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Sinusitis-associated epidural abscess presenting as posterior scalp abscess-a case report
International Journal of Pediatric Otorhinolaryngology 43 (1998) 147 – 151
Case report
Sinusitis-associated epidural abscess presenting as posterior scalp abscess-a case report Blanca Durand a, Christopher Poje a,c,*, Mark Dias b,c a
Department of Otolaryngology, State Uni6ersity of New York at Buffalo, Buffalo, NY, USA Department of Neurosurgery, State Uni6ersity of New York at Buffalo, Buffalo, NY, USA c School of Medicine and Biomedical Sciences and Children’s Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222 -2006, USA b
Received 3 August 1997; received in revised form 2 November 1997; accepted 3 November 1997
Abstract Complications of paranasal sinusitis constitute true surgical and medical emergencies. These complications appear to be more prevalent and seem to present in a more fulminant manner in the pediatric age group. The most common complication of paranasal sinusitis is orbital cellulitis followed collectively by all the intracranial complications. These include meningitis, subdural empyema, intracerebral abscess, epidural abscess and rarely cavernous or superior sagittal sinus thrombosis. We report the case of a 7-year old boy who presented with posterior scalp cellulitis and abscess as a complication of minimally symptomatic paranasal sinusitis. A combined neurosurgical and otolaryngologic approach was required to treat a unilateral ethmoid and frontal sinusitis associated with an epidural abscess abutting the length of the superior sagittal sinus and a posterior subgaleal abscess. The pertinent anatomy allowing for the development of this disease process is discussed. The danger of neurologic sequellae resulting from thrombosis of the superior sagittal sinus is emphasized. Aggressive treatment utilizing a multi-disciplinary surgical approach as well as broad spectrum antibiotics is paramount to obtain the best chance for a full recovery. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Paranasal sinusitis; Epidural; Subdural; Scalp cellulitis; Intracranial; Subgaleal abscess
* Corresponding author. Tel.: +1 716 8787852; fax: + 1 716 8787585 0165-5876/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 1 7 0 - 5
148
B. Durand et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 147–151
1. Introduction Complications of paranasal sinusitis are well documented in both children and adults, but remain relatively uncommon since the introduction of antibiotics. Because signs and symptoms of acute sinusitis may be absent, delays in diagnosis and treatment can occur and may result in orbital or intracranial complications. We describe a case of a 7-year old boy who presented with posterior scalp cellulitis and abscess as a complication of minimally symptomatic paranasal sinusitis.
2. Report of a case The patient is a 7-year old boy that presented to the emergency department for reported fever of 103°F, headache of 6-day’s duration, vomiting, diarrhea and a lump in the occipital area of 2-day’s duration. At that time, the patient was sent home with a presumptive diagnosis of a viral syndrome. The patient returned 2 days later to the emergency department. The parents noticed that the boy’s head was enlarging, was tender and the fever of 103°F was persistent. In the emergency department the temperature was 39.5°C, the scalp was tender and an area of
Fig. 1. Axial CT image showing opacification of the right frontal and ethmoid sinuses. Air fluid level is noted on the left sphenoid sinus.
B. Durand et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 147–151
149
Fig. 2. Contrast-enhanced axial CT image shows subgaleal and epidural collections.
induration was palpable in the occipital area. No deterioration in the patient’s neurological status was noticed; his WBC count was 20 800. The patient was admitted to the pediatric service with a diagnosis of scalp cellulitis. Intravenous antibiotic therapy was started with cefotaxime and oxacillin. An infectious disease consult was obtained and the possibility of scalp abscess was entertained for which a surgical consult was requested for incision and drainage. A CT scan of the head was done, which revealed a subgaleal fluid collection extending from the frontal region to the occipital region. An epidural abscess was appreciated as well in the frontal region, abutting the superior sagittal sinus. There was complete opacification of the right maxillary sinus, ethmoidal cells and right frontal sinus (See Figs. 1 and 2). Immediate neurosurgery and otolaryngology consultations were requested. By this time, the child appeared lethargic but able to respond appropriately and cooperate. No ophthalmoplegia, visual loss, or neurological deficits were observed. The nasal mucosa was erythematous and edematous without discharge. The scalp was tender and fluctuant over the parietal and occipital areas. The patient was taken to the operating room for emergency multidisciplinary surgical drainage. He underwent craniotomy and drainage of the epidural and subgaleal abscesses by neurosurgery. A right frontal sinusotomy (trephination) and right endoscopic total anterior and posterior ethmoidectomy with middle meatal antrostomy was carried out by otolaryngology.
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B. Durand et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 147–151
Postoperatively, the boy was treated with vancomycin, ceftriaxone and metronidazole intravenously. Presumably because of the oxacillin and cefotaxime administered pre-operatively, the material drained from the epidural space and the frontal sinus failed to yield a causative organism. The patient was discharged home on postoperative day 11 without any neurological sequelae. He is also virtually free of sinus disease at 15-months follow-up.
3. Comment The incidence of intracranial complications of paranasal sinusitis has decreased during the antibiotic era. Despite the reduction in frequency, these complications are nonetheless life threatening and require immediate attention. The most serious intracranial complications of sinusitis include meningitis, epidural, subdural, or brain abscesses and cavernous or sagittal sinus thrombosis.[1,2] When intracranial complications occur, a 10 – 20% mortality rate is reported despite early and aggressive therapy [3]. The frontal sinus is the most common source of intracranial complication [3]. The most frequent pressing signs are fever and headache [1,2].
Fig. 3. Extensive communication among diploic, emissary and cortical veins (Reproduced with permission) [3].
B. Durand et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 147–151
151
Infection from the paranasal sinuses to the intracranial cavity can occur by several routes: (1) extension along anatomic pathways; (2) retrograde thrombophlebitis; (3) direct inoculation (e.g. fracture or malignancy) and (4) through the blood (hematogenous spread) [4]. The frontal sinus has valveless diploic veins (veins of Breschet) that communicate extensively with the veins of the dura and emissary veins, which in turn communicate with the superior sagittal sinus and cortical veins. These communications provide the pathways for extension of infection from the sinuses to the intracranial area by retrograde thrombophlebitis (See Fig. 3) [3]. Ethmoid, sphenoid and maxillary sinusitis may lead as well to intracranial complications but are a less frequent source. Veins in these spaces also communicate via valveless veins to the intraorbital and intracranial cavity including the cavernous sinuses [5 – 7]. The most common organisms associated with intracranial abscess are anaerobes (Bacteroides, Streptococcus spp.), Staphylococcus Aureus and aerobic Streptococcus [3,5]. Partial treatment prior to drainage, as in our case, often results in no growth. The management of paranasal sinusitis complications include aggressive treatment utilizing a multidisciplinary surgical approach as well as broad spectrum antibiotics to obtain the best chance for full recovery. The literature recommends a simultaneous multidisciplinary (neurosurgery and otolaryngology) approach to treat paranasal sinusitis and its intracranial complication to prevent reseeding of the intracranial area from the infected sinuses [2]. Surgical management of the paranasal sinuses is paramount for adequate control of the infection. The frontal sinus may be managed via trephination or obliteration and/or exenteration depending on how extensive the disease is and whether bony involvement is present [3,4]. The ethmoid, sphenoid and maxillary sinuses may be managed via an intranasal endoscopic approach or via an external approach [4–7].
References [1] M.B. Singh, J.V. Dellev, S. Ramjritan, T.J. Maharay, Sinogenic intracranial complications, J. Laryngol. Otol. 109 (1995) 945–950. [2] G.L. Clayman, G.L. Adams, D.R. Paugh, C.F.Jr. Koopmann, Intracranial complications of paranasal sinusitis: a combined institutional review [see comments], Laryngoscope 101 (1991) 234–239. [3] D. Lerner, G. Zalzal, S. Choi, D. Johnson, Intracranial complications of sinusitis in childhood, Ann. Otol. Rhinol. Laryngol. 104 (1995) 288 – 293. [4] G.K. Rodgers, E. Tabor, S.R. Rood, J.T. Johnson, Complications of acute and chronic sinus disease., SIPAC (1990). [5] J.A. Stankiewicz, D.J. Newell, A.H. Park, Complications of inflammatory diseases of the sinuses, Otolaryngol. Clin. North Am. 26 (4) (1993) 639 – 655. [6] M. Wegenmann, R.M. Naclerio, Complications of sinusitis, J. Allergy Clin. Immunol. 90 (3) (1992) 552–554. [7] S.C. Manning, Endoscopic management of medial subperiorbital orbital abscess, Arch. Otolaryngol. Head Neck Surg. 119 (1993) 789 – 791.
Case report
Sinusitis-associated epidural abscess presenting as posterior scalp abscess-a case report Blanca Durand a, Christopher Poje a,c,*, Mark Dias b,c a
Department of Otolaryngology, State Uni6ersity of New York at Buffalo, Buffalo, NY, USA Department of Neurosurgery, State Uni6ersity of New York at Buffalo, Buffalo, NY, USA c School of Medicine and Biomedical Sciences and Children’s Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222 -2006, USA b
Received 3 August 1997; received in revised form 2 November 1997; accepted 3 November 1997
Abstract Complications of paranasal sinusitis constitute true surgical and medical emergencies. These complications appear to be more prevalent and seem to present in a more fulminant manner in the pediatric age group. The most common complication of paranasal sinusitis is orbital cellulitis followed collectively by all the intracranial complications. These include meningitis, subdural empyema, intracerebral abscess, epidural abscess and rarely cavernous or superior sagittal sinus thrombosis. We report the case of a 7-year old boy who presented with posterior scalp cellulitis and abscess as a complication of minimally symptomatic paranasal sinusitis. A combined neurosurgical and otolaryngologic approach was required to treat a unilateral ethmoid and frontal sinusitis associated with an epidural abscess abutting the length of the superior sagittal sinus and a posterior subgaleal abscess. The pertinent anatomy allowing for the development of this disease process is discussed. The danger of neurologic sequellae resulting from thrombosis of the superior sagittal sinus is emphasized. Aggressive treatment utilizing a multi-disciplinary surgical approach as well as broad spectrum antibiotics is paramount to obtain the best chance for a full recovery. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Paranasal sinusitis; Epidural; Subdural; Scalp cellulitis; Intracranial; Subgaleal abscess
* Corresponding author. Tel.: +1 716 8787852; fax: + 1 716 8787585 0165-5876/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 1 7 0 - 5
148
B. Durand et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 147–151
1. Introduction Complications of paranasal sinusitis are well documented in both children and adults, but remain relatively uncommon since the introduction of antibiotics. Because signs and symptoms of acute sinusitis may be absent, delays in diagnosis and treatment can occur and may result in orbital or intracranial complications. We describe a case of a 7-year old boy who presented with posterior scalp cellulitis and abscess as a complication of minimally symptomatic paranasal sinusitis.
2. Report of a case The patient is a 7-year old boy that presented to the emergency department for reported fever of 103°F, headache of 6-day’s duration, vomiting, diarrhea and a lump in the occipital area of 2-day’s duration. At that time, the patient was sent home with a presumptive diagnosis of a viral syndrome. The patient returned 2 days later to the emergency department. The parents noticed that the boy’s head was enlarging, was tender and the fever of 103°F was persistent. In the emergency department the temperature was 39.5°C, the scalp was tender and an area of
Fig. 1. Axial CT image showing opacification of the right frontal and ethmoid sinuses. Air fluid level is noted on the left sphenoid sinus.
B. Durand et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 147–151
149
Fig. 2. Contrast-enhanced axial CT image shows subgaleal and epidural collections.
induration was palpable in the occipital area. No deterioration in the patient’s neurological status was noticed; his WBC count was 20 800. The patient was admitted to the pediatric service with a diagnosis of scalp cellulitis. Intravenous antibiotic therapy was started with cefotaxime and oxacillin. An infectious disease consult was obtained and the possibility of scalp abscess was entertained for which a surgical consult was requested for incision and drainage. A CT scan of the head was done, which revealed a subgaleal fluid collection extending from the frontal region to the occipital region. An epidural abscess was appreciated as well in the frontal region, abutting the superior sagittal sinus. There was complete opacification of the right maxillary sinus, ethmoidal cells and right frontal sinus (See Figs. 1 and 2). Immediate neurosurgery and otolaryngology consultations were requested. By this time, the child appeared lethargic but able to respond appropriately and cooperate. No ophthalmoplegia, visual loss, or neurological deficits were observed. The nasal mucosa was erythematous and edematous without discharge. The scalp was tender and fluctuant over the parietal and occipital areas. The patient was taken to the operating room for emergency multidisciplinary surgical drainage. He underwent craniotomy and drainage of the epidural and subgaleal abscesses by neurosurgery. A right frontal sinusotomy (trephination) and right endoscopic total anterior and posterior ethmoidectomy with middle meatal antrostomy was carried out by otolaryngology.
150
B. Durand et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 147–151
Postoperatively, the boy was treated with vancomycin, ceftriaxone and metronidazole intravenously. Presumably because of the oxacillin and cefotaxime administered pre-operatively, the material drained from the epidural space and the frontal sinus failed to yield a causative organism. The patient was discharged home on postoperative day 11 without any neurological sequelae. He is also virtually free of sinus disease at 15-months follow-up.
3. Comment The incidence of intracranial complications of paranasal sinusitis has decreased during the antibiotic era. Despite the reduction in frequency, these complications are nonetheless life threatening and require immediate attention. The most serious intracranial complications of sinusitis include meningitis, epidural, subdural, or brain abscesses and cavernous or sagittal sinus thrombosis.[1,2] When intracranial complications occur, a 10 – 20% mortality rate is reported despite early and aggressive therapy [3]. The frontal sinus is the most common source of intracranial complication [3]. The most frequent pressing signs are fever and headache [1,2].
Fig. 3. Extensive communication among diploic, emissary and cortical veins (Reproduced with permission) [3].
B. Durand et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 147–151
151
Infection from the paranasal sinuses to the intracranial cavity can occur by several routes: (1) extension along anatomic pathways; (2) retrograde thrombophlebitis; (3) direct inoculation (e.g. fracture or malignancy) and (4) through the blood (hematogenous spread) [4]. The frontal sinus has valveless diploic veins (veins of Breschet) that communicate extensively with the veins of the dura and emissary veins, which in turn communicate with the superior sagittal sinus and cortical veins. These communications provide the pathways for extension of infection from the sinuses to the intracranial area by retrograde thrombophlebitis (See Fig. 3) [3]. Ethmoid, sphenoid and maxillary sinusitis may lead as well to intracranial complications but are a less frequent source. Veins in these spaces also communicate via valveless veins to the intraorbital and intracranial cavity including the cavernous sinuses [5 – 7]. The most common organisms associated with intracranial abscess are anaerobes (Bacteroides, Streptococcus spp.), Staphylococcus Aureus and aerobic Streptococcus [3,5]. Partial treatment prior to drainage, as in our case, often results in no growth. The management of paranasal sinusitis complications include aggressive treatment utilizing a multidisciplinary surgical approach as well as broad spectrum antibiotics to obtain the best chance for full recovery. The literature recommends a simultaneous multidisciplinary (neurosurgery and otolaryngology) approach to treat paranasal sinusitis and its intracranial complication to prevent reseeding of the intracranial area from the infected sinuses [2]. Surgical management of the paranasal sinuses is paramount for adequate control of the infection. The frontal sinus may be managed via trephination or obliteration and/or exenteration depending on how extensive the disease is and whether bony involvement is present [3,4]. The ethmoid, sphenoid and maxillary sinuses may be managed via an intranasal endoscopic approach or via an external approach [4–7].
References [1] M.B. Singh, J.V. Dellev, S. Ramjritan, T.J. Maharay, Sinogenic intracranial complications, J. Laryngol. Otol. 109 (1995) 945–950. [2] G.L. Clayman, G.L. Adams, D.R. Paugh, C.F.Jr. Koopmann, Intracranial complications of paranasal sinusitis: a combined institutional review [see comments], Laryngoscope 101 (1991) 234–239. [3] D. Lerner, G. Zalzal, S. Choi, D. Johnson, Intracranial complications of sinusitis in childhood, Ann. Otol. Rhinol. Laryngol. 104 (1995) 288 – 293. [4] G.K. Rodgers, E. Tabor, S.R. Rood, J.T. Johnson, Complications of acute and chronic sinus disease., SIPAC (1990). [5] J.A. Stankiewicz, D.J. Newell, A.H. Park, Complications of inflammatory diseases of the sinuses, Otolaryngol. Clin. North Am. 26 (4) (1993) 639 – 655. [6] M. Wegenmann, R.M. Naclerio, Complications of sinusitis, J. Allergy Clin. Immunol. 90 (3) (1992) 552–554. [7] S.C. Manning, Endoscopic management of medial subperiorbital orbital abscess, Arch. Otolaryngol. Head Neck Surg. 119 (1993) 789 – 791.