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Patient Story

A 10-year-old girl has a 2-week history of daily headaches and rhinorrhea. She is admitted from the emergency department to the pediatric intensive care unit for a 2-day history of worsening left frontal headache, mental status changes including lethargy and slurred speech, nausea, and mild periorbital edema. Computed tomography (CT) demonstrates opacification of bilateral frontal, maxillary, and anterior ethmoid sinuses as well as pneumocephalus (Figure 27-1A). Magnetic resonance imaging demonstrated extensive left sided subdural empyema (worse frontal and temporal) and diffuse bilateral dural enhancement (Figure 27-1B). She is urgently treated via a combined surgical approach with pediatric otolaryngology for bilateral endoscopic sinus surgery and pediatric neurosurgery for left craniotomy. She subsequently had 10 weeks of intravenous antimicrobial therapy. Her immediate postoperative course was complicated by seizures; she has now made a full recovery and is doing well.


A. Coronal CT scan demonstrating bilateral ethmoid and left maxillary sinus opacification along pneumocephalus, in a 10-year-old with intracranial extension from frontal sinusitis leading to subdural empyema. B. Same patient, coronal T2 MRI demonstrating a hyperintense extra-axial collection (arrow) along the falx to the left of midline and uniform dural enhancement overlying both cerebral hemispheres. (Used with permission from Prashant Malhotra, MD.)


Complications of acute sinusitis are typically extensions of infection beyond the paranasal sinuses into adjacent structures and can have devastating consequences, including blindness, neurologic morbidity, and even death.


Periorbital cellulitis, subperiosteal abscess, orbital cellulitis, orbital abscess, cavernous sinus thrombosis, meningitis, subdural abscess, subdural empyema, pyocele, mucopyocele, intracranial abscess, or invasive fungal sinusitis.


  • Orbital complications account for 90 percent of acute complications from sinusitis and approximately 3 percent of all acute rhinosinusitis.1

  • Children younger than age 7 years of age develop isolated orbital complications associated with acute ethmoiditis.2

  • Children older than 7 years, mostly teenage males, are more likely to develop intracranial complications.2,3 This is likely related to the age related development of the frontal and sphenoid sinuses.

Etiology and Pathophysiology

  • Children have a high rate of upper respiratory infections (URI) and viral rhinosinusitis.

  • Congenital or traumatic dehiscences in the lamina papyracea and skull base provide potential routes for direct spread.

  • The diploic veins of the skull and ethmoid bone as well as the ophthalmic veins are valveless and allow for communication between the nose, sinuses, face, orbit, cavernous sinus, and intracranial system.

  • The combination of phlebitis and direct entry of bacteria into perivascular structures results in a continuum of inflammatory and infectious changes.

  • The valveless intracranial venous system allows for further spread of thrombophlebitis and septic emboli.

  • Complications can be orbital (Table 27-1),4 intracranial, or involving adjacent ...

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