A 10-year-old girl has a 2-week history of daily headaches and rhinorrhea. She is admitted from the emergency department to the pediatric intensive care unit for a 2-day history of worsening left frontal headache, mental status changes including lethargy and slurred speech, nausea, and mild periorbital edema. Computed tomography (CT) demonstrates opacification of bilateral frontal, maxillary, and anterior ethmoid sinuses as well as pneumocephalus (Figure 27-1A). Magnetic resonance imaging demonstrated extensive left sided subdural empyema (worse frontal and temporal) and diffuse bilateral dural enhancement (Figure 27-1B). She is urgently treated via a combined surgical approach with pediatric otolaryngology for bilateral endoscopic sinus surgery and pediatric neurosurgery for left craniotomy. She subsequently had 10 weeks of intravenous antimicrobial therapy. Her immediate postoperative course was complicated by seizures; she has now made a full recovery and is doing well.

Complications of acute sinusitis are typically extensions of infection beyond the paranasal sinuses into adjacent structures and can have devastating consequences, including blindness, neurologic morbidity, and even death.

Periorbital cellulitis, subperiosteal abscess, orbital cellulitis, orbital abscess, cavernous sinus thrombosis, meningitis, subdural abscess, subdural empyema, pyocele, mucopyocele, intracranial abscess, or invasive fungal sinusitis.

• Orbital complications account for 90 percent of acute complications from sinusitis and approximately 3 percent of all acute rhinosinusitis.¹

• Children younger than age 7 years of age develop isolated orbital complications associated with acute ethmoiditis.²

• Children older than 7 years, mostly teenage males, are more likely to develop intracranial complications.^2,3 This is likely related to the age related development of the frontal and sphenoid sinuses.

• Children have a high rate of upper respiratory infections (URI) and viral rhinosinusitis.

• Congenital or traumatic dehiscences in the lamina papyracea and skull base provide potential routes for direct spread.

• The diploic veins of the skull and ethmoid bone as well as the ophthalmic veins are valveless and allow for communication between the nose, sinuses, face, orbit, cavernous sinus, and intracranial system.

• The combination of phlebitis and direct entry of bacteria into perivascular structures results in a continuum of inflammatory and infectious changes.

• The valveless intracranial venous system allows for further spread of thrombophlebitis and septic emboli.

• Complications can be orbital (Table 27-1),⁴ intracranial, or involving adjacent bone.

• Intracranial complications can include meningitis, epidural or subdural abscess or empyema, and intracerebral abscess or venous sinus thrombophlebitis.

• Culprit bacteria in children include the usual acute rhinosinusitis bacteria (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis); however, suppurative complications are also associated with other Streptococcus species, Staphylococcus aureus, anaerobes (such as Bacteroides and Fusobacterium species), and polymicrobial infections.⁹

• Local bony complications include mucocele, pyocele, or mucopyocele, as well as osteomyelitis.

• Children with immune deficiencies, cystic fibrosis, and ciliary dyskinesias are more likely to develop acute bacterial rhinosinusitis.^5,6

• Orbital complications are associated with ethmoiditis in 86 percent of cases.¹

• Intracranial complications are more likely in children with frontal sinusitis, adolescent age, and male gender.^3,7

Clinical Features

• Every patient with a possible complication of sinusitis should have an examination with anterior rhinoscopy or nasal endoscopy to evaluate for polyps or purulent drainage in the middle meatus.

• Endoscopy can also assist in identifying local complications and anatomic abnormalities such as mucopyocele.

• The eye must be assessed for visual acuity, extraocular movements, and proptosis. Upper and lower lid edema and erythema are common, and conjunctiva should be assessed for chemosis. Fluctuance of lids consistent with abscess is rare (Figure 27-2A, B).

• The orbital septum is a fascial continuation of the periosteum extending into the upper and lower eyelids, and is a physiologic barrier to the orbit. When post-septal involvement is suspected an ophthalmologic consultation should be obtained immediately to help with surgical planning.

• Generalized symptoms indicative of increased intracranial pressure include frontal or retro-orbital headache, nausea and vomiting, altered mental status, nuchal rigidity, abducent nerve palsy, and papilledema.

• Late intracranial findings include seizures, hemiparesis, and focal neurologic findings.⁸

• Specific complications of sinusitis and their common clinical findings are summarized in Table 27-2.