Published: Wed, June 28, 2017
World | By Tasha Manning

Neurology - Complications of Acute Sinusitis

Intracranial Complications of Acute Sinusitis: A Comparison of the Intracranial Complications of Acute Sinusitis in Patients With Sinusitis Intracranial extension of infection is the second most common complication of acute sinusitis. Infection may enter the intracranial compartment by two routes. Direct extension may occur through necrotic areas of osteomyelitis in the posterior wall of the frontal sinus or roof of the sphenoid sinus. The underlying dura becomes thickened with inflammatory exudate, and a heavy layer of granulation tissue develops. Bacterial penetration may take place along the course of the small vessels that traverse the hard. This direct route of intracranial extension is more commonly associated with chronic otitis rather than sinusitis.

An alternative route of intracranial bacterial entry is provided by the valveless venous network which interconnects the intracranial venous system and the vasculature of the mucosal sinus. Thrombophlebitis originating in the mucosal veins progressively involves the emissary veins of the skull, the dural venous sinuses, the subdural veins, and finally the cerebral veins. By this mode of spread, there may be no involvement of intermediate structures and therefore may be no evidence of extradural pus or osteomyelitis. Further intracranial spread of infection depends on the competence of the arachnoid as a barrier to bacterial invasion.

About 50% of patients with subdural empyema secondary to sinusitis present with signs and symptoms of acute frontal sinusitis or an acute exacerbation of a chronic pansinusitis. There is usually low grade fever, malaise, frontal headache, often accompanied by marked forehead tenderness. The initial headache worsens despite prolonged treatment with analgesics and oral antibiotics. Vomiting may become intractable and the level of consciousness deteriorates gradually. There is frequent evidence of meningeal irritation including nuchal rigidity and photophobia. Focal neurologic deficits may develop including isolated weakness, contralateral conjugate gaze palsy, and expressive dysphasia. Focal seizures are not uncommon. In more severe cases of increased intracranial pressure may be evident.

CT scanning is the most efficient diagnostic method. Lumbar puncture usually reveals CSF pleocytosis and abnormalities of CSF glucose and protein. Both EEG and radionuclide brain scans are also nonspecific to have any true diagnostic value. The most common organisms isolated from subdural empyemas include staph aureus, strep pneumonia, and anaerobes.

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Treatment mandates the surgical drainage of the paranasal sinuses and any intracranial abscesses. Antibiotics should be chosen to cover the most common organisms. Most authors recommend an initial antibiotic regimen including a combination of penicillin G, penicillinase-resistant penicillin, and chloramphenicol. Although complications associated with sinusitis include orbital cellulitis, orbital abscess, subperiosteal abscess, and cavernous sinus thrombosis.


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