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BackTable / ENT / Article
Surgical Management of Acute Sinusitis with Intracranial Complications
Megan Saltsgaver • Updated Oct 1, 2024 • 40 hits
Even amongst healthcare professionals, it is not commonly known that acute sinusitis can cause intracranial or intraorbital complications, especially when its origins are bacterial. Complications such as intracranial abscess or preseptal cellulitis of the eye can be quite severe, necessitating corrective surgery of the complication in addition to sinus surgery.
Despite their rare occurrence, it’s important for otolaryngologists to be prepared for intracranial complications of acute sinusitis and understand how unique presentations can impact treatment. Pediatric otolaryngologist Dr. Amanda Stapleton shares her approach to management, focusing on cases where multiple surgeries are indicated. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Surgery is sometimes necessary in acute sinusitis with intracranial complications. The decision to proceed with surgery depends on the patient’s stability and the nature of the complication, whether intraorbital or intracranial.
• Surgical techniques in acute sinusitis with intracranial complications depend on the surgeon's preference of scopes, navigation systems, and surgeon experience.
• An adenoidectomy may be performed during surgical cases of acute sinusitis as a means for infection source control.
• Patients normally follow up with an otolaryngologist twice after surgery. Once around three weeks and then around six weeks. The six week follow up is good to assess possible recurrent sinus infection when patients are off antibiotics and rinses.
• Recurrent intraorbital or intracranial abscesses in children are rare.
Table of Contents
(1) Surgical Indications of Acute Sinusitis with Intracranial Complications
(2) Surgical Techniques for Acute Sinusitis
(3) Source Control of Acute Sinusitis
(4) Follow Up Management of Acute Sinusitis with Complications
Surgical Indications of Acute Sinusitis with Intracranial Complications
When acute sinusitis presents with intracranial complications, surgery is always a consideration. The decision to proceed with surgery depends on the patient’s stability and the nature of the complication, whether intraorbital or intracranial. For instance, if a patient has an intracranial abscess and is experiencing seizures, surgery on the same day may be necessary. Dr. Stapleton describes a case where a patient required urgent surgery by the neurosurgery team to drain an abscess, followed by sinus surgery performed by ENT three days later once the patient was more stable.
In cases of acute sinusitis with preseptal cellulitis of the eye, a 48-hour trial of IV antibiotics is often attempted first, with ophthalmology typically involved in monitoring the patient. Surgical intervention for orbital abscesses depends on the size of the abscess. Sinus surgery in the setting of acute sinusitis can be challenging due to swollen and fragile mucosa, which can bleed and obscure the surgeon’s view. Controlling inflammation during and after these surgeries is key. Using topical epinephrine during the procedure and prescribing a course of oral steroids afterward can help reduce inflammation and the risk of needing additional surgery in the following days.
[Dr. Gopi Shah]
How do you think about when is surgery indicated for these patients?
[Dr. Amanda Stapleton]
It truly does depend on what complication we're dealing with and how stable the patient is. I had one girl roll in this fall with a huge intracranial abscess. The neurosurgery team took her back to the OR that day because she was lethargic and seizing, and opened her to drain this huge abscess. She was very unstable on the table. They were lucky to stop her bleeding. She was so anticoagulated from the infection. I was planning on doing her nose because her frontals were the source of this, but we had to close her up and then come back three days later and do her sinus surgery because we had to get her in a better state.
She had been down, she was dehydrated, she was trying to go into DIC. Sometimes you just have to pick the biggest problem, whether it be the intracranial abscess or the sinus side. When you start from the baseline, I think of acute sinusitis with a preseptal cellulitis of the eye, those kids are the ones that I definitely sit on longer, especially if they haven't been on antibiotics, or if they've only been on amoxicillin, and if they're under age seven. I give them a good 48 hours of IV antibiotics, check their eye exam. Optho always follows them with us and does serial eye exams.
If it's under a centimeter, most of those kids are going to resolve on their own. Once the orbital abscess gets bigger or the swelling isn't better, I'm all about giving people a chance on IV antibiotics, but sometimes when you see the size of the abscess, you know it's not going to improve. I'm more of an early surgeon than a late surgeon. I think some of that is also comfortability with sinus surgery. Not everybody is a pediatric sinus surgeon, and so some other people that might be in your same call pool would maybe sit on things longer, see if the IV antibiotics are helping because these are hard cases.
These are swollen noses that bleed the whole time. You can't see anything. You're trying to make sure you get into the right space and drain the right abscess. These are the cases that my fellows always say to me, "Oh, I thought I was a good sinus surgeon, and then this case showed me I'm not." I'm like, "These are why you do fellowship." I guess we could break it down by if you were talking frontals from a Pott's puffy versus a true intracranial from just a frontal sinusitis. Say you have a Pott's, and the anterior table is somewhat eroded, not a whole hole, but you could tell that the bone has broken down because he's got a big egg on the front.
The question with these ones are, number one, how much of the frontal do you take off? Meaning, how much of that bad bone do you have to remove? Number two, can you get there through the nose? Number three, should you just do a frontal trephination and flush out the frontal, and put a drain in and flush it daily? If there's an epidural behind the posterior table of that frontal, do you just treat that with an antibiotic versus having neurosurge come in and take down the whole posterior table and cranialize that kid? I don't cranialize kids unless the posterior table is involved, meaning that bone has already broken down.
We're not talking a frontal sinus fracture here. It's not a trauma, where we know that the nasal frontal recess is never going to work and that sinus is going to always be a disaster and you just need to clean it out to protect the kid in the long run. I find that frontal endoscopic sinus surgery for acute infection is probably the hardest thing that we do because people are trying to find the true drainage outflow pathway in a field of super-swollen mucosa. Then being confident that you kept it open is the tricky part. That's why a lot of people just do trephinations, period, because they're not 100% sure that they got that frontal open.
There's some tricks that you can do to maximize your outcomes there because I think those cases are the highest risk for going back to the OR in three or four days when the kid is not better because you thought you got into that frontal, but did you really? It's so swollen that it's still not going to drain because you're trying to expect it to drain through 1 millimeter of a diameter. I would say if your frontal table is already injured from your Pott's, you do your trephination and flush from above, but you need to make sure it's going down, and so you still have to do endoscopic sinus surgery.
These are the kids that you're using topical epi throughout the case. You really got to decongest that frontal drainage pathway. I'm not opposed to PROPELs. I think that putting a steroid in there is fine. I'm also not opposed to oral steroids for three to five days. Our old teaching was that you can't give infected kids steroids because you're going to affect their ability to fight an infection. When you actually talk to ID and ask them that, short-course steroids do not stop your ability to fight an infection. If you keep a kid on oral steroids long enough to get that frontal mucosa to decongest so that that sinus can drain, and spare them three trips to the OR to keep draining the same abscess, then you did them a benefit. Then really keeping a drain, sometimes I just leave an angiocath in there. Then every day you can go up onto the floor and flush that. If it's not coming out through the nose, then you know your frontal is not open. Then you got to do something about it. There's tips or things that you can do to try and get your frontal to stay open, especially if it's already shown you that it's spreading into an epidural or a subdural and neurosurge does a burr hole to clean out the subdural. Those are, I find, the hardest cases is true acute frontal sinusitis with a complication.
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Surgical Techniques for Acute Sinusitis
Dr. Amanda Stapleton shares her techniques for sinus surgery in children, particularly for opening the frontal sinuses. She emphasizes the use of a 70-degree camera and a "fat scope" for better visualization, noting that larger scopes can still be used in children's flexible nasal tissue. Dr. Stapleton advises removing the middle turbinate if necessary to gain better access, especially when draining an orbital abscess, as leaving it in place can hinder the procedure. Warm saline and topical epinephrine should be used to control bleeding and maintain visibility during surgery.
Surgeons should be proficient with navigation technology, especially during late-night emergencies when support staff may not be available. Augmented reality systems can also be used for preoperative planning and enhanced accuracy, which can be particularly useful in navigating difficult cases.
[Dr. Gopi Shah]
In terms of getting the frontals open, are you using 30 degrees? Does that tend to help you? Do you use a big shoulder roll? What other tips do you have?
[Dr. Amanda Stapleton]
Yes, so I always use a 70-degree camera. I think it just is the best for visualization. I always use a fat scope. I never use skinny scopes on children. Everyone gets nervous because they think it's big, and I'm like, "The nostril moves, guys. It's soft tissue. You're going to be able to get in there with a fat scope." Then it is important, you're right, to clean out the ethmoids. I always tell my fellows, "Never let a middle turbinate stand between you and draining an abscess. If you can't see or you need more room or especially orbital abscesses, it is okay to take out a middle turb. We do it all the time in skull base surgery. You are not going to give them empty nose syndrome. The other surrounding structures will accommodate that space over time. It is okay to take out a middle turbinate." I know this might be sacrilegious to some people, but it doesn't matter.
[Dr. Gopi Shah]
No, middle turbinates scar over. Patient had to go back, and maybe the abscess could have been drained better the first time, but because it was scarred over, I don't think that it allowed it to continue to drain. No, I've been burned by middle turbinates, both in the acute and the chronic setting.
[Dr. Amanda Stapleton]
Yes, it is okay to take out a middle turb, either partial or total, whatever you need to see and to get where you need to go. Don't be afraid of middle turbinate section. Secondly, I always use a 70 looking up with a fat scope. I always use 1 to 1,000 topical epi on pledges with fluorescein on them so we don't inject anything, but you really have to pack off that frontal recess. Let it sit there, go back and forth if it's, you're doing bilateral sides and reverse Trendelenburg. Getting the head up, warm irrigations. When you're flushing, you should be using warm saline.
That's been shown to help with bleeding. All those bleeding tricks that we have for the adults, you need to apply to kids too because you need to be able to visualize, so that way you're in the right spot. Obviously, navigation is super helpful in this location. This is when it's worth knowing how to work your navigation machine because a lot of times this is 2:00 in the morning and magically the rep is not there and nobody knows how to turn it on or get things to work. Making sure that you personally, as the attending surgeon knows how to troubleshoot your system of choice is really important because I think in an acute frontal, this is the time to use navigation.
[Dr. Gopi Shah]
One time I used an image-guided balloon for the frontal, and it helped drain some pus. Now, did it help keep the frontal open? I don't know. Was I in the right spot? I hope so, based on the scan. Do you ever use anything like that?
[Dr. Amanda Stapleton]
I haven't used that. There are some new systems that have augmented reality, and I have used those. The nice thing about those systems are you can pre-plan those. You can trace out where the frontal is supposed to be, and then as you're, navigating, it's almost like following a video game up through the loops to get into the right spot. Normally, I do that just to train, to practice with my residents and fellows during non-acute cases, but it can be also very helpful in an acute case because you can pre-operatively plan it on the CT. Then when you're in there, it's fairly accurate. Using the technology that's out there can only help us in this situation, and so I think this is a time to really use the new options that are available for advanced-level navigation.
Source Control of Acute Sinusitis
An adenoidectomy may be warranted in the setting of acute sinusitis, especially in younger children, as a biofilm on the adenoids could contribute to recurrent infections. Children under seven with sinusitis and orbital complications are often good candidates for this procedure. Dr. Stapleton notes cases where an adenoidectomy performed a month later should have been done initially. Isolated sphenoid sinusitis infections may also indicate the need for adenoid removal. Managing source control of the entire nasal area is important when treating acute sinusitis with complications.
[Dr. Amanda Stapleton]
I know it sounds crazy, but if you have a kid who's got isolated sphenoid infection and 100% adenoids, is there a biofilm there that's just going to re-flourish? It won't happen while they're on three IV antibiotics, but it might when they get off all that. Just making sure that you're managing the entire nose. You don't always think of that when you're dealing with acute forehead pus, but in younger patients, meaning kids under seven, it's worth keeping that on the back of your radar as well.
[Dr. Gopi Shah]
No, I'm glad you brought that up because every once in a while, like you said, a younger kid, what's the role of adenoidectomy in the acute setting when there is a complication? Is there a role? When do you consider just, hey, we're going to cauterize this while we're here?
[Dr. Amanda Stapleton]
If I look at the nose when we start the case, it's a kid under seven and you're dealing with like ethmoid and maxillary disease because that's basically the sinuses that they have pneumatized at that age, and it's an orbital complication, then I am definitely not opposed to taking out adenoids. I've had to go back on people that have been operated on by, say, my partners and do an adenoidectomy a month later. You really got to think about source control. It's really what it is. If these are the kids who have 10 colds a winter, and we know that their biofilm is covered in Moraxella and we need to get rid of it, then you got to get rid of it. It adds 20 minutes to the case on a case that you already spent 2 hours on. You might as well, nip it in the bud.
[Dr. Gopi Shah]
Every once in a while you will get, and again, it's going to be a little bit more common with the eye pests in terms of under seven, but you do get intracranial complications in the under seven too. I know for my kids, the younger ones usually, it's usually that 18-month-old that keeps getting preseptal cellulitis every six to eight weeks. When they're cooled down, then we'll go ahead and take the adenoids out. There's nothing else I'm going to do at that point. I always used to think about it in the back of my head, okay, I'm in the OR for this test because either the kid has, whether it's meningitis to--
What am I trying to say? Not preseptal abscess.
[Dr. Amanda Stapleton]
Subperiosteal abscess?
[Dr. Gopi Shah]
Subperiosteal. Thank you. Or a subperiosteal abscess and the child is eight or six. Do I need to look at the adenoids in this? I'm there with the bovie, should I just buzz something? There isn't data or literature on that. Is there?
[Dr. Amanda Stapleton]
It's true.
[Dr. Gopi Shah]
Now I feel like, okay, good. I have somebody else that also thinks about that. Then I'm like, "Okay."
[Dr. Amanda Stapleton]
We're so focused on, especially with I, getting the abscess drained. Making sure that you take down that lamina and get the whole pocket out because those are the kids that if you don't drain it, you know because their eye never gets better. Everyone is so focused on making sure you drain that abscess, but again, you got to really think, like you said, about source control here. I'm definitely not opposed to doing an adenoid in the middle of an acute sinus surgery.
Follow Up Management of Acute Sinusitis with Complications
In cases of acute sinusitis with complications, close follow up after surgical treatment is needed.
A follow-up at three weeks for a nasal endoscopy and debridement is ideal. This is also a good time to review the patient’s medical history prior to the infection, as this can help determine the level of follow-up needed. If allergies are suspected, managing them in a rhinology clinic is helpful. Dr. Stapleton typically sees patients twice after sinus surgery—once around three weeks and again at six weeks, when the patient is off antibiotics, rinses, and other treatments. The six-week follow-up helps assess whether another infection is developing. Fortunately, recurrent intraorbital or intracranial abscesses in children are rare, but they can happen.
[Dr. Gopi Shah]
In terms of follow-up, let's say the child gets better and they're discharged, what's your follow-up like? Do you follow them long term?
[Dr. Amanda Stapleton]
I do. I bring them in, in three weeks, and I check their nose. In little kids, I do it with a headlight and a speculum. In older kids, I do a true nasal endoscopy and debridement. Then I really dig into the history pre-infection. If this is an allergic kid who occasionally takes Zyrtec, but never really had testing or management, or if this is a teenager who this is the first time they've ever had a sinus infection. How long I follow them really depends on what their pre-infection history was. I do in-office allergy testing and management. I keep them all in my rhinology clinic so that I can address their whole nose because that's the number one thing parents ask you. "How did it happen? Is it going to happen again? Is every time they get a cold, do I have to worry she's going to have an orbital abscess?
[Dr. Gopi Shah]
It's my reasoning of it's just really bad luck. Is that not good enough?
[Dr. Amanda Stapleton]
I'm sorry.
[Dr. Gopi Shah]
Because I feel like it's otherwise healthy kids that don't really have a history and maybe there could be like a mild, well, they have allergies, but that is an issue. I feel like, is that not a separate issue?
[Dr. Amanda Stapleton]
It depends. It's pretty rare, honestly, that I get a kid who rolls in who's had chronic sinusitis and then gets an acute one because they're dealing with chronic sinusitis, not acute. These are not tonsils that have had seven streps. This is a sinonasal cavity. You're right. Sometimes it is, especially that's why we've been so interested the last two years, these kids haven't been sick for two and a half years, and then all of a sudden you get a strep in there and your body's like, "Whoa, what is this?" Then just can't manage it, and it moves too quick.
You're right. I do tell family a lot of it's bad luck. The chances of someone coming back in with a separate intracranial abscess that is two years later, kind of thing, I've never seen it. I have had, like you said, little kids come in with a couple rounds of preseptal. The one time they managed it with Augmentin, the next time they needed IV Unasyn, and then the third time. That has happened, but I haven't had kids drain abscesses that came back two years later with a second one.
[Dr. Gopi Shah]
I haven't seen that either. Then if you do see something like that, or now they have a new mastoiditis or something like that, then immunology or somebody else needs to get involved in terms of why, or a vaccine immunization history. My question for you is, do you ever follow these kids six months to a year out for any CRS-type potential complications?
[Dr. Amanda Stapleton]
That's a good question. I don't. Like I said, I normally see them probably two visits after their surgery. I see them at three weeks, and then maybe I see them another six weeks after that, just to make sure that, hey, we're off our washes by now. Yes, we did our FLONASE. We're looking better. When you see them at three weeks, they're still probably on IV antibiotics, so they're feeling good because they're still on systemic treatment. You just want to make sure their nose doesn't blow back up again after you take them off all that stuff. That's why I do a couple of visits. Then normally, I don't see them yearly, or, stuff after that. They tend not to come back. People come back when they have trouble. They'll call you, and their parents are more alert to it because of the trauma that they had from going through this process in the first time.
[Dr. Gopi Shah]
Every once in a while, if the initial neurological symptoms were something like aphasia or upper or lower extremity weakness, those kids go to rehab, and they do better. The studies have shown that their neurological symptoms, unless it's seizures, and even that most of the time, they tend to resolve, and they get better. It might take a little bit of time. Some of these, the recovery is, it can be very indolent and difficult, and it can be very traumatic. An otherwise healthy middle school kid, it's a lot. They've missed a ton of school and now really they're weak. Yes, it can be a lot.
[Dr. Amanda Stapleton]
Yes. It's like a parent's worst nightmare.
[Dr. Gopi Shah]
Yes, absolutely. I would see them back about two, three weeks after discharge. Just, A, make sure they're doing the rinses, making sure nothing new has collected on my exam. Then usually, at that, I'm looking in with like a otoscope in their nose or anterior rhinoscopy. Then I'll see him back probably about four to six weeks after that. By then, usually, they'll have had a cheat a little bit. They have an MRI or something. Then at that time, depending on their symptoms and how they look, depending on age and what exactly am I looking for, I might put a camera in just to see.
Sometimes I'll have older kids that start rinsing at three weeks. They drive me crazy because I'm like, "Hello, did you not see what just happened? Let's make sure there's no pus." Maybe they have slight stuff, a headache, and things like that. Then early on, I would follow them to six months and even a year because I was like, "Maybe I scarred them up caused chronic sinusitis or something," given that it was done in an acute setting. Fortunately, even with scarring in the nose, knock on wood, a lot of times children are asymptomatic. I don't know if you have any thoughts on that.
Podcast Contributors
Dr. Amanda Stapleton
Dr. Amanda Stapleton is a pediatric otolaryngologist, associate professor, and director of the pediatric otolaryngology fellowship program with the University of Pittsburgh in Pennsylvania.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2023, May 30). Ep. 113 – Intracranial Complications of Acute Sinusitis in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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