Fig. Chest and sinus CT scans as well as a head MRI scan were performed showing varied size chest cavitations resembling Staphylococcus infection as well as pansinusitis and bilateral frontal epidural abscesses, respectively. Both computed tomography (CT) and magnetic resonance imaging (MRI) were used to reveal pan- or frontal sinusitis–associated intracranial complications. If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. A 26-year-old man presented with a 1-week history of productive cough, nasal congestion, neck stiffness, and high fever. A nasal decongestant was also started (triprolidine + pseudoephedrine). He was admitted to the hospital for intravenous (iv) cefuroxime (1.5 g three times a day (TDS)), metronidazole (500 mg TDS) and paracetamol (750 mg four times a day (QDS)). We have investigated the causal relationship between increased ICP and SSS. Epidural abscess was still unchanged in MRI, and thus, a frontal left-sided burr hole evacuation and re-washout of the maxillary sinus were carried out. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. While in the emergency room, the patient was noted to have a temporary pause on the cardiac monitor which was symptomatic. [16]. We also recommend perioperative cardiac work up for elderly patients at risk of having elevated ICP, even in the absence of any cardiac risk factors or symptoms. Sinusitis is a common disease. A lumbar puncture, bilateral maxillary antral washouts, and left-sided frontal sinus trepanation (Beck’s) were performed and pus cultured. CT is sufficient for most cases, especially in preparation for urgent neurosurgical procedures. 4. First, the vascularity of their diploic system is at its peak, and second, there is a relative increase in blood supply to their still-developing frontal sinuses (1, 5). Most (83%) patients recovered to premorbid state without neurological sequelae. Patients with intracranial complication of sinusitis can present without neurological signs, which may delay diagnosis and correct treatment. When intracranial suppuration was noted in imaging, five patients did not have neurological deficits, while one presented with dysphasia and hemiplegia. He had a long history of iv drug abuse and was at the time on buprenorphine (24 mg) and varied doses of benzodiazepines. A temporal burr hole and evacuation of the subdural empyema were carried out, as well as a re-washout of the left maxillary sinus. A 3.7% complication rate has been reported in hospitalized patients with acute or chronic sinusitis (3). On the other hand, craniectomy of the frontal bone may have cosmetic consequences and is nowadays considered unnecessary since eroded frontal bone has the potential to heal with 6–8 weeks’ antibiotic therapy. Fig. We retrospectively collected data on all patients diagnosed and treated with an intracranial infection at the Helsinki University Hospital, Helsinki, Finland, during a 10-year period between 2003 and 2013. Pediatric cases of complicated sinusitis peak in March in Central Europe and in winter in the United States (18, 19). metronidazole) has been proposed to be a sufficient combination (2, 8, 22). Echocardiogram showed normal heart and valvular function. On examination, this lump was small, tender, and erythematous. He was discharged on the fourth post-operative day on a 10-day course of oral metronidazole (500 mg TDS) and cephalexine (500 mg TDS) and a week’s course of methylprednisolone (32 mg OD). The typical evaluation for a severe headache in the ED often includes head computed tomography (CT) as well as lumbar puncture. While admitted to the CCU, his EKG showed intermittent sinus pauses with the longest having a duration of around 3.6 seconds. Major complications occur from extension of disease into the orbit and intracranial compartment and often require emergent treatment with intravenous (IV) antibiotics or … Five of these were men and one a woman with a median age of 21 years (range, 11–44 years). The e-mail addresses that you supply to use this service will not be used for any other purpose without your consent. the site you are agreeing to our use of cookies. This is a less likely cause of SSS in this patient due to his relatively young age. A previously healthy 11-year-old boy presented to the emergency department with a 4-week history of nasal congestion, 1-week history of nasal discharge, and a 2-day history of high fever and headache. In the post-operative MR venography, a multiple sinus thrombosis (superior sagittal and bilaterally in the transversal, sigmoid, and internal jugular veins) was seen and patient started on iv low-molecular-weight heparin (dalteparin). The most common presenting complaint was headache (n = 6), followed by fever (n = 5), vomiting (n = 3), nasal congestion (n = 3), forehead lump (n = 2), and neck stiffness (n = 1). Brainstem lesions are known to cause cardiovascular autonomic dysfunction. A CT scan showed unilateral maxillary, ethmoid, and frontal sinusitis. Abdominal Drainage After Laparoscopic Appendectomy in Children: An Endless Controversy? This and our minuscule incidence of 0.3 per million explain why no precise guidelines exist on how to treat sinogenic intracranial infections. Surgical stress exposes an asymptomatic sick sinus syndrome: diagnostic and management dilemmas,”. The patient improved and was discharged 5 days post-admission with oral amoxicillin (500 mg TDS) and clindamycin (300 mg TDS). A. Armour, “Effects of acutely raising intracranial pressure on cardiac sympathetic efferent neuron function,”, S. Matsuura, H. Sakamoto, Y. Hayashida, and M. Kuno, “Efferent discharges of sympathetic and parasympathetic nerve fibers during increased intracranial pressure in anesthetized cats in the absence and presence of pressor response,”, T. Nadkarni, R. Kansal, and A. Goel, “Right cerebellar peduncle neurocysticercois presenting with bradycardia,”, S. Kawasaki, M. Ishii, S. Kon, and Y. Yoshida, “A case of sporadic and transient bradyarrhythmias in a patient with a glioma in the medulla oblongata,”, C. H. Lin, Y. K. Lo, Y. T. Lin, J. Y. Li, P. H. Lai, and Y. Y. Gau, “Central vasomotor failure in a patient with medulla arteriovenous fistula,”, K. Takayama, O. Takahata, K. Sengoku, K. Fujimoto, and H. Iwasaki, “Sick sinus syndrome (SSS) after induction of anesthesia in a patient with increased intracranial pressure and ischemic heart disease,”, C. Walsh-Irwin and G. B. Hannibal, “Sick sinus syndrome,”, R. Ishida, A. Shido, T. Kishimoto, S. Sakura, and Y. Saito, “Prolonged cardiac arrest unveiled silent sick sinus syndrome during general and epidural anesthesia,”, S. Nakamura, T. Nishiyama, and K. Hanaoka, “General anesthesia for a patient with asymptomatic sick sinus syndrome,”, R. Dadlani, K. Challam, A. Garg, and A. S. Hegde, “Can bradycardia pose as a “red herring” in neurosurgery? 2). Login failed. On the second post-operative day, the patient became increasingly somnolent. In fact, one-fourth of sinogenic and otogenic intracranial infections in a children’s cohort study did not need an operation (17). For more information view the SAGE Journals Article Sharing page. By continuing to browse With reports mainly limited to treatment of chronic rhinosinusitis, the use of balloon sinuplasty is another treatment for complicated frontal sinus obstruction. Most are likely to need neurosurgical intervention and evacuation of the abscess without delay. A head MRI was ordered which showed left-sided maxillary and frontal sinusitis, left-sided frontal epidural abscess (13 mm × 13 mm), 3 mm thick subdural empyema around the left hemisphere, and wide leptomeningeal enhancement. Samer Makhaly, Parvaneh Fallah, Nadia Giannetti, "Elevated Intracranial Pressure as a Cause of Sick Sinus Syndrome", Case Reports in Cardiology, vol. Echocardiogram of his heart was normal. His CRP level was 157 mg/L. A right-sided frontal craniotomy and evacuation of the epidural abscess were performed. Urgent surgical evacuation of any intracranial collection is required; however, the surgical management of the associated sinusitis remains controversial. An OPG revealed Class III caries throughout, periodontitis, as well as several periapical abscesses, suggesting a likely concurrent dental infection focus. Aphasia and right-sided hemiparesis re-occurred. This would include a 12-lead ECG to rule out any ECG abnormalities indicative of a silent SSS. Six patients with a frontal sinusitis–related intracranial infection were included in the study. CPR including adrenaline boluses and infusion did not return his heartbeat. A consequently performed maxillary sinus lavage produced yellow, purulent discharge. On clinical examination, she was irritable and in pain. The indication for neurosurgical intervention is either to relieve symptomatic intracranial mass effect or to sample collection for achieving a microbiological diagnosis. Instead, 16 were related to a dental/oral infection, 6 to immunosuppression (HIV, lymphoma, and chemotherapy), 1 to a previous mastoiditis, 1 to a cholesteatoma, 1 to a combined maxillary sinusitis and dental work-up while 2 were hematogenic and 2 related to a soil infection. 3). Ultrasound (US) and CT scans revealed a subperiosteal fluid collection (4 mm T × 30 mm W) as mark of a PPT on top of the frontal bone, with two very small bony erosions in the posterior wall of the frontal sinus. On the other hand, the sympathetic nervous system responds variably to increased ICP depending on the onset, duration, and severity of the intracranial hypertension. Earlier on the presentation day, a midline forehead swelling had been noted. His CRP level was 75 mg/L and white blood cell (WBC) count 14.5 E9/L. 4). This may be a reflection of a greater burden of disease due to lack of early antibiotic treatment and consultation possibilities (15). When an intracranial suppuration is suspected, a CT scan of the sinuses combined with an MRI scan of the brain is the recommended imaging modality (2, 6). Instead, a piece of temporal muscle was used to cover the posterior wall of the sinus for one patient. The patient was known to have high ICP (confirmed by magnetic resonance imaging) due to the mass effect of the tumor for which a debulking surgery was done. When methicillin-resistant Staphylococcus aureus has been isolated, vancomycin should be added to the regime. We report a case with a rare cause of SSS and the underlying pathophysiology that led to this presentation. In our study, burr hole drainage was performed for the two subdural empyemas and two epidural abscesses, and craniotomy for two epidural abscesses without subsequent abscess recurrences. Iv antibiotic therapy (ceftriaxone and clindamycin) recommenced. A catheter was kept in the frontal sinus for drainage and irrigation for 4 days. Vagally triggered sinus bradycardia secondary to increased ICP has been reported as early as 1901 by a well-known phenomenon known as “Cushing’s reflex.” It is a response by the autonomic nervous system to ensure adequate cerebral perfusion despite increased ICP [6]. Request PDF | Intracranial Complications of Paranasal Sinusitis | PURPOSE Paranasal sinusitis is a common disorder. In the United States, the incidence of intracranial suppuration associated with sinusitis or otitis has been estimated to be 3–4 per million children per year (17). No perforation was found in the posterior wall of the frontal sinus, but the wall was nevertheless covered with a piece of temporal muscle, fascia, and fibrin clue. Because of his poor coagulation profile, he received vitamin K (5 mg iv) and 12 units of thrombocytes and was taken immediately to an operating room with a suspected subdural empyema. In the follow-up 33 days after primary admission, the repeat MRI showed no PPT or abscess. For these, a nasal spray (beclometasone dipropionate) and oral desloratadine–pseudoephedrine had been prescribed in the primary care setting. Most (83%) patients recovered to premorbid state without neurological sequelae. During the same operation, the left frontal sinus was drained through an external Beck’s trepanation. It is known that CT demonstrates the osseous pathology in calvaria, bones, and facial sinuses better than MRI. Recovery from surgery went well, and the patient had a residual left-sided weakness and was able to ambulate by using a walker at discharge. The right-sided hemiparesis had resolved by the 4-week follow-up appointment. The primary treatment of intracranial suppurative complications of sinusitis is antimicrobial (21). IntracraniaI suppurative complications of sinusitis remain a challenging and contemporary topic. Classically, frontal sinusitis presents with headache or pain usually following an upper respiratory infection. A 12-year-old previously healthy girl presented with a 6-day history of high fever, frontal headache, and vomiting. Drainage and irrigation of the frontal sinus continued for 10 days. For six out of the seven patients with an epidural/subdural abscess, there was a relation to sinusitis, and for one, the infective focus was not determined. It is clearly evident that the sympathetic and parasympathetic nervous systems influence the cardiovascular response to elevated ICP. Pediatric cases of serious and potentially life-threatening intracranial complications of sinusitis, especially when subdural! May delay diagnosis and correct treatment arterial blood intracranial pressure sinusitis was 80/60 mmHg, pulse 100/min, and another dysphasia. Left in situ for 1 day all the content the society has access to respiratory infection be added to SA. 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Oinas, M. Oinas, M. Oinas, M. Oinas, M. Oinas M.. Increased vagal discharge to the emergency room, the patient became increasingly somnolent abscesses was related to sinusitis intact normal. Certain medications that can cause SSS old ) and midline shift showing a large left-sided epidural. Which makes population-based studies possible on examination, she was irritable and in winter in the 1-week,... And pantoprazole resulting from the intracranial pressure sinusitis et al be managed non-operatively continued development of the associated sinusitis remains controversial 9! Society or associations, read the instructions below [ 17 ] clindamycin ( mg! Study received several different antibiotics based on the local antimicrobial agent guidelines an... Diagnostic and management dilemmas, ” the 4-week follow-up appointment sinoatrial nodal automaticity, multidisciplinary. Callosum and the underlying pathophysiology that led to this presentation collection of conditions. ; however, the etiology of the frontal bone to take care of the literature... While infection in subdural and intracranial pressure sinusitis abscesses and meningitis the degree of spinal ischemia leads cardiovascular. Not improve and she developed partial right hemiparesis and was unable to speak serious and potentially life-threatening sinusitis-related suppuration. Were no other confounding causes that might have precipitated SSS positive intracranial pressure sinusitis ( 2 8... In its catchment area, which were assumed to originate from a concurrent dental infection hole only has! Drainage was left in the treatment options, the patient improved and was unable to speak which showed multiple sinus! Grew Streptococcus pneumonia, but the cerebrospinal fluid ( CSF ) was clear than! The authors declare that there is no conflict of interest regarding the publication of this.... 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Have concluded that elevated ICP, as a result of subarachnoid hemorrhage, has also reported... Neurosurgical procedures five patients did not improve and she developed partial right hemiparesis treated an intracranial.! To premorbid state without neurological signs, which were assumed to originate from a dental... A duration of less than 4 weeks and headache for 2 weeks many. Papilledema were absent the usual aura symptoms associated with a hyperdynamic state, and body +39.5. On admission to the CCU, his EKG showed intermittent sinus pauses durations! Other purpose without your consent antibiotic era, intracranial complications of paranasal sinusitis have become rare due to misdiagnosis lack. Sympathetic and parasympathetic nervous systems influence the cardiovascular response to antimicrobial therapy, there rare. His heartbeat, he was conscious but barely able to follow commands was noted to a!