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BackTable / ENT / Podcast / Transcript #113
Podcast Transcript: Intracranial Complications of Acute Sinusitis in Children
with Dr. Amanda Stapleton
This week on the BackTable ENT podcast, Dr. Gopi Shah and Dr. Amanda Stapleton, a pediatric otolaryngologist from UPMC Children's Hospital of Pittsburgh, chat about the unique challenges of treating pediatric sinus and skull base diseases, orbital complications, and biofilm-covered Moraxella. They discuss source control, biofilm, and her research focused on the bacteriology of pediatric chronic sinusitis and patients with cystic fibrosis. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Complications of Acute Sinusitis
(2) Initial Examination of Acute Sinusitis with Complications
(3) Imaging Modalities for Acute Sinusitis with Intracranial Complications
(4) Antibiotic Management of Acute Sinusitis with Intracranial Complications
(5) Surgical Indications of Acute Sinusitis
(6) Surgical Techniques
(7) Source Control of Acute Sinusitis
(8) Follow Up Management
(9) Being Proactive in Children with a History of Complications
(10) Antibiotic Rinses
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[Dr. Gopi Shah]
Hello, everyone, and welcome to The Backtable ENT Podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. My name is Gopi Shah. I'm a pediatric ENT, and I have a very special guest today for a really, really important topic. I have Dr. Amanda Stapleton. She's a pediatric otolaryngologist and endoscopic sinus and skull base surgeon at the University of Pittsburgh Medical Center Children's Hospital of Pittsburgh. She's the fellowship director for pediatric ENT and the director for the Center of Sinonasal and Rhinology Disorders.
Her research focus is on the bacteriology of pediatric chronic sinusitis and of patients with cystic fibrosis. She's been prolific in our research contributions to pediatric rhinology and her contributions to rhinology education through the Academy. I got to know Amanda a little bit better working alongside her on our fellowship committee through ASPO, as well as on some of the ACGME milestones that we did for the ENT fellowship. It is with great pleasure that I welcome you to the show, Amanda. How are you?
[Dr. Amanda Stapleton]
I'm doing well. How about you?
[Dr. Gopi Shah]
Good. I just want to tell you, I don't think I ever told you this, but I remember when I first started my practice a couple of years in, and we started to really want to develop a real pediatric sinus and skull base center at Children's. I started to look at my own patients, and then I'm doing the literature search, and I just see Amanda Stapleton, Amanda Stapleton, Amanda Stapleton. I knew your name, and I was like, "Who is Amanda Stapleton?" Then we got to be on the fellowship committee together, and I was like, "Okay, all right. Cool." Then, last year, we got to do a panel together. Anyway, so it was cool to match the name with the face, and then get to know you. That's been more fun.
[Dr. Amanda Stapleton]
It's always funny because I always think that I'm the only person in the world that cares about pediatric rhinology. Everyone thinks that everybody just has kids who have runny noses, and that's the end of the story. They'll grow out of it and move on in life. I've always found it much more interesting than that, and trying to get other people super excited about pediatric mucus is really been hard work, but we're getting a few more people on board to actually care about it. It's been exciting to see other people develop that area and start to try and study it from a truly objective standpoint. For me, I try and always look at what's happening in the adult world and see how it does or does not apply to kids. I'm always looking for new ideas or new approaches to how to manage these patients that roll into our office every day.
[Dr. Gopi Shah]
Absolutely. Just for our listeners, tell us a little bit about yourself and your training because you're double fellowship trained.
[Dr. Amanda Stapleton]
Yes. I did a regular ENT residency. Then during residency, I had the awesome opportunity to be a part of the skull base community at Pittsburgh, which really revolutionized how we do endoscopic or skull base surgery. At the time, the fellows who were there, were like, " You know what? You like kids and nobody else wants to go to Children's." They're like, "Hey, you should really think about pediatric skull base." At the time, there was no such thing as pediatric skull base. Adult guys would just go over to Children's and do cases, and that was it.
I knew, after making my way through residency, that I really wanted peds to be my base practice, meaning the population that I take care of. I didn't want to lose that awesome endoscopic skill set that we slowly develop over time as residents and fellows. I did a pediatric fellowship first, and then after that, did the adult endoscopic skull base fellowship so that I would have the skill set to hopefully be able to take care of these patients moving forward.
[Dr. Gopi Shah]
That's awesome. You're right. There's something that, it's taking care of kids, even when it comes to something like skull base to the runny nose to cystic fibrosis, allergic fungal sinus, whatever, chronic sinusitis, it's just a little bit different than treating adults. Even the way the system is in your clinic, to the hospital, to how you preempt the patient is going to be a little bit different. As an adult person having to come over to the Children's every four to six weeks, even if you had to reset your password, it takes a little bit. It is nice when there is a peds person that can really understand how it works, take care of the patient, and also do the surgery and take care of the post-op.
We're going to talk today about intracranial complications of acute sinusitis. It's a good topic because there's some case series out there, there's some papers that, in terms of how people practice, I think it's still a little bit variable whether we're talking about what the role of sinus surgery is not, when to watch, if you do watch, et cetera. Before we get into all of it, tell us first how these patients usually present to you.
(1) Complications of Acute Sinusitis
[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.
(2) Initial Examination of Acute Sinusitis with Complications
[Dr. Gopi Shah]
Absolutely. 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. Tell me about imaging. I feel like most of the time, the kids, by the time we see them, will have the CT and an MRI. The kids that have the meningitis or encephalitis, epidural, subdural, empyemas, et cetera, when do you consider something like an MRV?
(3) Imaging Modalities for Acute Sinusitis with Intracranial Complications
[Dr. Amanda Stapleton]
Just going back to the physical exam thing, the nice thing with the eye ones is that everybody has got a camera on their phone. Either parents or my residents, we have them take a picture of the eye because then you can truly say, "Are you getting better on IV antibiotics or not?" That part is nice because you can take a picture every 12 hours and see, and you can put those in the chart. Then, especially those small subperiosteals that you think might respond to IV antibiotics, it is really nice to try and get objective data in terms of, okay, yes, their lid was swollen shut today. Oh, it is improving, or yes, we are getting good movement.
That's important too, in terms of if you're going to take a kid to the OR or not for an orbital drainage. In terms of the imaging, a lot of times they roll into the ER, and they get a CT scan. Whether it's a CT head or a CT max/face, hopefully, we're at the point now where they're ordering a max/face because we're assuming that the ER is suspecting sinusitis, especially with, if it's orbital swelling that they're looking at. They don't always have an MRI. There's the fast MRIs that they do to make sure nothing big, bad, and ugly is happening. Sometimes if a kid rolls in with neurosymptoms, they'll do that first.
Those are big cuts. They're quick scans just to have a view of, is there something intracranial we have to worry about? The only time that I get worked up about an MRV is truly if we're dealing with that isolated sphenoid. Frontal disease rarely makes it all the way back to the cavernous. Can it happen? Yes. The diploid veins don't have valves, so is there a pathway that you could get from frontal all the way back? Probably. If you have a decent MRI, that's not one of the fast ones, you're probably going to be suspicious of that ahead of time.
I find that MRVs are useful if, like I said, we're worried about cavernous sinus thrombosis. Honestly, I use more MRVs in mastoid disease than I do sinus disease because I just feel like the incidence of sigmoid sinus thrombosis and acute mastoiditis is much higher than a frontal-causing vein occlusion that then puts them on anticoagulation for six months.
[Dr. Gopi Shah]
Yes, absolutely. Then in terms of the different types of intracranial complications, I do feel that an intracranial abscess is going to be-- I don't know. Do you feel like a intracranial abscess is worse than a meningitis? I think the better comparison would be an epidural abscess and a subdural empyema in terms of aggressiveness of the abscess itself and making the patient sicker, if you will. Do you ever think of it that way in our heads? Does that change how you manage the patient?
[Dr. Amanda Stapleton]
Anytime that either epidural or subdural, we're obviously dealing with an aggressive bacteriology or something that has decided that it doesn't want to stay in the nose. If it's a frontal and acute sinusitis, and you have a frontal epidural, I'm less excited about those. Meaning, I think that, okay, you can either have direct bone extension from the frontal osteomyelitis that you're dealing with, where, versus a subdural empyema, it's had to break through that dural wall, make its way back through that blood-brain barrier, to get into the subdural space.
Then it's interesting to me because I always assumed in the past that anything that went subdural or intracranial, you had to get a crani, take off the frontal, go in and drain it. Then we had a run where people were doing burr holes just to drain the abscess. Then I'm thinking to myself, "Is that good enough? Is that going to really clean things out so that this just doesn't refill back up?" You just think, "Oh, if they just put a hole in and sucked it out, is that going to work?" I think that's some of the debate in the neurosurgical world is what's adequate and what's not.
Once it's a true brain abscess where we are looking at an abscess and the frontal lobe is gone or pushed back, then obviously that kid is getting a crani. It really depends on extent. I rate them the way they are. Epidurals, I don't get as worried about. Subdurals, I'm like, "Eh, this is pretty big. It's really pushed everything back. Wow, that's 4 centimeters of pus. That's a lot of stuff." Once we're hitting brain abscess, then normally it's pretty bad.
(4) Antibiotic Management of Acute Sinusitis with Intracranial Complications
[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. Amanda Stapleton]
You're like, "Yes, we will do ceftriaxone. Thank you."
[Dr. Gopi Shah]
Like age, weight, how often. I'm not sure, but–
[Dr. Amanda Stapleton]
That's why they drain.
(5) Surgical Indications of Acute Sinusitis
[Dr. Gopi Shah]
Yes, exactly. Okay. Now let's talk about how do you manage these patients in terms of how do you think about when is surgery indicated for you, 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.
[Dr. Gopi Shah]
Yes, absolutely. Does neurosurgery ever ask you not to do the steroids because of, let's say they do have to do a crani or a burr hole from their wound healing standpoint? Is there ever that concern?
[Dr. Amanda Stapleton]
I haven't had anybody ask me not to, honestly. I try and give them my reasoning too. It'd be like, "Hey, I know you guys," even if they did a bicoronal came in and did a big crani, "I still think that the short course of it to keep things open and draining supersede any wound healing concerns."
[Dr. Gopi Shah]
I've seen just a little posterior table erosion type of complications. Then, in terms of anterior table, I have seen some anterior table erosion as well with a large abscess, like a large subperiosteal abscess, the Pott's. Usually, what I've done is, for the frontals, I've addressed it endoscopically and with my fingers crossed hoping, A, I'm in the right nasal outflow tract, B, that it stays open because like you said, it's infected, it's swollen. Even if you think you opened it up, maybe you could have potentially stripped something. Then the agger nasi is swollen, if they have a bunch of anterior ethmoid cells that you can't always predict on the imaging, all of that can be very difficult to–
Usually, I'll try to address them from below. Then from above, sometimes for a lot of them, I've done more of like a I&D, meaning, an incision at the hairline above the abscess, and then maybe get into that subperiosteal pocket, get the pus out, and then just tunnel a Penrose in. I learned that from Matt Ryan, he was one of the rhinologists I got to learn a lot from.
Actually, he's one of my mentors at UT Southwestern. He was like, "Just keep that Penrose in forever for weeks because the bone has osteomyelitis, it's going to potentially pus out." One of my very first cases was actually from the outpatient side. They were able to clear the frontals with oral antibiotics, but the child kept pusing out on her forehead. She came in, and basically we just did I&D, left the Penrose, and got culture. She was on IV antibiotics, and I think her Penrose stayed in for weeks,four weeks type of thing, until it stopped pusing out. I haven't done as many trephinations, and I don't know if that's just my limited skill set on one hand, as well as these aren't very common either. They have their upticks, and when they come in, the eye pus ones are going to come in more often. I did know when you do leave the angiocath in-- How long do you leave them in for?
[Dr. Amanda Stapleton]
I try at least five to seven days, or the whole time they're in the hospital. If they're still there, I keep it in as long as we can. It's hard to send a kid home with it just because you don't know what's happening at home, but just because it's so right in the front.
[Dr. Gopi Shah]
Mine look like unicorns, straight up. It looks like a unicorn, and I bet they'll like milk it out. Stuff will continue to pus out.
[Dr. Amanda Stapleton]
Yes, I guess that's my question with the Penrose, is you're anti-gravity there, right? You're trying to, get it to come up.
[Dr. Gopi Shah]
Yes.
[Dr. Amanda Stapleton]
Do you just have to squeeze it, or what do you do?
(6) Surgical Techniques
[Dr. Gopi Shah]
Massage the forehead a little bit. If there's still enough stuff there, you might get a little bit out. Then the question I always have is, when should I take this out because I'm like, "God, it's been like a week or two. Do I wait? Should I give it the solid four?" 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.
[Dr. Gopi Shah]
Yes. For these cases, let's say the patient looks more stable than the initial patient you described, and let's say there is maybe a 1-centimeter epidural abscess on the, let's say it's the lateral side just to keep it frontal pacification and some anterior ethmoid and max pacification on that side. What is your threshold for FESS at that time, and what are your goals?
[Dr. Amanda Stapleton]
I would take them. Anytime you have an intracranial complication, you know it's coming from the sinus. I'm very proactive in taking these. I know they're going to need IV antibiotics to deal with the epidural and intracranial side, but just like an abscess on the neck or in the tonsil, if you don't get rid of the source, what would make you think that it's going to get better faster? I think pretty universally, I take these kids back for endoscopic sinus surgery in an acute setting, within a day or two. Whether you have to run in at 1:00 in the morning for that, it really just depends that if they have sequelae. If they are stable, and they just have the bad imaging, I would add them on for the next day, and I would do it.
[Dr. Gopi Shah]
I agree. I think that if anything, like you said, source control is important. I think that having a bug for the IV antibiotics is very important. The question, I think we looked at our series, again, this was a couple of years ago, we tried to look at does it affect the type of neurosurgical intervention. Did it make it so that maybe if they did get something, it was a burr hole instead of a crani? These are limited numbers. I think it was 25. We found a trend, but what is that? Usually, it's within 24, maybe 48 hours, depending on the time of day in the OR.
Sometimes, it's hard to get these cases in, and they're not 20-minute cases like a neck I&D. You need some time and to find that sometimes in this sort of subacute. It's not like it had to go at 1:00 AM, but now it's turnover time at 3:00, but I need that two hours before the traumas, and we're down to one room. Sometimes that used to-- Anyways, that's a whole different conversation, but we can all relate to that one. Then, how often were y'all and neurosurgery going together, you think?
[Dr. Amanda Stapleton]
Often, honestly. Then it's always the who goes first game. As they like to say, the brain is clean, and I'm like, "If the brain has pus in it, is it really clean? Are we really going from sterile to non-sterile surgeries kind of thing?" Then it's like, whose room is it, and who's blocked off?
[Dr. Gopi Shah]
Those were the little–
[Dr. Amanda Stapleton]
Right, who's going first or not? We have a great working relationship because we're part of a skull base team together. Like I said, we have a good relationship with our neurosurgery colleagues and partners. Normally, I do let them do the intracranial stuff first, and then I'll do sinus afterwards. Ideally, you're doing it under one anesthetic, but again, is that six hours by the time neurosurgery goes and we go? You're taking up the whole OR for a whole day or a whole night depending on when you get to start. Like I said, if it's bad enough that they're either doing a crani or burr holes are much quicker, so, obviously, it's easy for them to do that, and then me to come in and do my sinus side. We work in tandem a lot, especially for these kind of complications.
[Dr. Gopi Shah]
Yes, I agree. My colleagues at Dallas, at UT, at Dallas Children's were amazing. You're right, that relationship is established. When it is something like this, let's just get the patient better, whatever. In terms of going back to the OR, when is it ever indicated, and when have you gone back where you saw more than just gradew? That's what Romaine Johnson used to call it, just swollen tissue that looked like garbage.
[Dr. Amanda Stapleton]
Right. I think the first question is really, when do you re-image? After a surgery, when do you expect improvement or resolution? Then when you re-image, are you re-imaging MRI? Are you re-imaging CT? Then on a re-image, how much of that is blood? If you're getting a CT scan and things look opacified, you're like, "That's just blood." Have you really got your 10-year-old to do his NeilMed sinus rinse for three days in the hospital to get the blood? How are we managing that wound? Which is really what it is. We're trying to flush out a wound, especially if you just did sinus surgery and didn't do external work.
I only re-image if I am worried that we're not progressing with symptom improvement. Fevers are spiking again, they're still tired and lethargic. Kids bounce back. That's why we all do pediatrics, is because within a day or two, kids are trying to be their energetic selves. If a parent is telling me, "Yes, it's been two days and they're still laying around, they haven't got out of bed, we had a mild fever last night," then I'm worried. Then, like I said, the bigger question is if it was an intracranial complication, then I do MRI, honestly, because I want to know, hey, is that abscess bigger or just not drained?
Because if I did a good sinus surgery, if I need to go back, I'm really just making sure that that frontal is open. We don't have to redo the whole thing. If anything, I think of it just like a nice endoscopic debridement. I'm in there cleaning out blood, getting the crust out, that kind of stuff. If you're worried that your frontal re-occluded, and it's continuing to fill up, then you got to go in and modify what you did.
[Dr. Gopi Shah]
You're right. Unless the child is deteriorating, I feel like if they have an intracranial complication, usually, it's about a week later that the child is doing well, that maybe neurosurgery or ICU, somebody is going to want to have another MRI. Then, you're right, they're going to look opacified because we just did a bunch of stuff, and it's hard to tell what is what. I don't think I've ever taken a kid back in that situation before, clinically, if they were doing better. Every once in a while, my colleague, the neurosurgical team might say, "Hey, we have to go in now and address this. Do y'all want to do anything?" Then I'll say, "Sure, I'll clean out your nose."
[Dr. Amanda Stapleton]
A funny kind of thing, right?
[Dr. Gopi Shah]
Yes, or sometimes I don't always because it just depends. You're right, maybe it's just some blood clots, maybe there is a little bit of pus, a little dishwater. Going in and doing that, is that going to make or break the outcome? I don't know. Those ones, unless it was just really bad the first time around, and there's probably some more pus, you know what I mean? I think that's, you're right, it probably is a little bit more of a gut feeling on that one. In terms of cavernous sinus thrombosis at Jowell's Institution, are y'all usually doing anticoagulation? Does hem/onc get involved? What's the management? What's the course on that?
[Dr. Amanda Stapleton]
Yes, for sure. Hematology gets on board as soon as they see it, and they are pretty pro-anticoagulation. In the past, it used to be forever. I would always be like, "Oh, there goes six months of being on anticoagulation." Really, they do base it now on MRI. They'll start them, I'd say, average, you're looking at six weeks to three months. These kids are getting serial MRIs to make sure they're getting flow again. Obviously, optho is following them closely. You have to make sure that your source of infection is gone. Not forgetting things like adenoids.
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.
(7) Source Control of Acute Sinusitis
[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.
(8) Follow Up Management
[Dr. Gopi Shah]
Yes. 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.
(9) Being Proactive in Children with a History of Complications
[Dr. Amanda Stapleton]
The thing to think about too, you're right, is the frontal. Especially in a teenager, ensuring that that is not scarred down. I see a lot of inferior turbinate scarred to lateral wall scarring because the nose was inflamed. You scraped it up 10 times when you went in with the camera, just trying to see. You'll see those little scar bands here and there, but is their frontal truly patent? Then, I get the question from parents is 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."
(10) Antibiotic Rinses
[Dr. Gopi Shah]
Yes, and like you said, it could just scar it up. It's hard to say what are we doing? Even if we say anecdotally, have I seen this happen in the same kid twice in the 10 years? 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.
[Dr. Gopi Shah]
We're coming up to the hour. What else am I missing, Amanda? What other pearls or lessons in your career, or anything else specific to intracranial complications of acute sinusitis in children?
[Dr. Amanda Stapleton]
Yes, I think you just have to set yourself up for success operatively. When you're going to go to the OR, you have to make sure that you've got all of your tips ready to be able to see, make sure you're in the right spot, be able to control bleeding. Like I said, using your 70-degree scope, using a fat scope, positioning the patient appropriately, using topical epi. Really, like I said, not being afraid of a middle turbinate to take it out. All those things really hopefully will make you a more successful acute sinusitis surgeon so that you can get through those challenging cases, and then you don't have to bring them back in two days because you didn't really get that outflow tract as open as you needed it to.
I think those are really important from an ENT standpoint of how to manage these people. Then, obviously, the collaboration between your subspecialties is really important with neurosurge, ophthalmology, and infectious disease being your top three people that are always making the decisions on these kids in terms of who needs to go to the OR and how quickly.
[Dr. Gopi Shah]
Absolutely. Thank you so much, Amanda. I really appreciate your time. I always love talking shop, if you will, with you. Are you on any social media if our listeners wanted to reach out to you?
[Dr. Amanda Stapleton]
Yes. We have all our Pitt social media. We have the usual Twitter and Facebook and other streaming stuff that we'll try and post this podcast on for people. We do check that. We have a Pediatric Pitt ENT feed, and we try and keep things open for people to see what we're up to.
[Dr. Gopi Shah]
Awesome. All right. Thank you for coming on today.
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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