112 / 232
the
probability
of
neurosurgical
intervention
and
long-term
neurologic
deficits
[9]
.
Some
bacteriological
differences
between
SE and EE
result
from
the more anaerobic environment of SE due
to
its
reduced
connection
to
the
pneumatized
paranasal
sinuses.
Hence why
staphylococci
are more
frequently
observed
in
EE
and
anaerobic bacteria
in SE
(present
study,
[4,5,9]
). This microbiolog-
ical
data
differs
from
those
observed
in
uncomplicated
PABS,
where
Streptococcus
pneumoniae
,
Haemophilus
influenzae
,
and
Moraxella
catarrhalis
are
isolated
in
about
30%,
30%,
and
10%
of
cases,
respectively
[15]
.
SE
and
EE
always
require
hospitalization
in
a
pediatric
neurosurgical
intensive
care
unit
and
the
rapid
institution
of
a
medical
treatment.
With
regards
to
surgical
indications
and
modalities,
our
data
strongly
suggests
that
they
considerably
differ
between
SE
and
EE.
In
SE,
the most
effective
procedure
is
a
direct
and
large
drainage
through
a
craniotomy.
ETA
alone
is
not
advisable:
in
the
present work,
out
of
7
patients with
SE
treated
this way, only one recovered while
the 6 others required additional
surgery with ONA
(
Fig. 1
, A3). As
shown
in
Fig. 1
,
the poor
results
from
ETA
in
the
case
of
this
indication were
observed
even when
the
initial
extension
of
the
SE
was
very
limited.
However,
the
adjunction
of
ETA
to
ONA
was
useful
for
the
purpose
of
bacteriological
diagnosis
as
in
our
series
of
patients with
SE,
half
of
the
positive
bacteriological
samples
were
harvested
from
paranasal
sinuses
during
the
ETA
procedure.
Hence,
we
recom-
mend
rapid
surgery
combining
ETA
and ONA
in
pediatric
cases
of
SE.
In EE,
as
shown by
the present data, more patients will
recover
after a
single
surgical procedure
than
in cases of SE. ETA may be an
alternative
to ONA, especially when a direct drainage of
the EE can
be
performed
through
a
Draf
III
approach
and
an
opening
of
the
posterior wall
of
the
frontal
sinus.
In
some
instances
however,
a
direct
endoscopic
drainage
is
impossible
due
to
the
location
and
extensions
of
the
EE,
or
due
to
the
presence
of
associated
lesions
requiring ONA
(
Fig. 1
, cases D1, D2 and D4). One of our cases
(
Fig. 1
,
C2) and other
literature data
[20]
show
that
the presence of a Pott’s
puffy
tumor
does
not
contraindicate
an
exclusively
endoscopic
approach.
Finally,
the
drainage
or
obliteration
of
the
frontal
sinus
did not
influence surgical outcomes
in patients with EE as well as
in
those with
SE.
Regarding outcomes,
in accordance with
literature data
[3–6]
, no
mortalities were
observed.
Persistent
disorders
at
the
end
of
the
follow-up period, especially headaches and cognitive, concentration,
or
schooling problems,
tended
to be more
frequent
in
the
SE group
than
in
the
EE
group
(67%
vs 29%). As
a
consequence
of
their more
uneventful postoperative course, children with EE were
followed up
for
a
shorter
period
of
time
(
Table
5
,
p
<
10
6
).
The
probability
of
persistent
symptoms was higher when
several
surgical procedures
were needed
(
p
= 0.05).
The
present
study
contains
some
limitations
and
drawbacks:
it
is
a
single-center
and
retrospective
study
it
includes
a
small
number
of
patients,
even
if
it
represents
the
second
largest
published
series
of
pediatric
sinogenic
intracra-
nial
complications
[9]
only
children
who
underwent
surgery
for
SE
and
EE
were
retrieved meaning
that
empyema
cases which
did
not
require
surgery were
not
included.
5. Conclusions
Intracranial
empyema
and
particularly
subdural
empyema
are
severe
infections
that
require
a multimodal
approach,
involving
neurosurgeons,
ENT
surgeons,
radiologists
and
infectiologists.
ETA
has
an
important
role
in
the management
of
intracranial
empyema.
If
its
role may be
limited
to microbiological diagnosis
in
SE,
it
can
sometimes
successfully
treat EE,
especially when
the
EE
can
be
directly
drained
by
opening
of
the
posterior
wall
of
the
frontal
sinus
or
of
the
ethmoidal
roof.
References
[1]
M.J. Abzug, Acute sinusitis in children: do antibiotics have any role? J. Infect. 68 (Suppl. 1) (2014) S33–S37.
[2]
A.R. Sedaghat, C.O. Wilke, M.J. Cunningham, S.L. Ishman, Socioeconomic dispar- ities in the presentation of acute bacterial sinusitis complications in children, Laryngoscope 124 (2014) 1700–1706.[3]
L.E. Oxford, J. McClay, Complications of acute sinusitis in children, Otolaryngol. Head Neck Surg. 133 (2005) 32–37.[4]
D. Kombogiorgas, R. Seth, R. Athwal, J. Modha, J. Singh, Suppurative intracranial complications of sinusitis in adolescence, single institute experience and review of literature, Br. J. Neurosurg. 21 (2007) 603–609.[5]
N. Adame, G. Hedlund, C.L. Byington, Sinogenic intracranial empyema in children, Pediatrics 116 (2005) e461–e467.[6]
M. Calik, A. Iscan, M. Abuhandan, I. Yetkin, F. Bozkus¸
, M.F. Torun, Masked subdural empyema secondary to frontal sinusitis, Am. J. Emerg. Med. 30 (2012) 1657.e1–1657.e4.[7]
P.K. Sharma, B. Saikia, R. Sharma, Orbitocranial complications of acute sinusitis in children, J. Emerg. Med. 47 (2014) 282–285.Table
5
Treatments
and
outcomes.
SE
(
n
= 9)
EE
(
n
=8)
p
Follow-up
(months)
a
25
5
7
4.5
<
10
6
Duration
of
hospital
stay
(days)
a
23
9
22
6
NS
IV
antibiotics
(days)
a
22
7
17
7
NS
Success
of
initial
surgical
procedure
33%
(3/9)
75%
(6/8)
0.06
-ETA
(
n
= 6)
17%
(1/6)
75%
(3/4)
-ONA
(
n
= 2)
50%
(1/2)
67%
(2/3)
-ONA
combined with
ETA
(
n
=1)
100%
(1/1)
100%
(1/1)
Mean
number
of
surgical
procedures
a
1.8
0.7
1.4
0.7
0.18
Hospitalization
duration
(days)
a
23
9
22
6
NS
All
surgical
procedures
Children with
persistent
symptoms
at
the
end
of
the
follow-up
period
67%
(6/9)
29%
(2/7)
b
NS
-Headaches
3
0
-Concentration,
cognitive
or
schooling
problems
3
1
-Abnormal
EEG
1
1
-Speech
difficulties
1
0
-Motor
difficulties
1
0
-Unsightly
cranial
vault
deformity
1
1
NS:
not
significant.
a
Values
are
expressed
as means
SD.
b
In
the
calculation of
the percentage of persistent
symptoms
at
the
end of
the
follow-up period
in
the EE group,
the denominator was
reduced
to 7
as one patient never
attended
the
scheduled
follow-up
visits.
A.
Garin
et
al.
/
International
Journal
of
Pediatric Otorhinolaryngology
79
(2015)
1752–1760
90