106 / 232
children
with
complicated
ABS,
14
intracranial
complications
including
2
brain
abscesses,
7
epidural
and
6
subdural
empyema
were
retrieved
[3]
.
In
another
pediatric
series
of
11
suppurative
intracranial
complications
of
sinusitis,
3
intracranial
abscesses
(ICA), 3 SE, 2 EE, 2 SE associatedwith EE, and 1 SE associatedwith
ICA
were observed
[4]
. This data
suggests
that EE
and
SE
represent
the
most
frequent
intracranial complications of pediatric ABS. However,
only
a
few publications have
specifically
focused on
their manage-
ment,
especially
concerning
the
respective
roles
of
ONA
and
ETA
[3–9]
.
The primary objective of
the present
study was
to
compare
the
outcomes
of
ONA
and
ETA
in
a
retrospective
pediatric
cohort
of
sinogenic empyema,
in order to optimize the
indications of surgical
treatments
of
these
complications. A
secondary
end
point was
to
describe
the clinical, bacteriological and
imaging characteristics of
pediatric
cases
of
sinogenic
SE
and
EE.
2. Material
and methods
The
manuscript
was
prepared
in
accordance
with
STROBE
guidelines
[10]
.
2.1.
Study
design
This
single-center
retrospective
study
included
all
consecutive
pediatric
cases
of
epidural
or
subdural
empyema
operated
in
the
Pediatric Neurosurgical
and
ENT Departments
of Necker Hospital
between
January
2012
and
February
2014.
2.2.
Inclusion
criteria
The diagnosis
of
sinogenic
subdural
or
epidural
empyema was
based
on
the
association
of
the
following
findings:
(i)
clinical
or
biological
signs
of
infection,
(ii)
the
observation
of
an
empyema
mainly or solely
located
in
the
frontal
lobe, and of an opacity of
the
ethmoidal or
frontal
sinus on CT and MR
imaging,
(iii)
the absence
of
recent
cranial
trauma
or
surgery,
and
the
absence
of
any
other
infection
(tooth, middle
ear.) which
could
have
been
responsible
for
the
empyema.
Neither
the
presence
of
clinical
symptoms
compatible
with
sinusitis
(fever,
headache,
facial
subcutaneous
swelling)
nor
the
contiguity
between
the
sinus
opacity
and
the
empyema
on
imaging
were
judged
necessary
to
make
the
diagnosis
of
sinogenic
empyema.
Indeed,
concerning
the
latter
point,
the sinus opacity and
the
resulting empyema can sometimes
be
separated
from
each
other
due
to
one
of
the
following
mechanisms:
Indirect spread of
infection between the sinus and the epidural or
subdural
space
through
the mucosal
veins
of
the
sinus
to
the
emissary
veins
that
link
the
facial
and
dural
venous
systems
[11,12]
or,
in
cases of EE,
through an osteomyelitis of
the
frontal
bone
(Pott’s
puffy
tumor)
Antibiotic
treatment prior
to brain
imaging: often, at
the
time of
diagnosis of
empyema,
the
sinusitis has
already been diagnosed
and
treated
for
several days with antibiotics. This
treatment
can
modify
the
extension
of
the
sinus
infection
and
induce
a
separation
between
the
sinus
opacity
and
the
empyema
on
imaging.
2.3.
Exclusion
criteria
The
exclusion
criteria were
the
following:
Non-sinogenic
empyema.
Patients
older
than
18
years.
Insufficient
clinical,
biological
or
imaging
data.
2.4.
Review
of medical
records
Clinical
charts were
retrieved
using
the
institutional
database
CCAM
(Classification Commune des Actes Me´ dicaux). The medical
records
of
children with
SE
or
EE were
reviewed
for
age,
gender,
underlying
conditions
before
diagnosis,
presenting
symptoms,
duration
of
symptoms
before
admission,
CRP
(C-reactive
protein)
levels,
bacteriological
data,
CT
and MR
imaging
findings, medical
and
surgical
treatments
and
final
clinical
outcomes.
2.5.
Data
analysis
Quantitative
variables
were
described
using
their
mean
or
median
value
and
standard
deviation,
and
qualitative
variables
were
described
as
numbers
and
percentages.
Statistical
compar-
isons
were
performed
using
Student’s
t
-test
or
Mann–Whitney
U
test
for
quantitative
variables
and
Chi-square
or
Fisher’s
exact
test
for
qualitative
variables.
P
values
0.05
were
considered
statistically
significant.
3. Results
Out of 23 pediatric
cases of
SE or EE operated
at our
institution
during
the
study
period,
6 were
discarded
because
of
their
non-
sinogenic origin
(5 otogenic and 1 post-traumatic empyema). Nine
SE
(53%)
and
8
EE
(47%)
cases
were
finally
included.
Patients’
demographics
and
symptoms
are
described
in
Tables
1–3
.
The
median
age was
11
years
(8.8–13.5)
in
the
SE
group
and
10
years
(9.0–10.8)
in
the
EE
group
(NS).
The
sex
ratio was
not
different
between
both
groups
(
Table
1
).
3.1.
Clinical
features
on
admission
and
before
surgery
Clinical
features
are
presented
in
Tables
1–3
.
The
major
difference
between
both
groups
was
the
neurological
clinical
presentation.
Indeed,
the
number
of
neurological
symptoms
per
patient
(mean
SD) was
1.8
1.2
in
the
SE
group
and
0.4
0.5
in
the
EE
group
(
p
= 0.01).
The most
frequent
neurological
symptoms
were
seizures
(6
children
with
SE
and
2
with
EE)
and meningeal
syndrome
(4 patients with SE and none of
those with EE). Among
the
two patients with EE and
seizures, one patient had a
frontal
subdural
aeroma
(
Table 2
), possibly explaining
the cortical
irritation
leading
to
the
seizure. Pott’s puffy
tumors
tended
to be more
frequent
in
the EE
group
(37.5%
vs
11%)
(NS)
(
Table
4
).
3.2.
CRP
levels
and
bacteriological
findings
CRP
levels
and
bacteriological
data
are
presented
in
Tables
2
and
3
.
Table
1
Patient
clinical
characteristics.
SE
(
n
= 9)
EE
(
n
= 8)
Age
(years)
(median
SD)
11
3
10
4
Sex
ratio
(males/females)
4/5
5/3
Fever
(
n
)
3
5
Palpebral
edema
(
n
)
1
2
Headaches
(
n
)
a
4
2
Neurological
symptoms
findings
(
n
)
-Aphasia
1
0
-Altered
consciousness
1
0
-Meningeal
syndrome
4
0
-Focal
neurological
deficit
2
0
-Seizure
6
2
-Intracranial
hypertension
1
1
a
Headaches were
excluded
from
the
list
of
neurological
symptoms
as
it
could
have
also
resulted
from
sinusitis.
A.
Garin
et
al.
/
International
Journal
of
Pediatric Otorhinolaryngology
79
(2015)
1752–1760
84