107 / 232
The
preoperative
CRP
levels
(mg/l)
(mean
SD)
were
not
different
between
the
SE
(102
101)
and
EE
groups
(112
119).
Nor
did
the
CRP
levels
differ
between
patients
requiring
only
one
(114
127)
or
several
drainage
surgeries
(97
75).
Blood cultures were positive
in only one patient with SE and
in no
patients with
EE.
Perioperative
pus
samples were
positive
in
67%
(
n
= 6) of SE
(3 sinus samples and 3
intracranial samples) and
in 75%
(
n
= 6)
of
EE
(2
sinus
samples
and
4
intracranial
samples).
Lumbar
punctures were performed
in 4 patients with
SE due
to meningeal
syndrome
and
did
not
retrieve
any
bacteria.
In
cases
of
SE,
the
isolated
bacteria
were
the
following:
Streptococcus
constellatus
(
n
= 2), Non-specified
Streptococcus
(
n
= 2),
Streptococcus
intermedius
(
n
= 1),
Fusobacteriumnecrophorum
(
n
= 1),
Fusobacteriumnucleatum
(
n
= 1)
and
Provatella
species
(
n
= 1).
Bacteria
isolated
in
children
with
EE
were:
S.
intermedius
(
n
= 4),
Staphylococcus
lugdunensis
(
n
= 1)
,
Staphylococcus
aureus
(
n
= 1),
Staphylococcus
capitis
(
n
= 1)
and
Propionobacterium
acnes
(
n
= 1).
3.3.
Radiological
findings
The
imaging
techniques
performed
before
the
first
surgical
procedure were
the
following: CT scans
in 10 cases
(59%)
(6 SE and
4 EE), MRI
in 4 cases
(23.5%)
(2 SE and 2 EE) and CT scan and MRI
in
3
cases
(17.5%)
(1
SE
and 2 EE).
There was no
clear
explanation
in
the clinical charts concerning the choice of
the
imaging
techniques.
A
thickened
inflammatory mucosa,
possibly
associated with
the presence of pus, was observed
in
the maxillary and ethmoidal
sinuses
in
100%
of
cases,
in
the
frontal
sinus
in
88%
of
cases
(
n
= 15), and
in the sphenoid sinus
in 53% of cases (
n
= 9). Fifty nine
percent of
cases of maxillary
and
ethmoidal
sinusitis,
and 59% of
cases
of
frontal
sinusitis were
bilateral.
Ethmoidal
inflammation
mostly
concerned
the
interior
part
of
this
paranasal
sinus.
Two
cases
clearly
resulted
from
the
ethmoidal
sinus
since
these
patients
did
not
have
any
frontal
sinus.
In
one
case,
the
EE
originated
from a Pott’s puffy
tumor and not directly
from a
sinus
cavity
(
Fig.
1
, D1).
In three cases (2SE and1 EE), the empyema and the infected sinus
were not
contiguous
(
Fig. 2
). An erosion of
the posterior wall of
the
frontal
sinus was
observed
in
one
case
(EE)
and
an
erosion
of
the
ethmoidal roof
in two cases (1 SE and 1 EE) (
Fig. 3
). The
locations and
extensions of
the empyema on
the
initial
imaging and at
the
time of
theirmaximal expansionare shown in
Figs. 1 and4
, respectively. The
locations
of
empyema were
as
follows:
For
SE,
the
frontal
polar
region
was
involved
in
89%
of
cases
(
n
= 8),
the
frontal basal
in one
case,
the parietal
region
in 78% of
Table
2
Neurological
symptoms,
CRP
levels,
size
of
empyema,
surgical
treatment
and
outcomes
in
patients with
SE.
Patient
initials
Neurological
symptoms
a
Initial
CRP
level
(mg/ml)
Extension
of
empyema
before
1st
surgery
b
Bacteria
First
procedure
Second
procedure
Third
procedure
Residual
symptoms
and
treatments
during
the
last
visit
(follow-up
duration)
BD
FND
DC
S
MS
72
Extended
Gram
positive
cocci
ONA
(Burr
hole
drainage)
ONA
(frontal
and
parietal
craniotomy)
Speech
and motor
difficulties
(27 months),
AEDs
DC
S
MS
6
Localized
NG
EEA
ONA
(frontal
and
parietal
craniotomy)
Intermittent
headaches
(22 months)
ID
S
NA
Extended
Streptococcus
constellatus
and
Prevotella
species
EEA
ONA
(parietal
craniotomy)
and
FSO
Concentration
problems,
EEG
abnormalities,
AEDs
(23 months)
LM MS
S
124
Localized
Streptococcus
intermedius
EEA
FSDext
ONA
(Burr
hole
drainage +
puncture
of
frontal
BA
under
US
guidance)
Schooling
difficulties,
headaches
(29 months)
PLam S
NA
Localized
Fusobacterium
necrophorum
EEA
ONA
(parietal
craniotomy)
ONA
(frontal
medial
and
parietal
craniotomies)
+ FSO
Schooling
difficulties,
frontal
and
parietal
bone
defect,
AEDs
(20 months)
RM FND
A
S
NA
Extended
Streptococcus
constellatus
EEA
and
FSDext
ONA
(Frontal
and
parietal
craniotomy)
AEDs
(24 months)
PLen
MS
86
Extended
NG
EEA
Headaches
(27 months)
TL
S
ICHS
292
Extended
Streptococcus
species
ONA
(frontal
medial
craniotomy)
No
problem
(18 months)
VJ
None
35
Extended
Fusobacterium
necrophorum
EEA
ONA,
(frontal
medial
and
parietal
craniotomies),
FSO
No
problem
(33 months)
Shaded portion: Cases
requiring more
than one procedure. Unshaded portion: Cases
successfully
treated with a
single operation. AEDs: antiepileptic drugs BA: brain abscess
DC: decreased consciousness EEA: endoscopic ethmoidectomy and antrostomy EEG: electroencephalogram FND:
focal neurological deficit FSD:
frontal sinus drainage, either
through
an
external
(FSDext)
or
through
an
endoscopic Draf
type
III
approach
(FSDendos)
FSO:
frontal
sinus
obliteration
ICHS:
Intracranial
hypertension
syndrome MS:
Meningeal
syndrome NA:
not
available NG:
no
bacterium
isolated
in
bacteriological
samples ONA:
open
neurosurgical
approach
S:
seizure.
a
Headaches were
excluded
from
the
list
of
neurological
symptoms
as
it
could
have
also
resulted
from
sinusitis.
b
Localized empyema corresponded
to empyema
located
in
the
front of
the polar or basal part of
the
frontal
lobe, next
to
the
infected
frontal and anterior ethmoid sinuses.
Extended
empyema
had
spread way
beyond
the
polar
or
basal
region
of
the
frontal
lobe
facing
the
infected
sinus
(see
also
Figs.
1
and
4
).
A.
Garin
et al.
/
International
Journal
of
Pediatric Otorhinolaryngology
79
(2015)
1752–1760
85