CONCISE REVIEWS

OF

PEDIATRIC INFECTIOUS DISEASES

CONTENTS
Complications of Sinusitis

EDITORIAL BOARD
Co-Editors: Margaret C. Fisher, MD, and Gary D. Overturf, MD
Editor for this Issue: Geoffrey A. Weinberg, MD
Board Members
John S. Bradley, MD
Barbara Jantausch, MD
Leonard R. Knilov, MD
Charles T. Leach, MD

Deborah Lewinschn, MD
Debra L. Palazzi, MD
Jennifer Read, MD
Geoffrey A. Weinberg, MD

Leonard Weiner, MD
Charles R. Woods, MD
Theoblis Zanoutis, MD

Complications of Acute Bacterial Sinusitis in Children

Gregory P. DeMuri, MD, and Ellen R. Wald, MD
Key Words: sinusitis, complications, children,
orbital abscess, orbital cellulitis, periorbital
cellulitis, subdural empyema, epidural empyema,
brain abscess
(Pediatr Infect Dis J 2011;30: 701702)

pper respiratory infections are the most

common illnesses evaluated by the primary care pediatrician. Observational studies
have shown that 5% to 10% of upper respiratory infections are complicated by acute
bacterial sinusitis (ABS).1,2 It has been estimated that ABS and its complications are
responsible for 23 million visits to the
healthcare provider annually and result in
over 20 million prescriptions for antibiotics.3
It has been estimated that 2% to 30% of
patients hospitalized for ABS have complications.4 Since most of ABS is treated in the
ambulatory setting, the actual prevalence
must be much lower. Even with aggressive
management, intracranial complications
have a 10% to 20% mortality rate.5 The peak
prevalence of complications of ABS occurs
in the winter months. The mean age is 3 to 6
years which likely reflects the greater prevalence of orbital involvement. Intracranial
complications occur more frequently in adoFrom the Department of Pediatrics, University of
Wisconsin School of Medicine and Public Health,
Madison, WI.
Address for correspondence: Gregory P. DeMuri, Department of Pediatrics, University of Wisconsin
School of Medicine and Public Health, 600 Highland Ave, H6/570 CSC, Madison, WI 537924108. E-mail: demuri@pediatrics.wisc.edu.
Copyright 2011 by Lippincott Williams & Wilkins
ISSN: 0891-3668/11/3008-0701
DOI: 10.1097/INF.0b013e31822855a0

lescents.6 In nearly every survey of the complications of ABS males account for 60% to
70% of cases.

PATHOGENESIS
The complications of ABS relate directly to the proximity of the paranasal sinuses to the orbit and brain. The maxillary
sinuses are present at birth, as are the ethmoids that are responsible for the majority of
orbital complications. The ethmoid sinuses
are comprised of 5 to 15 air cells on each
side, separated from one another by thin
bony partitions. The medial wall of the ethmoid sinus is a paper thin bone called the
laminae papyracea, which provides a minimal barrier for infectious complications. The
ethmoid sinuses empty into the middle and
superior meatus via tiny ostia that are easily
obstructed. The frontal sinuses, which develop from an anterior ethmoid cell, are
usually present just above the orbital ridge
by the 5th or 6th birthday. The roof of the
orbit is the same as the floor of the frontal
sinus and the posterior wall of the frontal
sinus is immediately adjacent to the dura.
This location allows for easy and rapid
spread of infection to the meninges, brain,
and orbital structures. The later development
of the frontal sinuses explains the predilection for intracranial complications in older
children and adolescents. The venous drainage of the frontal and sphenoid sinuses is
provided by the cavernous venous sinus.
This vascular structure, which is at risk for
thrombosis, serves as another path for infection to spread from the sinuses to intracranial
structures.

COMPLICATIONS
Complications of ABS may be categorized as extracranial, intracranial, and
those involving the bone of the sinus wall
(osteitis). Extracranial manifestations may
be divided into preseptal or postseptal infection. The orbital septum is a connective tissue extension from the periosteum of the
orbital rim into the tarsal plates of the eyelids
and serves as a barrier to invasion of the
orbital space from preseptal infections. Inflammatory edema is a preseptal condition
that usually arises from infection of the ethmoid sinus and is the most common complication of ABS in children, representing 80%
to 90% of all extracranial complications.5
Inflammatory edema is often referred to as
preseptal or periorbital cellulitis. This terminology can be confusing as the term periorbital cellulitis is also used to refer to infections of the skin and soft tissue of the lid and
lid structures. Inflammatory edema is caused
by impaired venous and lymphatic drainage
of an infected sinus; however, infection is
confined to the sinus. Patients with inflammatory edema usually present with lowgrade or no fever and redness and swelling of
the eyelids and periorbital skin.
In contrast, orbital complications involve the orbital space proper and include
orbital cellulitis, orbital abscess, periosteal
abscess, and optic neuritis. Postseptal infections arise from the ethmoid and frontal sinuses in that order.5 Patients with orbital
infection present with similar clinical findings as in preseptal involvement with the
addition of proptosis, ophthalmoplegia, or
impaired visual acuity. Because orbital complications may result in permanent visual

The Concise Reviews of Pediatric Infectious Diseases (CRPIDS) topics, authors, and contents are chosen and approved independently by the Editorial Board of CRPIDS.
The Pediatric Infectious Disease Journal Volume 30, Number 8, August 2011

www.pidj.com |

701

Concise Reviews

loss or spread to intracranial structures, distinguishing this condition from preseptal involvement is critical. The clinical findings of
ophthalmoplegia and proptosis each have a
positive predictive value for orbital infection
of 97% and their absence a negative predictive value of 93%.6 If neither of these findings are detected, the chances of orbital involvement are low.
Epidural empyema is the most common intracranial complication of ABS followed by subdural empyema, meningitis,
brain abscess, and rarely, cavernous sinus
thrombosis.7 Headache and fever are nearly
universal findings at presentation and are
often accompanied by mental status changes,
seizures, or focal neurologic deficits. Children with orbital involvement may also have
intracranial complications. Importantly, patients with intracranial complications may not
have the diagnostic symptoms of ABS (cough,
nasal discharge, or congestion) or may have
them for only 5 to 7 days before presentation.8
Symptoms referable to the central nervous system are often predominant.
Potts puffy tumor is an osteitis (infection and inflammation of the wall) of the
frontal sinus, which presents with forehead
swelling and tenderness. It is often associated with intracranial extension such as subdural and epidural empyema.9

MICROBIOLOGY
The microbiology of orbital and intracranial complications of sinusitis parallels that
of ABS in that S. pneumoniae, H. influenzae,
and Moraxella catarrhalis are commonly isolated. However, other gram-positive organisms
including staphylococci and streptococci, and
gram-negative and anaerobic bacteria are also
significant pathogens (Table 1). In the past
decade, there has been increasing recognition
of the importance of Streptococcus anginosis
(formerly S. milleri) and methicillin-resistant
Staphylococcus aureus (MRSA) in these infections.5,7,10 Many of the complications of ABS
are polymicrobial in nature.

IMAGING
When an orbital or intracranial complication of ABS is suspected on clinical
grounds, imaging studies are essential to
confirm the diagnosis and to determine the
need for surgical intervention. Computed tomography provides the best definition of
bony structures and is most likely to show
subperiosteal abscess and osteitis, particularly when orbital complications are suspected. In addition, computed tomography
will delineate the osteomeatal complex and
sinuses themselves in great detail, which
may provide important information when sinus surgery is planned. Magnetic resonance
imaging affords more detailed images of the

702

| www.pidj.com

The Pediatric Infectious Disease Journal Volume 30, Number 8, August 2011

TABLE 1. Microbiology of the

Complications of Sinusitis*
Gram-positive
Staphylococci
Staphylococcus aureus
Coagulase-negative staphylococci
Streptococci
Streptococcus pneumoniae
S. anginosis
Group A streptococcus
Group C streptococcus
Other -hemolytic streptococci
Gram-negative
Haemophilus influenzae
H. aphrophilus
Moraxella catarrhalis
Pseudomonas aeruginosa
Klebsiella pneumoniae
Moganella morganii
Serratia marcescens
Citrobacter freundii
Anaerobes
Bacteroides sp.
Prevotella sp.
Eikenella corrodens
Fusobacterium sp.
Peptostreptococcus sp.
Porphyromonas sp.

*From references 8, 11, 14.

brain and surrounding structures. Meningitis

and local fluid collections, such as subdural
and epidural empyema, are best detected
using magnetic resonance imaging.11

MANAGEMENT
The management of the complications
of ABS consists of targeted antimicrobial
therapy and surgical drainage. Empirical antimicrobial choice depends on the location of
infection and suspected pathogens. For sinus
and periorbital and orbital involvement, a
combination of ceftriaxone and clindamycin
should be used initially. In areas where
MRSA isolates are typically resistant to clindamycin, vancomycin should be used in addition to ceftriaxone. Ampicillin/sulbactam
is an acceptable alternative if MRSA is not
suspected. Therapy should usually be parenteral except in cases of mild inflammatory edema in which case amoxicillin/
clavulanate may be used. Intracranial complications should always be treated with
intravenous antimicrobials and therapy
must include agents that have adequate
penetration into cerebrospinal fluid and
brain. Combination therapy with vancomycin, ceftriaxone, and metronidazole provides coverage for most intracranial pathogens complicating ABS. In all cases,
antimicrobial therapy should be dictated
by microbiological data and changed to the
most narrow spectrum agent available.

Small orbital abscesses may be treated

conservatively with antimicrobial agents
alone.12,13 Surgery has 2 purposes: to provide
microbiological data that will guide antibiotic
selection and to drain significant fluid collections. Prompt surgical drainage is paramount
when the CNS and ocular structures are threatened. Samples taken in the operating room
must be promptly transported to the laboratory,
and anaerobic transport media should always
be used to optimize recovery of pathogens.
Outcomes depend on prompt recognition of orbital and intracranial involvement and
early intervention. Patients should be managed
in consultation with the appropriate surgical
subspecialties. Supportive care such as anticonvulsants, analgesics, and measures to reduce intracranial pressure should be used as
indicated. Since the complications of ABS are
rare, it is difficult to establish that early treatment in the ambulatory setting reduces complications. Treatment of uncomplicated ABS
should follow established guidelines.
REFERENCES
1. Berg O, Carenfelt C, Rystedt G, et al. Occurrence
of asymptomatic sinusitis . Rhinology. 1986;
24:223225.
2. Wald ER, Guerra N, Byers C. Upper respiratory
tract infections in young children: duration of and
frequency of complications. Pediatrics. 1991;87:
129 133.
3. Ray NF, Baraniuk JN, Thamer M, et al.
Healthcare expenditures for sinusitis in 1996: .
J Allergy Clin Immunol. 1999;103:408 414.
4. Hakim HE, Malik AC, Aronyk K, et al. The
prevalence of intracranial complications in pediatric frontal sinusitis. Int J Pediatr Otorhinolaryngol. 2006;70:13831387.
5. Botting AM, McIntosh D, Mahadevan M.
Paediatric pre- and post-septal peri-orbital infections . A retrospective review of 262 cases. Int
J Pediatr Otorhinolaryngol. 2008;72:377383.
6. Sobol SE, Marchand J, Tewfik TL, et al. Orbital
complications of sinusitis . J Otolaryngol.
2002;31:131136.
7. Germiller JA, Monin DL, Sparano AM, et al.
Intracranial complications of sinusitis in children
and adolescents Arch Otolaryngol Head Neck
Surg. 2006;132:969 976.
8. Bair-Merritt MH, Shah SS, Zaoutis TE, et al.
Suppurative intracranial complications of sinusitis Pediatr Infect Dis J. 2005;24:384 386.
9. Bambakidis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Potts puffy
tumor revisited. Pediatr Neurosurg. 2001;35:8289.
10. Liao S, Durand ML, Cunningham MJ. Sinogenic
orbital and subperiosteal abscesses: microbiology
and MRSA incidence. Otolaryngol Head Neck
Surg. 2010;143:392396.
11. Younis RT, Anand VK, Davidson B. The role of
computed tomography and magnetic resonance
imaging in patients with sinusitis with complications. Laryngoscope. 2002;112:224 229.
12. Eviatar E, Gavriel H, Pitaro K, et al. Conservative
treatment in rhinosinusitis orbital complications
in children aged 2 years and younger. Rhinology.
2008;46:334 337.
13. Clinical practice guideline: management of sinusitis. Pediatrics. 2001;108:798 808.

2011 Lippincott Williams & Wilkins