Complications of Acute Bacterial Sinusitis in Children (printer...

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Complications of Acute Bacterial Sinusitis in

Children
DeMuri, Gregory P. MD; Wald, Ellen R. MD
Posted: 08/19/2011; Pediatr Infect Dis J. 2011;30(8):701-702. 2011 Lippincott
Williams & Wilkins

Abstract and Introduction

Introduction

Upper respiratory infections are the most common illnesses evaluated by the primary care pediatrician.
Observational studies have shown that 5% to 10% of upper respiratory infections are complicated by acute
bacterial sinusitis (ABS).[1,2] It has been estimated that ABS and its complications are responsible for 23 million
visits to the healthcare provider annually and result in over 20 million prescriptions for antibiotics.[3] It has been
estimated that 2% to 30% of patients hospitalized for ABS have complications.[4] Since most of ABS is treated
in the ambulatory setting, the actual prevalence must be much lower. Even with aggressive management,
intracranial complications have a 10% to 20% mortality rate.[5] The peak prevalence of complications of ABS
occurs in the winter months. The mean age is 3 to 6 years which likely reflects the greater prevalence of orbital
involvement. Intracranial complications occur more frequently in adolescents.[6] In nearly every survey of the
complications of ABS males account for 60% to 70% of cases.

Pathogenesis
The complications of ABS relate directly to the proximity of the paranasal sinuses to the orbit and brain. The
maxillary sinuses are present at birth, as are the ethmoids that are responsible for the majority of orbital
complications. The ethmoid sinuses are comprised of 5 to 15 air cells on each side, separated from one another
by thin bony partitions. The medial wall of the ethmoid sinus is a paper thin bone called the laminae papyracea,
which provides a minimal barrier for infectious complications. The ethmoid sinuses empty into the middle and
superior meatus via tiny ostia that are easily obstructed. The frontal sinuses, which develop from an anterior
ethmoid cell, are usually present just above the orbital ridge by the 5th or 6th birthday. The roof of the orbit is the
same as the floor of the frontal sinus and the posterior wall of the frontal sinus is immediately adjacent to the
dura. This location allows for easy and rapid spread of infection to the meninges, brain, and orbital structures.
The later development of the frontal sinuses explains the predilection for intracranial complications in older
children and adolescents. The venous drainage of the frontal and sphenoid sinuses is provided by the
cavernous venous sinus. This vascular structure, which is at risk for thrombosis, serves as another path for
infection to spread from the sinuses to intracranial structures.

Complications
Complications of ABS may be categorized as extracranial, intracranial, and those involving the bone of the sinus
wall (osteitis). Extracranial manifestations may be divided into preseptal or postseptal infection. The orbital
septum is a connective tissue extension from the periosteum of the orbital rim into the tarsal plates of the
eyelids and serves as a barrier to invasion of the orbital space from preseptal infections. Inflammatory edema is
a preseptal condition that usually arises from infection of the ethmoid sinus and is the most common
complication of ABS in children, representing 80% to 90% of all extracranial complications.[5] Inflammatory
edema is often referred to as preseptal or periorbital cellulitis. This terminology can be confusing as the term
periorbital cellulitis is also used to refer to infections of the skin and soft tissue of the lid and lid structures.
Inflammatory edema is caused by impaired venous and lymphatic drainage of an infected sinus; however,
infection is confined to the sinus. Patients with inflammatory edema usually present with low-grade or no fever
and redness and swelling of the eyelids and periorbital skin.

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In contrast, orbital complications involve the orbital space proper and include orbital cellulitis, orbital abscess,
periosteal abscess, and optic neuritis. Postseptal infections arise from the ethmoid and frontal sinuses in that
order.[5] Patients with orbital infection present with similar clinical findings as in preseptal involvement with the
addition of proptosis, ophthalmoplegia, or impaired visual acuity. Because orbital complications may result in
permanent visual loss or spread to intracranial structures, distinguishing this condition from preseptal
involvement is critical. The clinical findings of ophthalmoplegia and proptosis each have a positive predictive
value for orbital infection of 97% and their absence a negative predictive value of 93%.[6] If neither of these
findings are detected, the chances of orbital involvement are low.
Epidural empyema is the most common intracranial complication of ABS followed by subdural empyema,
meningitis, brain abscess, and rarely, cavernous sinus thrombosis.[7] Headache and fever are nearly universal
findings at presentation and are often accompanied by mental status changes, seizures, or focal neurologic
deficits. Children with orbital involvement may also have intracranial complications. Importantly, patients with
intracranial complications may not have the diagnostic symptoms of ABS (cough, nasal discharge, or
congestion) or may have them for only 5 to 7 days before presentation.[8] Symptoms referable to the central
nervous system are often predominant.
Pott's puffy tumor is an osteitis (infection and inflammation of the wall) of the frontal sinus, which presents with
forehead swelling and tenderness. It is often associated with intracranial extension such as subdural and
epidural empyema.[9]

Microbiology
The microbiology of orbital and intracranial complications of sinusitis parallels that of ABS in that S.
pneumoniae, H. influenzae, and Moraxella catarrhalis are commonly isolated. However, other gram-positive
organisms including staphylococci and streptococci, and gram-negative and anaerobic bacteria are also
significant pathogens (Table 1). In the past decade, there has been increasing recognition of the importance of
Streptococcus anginosis (formerly S. milleri) and methicillin-resistant Staphylococcus aureus (MRSA) in these
infections.[5,7,10] Many of the complications of ABS are polymicrobial in nature.
Table 1. Microbiology of the Complications of Sinusitis*

Gram-positive
Staphylococci
Staphylococcus aureus
Coagulase-negative staphylococci
Streptococci
Streptococcus pneumoniae
S. anginosis
Group streptococcus
Group streptococcus
Other -hemolytic streptococci
Gram-negative
Haemophilus influenzae
H. aphrophilus
Moraxella catarrhalis

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Pseudomonas aeruginosa
Klebsiella pneumoniae
Moganella morganii
Serratia marcescens
Citrobacter freundii
Anaerobes
Bacteroides sp.
Prevotella sp.
Eikenella corrodens
Fusobacterium sp.
Peptostreptococcus sp.
Porphyromonas sp.
*From references 8, 11, 14.

Imaging
When an orbital or intracranial complication of ABS is suspected on clinical grounds, imaging studies are
essential to confirm the diagnosis and to determine the need for surgical intervention. Computed tomography
provides the best definition of bony structures and is most likely to show subperiosteal abscess and osteitis,
particularly when orbital complications are suspected. In addition, computed tomography will delineate the
osteomeatal complex and sinuses themselves in great detail, which may provide important information when
sinus surgery is planned. Magnetic resonance imaging affords more detailed images of the brain and
surrounding structures. Meningitis and local fluid collections, such as subdural and epidural empyema, are best
detected using magnetic resonance imaging.[11]

Management
The management of the complications of ABS consists of targeted antimicrobial therapy and surgical drainage.
Empirical antimicrobial choice depends on the location of infection and suspected pathogens. For sinus and
periorbital and orbital involvement, a combination of ceftriaxone and clindamycin should be used initially. In
areas where MRSA isolates are typically resistant to clindamycin, vancomycin should be used in addition to
ceftriaxone. Ampicillin/sulbactam is an acceptable alternative if MRSA is not suspected. Therapy should usually
be parenteral except in cases of mild inflammatory edema in which case amoxicillin/clavulanate may be used.
Intracranial complications should always be treated with intravenous antimicrobials and therapy must include
agents that have adequate penetration into cerebrospinal fluid and brain. Combination therapy with vancomycin,
ceftriaxone, and metronidazole provides coverage for most intracranial pathogens complicating ABS. In all
cases, antimicrobial therapy should be dictated by microbiological data and changed to the most narrow
spectrum agent available.
Small orbital abscesses may be treated conservatively with antimicrobial agents alone.[12,13] Surgery has 2
purposes: to provide microbiological data that will guide antibiotic selection and to drain significant fluid
collections. Prompt surgical drainage is paramount when the CNS and ocular structures are threatened.
Samples taken in the operating room must be promptly transported to the laboratory, and anaerobic transport
media should always be used to optimize recovery of pathogens.

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Outcomes depend on prompt recognition of orbital and intracranial involvement and early intervention. Patients
should be managed in consultation with the appropriate surgical subspecialties. Supportive care such as
anticonvulsants, analgesics, and measures to reduce intracranial pressure should be used as indicated. Since
the complications of ABS are rare, it is difficult to establish that early treatment in the ambulatory setting reduces
complications. Treatment of uncomplicated ABS should follow established guidelines.
References

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3. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996:. J Allergy Clin
Immunol. 1999;103:408414.
4. Hakim HE, Malik AC, Aronyk K, et al. The prevalence of intracranial complications in pediatric frontal
sinusitis. Int J Pediatr Otorhinolaryngol. 2006;70:13831387.
5. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections. A
retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol. 2008;72:377383.
6. Sobol SE, Marchand J, Tewfik TL, et al. Orbital complications of sinusitis. J Otolaryngol.
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Pediatr Infect Dis J. 2011;30(8):701-702. 2011 Lippincott Williams & Wilkins

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