Complications of Pediatric Sinusitis

Naana Afua Jumah, HMS IIIGillian Lieberman, MD

Complications of Pediatric Sinusitis


22 January 2007

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Outline

1. Paranasal sinus anatomy2. Definitions3. Indications for imaging4. Imaging modalities5. Patient presentation6. Summary

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Sinus Anatomy

Essential Clinical Anatomy, 2002

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Sinus Plain Films

http://xray.20m.com/photo.html

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Sinus Development

Age (years)Sinus Appearance Maturity

Maxillary Embryo 12-20

Ethmoid Birth 12

Sphenoid 1-3 7-14

Frontal 1-4 ≥

12

Kronemer and McAlister, 1997

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Acute vs Chronic Sinusitis

Acute • Bacterial infection of the paranasal sinuses• Symptoms last less than 30 days • Complete resolution

Chronic• Inflammation of the paranasal sinuses • Symptoms last more than 90 days • Persistent residual respiratory symptoms of cough,

rhinorrhea and nasal obstruction

American Academy of Pediatrics, 2001

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Complications of Sinusitis

Reid, 2004

Orbital Intracranial1. Edema2. Preseptal cellulitis3. Postseptal cellulitis4. Subperiosteal abscess5. Orbital abscess6. Cavernous sinus

thrombosis

1. Epidural empyema2. Subdural empyema3. Meningitis4. Cerebritis5. Parenchymal abscess6. Mycotic aneurysm7. Brain infarction

Subgaleal1. Pott’s puffy tumor2. Osteomyelitis

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Indications for Imaging

1. Purulent nasal discharge >10 days2. Recurrent or persistent clinical sinusitis3. Preoperative evaluation for functional

endoscopic sinus surgery (FESS)4. Suspected complication5. Complex sinus disease 6. Suspected fungal sinusitis

*Imaging is not recommended for uncomplicated acute sinusitis

American College of Radiology, 2006


Imaging Modalities to Diagnose Chronic Sinustis

Plain Film Radiograph• Low sensitivity and therefore seldom used• Caldwell (anteroposterior) - frontal, ant ethmoid• Normal lateral – sphenoid• Waters (occipitomental) - maxillary, ethmoid

CT• High sensitivity and therefore the test of choice• Coronal projection most accurate view of sinus anatomy• Bone window on bone algorithm for sinus views• Contrast for intracranial pathology• Imaging for functional endoscopic sinus surgery (FESS)• Radiation exposure

American College of Radiology, 2006


Imaging Modality for Complications of Sinusitis

T1 Anatomy

T1 + Gadolinium Vasculature, malignancy

T2 Inflammation/fluid

FLAIR Inflammation

Diffusion weighted Ischemia

Angiography Vasculature

MRI• Intracranial pathology and complex sinus disease• Lacks bony detail of sinus anatomy• Long image collection time may require sedation• No radiation

American College of Radiology, 2006 and Boyle, 2006

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Abnormal Sinuses in

Children

Incidence of abnormal sinus CT in children with no history of sinusitis

• 55% had abnormal sinuses• 33% had air fluid levels in sinuses

High incidence (62%) of viral URI symptoms or allergic rhinitis within the past 2 weeks

Maning et al, 1996

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Modified Lund-Mackay

Staging System

Correlation of clinical symptoms of chronic sinusitis with CT radiographs

• Paranasal sinuses opacification0 none, 1 partial, 2 completeAssign score independently to left and right paranasal sinuses

• Osteomeatal complex0 not occluded, 2 occluded

• Sinus not developed: 0

Score: 0-2 no disease, 3-4 equivocal, ≥5 chronic sinusitis

Bhattacharyya et al, 2004


Patient Presentation

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Patient BE

• 11 year old previously healthy girl

• 4 day history of headache, lethargy, fever, malaise and sinus congestion

• Seizure during transfer from OSH

• No significant past medical history

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Patient BE: Sinusitis on CT

Coronal CT Bone Window

Courtesy of Dr Hines-Peralta

1

2

3

4

4. Near total opacification of the frontal sinuses

1. Opacification of the ethmoid sinuses2. Opacification of the right maxillary sinus3. Concha bullosa a normal variant

Axial CT Bone Window

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Differential of

Opacified Sinsuses1. Sinusitis

• GERD• Immune deficiency

syndrome• URI

2. Trauma• Hemorrhage• Edema

3. Allergy4. Cystic fibrosis

5. Inflammatory mass• Mucocele• Cyst• Pyocele• Polyp

6. Malignancy • Burkitt Lymphoma• Osteoma

7. Granulomatous Disease• Sarcoidosis• Tuberculosis

8. Dysfunctional cilia• Kartagener’s syndrome• Immotile cilia syndrome

Reeder, 2003

Naana Afua Jumah, HMS IIIGillian Lieberman, MD `

Axial CT Bone Window Axial MR T2


1. Opacification of the ethmoid sinuses2. Opacification of the sphenoid sinuses3. Fluid in the right mastoid air cells

4. Chronic sinusitis in the maxillary sinuses5. Frothy appearance of acute sinusitis in

the maxillary sinus

2

3

1 45

Patient BE: Sinusitis on CT and MRI


MR T1 Pre-contrast MR T1 Post-contrast


1. Low signal areas in the anterior and left lateral temporal lobes indicating regions of restricted diffusion suggestive of edema or fluid

1

1

2

2

2. Low signal areas in the anterior and left lateral temporal lobe surrounded by a rim of enhancement consistent with empyema

Patient BE: Subdural Empyema on Axial MRI



Coronoal MR T1 with Contrast2. Low signal areas surrounded by

a rim of enhancement consistent with empyema on sagittal section

1

12

Patient BE: Subdural Empyema on MRI

1. Low signal areas surrounded by a rim of enhancement consistent with empyema on coronal section

Sagittal MR T1 with Contrast



Patient BE: Meningitis on MRI

Axial MR T1 with Contrast

1

1. Focal areas of subtle enhancement of the meninges consistent with meningitis


Companion Patient 1: Meningitis on MRI

http://www.math.uno.edu/~jensen/L/neuropath/images.htm

Axial MR T1 Pre-contrast Axial MR T1 Post-contrast

1 2

2. Ring of enhancement surrounding the cerebellum consistent with meningitis

1. Meninges appear as a ring of low signal intensity

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Patient BE: Cerebral Edema

on MRI


Axial MR T1 Pre-contrast

1. Midline shift

2. Compression of the anterior horn of the lateral ventricle

3. Compression of the left posterior horn of the lateral ventricle

4. Diffuse effacement of the cortical gyri shown best in the left parietal lobe

2

1

4

3


Patient BE: Cerebral Edema


Axial MR T1 Post-contrast Axial MR T2-weighted1. Low signal areas indicating restricted

diffusion in the frontal lobes bilaterally and the temporal lobe suggestive of edema or a fluid collection

2. High signal areas that follow the pattern of the gyri in the frontal lobes bilaterally and the temporal lobe more suggestive of edema than a fluid collection

1 2

on MRI


Patient BE: Cerebral Ischemia on Diffusion-Weighted Imaging


Axial MR Diffusion-Weighted Image

1. High signal areas that follow the pattern of the gyri in the frontal lobes bilaterally and the temporal lobe localizing areas of cerebral ischemia

1

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Patient BE: Shunt &

Craniectomy on CT


Axial CT Brain Window

1

2

3

1. Intraventricular shunt

2. Craniectomy site and herniation of the left cerebral hemisphere beyond the skull margin

3. Post surgical aberrant air collections

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Brain Abscess on CT & MRI

Courtesy of Dr Hines-Peralta and Nadalo and Hunter, 2004

Companion Patient 2: Axial MR T1 with Contrast

Patient BE: Follow-up Axial CT Brain Window

1

2

3

1. Site of second craniectomy

2. Suspected abcess in left parietal lobe. Finding needs to be confirmed on MRI

3. Pair of rim enhancing lesions with low signal intensity indicating the presence of an intraparenchymal abscess

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Summary of Patient BE

• 11 year old girl with symptoms of sinusitis suspected of having complications

• Coronal CT showed opacification of the paranasal sinuses

• MRI showed subdural empyema, meningitis, cerebral edema and cerebral ischemia

• An interventricular shunt was placed and a craniectomy was performed

• CT showed a second craniectomy site and the development of a possible parenchymal abscess and

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Companion Patients

Companion patients are shown to illustrate the following radiographic findings:

• Orbital cellulitis and subperiosteal abscess - the most common complication of sinusitis

• Cavernous sinus thrombosis - a must not miss diagnosis

• Pott’s Puffy Tumor


Orbital Cellulitis & Subperiosteal Abscess on CT

Kirsch and Turbin, 2005 and Reid, 2004

Companion Patient 4: Axial CT with Contrast Soft Tissue Window

Companion Patient 3: Coronal CT with Contrast Soft Tissue Window

2

16

5

3

4

1. Opacification of the ethmoid sinuses

2. Air-fluid level in the right maxillary sinus

3. Periobital soft tissue edema

4. Hypoplasia of the left maxillary sinus

5. Proptosis of the right orbit

6. Lentiform region of low signal with rim enhancement consistent with abscess. Lateral deviation of the medial rectus.


Cavernous Sinus Thrombosis on MRI

Zimmer et al, 2006

Companion Patient 5: MR Angiogram

Companion Patient 5: Coronal MR T1 Post-contrast

12

1. Cavernous sinus thrombosis 2. Wall thickening of the right cavernous sinus

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Pott’s Puffy Tumor on MRI

Ghorayeb, 2006 and Thomson Health, 2006

Companion Patient 6: MR T1 with Contrast

Companion Patient 7

1. Sagittal view of opacified frontal sinus with fistula to soft tissue overlying the frontal bone and soft tissue edema

2. Axial view showing the same

12

Naana Afua Jumah, HMS IIIGillian Lieberman, MD Summary

Sinusitis, complications and correlation with imaging

Coronal CT MR T1 ±

contrast MR T2 & T2 weighted

Naana Afua Jumah, HMS IIIGillian Lieberman, MD References

1. American College of Radiology. 2006. ACR Appropriateness Criteria, Sinusitis – Child.2. KL Moore and AMR Agur. Essential Clinical Anatomy, 2nd ed. Baltimore: Lippincott Willams & Wilkins,

2002. p 577.3. SJ Zinreich. 2006. Progress in sinonasal imaging. Ann Oto Rhino Laryn. 115(9)Suppl 196:61-65.4. JR Reid. 2004. Complications of pediatric paranasal sinusitis. Pediatr Radiol. 34:933-942.5. N Bhattacharrya, DT Jones, M Hill and NL Shapiro. 2004. The diagnostic accuracy of computed

tomography in pediatric chronic sinusitis. Arch Otolaryngol Head Neck Surg. 130:1029-1032.6. Welcome to radiography reporting. http://xray.20m.com/photo.html. Accessed 18 January 2007.7. S Maning, MJ Biavati and DL Philips. 1996. Correlation of clinical sinusitis signs and symptoms to

imaging findings in pediatric patients. Int J Pediatr Otorhinolaryn. 37:65-74.8. GE Boyle, M Ahern, J Cooke, NP Sheehy, and JF Meaney. 2006. An Interactive Taxonomy of MR

Imaging Sequences. Radiographics. 26:e24 9. KA Kronemer and WH McAlister. 1997. Sinusitis and its imaging in the pediatric population. Pediatr

Radiol. 27:837-846.10. Congental malformations, hydroencephaly, and herniation.

http://www.math.uno.edu/~jensen/L/neuropath/images.htm. Accessed 18 January 2007.11. J Zimmer, J Bhatt, JH Conway, M Edwards-Brown, DK Sokol. 2006. Is it all in his head?. Internet J

Pediatr Neonat. 6(1) .12. BY Ghorayeb. 2006. Otolaryngology Houston. Accessed 18 January 2007.

http://www.ghorayeb.com/PottsPuffyTumor.html13. Thomson Healthcare. 2006. Sinusitis. PDR Health.

http://www.pdrhealth.com/patient_education/BHG01ID21.shtml. Accessed 19 January 2007. 14. American Academy of Pediatrics. 2001. Clinical practice guideline: management of sinusitis.

Pediatrics. 108:798-808.15. LA Nadalo and LK Hunter. 2004. Brain Abscess. http://www.emedicine.com/radio/topic91.htm.

Accessed 20 January 2007.16. CFE Kirsch and R Turbin. 2005. Orbit, Infections. eMedicine.

http://www.emedicine.com/radio/topic490.htm. Accessed. 20 January 2007. 17. MM Reeder. Reeder and Felson’s Gamuts in Radiology, 4th ed. New York: Springer, 2003, p 133.

http://xray.20m.com/photo.html

http://www.math.uno.edu/~jensen/L/neuropath/images.htm

http://www.ghorayeb.com/PottsPuffyTumor.html

http://www.pdrhealth.com/patient_education/BHG01ID21.shtml

http://www.emedicine.com/radio/topic91.htm

http://www.emedicine.com/radio/topic490.htm

Naana Afua Jumah, HMS IIIGillian Lieberman, MD With Thanks to . . .

Andrew Hines-Peralta, MDNeil Bhattacharyya, MD FACSGillian Lieberman, MDPamela LepkowskiLarry Barbaras, Webmaster

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Complications of Pediatric Sinusitis