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Intracranial Complications of Acute Sinusitis: Examination, Treatment & Prevention
Megan Saltsgaver • Updated Oct 1, 2024 • 37 hits
Acute sinusitis refers to inflammation of the nasal cavity and sinus mucosa lasting up to 4 weeks. While it’s most commonly caused by viral infections, which typically resolve on their own within 10 days, bacterial sinus infections can occur and are often treated with antibiotics. Though complications are rare, acute bacterial sinusitis is more likely to lead to more severe sequelae, such as intracranial, intraorbital, or osseous complications. Pediatric otolaryngologist Dr. Amanda Stapleton offers valuable insights on managing these rare but serious conditions in children.
This article includes excerpts from the BackTable ENT Podcast, featuring key highlights. You can listen to the full podcast below.
The BackTable ENT Brief
• Patients and families are often unaware of the more serious complications of an acute sinus infection. Acute sinusitis can cause intraorbital, intracranial, and osseous complications if left untreated.
• Patients with these complications often present very sick to the emergency room. Symptoms may include lethargy, nausea, vomiting, seizures, limb weakness, dysphagia, and other neurological deficits
• Physical examination typically includes a bedside nasal endoscopy, eye exam, and a basic neuro exam to assess a child's baseline to be able to monitor for progression.
• Unasyn is an appropriate broad coverage antibiotic that patients can be started on when they first present to the hospital. Unasyn will cover aerobic and anaerobic bacteria that reside in the nose.
• Patients can expect to be on a prolonged course of antibiotics after their treatments for intracranial complications from acute sinusitis. Antibiotic and steroid nasal rinses are often used as another means to combat residual bacteria in the nose.
• Once someone has had intracranial complications from acute sinusitis, they should be made aware to alert their doctor if they are having fevers, yellow-green nasal discharge, or other acute sinus infection symptoms.
Table of Contents
(1) Intracranial Complications of Acute Sinusitis
(2) Initial Examination of Acute Sinusitis Complications
(3) Antibiotic Management of Intracranial Complications
(4) Being Proactive in Children with a History of Sinusitis Complications
Intracranial Complications of Acute Sinusitis
Patients and families are often unaware that acute sinus infections can spread beyond the sinuses, leading to delays in treatment. If left untreated, sinusitis can cause intraorbital, intracranial, and osseous complications.
Intraorbital complications are the most common and range from preseptal cellulitis and orbital cellulitis to subperiosteal and orbital abscesses, according to the Chandler classification. These conditions can affect eyesight and extraocular movement, with symptoms including swelling and pain around the eye and surrounding structures.
Intracranial complications, such as meningitis, brain abscesses, superior sagittal and cavernous thrombosis, subdural and epidural abscesses, or even oculomotor and abducens nerve palsies, are more severe. Patients with these complications often present with systemic illness and are typically very sick. Symptoms may include lethargy, nausea, vomiting, seizures, limb weakness, dysphagia, and other neurological deficits as the condition progresses. Osteomyelitis, a bone infection, can also develop from untreated sinusitis and may contribute to intracranial complications.
It's important to note that affected patients often present to the ER with complaints unrelated to an acute sinus infection. Imaging is frequently performed before the underlying cause is identified as sinusitis. Providers should always inquire about recent illnesses such as sinus infections when evaluating these patients.
[Dr. Amanda Stapleton]
We've all been more acutely aware of these cases because it seems like they've been rolling in more frequently over the past one to two years post-pandemic. At least in our practice, we even went back and looked at the data to see, hey, are we getting more orbital complications specifically of sinusitis compared to, if you took '18, '19, and then compared it to '21, '22. We saw a slight uptick, maybe 5% to 10% more. Maybe it's just, it seems like a lot when you're on call, and every time you're on call, you're taking a kid to the OR for an acute complication case.
Definitely, this fall, it really started ramping up in October in our area. I'd say once or twice a week we're taking a patient to the OR either to drain an orbital abscess or address a intracranial abscess, or a frontal osteomyelitis. These kids frequently, unfortunately, roll in pretty sick. They roll into the ER, and either one eye is swollen shut, or in the case of intracranials, you really have to worry about more the systemic presentation. Kids are rolling in lethargic. Maybe they have nausea and vomiting. When we're getting to the point where they're rolling in with seizures, then you're really nervous.
Are we dealing with something really aggressive or big, whether it be an intracranial abscess versus just an epidural, a subdural? It's rare for kids to just show up in the ER with yellow stuff coming out their nose. Most of the time, it's not even that they have a bunch of sinus symptoms. Parents will say, "Oh, well, they had a cold last week. We got some amoxicillin from our pediatrician. They seemed okay. Then today their eye is so swollen, and they can't open it." Or, "I noticed that their forehead looked puffy, or they just don't seem themselves. I brought them in and my pediatrician just told me to go to the ER." They show up in the ER. Somebody decides to get imaging on them, and then they call you.
[Dr. Gopi Shah]
Yes, you're right. They're usually either in the ER sick, sick, sick, or already taken to the ICU at that point. Then through the scans, by the time they've called you, the patient is already in the unit. I remember, especially my first few years out, thinking, "Man, we're not used to seeing kids with neurological signs and symptoms." Most of them will have headache, nausea, vomiting, but when you have that first kid, the child that has the dysphagia, or the upper or lower extremity weakness, it's pretty scary just because that's not in our normal symptoms.
We have the clogged ear, the runny nose, things like that. The other thing, like you said, with seizures, sometimes it's hard to know is this how involved intracranially. Those are the red flags, but sometimes it is hard to say how much of the physical exam finding is actually correlated with the imaging. Some kids look pretty good, and you're like, "You got a pretty big intracranial abscess in there." Sometimes the symptoms can be scarier than sometimes a scan and vice versa. In terms of eye swelling, I found this in my clinical practice, but I think I read a case series. Do you find that your lateral orbital abscesses have a higher predilection for intracranial, or do you think that that matters? I think I read maybe it was 10% of orbital complications can also have simultaneous intracranial. What do you see?
[Dr. Amanda Stapleton]
It really, I think, depends on age and location. We see a lot of just confined orbital complications that don't have intracranial. Those tend to be the medial orbital wall subperiosteals that really aren't draining all the way back, making it to the cavernous. If you're talking about a teenage boy who's 16 and has real frontals, meaning truly pneumatized sinuses and has a bad frontal acute infection that also led to the floor of that frontal sinus easily drains through the orbital veins, and then does that then get you an epidural abscess posterior to that? The medial ones I don't really see tend to truly go intracranial, but it can be bad frontals that can start to really back up and start to spread more into the intracranial compartment.
[Dr. Gopi Shah]
You're right. It's usually that sort of, we say the adolescent males. We say that because the frontals tend to pneumatize during adolescence. You have more venous supply and an easier way for spread as there's more development whether it's through blood, direct contact, et cetera. It's crazy. Every once in a while, it's not common. Everyone is going to have a younger kid that does have some pneumatized frontals or younger kids where it's sphenoid, the disease is posterior a little bit. Tell me about some of those patients.
[Dr. Amanda Stapleton]
Yes. I had a case this year of a nine-year-old who had isolated sphenoid sinusitis. All the other sinuses look beautiful on the CT scan that he rolled in with. He rolled in with new headache, and he was a kid who never had a headache. Parents were physicians, they were very reliable in terms of symptoms. He had a new headache that he'd never had in his life and little family history of migraine, but it was just that it was so distinctly different than anything he had ever shown up with. When you looked at him, he had had a cold for a week, had a history of adenoiditis, was getting a sleep study for possible sleep apnea just because he had moderate adenoids and moderate-sized tonsils.
Then rolls in with a cavernous sinus thrombosis from isolated sphenoid sinusitis. He was nine. He wasn't the 16-year-old boy who sat at home for two weeks, never told anybody he had a cold, and then rolls in with a giant frontal Pott's puffy tumor or something around those lines.
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Initial Examination of Acute Sinusitis Complications
When children present to the emergency department with signs of intracranial complications, they are typically scoped first. If pus is visible on the physical exam, culturing it can guide the use of appropriate antibiotics. These patients may not always display significant nasal changes and often present with erythematous mucosa and swollen turbinates. Conducting a thorough eye exam to establish a baseline and assess extraocular muscle movement is also important. Additionally, a basic neurological exam should be performed to evaluate cognition, strength, and other cranial nerve functions to monitor for any progression of the condition.
[Dr. Gopi Shah]
In terms of physical exam, do you do anything special? Are you scoping any of these kids? I know it's a ridiculous question now that I ask it out loud, but a lot of these kids can be young, or if they have such a bad headache or altered mental status. Also, I don't know, once you have that imaging, if putting a scope in is going to change your management.
[Dr. Amanda Stapleton]
A lot of times these kids roll into the ER overnight. The first people that tend to see them are my residents. They do tend to scope them because they're trained to scope everybody. We're not talking three-year-olds here. Most kids 10 and up can handle a bedside flex scope, no big deal. I always tell them that if you see pus, culture it because sometimes that can be helpful, especially if they can tell me, "Yes, there's purulence coming out of the middle meatus I cultured in the ER before he got put on his IV Unasyn," just to move forward with being able to appropriately treat medically on top of what you'll eventually do surgically.
Sometimes it just helps identify purulence, helps you get culture-directed swabs and just know what you're dealing with. Then the tough ones are the ones where their nose doesn't look so bad. They're a little bit red, turbs are a little bit puffy, but they're not pouring out thick yellow-green slime. You're like, "I guess it all went intracranially instead of coming out your nose because your nose looks okay." It doesn't typically change my decision-making. It's more just to help with either getting a decent culture on them ahead of time before they start IV antibiotics, or just to know the level of what we're going to have to deal with in the OR, depending on how edematous they are.
[Dr. Gopi Shah]
I agree. If you're able to get a culture, that's great. I think once they come in with an intracranial, and again, we'll talk about the role of FESS and all that in a little bit, but the other things I tend to try to get if I can is just a good eye exam, like extraoculars, eye swelling. Those things are important to me. If there is a Pott's, how bad, how indurated, how swollen, how big is it so that we have a baseline and something to follow with. I think the eye exam and the eye swelling, all that's more important to me if there is a simultaneous orbital abscess or post-septal or orbital cellulitis or whatever we're following along, that is important to me.
Then depending on the kid's age and how with it they are, sometimes I'll get my own neuro exam. Depending, in terms of nothing crazy, just like grip, shoulder shrug, push on the gas type stuff, just to see what's going on.
Antibiotic Management of Intracranial Complications
Hospitalization for intracranial complications of acute sinusitis often involves a long hospital stay of 10-14 days. Antibiotic management is usually coordinated with an infectious disease (ID) consultation to determine whether intravenous or oral antibiotics are necessary. Consulting ID is important due to the need for a prolonged course of antibiotics, especially if a brain abscess is present, which may require 4-6 weeks of treatment. Unasyn (ampicillin/sulbactam) is commonly started for broad coverage of aerobic and anaerobic bacteria in the nasal cavity, and vancomycin may be added in certain cases.
Antibiotic rinses are often continued after both medical and surgical interventions. While there is limited data on some rinses, most ENTs agree that delivering antibiotics to the nasal cavity via rinses is beneficial. Mupirocin is commonly used as a rinse to target streptococcus and staphylococcus species. For children who are immunocompromised or have cystic fibrosis, tobramycin mixed with saline is appropriate for pseudomonal coverage. Steroid rinses, such as budesonide, are often added to the regimen to help reduce edema.
[Dr. Gopi Shah]
Those kids, regardless, and again, we're about to talk about the role of FESS, but in terms of talking to the families, once it is a large epidural, subdural or intracranial, or once it is a subdural or intracranial, that, of course, is indolent. It's really difficult to manage expectations, I think. It's not always a clear cut, and I don't want to say no matter what. There's definitely a range of days in the hospital for these kids, but I would say on average, the child will be in the hospital 10 to 14 days depending on the severity of the disease and how they do.
Especially once if they do end up having to go and have a neurosurgical procedure, which it's a coin toss, it's about 50%. Depending on the clinical picture and the imaging and all that, it's a coin toss almost. In terms of, before we talk about FESS, antibiotics, what do you usually recommend? I realize for most of these, I would say our infectious disease colleagues are consulted on board because can be polymicrobial, they're aggressive, and the child may need something longer term with IV PICC or something, intravenous antibiotics for several weeks after. What do you think is important in terms of antibiotic coverage?
[Dr. Amanda Stapleton]
Definitely intracranial, I always get IDM involved, and for all those reasons. Once you got to the point where you got a brain abscess, you know you're going to be on at least four to six weeks of something. Our typical teaching was always start them on Unasyn because you're going to cover the aerobes and anaerobes that live in the nose. Sometimes, like I said, they'll broaden it just because we don't have directed antibiotics until we go to the OR. They put them on vanco. It's not quite the, "Hey, let's put them on Flagyl, vanco, and Unasyn to cover every possible thing," unless there was some immunocompromised state or a kid who has an underlying diagnosis that would predispose them to more aggressive infections.
Honestly, most of these are strep, some version of the strep family, strep milleri. There's all kinds of more aggressive strep that has been what we culture. Occasionally, I get staph, but honestly, that doesn't seem to be my number one thing that's growing out. Putting everybody on vanc and Unasyn, whether you need to or not is I don't know that you always need that extra coverage. Yes, we pretty much start everybody on Unasyn.
[Dr. Gopi Shah]
You're right. It usually is that strep milleri family. When we looked at our series a couple of years ago, I would say half were polymicrobial. Some anaerobic coverage and then ID is always very good at CNS penetration and things. I'm thankful that the ID people are there.
[Dr. Gopi Shah]
You had mentioned antibiotic rinses. What do you have them put in there?
[Dr. Amanda Stapleton]
Sure. I do a lot of mupirocin. I know it's not awesome for getting it to solubilize in there, but I definitely do it because you're dealing with staph and strep. It'd be easier if they were growing out pseudomonas like the CF kids because then you can just get them tobramycin, little vials. Pour that in and it mixes better like when you do budesonide. I do. Again, I know there's not a ton of data to show the difference between saline by itself versus saline plus mupirocin, but I figure if we can get some antibiotic up into that cavity, awesome. When we flush out a neck abscess, we flush it with antibiotic saline. I think of doing the same with sinus rinses. It's not overly expensive or burdensome. If they're already washing their nose, cool, put some antibiotic in there, and rinse it through.
[Dr. Gopi Shah]
Do you just tell them to-- I would just tell them to do a dime size amount or something.
[Dr. Amanda Stapleton]
Yes, I tell them half a teaspoon, just give it a good squirt. Then I tell them if it still looks like a clump in the bottom, you can microwave it for 10 seconds, and then just wait for it to cool down before you rinse it back through. Normally if you give it a really good shake, you can get it to dissolve a little bit.
[Dr. Gopi Shah]
No, that's a good tip. Then, do you ever do budesonide rinses in these settings?
[Dr. Amanda Stapleton]
For sure, yes. If you're really worried about edema, you can do both. You can put your budesonide in the bottle and your mupirocin and just double rinse because just telling a kid to go home with two sprays of fluticasone, you know you're not getting it up into the frontal. The teenagers are just like, "Meh." I barely hit your septum, let alone get it high enough to do anything. I think acutely for the first month afterwards, you can do budesonide and mupirocin together.
[Dr. Gopi Shah]
I like that.
[Dr. Amanda Stapleton]
We do get some pushback on covering budesonide, so that can be a pain, but I think it's worth getting topical steroid into the area.
Being Proactive in Children with a History of Sinusitis Complications
It is imperative that parents of children with a history of intracranial complications from acute sinusitis be proactive in managing future sinus infections. For patients without a history of complications, antibiotic treatment is usually considered after 10 days of sinusitis symptoms that show no improvement. However, Dr. Stapleton recommends a more aggressive approach for children with a history of complications. She advises against waiting two weeks before seeing a doctor. Instead, she suggests starting antibiotic rinses and an oral course of Augmentin if symptoms such as yellow-green discharge, fever, and other sinusitis signs are present.
[Dr. Amanda Stapleton]
I get the question from parents: what happens when they get another cold? Are they more predisposed to having this happen because the pathway has already been created?
The question, especially if you had blow out of the posterior table, do I need to be more proactive? I tell families, yes. This is not a kid that I would sit on two weeks of nasal drainage, and before I see the doctor. We always tell people, oh, 10 days before you get put on an antibiotic, or, you got to have symptoms long enough. I'm like, "Hey, if this kid starts to pour yellow-green drainage out his nose and spike a fever, you're going to do your antibiotic washes. You're going to call me or your pediatrician, and we're going to start you on Augmentin. We are not going to hang around and see if this spreads intracranially again."
Parents are hyper-aware to that because they are traumatized from what happened. Is there data to support that? I don't know. I don't know that. Like I said, I haven't really seen anybody come back with a repeat frontal from a separate infection that's greater than six months from the original thing. I also have people that are treated with just IV antibiotics for intracranial complications. Then those are the kids that I actually worry more about. Those are kids that actually get more imaging because we are so nervous that we didn't take them to the OR.
Do they need MRIs every six months, or three months, especially in the beginning? I have one kid that they're following that has had an MRI monthly for the past three months to make sure that it has resolved, and his frontals look beautiful. Then they asked me, "Do you need to do sinus surgery on him to prevent this from happening again?" I'm like, "Your frontals look so beautiful. I'd hate to scar them up." Those are conversations that you get too. Should you do preemptive sinus surgery if you didn't have to do it the first time, but we should do it to prevent this from happening again.
Unless there's some true anatomic, like a huge agger cell or a frontal that has four cells up through it, and you know that frontal is never going to work, or they still have residual mucosal inflammation three months after IV antibiotics, then it's a different story. When your frontals look beautiful because you've been on two months of IV antibiotics and your MRIs are clear, it's harder to say, "Okay, let's just do sinus surgery to say we did it."
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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