical correlates in pediatric periorbital infections. Int J Otorhinolaryngol. 2015 Jan;2(1). pii: 5.

Pathogenesis

Learning Objectives 
  1. Understand the microbiology of complicated sinusitis.
    1. Know that Streptococcus milleri and related species are common pathogens in complications of sinusitis.
  2. Recognize that orbital and intracranial complications of sinusitis in children are usually associated with acute sinus infection.
  3. Classify orbital complications of sinusitis and describe the clinical and radiographic features of each condition.
    1. preseptal inflammatory edema/cellulitis.
    2. orbital cellulitis.
    3. subperiosteal orbital abscess.
    4. orbital abscess.
    5. cavernous sinus thrombosis.
  4. Classify the intracranial complications of sinusitis.
    1. meningitis.
    2. epidural abscess.
    3. subdural abscess/empyema.
    4. brain abscess.
    5. dural sinus thrombosis.
  5. Understand the need for urgent evaluation of immunocompromised children with suspected fungal sinusitis.
References 
  1. Brook I. Microbiology and choice of antimicrobial therapy for acute sinusitis complicated by subperiosteal abscess in children. In J Pediatr Otorhinolaryngol. 2016;84:21-26.
  2. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970;80:1414-1428.
  3. Giannoni C, Sulek M, Friedman EM. Intracranial complications of sinusitis: a pediatric series. Am J Rhinol.1998;12:173-78.
  4. Coudert A, Ayari-Khalfallah A, Suy P, Truy E. Microbiology and antibiotic therapy of subperiosteal orbital abscess in children with acute ethmoiditis. Int J Pediatric Otorhinolaryngol. 2018;106:91-95.
  5. Brook I. Microbiology and antimicrobial treatment of orbital and intracranial complications of sinusitis in children and their management. Int J Pediatr Otorhinolaryngol. 2009;73(9):1183-1186.
  6. Oxford LE, McClay J. Complications of acute sinusitis in children. Otolaryngol Head Neck Surg. 2005; 133:32-37.
  7. Ardeshirpour F, Bohm LA, Belani KK, et al. Surgery for Pediatric Invasive Fungal Sinonasal Disease. Laryngoscope. 2014;124:1008-1012.

Incidence

Learning Objectives 
  1. Recognize that complications of sinusitis are rare, but the morbidity of these complications can be extreme.
  2. Know that orbital infection from sinusitis is more common in children than adults.
  3. Know that intracranial infection from frontal sinusitis occurs predominantly in male older children and adolescents.
References 
  1. Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolaryngol Head Neck Surg. 1991;104:789-95.
  2. Hicks CW, Weber JG, Reid JR, Moodley M. Identifying and managing intracranial complications of sinusitis in children-a retrospective series. Pediatr Infect Ds J. 2011;30(3):222-226.
  3. El-Hakim H, Malik AC, Aronyk K, et al. The prevalence of intracranial complications in pediatric frontal sinusitis. Int J Pediatr Otorhinolaryngol. 2006;70:1383-1387.
  4. Marchiano E, Raikundalia BS, Carniol ET, et al. Characteristics of patients treated for orbital cellulitis: an analysis of inpatient data. Laryngoscope. 2016;126:554-559.

Genetics

Learning Objectives 

Understand that paranasal sinus mucoceles are unusual in children, and are often associated with cystic fibrosis, trauma, or prior sinus surgery.

References 
  1. Alvarez RJ, Liu NJ, Isaacson G. Pediatric ethmoid mucoceles in cystic fibrosis: long term follow-up of reported cases. Ear Nose Throat J. 1997;76:538-46.

Patient Evaluation

Learning Objectives 
  1. Review the key points on physical examination to assess the likelihood of an orbital complication of sinusitis.
    1. know the importance of early documentation and serial assessment of visual acuity.
    2. understand the clinical evaluation of globe position, papillary reaction, and extraocular motion.
  2. Review the key findings seen in patients with intracranial spread of sinus infection.
    1. understand that sinusitis may not be suspected initially in patients with intracranial infection.
  3. Review the indications for surgical intervention in patients with orbital and/or intracranial complications of sinusitis.
  4. Understand the need for multidisciplinary evaluation and treatment of children in complicated sinusitis.
    1. know when to obtain ophthalmology, neurosurgery, infectious disease consultations.
    2. review the need for ancillary testing when complications are suspected, including imaging, lumbar puncture, etc.
References 
  1. Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis and subperiosteal abscess formation: diagnosis and treatment. Otolaryngol Head Neck Surg. 1993;109:886-94.
  2. Ong YK, Tan HKK. Suppurative intracranial complications of sinusitis in children. Int J Pediatr Otorhinolaryngol. 2002;66:49-54.
  3. Sobel SE, Marchand J, Tewfik TL, et al. Orbital complications of sinusitis in children. J Otolaryngol. 2002;31:165-69.
  4. Sciarretta V, Dematte M, Farneti P, et al. Management of orbital cellulitis and subperiosteal abscess in pediatric patients: a ten year review. Int J Pediatr Otorhinolaryngol. 2017;96:72-76.

Imaging

Learning Objectives 
  1. Identify the computed tomography findings seen in patients with orbital complications of sinusitis.
  2. Understand the role of computed tomography and magnetic resonance imaging for patients with suspected intracranial infection from sinusitis.
  3. Know the advantages of magnetic resonance imaging for children with suspected intracranial extension of sinonasal infection.
References 
  1. Clary RA, Cunningham MJ, Eavey RD. Orbital complications of acute sinusitis: comparison of computed tomographic scan and surgical findings. Ann Otol Rhinol Laryngol. 1992;101:598-600.
  2. Younis RT, Anand VK, Davidson B. The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications. Laryngoscope. 2002;112:224-29.
  3. Germiller JA, Monin DL, Sparano AM, Tom LW.  Intracranial complications of sinusitis in children and adolescents and their outcomes.  Arch Otolaryngol Head Neck Surg. 2006; 132:969-976.
  4. Vasquez E, Creixell S, Carreno JC, et al. Complicated acute pediatric bacterial sinusitis: imaging updated approach. Curr Probl Diagn Radiol. 2004;33(3):127-145.

Treatment

Learning Objectives 
  1. Understand the need for broad spectrum antibiotics targeted against the usual organisms of pediatric sinusitis and orbital/intracranial infections.
  2. Understand the need for rapid initial assessment and careful monitoring to assess the need for surgical therapy.
References 
  1. Hengerer AS, Klotz DA. Complications of nasal and sinus infections. In Bluestone CD, et al., editors. Pediatric otolaryngology. 4th ed. Philadelphia: WB Saunders; 2003:1021-031.
  2. Nation J, Lopez A, Grover N, et al. Management of large-volume subperiosteal abscess of the orbit: medical vs surgical outcomes. Otolaryngol Head Neck Surg. 2017;157(5):891-897.

Medical Therapies

Learning Objectives 
  1. Discuss the controversies involved in medical management of orbital subperiosteal abscesses in children.
  2. Understand the need for well-defined surgical indications and close clinical followup, because many orbital infections require surgery to treat infection and preserve vision.
References 
  1. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit. Ophthalmology. 2000; 107:1454-458.
  2. Padia R, Thomas A, Alt J, et al. Hospital cost of pediatric patients with complicated acute sinusitis. Int J Pediatr Otorhinolaryngol. 2016;80:17-20.
  3. Emmett Hurley P, Harris GJ. Subperiosteal abscess of the orbit: duration of intravenous antibiotic therapy in nonsurgical cases. Ophthalmic Plast Reconstr Surg. 2012;28(1):22-26.

Surgical Therapies

Learning Objectives 
  1. Know the indications for surgical drainage of orbital infections from sinusitis.
  2. Understand the surgical approaches to the orbit, including the advantages and limitations of each approach.
  3. Discuss the timing of surgical drainage of sinus infection in relation to neurosurgical drainage of intracranial processes.
References 
  1. Froehlich P, Pransky SM, Fontaine P, et al. Minimal endoscopic approach to subperiosteal orbital abscess. Arch Otolaryngol Head Neck Surg. 1997;123:280-82.
  2. Neal GD. External ethmoidectomy. Otolaryngol Clin North Am. 1985;18:55-60.
  3. Rubin F, Perrot S, Lebreton M, et al. Drainage of subperiosteal orbital abscesses complicating pediatric ethmoiditis: comparison between external and transnasal approaches. Int J Pediatr Otorhinolaryngol. 2013;77(5):796-802.
  4. Pelton RW, Smith ME, Patel BCK, et al. Cosmetic considerations in surgery for orbital subperiosteal abscess in children: experience with a combined transcaruncular and transnasal endoscopic approach. Arch Otolaryngol Head Neck Surg. 2003;129:652-55.
  5. Gitomer SA, Zhang W, Marquez L, Chandy BM. Reducing surgical revisions in intracranial complications of pediatric acute sinusitis. Otolaryngol Head Neck Surg. 2018 Mar 1:194599818765160.

Staging

Learning Objectives 

Know the Chandler classification of orbital infection from sinus disease.

Case Studies

  1. Suspected frontal sinusitis with possible epidural abscess: A 12-year-old male child has a severe frontal headache for 2 days, fever to 100.3 F for 1 day, and mild nasal congestion without rhinorrhea for 1 week. The headache is no longer relieved by acetaminophen or ibuprofen.
  2. Suspected subperiosteal orbital abscess from sinusitis: A 3-year-old female child has a 1-day history of right eye redness and swelling. She has been febrile with rhinorrhea for 3 days. Her right eyelid is tense and swollen, with the upper lid more prominent. She is difficult to examine, but her pupils are reactive and reactive without an afferent pupillary defect. She seems to have difficulty moving the right eye up and out.
  3. Invasive fungal sinusitis in an immunocompromised child: A 2-year old child has a swollen right eye with facial pain and erythema.  He is undergoing chemotherapy to treat acute lymphoblastic leukemia, and his absolute neutrophil count is 250.  There is a two-day history of intermittent fever spikes to 39 degrees C.

Review

Review Questions 
  1. What is the name of the structure that separates periorbital infection and true orbital infection? What are the attachments of this structure?
  2. Infection of which of the paranasal sinuses is usually responsible for development of an epidural abscess?
  3. What are the advantages of the endoscopic approach for drainage of a subperiosteal orbital abscess? What are the limitations of such an approach?
  4. What are the clinical signs and symptoms of a subperiosteal orbital abscess? Of cavernous sinus thrombosis?
  5. What is the workup to confirm the diagnosis of invasive fungal sinusitis in an immunocompromised child with persistent fevers and sinonasal symptoms?
Resources 

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  1. Annual Meeting Webcast (AMW):