Subdural empyema as a complication of sinusitis in the pediatric population

Sinusitis is a rare cause of intracranial infection in children. While intracranial complications of sinusitis are rare, the morbidity and mortality remain high. Subdural empyema is recognized as the most common sinogenic intracranial complication. We undertook a review of our cases of subdural empyema and other intracranial complications of sinusitis over the past 8 years at a busy inner city hospital. Our intent was to identify factors that may predispose children to these serious complications.

A retrospective chart review was conducted using ICD-9 codes to identify pediatric patients treated for complications of sinusitis at University Hospital (UH) from 1996 to 2004. Only patients age 18 or younger at the time of admission were included in this study. The following data were collected from hospital medical records: age, gender, past medical and social history, presenting symptoms, history of present illness, microbiology, surgical and medical intervention, and outcome.

Twelve patients were identified that fit the criteria for this study. The mean age of these patients was 14.1 years, and 10 of our 12 patients were male (83.3%). The most common presenting complaints were fever, headache, altered mental status, orbital cellulitis, nasal symptoms, nausea and vomiting, and photophobia. In the week prior to admission for intracranial complications, nine patients were seen by a physician: five patients were seen in the ER and four by a primary care physician. Subdural empyema was the most commonly observed intracranial complication in this series. Microaerophilic and anaerobic organisms were most commonly identified in this series. Most sinus procedures consisted of endoscopic ethmoid and maxillary sinus drainage. There was a long-term morbidity rate of 16% and a mortality rate of 8%.

Three conclusions may be drawn from this study. First, the morbidity and mortality of intracranial complications of sinusitis remain high in the pediatric inner-city population despite adequate access to medical care. Second, subdural empyema appears to arise in the setting of subacute rather than acute frontal sinusitis. Lastly, there may be an under-diagnosis and delay in treatment of patients with frontal sinusitis, resulting in subsequent intracranial complications.