Acute sinusitis is a common pediatric disorder, accounting for 21 percent of children’s antibiotic prescriptions.
Depending on the location of the infection, acute sinusitis could cause serious complications to the bony cavity surrounding the eye or inside the skull; children with these complications may experience significant illness from their infection, including blindness, neurological defects, and even death.
Two otolaryngologist—head and neck surgeons reviewed the case records of children who were treated for a complication of acute sinusitis for more than seven years at Children’s Medical Center of Dallas. They evaluated the number and type of complications, the bacteria involved, the response to treatment, and the persistent illnesses associated with these infections.
The authors of “Complications of Acute Sinusitis in Children,” are Lance E. Oxford MD, and John McClay MD, both from the Department of Otolaryngology-Head and Neck Surgery, University of Texas-Southwestern Medical Center, Dallas, TX. Their findings are being presented at the American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting & OTO EXPO, being held September 19-22, 2004, at the Jacob K. Javits Convention Center, New York City, NY.
A retrospective chart review was conducted of all patients admitted to Children’s Medical Center of Dallas from January 1995 to July 2002 with complications of acute sinusitis. Charts were identified by searching for ICD-9 codes for acute sinusitis, orbital cellulitis, orbital abscess, intracranial abscess, meningitis, cavernous sinus thrombosis, and thrombosis of intracranial sinuses. Patients were included if their charts documented evidence of a complication of acute sinusitis on admission.
Charts were evaluated for age, gender, month of admission, type of complication, symptoms, physical exam findings, radiology studies, surgical procedures, culture results, and any follow-up information.
After the ICD-9 search, 104 patients met the criteria for the study and had available medical records for review. A total of 116 complications of acute sinusitis were diagnosed in the 104 patients. Orbital complications occurred in 95 patients and included 51 cases of cellulitis and 44 abscesses. Eighteen intracranial complications occurred in 14 patients and included seven epidural empyemas, six subdural empyemas, two intracerebral abscesses, two cases of meningitis, and one cavernous sinus thrombosis.
Five patients were diagnosed with both intraorbital and intracranial complications. Three patients presented with Pott’s puffy tumor, two of which presented with epidural abscess and one patient with orbital cellulites.
The review confirmed previous research reporting a higher incidence of sinusitis complications in males (66.3 percent). The mean age of patients with intracranial complications (6.5) was significantly less than patients with orbital complications (12.3). This finding was expected given the embryology of the paranasal sinuses; the ethmoid sinuses present at birth and are more commonly associated with orbital complications and the frontal sinuses develop later in childhood and are associated with intracranial complications.
Complications demonstrated a significant seasonal incidence with 64.4 percent of patients admitted from November to March. The highest number of admissions occurred in February (18.3 percent). The seasonal incidence is likely secondary to the increased incidence of viral upper respiratory infections in the fall and winter, which is the most common predisposing factor for the development of acute sinusitis in children.
Ocular deficits on admission included limitation of eye movement in 55 patients, severe vision loss in eight patients, and a nonreactive pupil in three patients. Some 54/55 patients completely recovered. In the 14 patients with intracranial complications, four patients presented with seizures and seven patients presented with neurological deficits including loss of cranial nerve function and hemiparesis. All deficits resolved and seizures resolved in two of four patients.
All patients were treated with intravenous antibiotics. Thirty nine patients (37.5 percent) underwent surgery for a complication of sinusitis.
Streptococcus milleri group was the most common cultured pathogen, (11/34 patients, 32.4 percent), present in 7/23 of positive orbital complication cultures and 4/11 intracranial cultures. The Streptococcus milleri group includes the three species: S. intermedius, S. constellatus, and S. anginosus, symbiotic organisms present in the oral cavity, gastrointestinal tract, and urogenital system. The S. milleri group is often associated with abscess formation. Anaerobic organisms were isolated in 11/34 patients (30.6 percent).
There were no mortalities and morbidity only occurred in four patients (3.8 percent). Morbidities included two patients with seizure disorder that is well controlled with anticonvulsants, one patient with moderately decreased vision and eye movements, and one patient with mild ptosis of his upper eyelid after undergoing surgery for an abscess.
This research found that in children admitted to the hospital for cases of acute sinusitis, orbital and intracranial complications occurred in 91.3 percent and 13.5 percent of patients, respectively. Complications most commonly occur in males in the winter; patients with orbital complications were younger, had a shorter hospital stay, and shorter duration of early symptoms. Despite often presenting with significant ocular and neurological deficits, permanent morbidity was rare. Streptococcus milleri and anaerobic organisms were commonly isolated pathogens in children with complications of sinusitis in this retrospective review.