Reducing Surgical Revisions in Intracranial Complications of Pediatric Acute Sinusitis

Abstract

Objective (1) To describe the demographics and clinical course of children with intracranial complications of sinusitis. (2) To elucidate factors that predict revision surgery in this population, such as type of initial surgery. Study Design Case series with chart review. Setting Tertiary care academic children's hospital. Subjects and Methods A 15-year retrospective review identified 71 patients with intracranial complications of acute sinusitis. Primary outcome was need for revision surgery. Secondary outcomes were readmission, length of hospitalization, and long-term complications. Results This study is the largest to date examining this disease process. Overall, 69 (97%) patients had surgery; 33 (46%) required revision surgery. Half of the patients with frontal sinus opacification underwent frontal sinus surgery at presentation (endoscopic, trephination, or cranialization). There was no difference in revision surgery between patients who had frontal sinus surgery and those who did not. Patients with frontal sinus surgery did not have a higher rate of complications or chronic sinusitis ( P > .05). Subdural abscess was associated with multiple surgical procedures (odds ratio, 20.0; P < .01). Thirty-four patients (49%) required neurosurgery. These patients had a longer length of stay (odds ratio, 11.0; P < .01) and a higher readmission rate ( P = .02). During the mean 92-month follow-up, 22 patients (33%) had long-term complications, and there was 1 death (1.4%). Conclusion Almost half of this cohort required multiple surgical procedures. In particular, patients with subdural abscess had significantly higher rates of revision surgery. Type of frontal sinus surgery was not correlated with need for revision surgery and was not associated with an increased rate of complications.

Editorial. Endoscopic sinus surgery in sinusitis-induced intracranial abscess: concepts and controversies

“…4 These conclusions are in contrast to some previously published reports 2,5 and are supported by others. 1,3 Koizumi et al 4 investigated the association between outcomes in patients undergoing neurosurgical interventions for SIIA and an ESS performed within the same hospitalization. The study design was retrospective in nature, and data on the patients with SIIA were collected from a large administrative nationwide inpatient database over a period of 8 years.…”

“…SIIA carries a mortality risk of 0%-7% and a morbidity risk of 10%-25%. [1][2][3]5 The most common patterns of SIIA in decreasing frequency are subdural empyema, intracerebral abscess, extradural abscess, meningitis, and, more rarely, sinus thrombosis. Intracranial spread of infective foci from the paranasal sinuses (PNSs) can result from either direct contiguous spread via bony defects/ ostomyelitic bone or indirect hematogenous spread via thrombophlebitis of valveless diploic veins draining PNSs, leading to spread of infection by thrombus propagation or release of septic emboli.…”

“…Intracranial spread of infective foci from the paranasal sinuses (PNSs) can result from either direct contiguous spread via bony defects/ ostomyelitic bone or indirect hematogenous spread via thrombophlebitis of valveless diploic veins draining PNSs, leading to spread of infection by thrombus propagation or release of septic emboli. [1][2][3]5 The latter is a much more common route seen in clinical practice, especially in the setting of acute rhinosinusitis (ARS). Adolescent males are most commonly affected by SIIA probably because of the formation of the PNSs in adolescence and a highly vascularized diploic venous system, more susceptible to indirect means of intracranial spread of infection.…”

“…Adolescent males are most commonly affected by SIIA probably because of the formation of the PNSs in adolescence and a highly vascularized diploic venous system, more susceptible to indirect means of intracranial spread of infection. [1][2][3]5 The radiological investigation of choice for patients with suspected SIIA is contrast-enhanced CT, primarily because it is easier to obtain in an emergency setting. However, gadolinium-enhanced MRI is complementary to CT in ascertaining potential complications of sinusitis.…”

“…Although there are no consistently acceptable management guidelines for SIIA, the three pillars of the management strategy include medical management with injectable broad-spectrum antibiotics, ESS for clearing PNS abscess, and neurosurgical intervention for intracranial abscess drainage. [1][2][3]5 ESS is a standard practice in patients with medically refractory chronic rhinosinusitis. 1 However, its role in ARS is controversial.…”