Intracranial complications of pediatric sinusitis: Identifying risk factors associated with prolonged clinical course

Intracranial extension is one of the most serious and morbid complications of pediatric sinusitis. Managing this complication continues to be challenging even after widespread pneumococcal vaccination adoption. We aim to identify risk factors associated with complicated clinical courses, and to assess for altering microbial communities and increased antibiotic resistance.

A retrospective review was conducted of sinus procedures performed at a single institution for acute sinusitis with intracranial extension, and 16 cases were identified. Variables collected included patient demographics, vaccination status, laboratory results, imaging data, antibiotic therapy, sinus and intracranial cultures, perioperative and surgical reports, and hospital course.

The average patient age was 11.9 years, and 75% were male. The dominant microbial organisms were gram positive in 93.8% (15/16) of cases and 37.5% (6/16) were anaerobic. There were no cases of resistant bacterial growth, and only one case of Streptococcus pneumoniae. Increased antibiotic therapy duration was associated with anaerobic and polymicrobial sinus cultures. A significant increase in length of hospital stay was identified in polymicrobial sinus cultures and frontal sinus involvement. Intracranial abscess re-accumulation was associated with sinus cultures positive for fusobacterium (p = 0.036), polymicrobial infections (p = 0.034), and involvement of brain parenchyma (p = 0.036). Patients with frontal sinus involvement required a greater number of surgical procedures for abscess drainage (p = 0.046). An anaerobic intracranial culture was associated with an increased number of revision craniotomies (p < 0.001). Parenchymal involvement of the infection was associated with an increased number of surgical complications.

Frontal sinus involvement, and anaerobic and polymicrobial sinus cultures were predictive of a more severe infection requiring more surgical interventions, prolonged intravenous antibiotic treatment and overall hospital length of stay. Streptococcus pneumoniae was not prevalent in our series, and there seems to be a shift in the microbial profile of this patient subset, compared to previous studies, which can likely be attributed to the adoption of pneumococcal vaccinations. Sinus cultures were more predictive of a complicated clinical course compared to intracranial cultures, suggesting the importance of a thorough sinus debridement and obtaining directed sinus cultures.