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Complicações Intracranianas de Sinusite Aguda. Relato de Dois Casos Intracranial Complications of Acute Sinusitis. Report of Two Cases Gustavo Guagliardi. Pacheco - Médico Staff do Hospital da Lagoa, Everton de Souza Ameno - Chefe do Serviço de Otorrinolaringologia do Hospital da Lagoa, Avenida das Américas, 700, bloco 01, sala 211, Barra da Tijuca Tel: (0xx21) 2494-9170 FAX (0xx21) 2429-0390 Intracranial Complications of Acute Sinusitis. Report of Two Cases INTRODUCTION: On these last years, the intracranial complications of acute sinusitis (ICS) have been rare, due, mainly, to the great progresses in the diagnosis and treatment of OBJECTIVE: The main goal of the present work is to demonstrate the importance of always maintaining lives the clinical suspicion of intracranial complications, giving emphasis to the precocious diagnosis and the appropriate therapeutic orientation as indispensable tools in the prevention and treatment of those complications, as well as in the optimization of the time of hospital internment. MATERIAL AND METHOD: The authors report nine cases of intracranial complications in the course of acute sinusitis in children, diagnosed through ear, nose and throat exam, and confirmed by the result of cultures and computerized tomography of skull. The patients' age ranged from 5 to 12 years, being three girls and six boys. A literature revision and comparison was accomplished from our cases to the already published. RESULT: In the period of five years, there were 9 cases of intracranial complications of sinusitis of acute evolution. In all the cases meningitis was present, accompanied by epidural abscess in one of them, and cerebral abscess in another, the isolated etiological agent was the Staphylococcus aureus in two of the whole cases. In the majority of the patients (seven of them), the treatment was eminently clinical, and in the other two, it was accomplished by intervention in the primary sinusal focus. A neurosurgical drainage procedure beyond the sinus approach was necessary in the case of the cerebral abscess. Among the seven who were clinically treated, six were discharged of the hospital before the 30th day of admission, the other patient clinically treated, after 38 days. Finally, the one who was submitted to a neurosurgical intervention, was discharged only after 65 days, while the other surgically managed patient was ready to go back home in the 32nd day. All CONCLUSION: As a consequence of their intimate relationships with the cranial cavity, the sinusal infections can lead to complications inside those cavities. The frontal and ethmoidal sinuses are limited directly with the previous cerebral sewage and, in reason of this, the complications usually occur after frontoethmoidal infections. The most frequent pathogenic mechanism is the infection through the bone road, followed by the vascular road. In spite of rare, they present high morbity and mortality, and to them, aggressive treatment should be used. Its incidence is larger between youths and the computerized tomography is the gold standard exam for the diagnosis. The initial antibiotictherapy should include 3rd generation cefalosporin, metronidazol and an anti-staphyloccocic drug, being * * Staff of the Otorhinolaryngology Department of the Hospital da Lagoa; * * * Boss of the Otorhinolaryngology Department of the Hospital da Lagoa; The paranasal sinuses are cavities within the facial skeleton that are lined by ciliated respiratory ephitelium and drain into the nose. Its considered that the infectious sinusitis is one of the public health problems of larger incidence in the world. It is an infectious disease located in the mucous membranes that covers the sinusal cavities (an anatomical continuity of the nasal mucous membrane). They are usually banal, of benign clinical course; however, they can lead to complications and culminate with the death in some cases. On these last years, the intracranianal complications of sinusitis (ICS) have been rare, due, mainly, to the great progresses in the diagnosis and treatment of the same ones. They elapse of inadequate or late treatments, inherent factors to the patient's immunology and they present high morbity and mortality. The most common intracranial complication is the meningitis, and the most serious, the cerebral tumor. The paranasal sinuses infection can spread to the intracranial cavity for several roads: through anatomical structures (bone, for proximity); retrograde tromboflebitis; direct The meningitis is an inflammation of the dura-mater and aracnoidis, and it is the most common intracranial complication. Sphenoid sinusitis is the most common cause of meningitis, followed by the ethmoid, frontal and maxillary. In these patients, Streptococcus pneumoniae are the most common agents. Infection by anaerobe should be considered when we have chronic sinusitis. The signs and symptoms include fever, intense migraine, cervical rigidity, irritability and fall of the level of conscience. In the meningitis suspicion, it is necessary the study of the liquor, that will reveal an increase of the celularity and of the proteins, could also identify the etiological agent and to accomplish antibiogram. The treatment is clinical, using specific antibiotics. The epidural tumor is defined as a granulation fabric and festering secretion in the space among the dura-mater and the internal surface of the cranium. The veins from the frontal sinuses communicate with the dura-mater of the subsequent bone board, allowing the progression of the infection. The intimate relationship between the bone board and the epidural space explains the progression of the disease. Isolated organisms include Staphylococcus albus, S. aureus, Streptococcus sp, Escherichia coli, Pseudomonas sp and Proteus sp. The patient develops intense migraine, picks of high temperature, and even personality disturbance due to the pressure on the front lobule. The focus is limited to the closed area to the osteomielitis. The differential diagnosis with subdural empiema can be The subdural empiema is a festering collection in the space among the dura-mater and the sink-aracnoidis, usually a consequence of frontal sinusitis. The infection can happen directly among the veined connections between the frontal lobule and the dura- mater. It can happen multiple collections, including at the subsequent sewage. The patient presents fever, weakness, intense migraine and fall of the level of conscience in small period of time. Signs of neurological compromising are observed. The liquor reveals increase of the lumbar pressure, increase of proteins, pleiocitosis and negative culture. They can present growing form or lentiform and they don't cross the medium line. The neurosurgical combined treatment is necessary. With the coming of the antibiotics, this complication became uncommon. The propagation route of the disease is through the ophthalmic veins or infratemporal veins in case of osteomielitis of the jawbone. The most common agent is S. aureus positive coagulase. Cerebral and meningic edema can happen due to the progression of the The thrombosis of the cavernous sinus can be a complication of ethmoidal or sphenoid sinusitis, and, less commonly, due to disease in the frontal sinuses. The signs and symptoms are exoftalmia, quemosis, ocular edema and papiledema. The number of cerebral tumors has been decreasing lately. However, the mortality associated to the tumor continues high, around 50%. Many frontal tumors are due to frontal sinusitis and, less commonly, the sphenoid and the maxillary are implicated. Streptococcus sp. and Staphylococcus sp are the main agents, as well as anaerobic germs. In the beginning it leads to an encephalitis, with cerebral edema, tromboflebitis and increase of the intracranial pressure. The signs include fever, mental confusion, migraine, lethargy and agitation. The symptoms are variable depending on the association with meningitis. Convulsions can happen. The lumbar puncture should be avoided due to the uncus hernia risk. The computerized tomography can demonstrate low density area. The partial cerebritis resolution can result in thrombosis, with liquefaction of the necrosis area and formation of the tumor. The natural progression of the tumor is the patient's death, by the increase of the intracranianal pressure or rupture of the tumor in the ventricles. The surgical treatment can be made together with the neurosurgeon or later, when the patient's conditions stabilize, with eradication of the sinusal focus. F. D. Z., 6 years, male, directed to the Ear, Nose and Throat Department of the Hospital da Lagoa, with complaints of intense frontal migraine, festering nasal secretion and fever, proceeding squares influenza before the present 2 weeks. The previous rhinoscope revealed presence of abundant festering secretion in right medium meatus and nasal congestion. They were instituted, then, oral antibiotics (amoxicilin), nasal wash with physiologic solution, analgesic medication and systemic decongestant associate to The patient returns in 1 month referring he hasn’t followed the proposed treatment. He developed with worsening of the general state, intensification of the migraine, emergence of flogistic signs in frontal area and vomits. The computerized tomography revealed the presence of hydro level inside the right frontal sinus, areas of bone erosion, with rupture of the wall previous of the frontal sinus and thickening of the adjacent soft parts. In the secretion culture of right maxillary sinus, it was founded Staphylococcus Antibiotic therapy was instituted with ceftriaxone, metronidazol and oxacilin, accompanied by measures of general support that resulted in substantial clinical The patient was discharged of the hospital in the 34th day of internment without sequels. The computerized tomography of control, after three months, didn't reveal any A. A. M., 12 years, female, it sought our Service with history of frontal and ethmoidal sinusitis eight days ago, in treatment with amoxicilin, systemic decongestants and nasal washes with physiologic solution, maintaining picture of fever, front migraine, nasal obstruction to the left and festering nose dripping. There is a day of the internment, it presented left palpebral ptosis and decrease of the conscience level. She brought paranasal sinuses x-ray that showed total cover of the frontal, ethmoidal, left maxillary and sphenoid sinuses. To the exam, the patient met knocked down, and resisting with strong pain to the palpation and percussion of the frontal area. The left nasal sewage drained pus and mucous The puncture of the left maxillary sinus gave exit to the great amount of festering secretion of bad smell. The bacteriological exam was revealed negative. The neurological exam showed papiledema on the left and other optical signs of intracranianal hypertension. The computerized tomography verified bulky tumor of left It was initiated treatment in intensive care unit with barbituric mitigation, manitol to 20%, dexametasone, ceftriaxone, metronidazol and oxaciline. Accomplished liquor puncture after normalization of the intracranianal pressure revealed the growth of Staphylococcus aureus resistant to multiple drugs, being changed the oxaciline by The patient was submitted to the drainage of the paranasal sinuses and craniotomia for retreat of the cerebral tumor. During the surgical act destruction of the wall previous and subsequent of the frontal sinuses was verified, having direct communication with the The evolution was satisfactory, the patient was discharged of the hospital in the 48th operative day of powders, in good conditions. The tomographyc control accomplished after two months didn't reveal any abnormality. Any extension of local disease for adjacent structures constitutes a sinusitis complication. Around 75% of these complications come from sharp sinusitis, according to literary citations, having certain agreement with our work, where, both cases, they were preceded of sinusitis of sharp clinical course. Excluding the orbitary complications, among the intracranial, the most common is the meningitis, being the cerebral tumor the most serious, with mortality taxes edging the The more frequent physiopathologic mechanism of the ICS is the direct extension of the infection by anatomical roads, usually by the bone road. Another road is the retrograde tromboflebitis of veins that interconnect the paranasal sinuses and the skull and they don't present valves (dyploic and communicant veins). The largest incidence in young people, mainly in the 2nd decade of life, described in the literature, is also noticed in the present work; the totality of the patients was pediatric. This fact is still no totally elucidated; it could be due to the pick of vascularization and sinusal growth in that age group. The male predominance is almost unanimity in the The clinical history of sinusitis already in treatment, but with bad evolution is very common. Fever and persistent migraine should lift the suspicion of ICS. Comorbities as diabetes mellitus, renal inadequacy, AIDS and allergic rinitis, although they were present in only one case (11,1%), are noticed in up to 42%. Nowadays, the computerized tomography (CT) is, the gold standard image method in the evaluation of the paranasal cavities, being important to point out that the magnetic nuclear resonance is something more sensitive for the precocious diagnosis of small cranial The initial empiric antibiotic therapy defended is the association of a 3rd generation cefalosporine, metronidazol and an antistaphilococic drug that could be reviewed after the result of cultures, with time of treatment of four to eight weeks. Among the germs more described, we have: Staphylococcus aureus, Streptococcus sp, Haemophylus influenzae and anaerobes. However, in 50% of the cultures there is no bacterial growth. Such fact is attributed to the use of previous antibiotic to the collection. The morbidity index is loud, with neurological sequels happening in 30% of the cases, already the mortality is much rarer. Accurate diagnosis and precocious aggressive treatment are pre-requirements for the favorable ending. As a consequence of their intimate relationships with the cranial cavity, the infection of the sinuses, can lead to serious complications. The frontal and ethmoidal sinuses are limited directly with the previous cerebral sewage and, in reason of this; the complications usually come from fronto-ethmoid infections. The most frequent pathogenic mechanism is the spread of the infection through the bone road, followed by the vascular road. In spite of rare, they present high morbidity and mortality, and to them, aggressive treatment should be spared. Its incidence is larger between youths and the computerized tomography is the gold standard exam for its diagnosis. The initial antibiotic therapy should include a 3rd generation cefalosporine, metronidazole and an anti-staphylococic drug, being guided, later, for the result of the culture. 1. BRADLEY, P. J.; SHAW, D. W. - Brain abscess secondary to paranasal sinusitis. The Journal of Laringology and Otology, 98: 719-725, 1984. 2. CLAYMAN, G. L.; ADANMS, G. L.; PAUGH, D. R. - Intracranial complications of paranasal sinusitis: the combined institutional review. Laringoscope, 101: 234-9, 1991. 3. GIANNONI, C. M.; STEWART, M. G.; ALFORD, E. L. - Intracranial complications of sinusitis. Laringoscope, 107:863-7, 1997. 4. JONES, R. L.; VIOLARIS, N. S.; CHAVDA, S. V. - Intracranial complications of sinusitis: the need goes aggressive management. J. Laringol. Otol., 109:1061-2, 1995. 5. LERNER, D. N.; CHOI, S. S.; ZALZAL, G. H. - Intracranial complications of sinusitis in childhood. Ann. Otol. Rhinol. Laringol., 104: 288-93, 1995. 6. MORTIMORE, S.; WORMALD, P. J.; OLIVER, S. - Antibiotic choice in acute and complicated sinusitis. J. Laringol. Otol., 112: 264-8, 1998. 7. ROSENFELD, E. A.; ROWLEY, A. H. - Infections intracranial complications of sinusitis, other than meningitides, in children: 12 year review. Clin. Infec. Dis., 18: 750-4,


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was some long seconds before she started fiddlingfurther with the equipment and it transpired thatthe major problem was with the scanner and notthe baby. Babies don’t have a tendency to freezeFor those of you that don’t already know, this willup and crash all that often as far as we know yet. probably be the last year that it’s just two of usIf there is an equivalent of Murphy’s law

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