Complications
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Richtlijn acute rinosinusitisPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2023Guide de pratique clinique rhinosinusite aiguëPublished by: Groupe de travail Développement de recommandations de première ligneLast published: 2023Defined as rhinosinusitis symptoms persisting 12 weeks or longer.[1]
The microbial pathogens responsible for acute rhinosinusitis and chronic rhinosinusitis are different, so the empiric antibiotics of choice should reflect the likely causative bacteria.
Although the true rate of bacterial meningitis from acute rhinosinusitis is unknown, it is considered to be uncommon. It occurs due to direct extension of the sinus infection.
A common organism associated with infection is Streptococcus milleri, which is often difficult to isolate from routine culture.[76]
Appropriate intravenous antibiotics and surgical intervention are the mainstays of management.
Occurs due to direct extension of the sinus infection into the subdural space. Most common intracranial complication of rhinosinusitis.[77]
Commonly caused by S milleri.[76]
Subdural abscess is more common in adults than in children.[77] However, 25% of brain abscesses overall occur in children.[78]
Appropriate intravenous antibiotics, seizure prophylaxis, and surgical intervention are the mainstays of management.
Cerebral abscess results from extension of epidural abscess or subdural empyema into the brain parenchyma. Headache is most common sign, though fever, altered mental status, seizure, and other neurologic deficits are also possible.[77] Appropriate intravenous antibiotics, surgical drainage, and seizure prophylaxis are usual approaches to treatment. Cerebral (brain) abscess, epidural abscess, and subdural empyema are key suppurative intracranial complications.[79] These are rare conditions with widely varying treatment protocols.
Epidural abscess is purulence that develops between skull and dura mater. It occurs most often due to osteomyelitis of posterior table of frontal sinus.[79] It may be the most common intracranial complication of rhinosinusitis in children.[77]
Periorbital (preseptal) cellulitis occurs more commonly in children under 3 years of age, and does not affect vision.
Orbital (postseptal) cellulitis occurs more commonly in children over 3 years of age, and may cause vision impairment.
Periorbital cellulitis may develop into orbital cellulitis, which is a more serious condition that warrants hospital admission, and has a higher morbidity compared with periorbital cellulitis.
Mainstay of treatment is broad-spectrum antibiotics. Treatment is always empiric initially, with therapy targeted according to cultures, once known.
Although the incidence is unknown, these are common enough that physicians who manage patients with acute rhinosinusitis should be familiar with these complications.
Diagnosis is made based on physical exam that demonstrates exophthalmos and periorbital erythema. CT scan confirms the diagnosis.
Appropriate empiric intravenous antibiotics and intravenous corticosteroids (in some cases) are the mainstays of management. However, patients with an abscess >2 cm and age >9 years are more likely to require surgical intervention. A meta-analysis found that approximately half of pediatric patients (<18 years) with a subperiosteal abscess undergo surgical drainage; abscess volume appears to be the most significant predictive risk factor.[80]
Extremely rare, but should be considered as a possible complication.
Culture-directed intravenous antibiotic therapy, anticoagulation, and appropriate surgical intervention are important for optimal outcome.
Osteomyelitis of the frontal bone with subperiosteal abscess, resulting in forehead edema, headache, fever, and rhinorrhea. Common organisms associated with infection include Streptococcus and Staphylococcus species.[81]
Typically managed with a combination of intravenous antibiotics and surgery.[81][82]
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