A 7-year-old male with a history of eczema presented to the emergency department with persistent fever, cough, and nasal congestion of 2 weeks’ duration that had worsened over the last three days.
An initial ED visit had occurred 10 days earlier for congestion, cough, and fever resulting in a diagnosis of viral syndrome. During the second ED evaluation, the patient’s symptoms improved with administration of IV fluids and antipyretic. A chest X-ray, labs, andnasopharyngeal Covid-19 PCR test were unremarkable. No antibiotics were prescribed.
The patient returned to the ED the following day with fatigue, persistent high fever, and orbital swelling. Initial vital signs included BP 111/61, pulse 154, temp 39.3 °C (102.7 °F), resp 22, and SpO2 97%. Physical exam revealed leftorbital swelling, tenderness to palpation, yellow/green nasal discharge, dry oral mucous membranes, clear breath sounds, and a soft and nontender abdomen. Extraocular movements were documented to be intact with normal conjunctiva. The initial differential diagnosis included sepsis with bacterial sinusitis with osteal, orbital, or intracranial involvement including abscess.
A CT scan revealed pansinusitis including opacification of the frontal, right and left maxillary, and right ethmoid sinuses. In addition, left superior ophthalmic vein thrombosis, sagittal sinus septic thrombosis, and orbital cellulitis were noted. The patient received broad spectrum IV antibiotics including ceftriaxone, vancomycin, and metronidazole. He was admitted to the PICU for further workup and management.
During PICU admission, the patient had an MRI/MRV that showed subdural empyema and superior ophthalmic vein thrombosis. He received an emergent craniotomy with subdural effusion evacuation. Operative cultures grew methicillin-resistant Staphylococcus aureus, coagulase-negative Staphylococcus species, Streptococcus constellatus,and Prevotella Intermedia. A PICC line was placed for provision of long-term broad spectrum antibiotics. Ultimately, the patient developed subdural empyema of the right hemi-cranium and required bifrontal craniotomy drainage. After 6 weeks in the PICU, his clinical status improved, and he was discharged on a further 4-week outpatient course of linezolid, levofloxacin, and metronidazole.
Discussion
This case demonstrates the serious complications that can accompany sinusitis, including orbital cellulitis and septic thromboembolism with intracranial abscess. Rhinosinusitis, defined as inflammation of the mucosal lining of the nasopharynx and sinuses, is most commonly caused by a viral infection. Acute bacterial rhinosinusitis (ABRS) most commonly occurs when there is a secondary infection of the sinuses. It is most common in ages 4-7 years but can occur at any age. Patients will present with symptoms consistent with upper respiratory illness (URI) for a protracted duration, usually for more than 10 but fewer than 30 days. There can also be a biphasic presentation, such as in this patient, in which symptoms improve for a period of time but then exacerbate and the patient’s condition acutely worsens.1-4
When evaluating a patient with suspected bacterial rhinosinusitis, it is not always necessary to obtain radiologic imaging. If symptoms have lasted fewer than 7 days, then supportive care with nasal wash, decongestants, and intranasal corticosteroids can be trialed. For sinusitis lasting more than 7 days, high-dose amoxicillin with clavulanate can be prescribed.2,5 Failure to improve within 72 hours should prompt further investigation, with consideration of performing advanced imaging and possible escalation to parenteral antibiotic therapy. CT scans of sinuses and the brain should be obtained if there are concerning symptoms suggesting disease extension, such as periorbital/orbital swelling, vomiting, altered mental status, neck stiffness, neurological deficit, or high fevers lasting for more than 3 days.1,6
It is estimated that anywhere from 0.5% to 24% of children are hospitalized with sinusitis, likely because of the risk of severe complications ranging from orbital cellulitis to intracranial infection.7 The cavernous sinus collects blood from various sites including the face, ears, nose, pharynx, sinuses, and cerebral cortex. The valveless flow of blood within the cavernous sinus increases the risk for spread of infection as the blood can flow in any direction. The sinuses are particularly vulnerable to the spread of infection and formation of septic thrombosis because of this blood flow.
Approximately 5% of children hospitalized with ABRS develop intracranial complications such as septic dural sinus thrombosis, subdural empyema, epidural abscess, meningitis, cerebritis, brain abscess, or cavernous sinus thrombosis.8,9 In a retrospective study of hospitalized children with intracranial complications of ABRS, 89% had visited a health care provider prior to their admission, but only half were prescribed antibiotics.7 Of those prescribed antibiotics, 44% had been receiving antibiotics for more than 7 days before developing intracranial complications — signifying the potential complexity of treating the infection with oral antibiotics on an outpatient basis.7
Despite the severity of the intracranial complications of sinusitis (ICS), most children make a good neurologic recovery. In a sample of 25 children with ICS, 40% experienced neurologic deficits, but most resolved within 2 months. Only 2 patients had permanent neurologic sequelae.8
At a 6-month follow-up exam with neurosurgery, the young boy in our case was noted to have made a full recovery without any deficits.
References
- Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
- Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical infectious diseases. 2012;54(8):e72-e112.
- Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol. 2004;114:155.
- Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: Developing guidance for clinical trials. Otolaryngol Head Neck Surg. 2006;135:S31.
- Okuyemi KS, Tsue TT. Radiologic imaging in the management of sinusitis. Am Fam Physician. 2002;66(10):1882-1886.
- Wald ER, Applegate KE, Bordley, C, et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics. July 2013;132 (1): e262–e280.
- Germiller JA, Monin DL, Sparano AM, Tom LW. Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg. 2006 Sep;132(9):969-76.
- Bair-Merritt MH, Shah SS, Zaoutis TE, et al. Suppurative intracranial complications of sinusitis in previously healthy children. Pediatr Infect Dis J. 2005;24:384–6.
- Otto WR, Paden WZ, Connors M, et al. Suppurative Intracranial Complications of Pediatric Sinusitis: A Single-Center Experience. Journal of the Pediatric Infectious Diseases Society. 2021;10(3):309-316.