Sinogenic Intracranial Empyema in Children

Abstract

ABSTRACT. Background. Sinogenic intracranial empyema (SIE) is an uncommon complication of sinusitis that can lead to devastating neurologic sequelae. Early recognition of the clinical findings is critical so that proper management can be instituted.Objective. To describe the symptoms, signs, and laboratory and imaging findings from one of the largest pediatric SIE case series reported.Methods Results. Twelve children with SIE were identified. The median age of children with SIE was 11.5 years. Symptoms were usually present 10 days (median) before diagnosis and included headache (10), fever (11), nausea/ vomiting (7), mental-status changes (5), and seizures (3). Physical findings included abnormal neurologic examination (9), Pott's puffy tumor (4), and orbital cellulitis (3). Using the Intermountain Health Care system's computerized database, 142 children with uncomplicated sinusitis treated as outpatients were identified. Children with SIE had markedly higher CRP levels (median: 10.05 mg/ dL) and ESRs (median: 87 mm/hour) than those with uncomplicated sinusitis (median CRP: 0.7 mg/dL; median ESR: 6 mm/hour). Four children had hyperglycemia. Four children had a lumbar puncture at presentation, and the findings were normal for all of them. Craniofacial imaging included computed tomography (CT) and magnetic resonance imaging (MRI). SIE was not detected in 4 patients who had nonenhanced CT. Axial imaging alone was unable to demonstrate SIE in 1 child with sphenoid and ethmoid sinusitis, and coronal images were needed to demonstrate its presence and extent. The initial facial/ orbital imaging studies in 2 patients with physical signs of complicated sinusitis (orbital cellulitis and Pott's puffy tumor) were not adequate to detect SIE. Using contrast-enhanced head CT or MRI, SIE was diagnosed in all 12 children.Conclusions. Children with sinusitis and any neurologic finding, signs of complicated sinusitis such as Pott's puffy tumor or orbital cellulitis, or persistent headache, fever, or nausea and vomiting after antibiotic therapy should have additional evaluation for SIE. Children with hyperglycemia or diabetes may be at increased risk for SIE. The ESR and CRP levels are markedly elevated in children with SIE and may be useful screening tools. MRI with gadolinium is the preferred method to diagnose SIE. If MRI is unavailable, a contrast-enhanced head CT with axial and coronal planes should be obtained. Nonenhanced CT alone lacks sensitivity, and a normal study may be falsely reassuring.

Paediatric intracranial empyema: differences according to age

“…This is why this former entity could have been under recognized in conservatively managed patients. Finally, although MRI might be considered to be more sensitive to diagnose and localize intracranial infections [1,10], enhanced CT scan was reliable in our cohort for diagnosing PICE. Thus, CT scan can provide reliable evaluation if performed with proper planes including coronal and sinuses planes, with the possibility to perform a second line MRI to refine localization and size.…”

“…Thus, recent improvements in surgical techniques and postoperative care, as well as better diagnostic procedures, are probably responsible for better outcomes in patients with PICE [1,18]. However, even in these later studies [9,18,19,28], the inclusion of cases over a long period of time, coupled with small sample sizes and heterogeneity in diagnostic and therapeutic procedures, precludes any conclusion regarding the outcome and clinical features of PICE.…”

Intracranial suppuration complicating sinusitis among children: an epidemiological and clinical study

“…1,[25][26][27][28][29]31,[34][35][36][37][38][39][40][41][42][43][44][45][48][49][50][51][52][53][54][56][57][58][59][60] Many of these reports are inhomogeneous with respect to etiology, including infectious collections related to community-acquired meningitis, congenital heart disease, trauma, and previous surgery. Many reports limited to complications of sinusitis include orbital cellulitis, dural sinus thrombophlebitis, and meningitis, which were not considered in the current study.…”

Recurrent Pott's puffy tumor – atypical presentation of a rare disorder

“…The interval between onset of sinusitis symptoms and definite diagnosis of Pott's puffy tumor was quite typical, most cases of the tumor following a 6-week history of sinusitis [13]. Fever, leucocytosis and raised CRP are usually associated with intracranial lesions such as intracranial empyema [14], nevertheless our patient had neither fever, leucocytosis, nor raised CRP levels. This led to the differential diagnosis of a malignant tumor; however, this was ruled out in the further course, based on the typical clinical picture and findings of imaging techniques.…”