Bacterial sinusitis in children: orbital and intracranial complications

12 year-old female patient arrived to the emergency room with fever up to 39ºC and vomiting. 3-4 days before she had an episode of common cold with mucus. At the physical exploration mild palpebral edema was detected so orbital cellulitis was suspected. First emergent CT showed signs of acute diffuse sinusitis affecting the frontal, ethmoid and maxillary sinus with no associated complications. The patient had a poor evolution with irritation meningeal signs and facial hypoesthesia, so due to clinico-radiological dissociation another contrast enhanced CT including the brain was repeated. The infection complicated with frontal osteomyelitis and subperiosteal abscesses as a Pott's puffy tumor. Extraconal fat infiltration secondary to bilateral postseptal orbital cellulitis was also identified, and it complicated with an intraorbital abscess at the superoextern margin of the orbita. There was also intracranial complication as a superior sagittal and transverse sinus vein thrombophlebitis with a secondary voluminous subdural empyema at the falx cerebri and cerebellar tentorium.?

There is a considerable overlap between the symptoms and clinical findings of uncomplicated upper respiratory infections and its complication with an acute bacterial rhinosinusitis especially in paediatric population, as this patient. This case report illustrates the life-threatening orbital and intracranial complications that can occur due to bacterial rhinosinusitis. The transition to the complications can be straightforward and fast, so when suspected imaging techniques are mandatory for their identification. Early diagnosis is essential for avoiding dreaded complications due to treatment delay, and therefore, for having a better prognosis. Complications in rhinosinusitis occur due to the anatomic relationship of the paranasal sinuses to the orbital and intracranial compartments, infection can spread from the ethmoid sinus to the orbit through the lamina papyracea and frontal sinusitis can spread intracranially through dehiscences or osteomyelitis.An urgent surgical resection of the frontal bone and drainage of the empyema was performed in this patient. The evolution was not favourable, with persistence of the empyema in the posterior part of the falx cerebri (the anterior part was drained through the frontal approach), so up to four major surgical interventions were needed. A prompt diagnosis and treatment could have had probably avoided the catastrophic complications in this case.

In the daily practice at the emergency room, acute bacterial rhinosinusitis are a common diagnosis and radiologists need to be aware of the specific imaging findings of its orbital and intracranial complications, especially in early stages.

- Dankbaar JW, Van Bemmel AJM, Pameijer FA. Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis. Insights Imaging 2015, 6: 509-218. - Nguyen VD, Singh AK, Altmeyer WB, Tantiwongkosi B. Demystifying Orbital Eme