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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 50  |  Issue : 2  |  Page : 63-68

Neurosurgery for sinusitis-related and sinusitis-unrelated intracranial abscess


1 Department of Neurosurgery, Neuro-Medical Scientific Center, Buddhist Tzu Chi Hospital; Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
2 Department of Neurosurgery, Neuro-Medical Scientific Center, Buddhist Tzu Chi Hospital, Hualien, Taiwan
3 Department of Surgery, Buddhist Tzu Chi General Hospital; School of Medicine, Tzu Chi University; Department of Pharmacology, Tzu Chi University, Hualien, Taiwan

Date of Submission07-Mar-2016
Date of Decision13-Jul-2016
Date of Acceptance23-Aug-2016
Date of Web Publication18-Apr-2017

Correspondence Address:
Tsung-Lang Chiu
Department of Neurosurgery, Buddhist Tzu Chi General Hospital, Number 707, Sec. 3, Chung Yang Road, Hualien 970
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_21_17

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  Abstract 

Background: Sinusitis-related intracranial abscess (ICA) is a rare but serious complication and is different from those of sinusitis-unrelated ICA. Purpose: This study aimed to analyze the differences in bacteriology, host factors, presentations, and prognoses between cases of sinusitis-related and sinusitis-unrelated ICA.
Methods: This retrospective study was conducted at Buddhist Tzu Chi General Hospital (Hualien, Taiwan), during January 2010–August 2014, and enrolled patients with pathologically proven postsurgery ICA. P < 0.05 was considered statistically significant.
Results: The number of patients with sinusitis-related and sinusitis-unrelated ICA was 10 and 17, respectively. Compared with sinusitis-unrelated ICA patients, significantly more patients with sinusitis-related ICA experienced cirrhosis, ophthalmic abnormalities, and frontal and cavernous sinus involvement. Among all ICA patients, diabetes mellitus (DM) was associated with an increased mortality risk. Patients with DM exhibited the highest positive culture rates for Klebsiella pneumoniae.
Conclusion: Frontal sinusitis is associated with an increased risk of intracranial invasion. DM and liver cirrhosis patients exhibited the highest mortality rates among all ICA patients. Patient comorbidity should be considered when prescribing antibiotics for treatment.

Keywords: Intracranial abscess, neurosurgery, sinusitis


How to cite this article:
Wang GC, Chen KP, Su CF, Huang YT, Chiu TL. Neurosurgery for sinusitis-related and sinusitis-unrelated intracranial abscess. Formos J Surg 2017;50:63-8

How to cite this URL:
Wang GC, Chen KP, Su CF, Huang YT, Chiu TL. Neurosurgery for sinusitis-related and sinusitis-unrelated intracranial abscess. Formos J Surg [serial online] 2017 [cited 2019 Jan 18];50:63-8. Available from: http://www.e-fjs.org/text.asp?2017/50/2/63/204660


  Introduction Top


Acute sinusitis, which typically develops after a viral upper respiratory tract infection, is a common localized disease. Sinusitis can lead to severe complications, including local (osseous), orbital, and intracranial disorders.[1] The incidence rates of sinusitis-related intracranial complications, such as periorbital abscess, extradural abscess, subdural empyema, intracerebral abscess, meningitis, and cavernous and superior sagittal sinus thrombosis, have been reported to be 3.7%–24%,[2],[3] while mortality and morbidity rates have been reported to be 25% and 10%, respectively.[4]

Purpose

In this study, we reviewed patients with sinusitis-related intracranial abscess (ICA) and analyzed the differences between these patients and patients with sinusitis-unrelated ICA at Buddhist Tzu Chi General Hospital (Hualien, Taiwan). The pathogens and locations typical of sinusitis-related ICA differ from those of sinusitis-unrelated ICA.[5],[6]


  Methods Top


Patients

The present study was a single-center, retrospective chart review study conducted during January 2010–August 2014, following the Institutional Review Board approval (IRB104-121-B). Patients who exhibited pathological proof of ICA (both sinusitis related and sinusitis unrelated) after surgery were enrolled. Initially, neurological presentations, pathogens, host factors (diabetes mellitus [DM] or liver cirrhosis), complications, and prognoses (cure or mortality) were analyzed. The initial neurological presentations recorded were ophthalmological symptoms or signs (e.g., diplopia, blurred vision, and ptosis), headache, change of consciousness, and seizure attack.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.

Statistical analysis

Categorical variables are presented as proportions (%) and were compared using Fisher's exact test. Abnormally distributed continuous variables are presented as the median (25%–75% interquartile range) and were compared using Mann–Whitney U-test. Multivariate analysis was performed using logistic regression tests. Variables were considered statistically significant if P < 0.05. All statistical tests were performed using SPSS 18 software (IBM Corporation, Armonk, NY, USA), and graphs were constructed using GraphPad Prism 6 (GraphPad Software, La Jolla, CA, USA).


  Results Top


From January 2010 to August 2014, 27 patients were pathologically diagnosed with ICA and underwent surgery. The mean length of hospital stay was 42.48 days (range: 7–105 days), and the average patient age was 52 years (range: 13–81 years). Seven patients were women (25.9%), while twenty were men (74.1%). Of all patients, ten had sinusitis-related ICA [Table 1], with the most common site of origin being the frontal sinus (n = 7), followed by the cavernous sinus (n = 5). The two most common types of sinusitis-related intracranial complications were subdural empyema (n = 7) and sphenoiditis (n = 3). Various causative pathogens, including Eikenella corrodens, Prevotella spp., Propionibacterium spp., Streptococcus constellatus, coagulase-negative staphylococci, viridans streptococci, vancomycin-resistant Enterococcus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Aspergillus spp., were identified. Tests yielded negative culture results for four patients, while multiple pathogens were detected in five patients (18.5%). The status of 14 patients was immunocompromised, with the patients having liver cirrhosis (n = 5), DM (n = 8), a history of splenectomy (n = 1), a history of kidney transplant (n = 1), and HIV (n = 1). Seven patients died after the treatment (overall mortality rate: 26%). Surgical techniques included functional endoscopic sinus surgery, craniectomy, craniotomy, trephination, and stereotactic aspiration [Table 2]. Overall, stereotactic aspiration was the main operational strategy (n = 13; 48%), especially for deep-seated or multifocal ICA.
Table 1: Characteristics of all patients with intracranial abscess

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Table 2: Surgical procedures conducted on all patients

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Comparison between sinusitis-related and sinusitis-unrelated intracranial abscess

[Table 3] presents the characteristics of the cases of sinusitis-related and sinusitis-unrelated ICA. Compared with patients with sinusitis-unrelated ICA, a higher number of patients with sinusitis-related ICA had comorbid liver cirrhosis (50% vs. 0%, P = 0.003) and ophthalmological abnormalities (60% vs. 17.6%, P = 0.04). We subsequently compared the involvement of the frontal and cavernous sinuses between the two groups. Compared with those with sinusitis-unrelated ICA, more patients with sinusitis-related ICA exhibited involvement of the frontal and cavernous sinuses (90% vs. 23.5%, P = 0.001). The two groups did not differ significantly in age, sex, pathogen characteristics, or outcome.
Table 3: Comparison between sinusitis-related and sinusitis-unrelated intracranial abscess

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Host factors for all cases of ICA were subsequently evaluated. Although both patients with DM and those with cirrhosis exhibited a higher mortality rate than that of patients with other disease factors, only the mortality rate for patients with DM was significantly higher [Figure 1] (DM: P = 0.02; cirrhosis: P = 0.054). In multivariate analysis, DM was the only risk factor influencing mortality in the ICA patients (odds ratio = 8.68, P = 0.03). Compared with those without DM, patients with DM showed the highest positive culture rate of K. pneumoniae (50% vs. 7%, P = 0.047).
Figure 1: Differences in the mortality rates of intracranial abscess patients with and without diabetes mellitus (DM, non-DM) as well as those with and without cirrhosis

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  Discussion Top


In the present study, most patients with sinusitis-related ICA received surgical debridement, which entails functional endoscopic surgery for treating the sinusitis, and craniotomy, craniectomy, or stereotactic aspiration treatment for removing the ICA. The importance of surgical debridement has been emphasized in several previous studies.[7],[8],[9] Infections associated with sinusitis-related ICA are often polymicrobial, with Streptococcus spp. being the most common pathogen.[5] Nevertheless, in contrast to the results of several previous studies, the results of the present study demonstrated that the patients with sinusitis-related ICA did not have higher polymicrobial infections.[4],[8] In this study, P. aeruginosa, Prevotella spp., and Streptococcus spp. were the three most common pathogens in the sinusitis-related ICA group (infection rate: 20% each). These differences in pathogens might be the result of regional differences in bacterial flora or patient comorbidity. In addition, we noted that anaerobic bacteria were more often cultured in the sinusitis-related ICA group, although the result was nonsignificant (77% and 33% in the sinusitis-related and sinusitis-unrelated ICA groups, respectively; P = 0.079). This result can be clarified by the nature of sinusitis.[7],[8] Anaerobic bacteria are more commonly observed in chronic sinusitis, which might cause intracranial invasion;[10],[11],[12] thus, when treating sinusitis-related ICA, empirical antibiotics against common pathogens should be prescribed.

Subdural empyema has been reported as the most common complication of sinusitis-related ICA;[7],[8] we observed similar results in our study. In addition, our results indicated the frontal sinuses to be the most common site of sinusitis-related ICA [Figure 2]. Similar results to that of the present study have been demonstrated previously, probably because of the anatomy and nearby blood supply of the frontal sinuses and the frontal lobe of the cerebrum.[10] Frontal sinusitis can invade the intracranial space through either direct invasion or the valveless diploic venous system.[9],[13] A higher number of patients with sinusitis-related ICA exhibit abnormal ocular symptoms and signs, which are likely associated with the involvement of the cavernous sinus, the second most common sinusitis location in patients in this study [Figure 3].
Figure 2: A brain magnetic resonance image of a 35-year-old male with fever, headache, and drowsiness revealed frontal and maxillary sinusitis (a, arrow) and right frontal lobe brain abscess (b, arrow)

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Figure 3: A brain computed tomographic scan (a and b) of a 60-year-old male with fever, headache, and eyeball swelling revealed sinusitis with cavernous sinus invasion. A brain magnetic resonance image (c, arrow) showed right ophthalmic vein engorgement because of septic thrombosis of the cavernous sinus (d, arrow)

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Some studies have demonstrated that patient comorbidity might be associated with sinusitis-related ICA, with DM also being a risk factor.[2],[14],[15] In the current study, we identified liver cirrhosis as another risk factor, likely a result of the immunocompromised status of our patients. Identifying the associated risk factors can facilitate early identification of ICA in sinusitis patients. Tsou et al.[16] demonstrated K. pneumoniae to be the most common bacterium isolated in patients with DM in Taiwan, and this was corroborated by our results, confirming the importance of K. pneumoniae in ICA.


  Conclusion Top


Frontal sinusitis is associated with an increased risk of ICA. If any suspicious symptoms and signs are observed in patients with frontal sinusitis or the comorbidities of DM and liver cirrhosis, further examination and treatment should be administered. Specific pathogens of ICA in patients with DM and sinusitis should be considered during initial treatment with empirical antibiotics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology 2012;50:1-12.  Back to cited text no. 1
    
2.
Clayman GL, Adams GL, Paugh DR, Koopmann CF Jr. Intracranial complications of paranasal sinusitis: A combined institutional review. Laryngoscope 1991;101:234-9.  Back to cited text no. 2
    
3.
Germiller JA, Monin DL, Sparano AM, Tom LW. Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg 2006;132:969-76.  Back to cited text no. 3
    
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Giannoni CM, Stewart MG, Alford EL. Intracranial complications of sinusitis. Laryngoscope 1997;107:863-7.  Back to cited text no. 4
    
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Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR. Brain abscess: Current management. J Neurosci Rural Pract 2013;4 Suppl 1:S67-81.  Back to cited text no. 5
    
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Mathisen GE, Johnson JP. Brain abscess. Clin Infect Dis 1997;25:763-79.  Back to cited text no. 6
    
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Osborn MK, Steinberg JP. Subdural empyema and other suppurative complications of paranasal sinusitis. Lancet Infect Dis 2007;7:62-7.  Back to cited text no. 7
    
8.
Bayonne E, Kania R, Tran P, Huy B, Herman P. Intracranial complications of rhinosinusitis. A review, typical imaging data and algorithm of management. Rhinology 2009;47:59-65.  Back to cited text no. 8
    
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Jones NS, Walker JL, Bassi S, Jones T, Punt J. The intracranial complications of rhinosinusitis: Can they be prevented? Laryngoscope 2002;112:59-63.  Back to cited text no. 9
    
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Herrmann BW, Forsen JW Jr. Simultaneous intracranial and orbital complications of acute rhinosinusitis in children. Int J Pediatr Otorhinolaryngol 2004;68:619-25.  Back to cited text no. 10
    
11.
Brook I. Bacteriology of chronic maxillary sinusitis in adults. Ann Otol Rhinol Laryngol 1989;98:426-8.  Back to cited text no. 11
    
12.
Brook I. Microbiology of intracranial abscesses and their associated sinusitis. Arch Otolaryngol Head Neck Surg 2005;131:1017-9.  Back to cited text no. 12
    
13.
Dolan RW, Chowdhury K. Diagnosis and treatment of intracranial complications of paranasal sinus infections. J Oral Maxillofac Surg 1995;53:1080-7.  Back to cited text no. 13
    
14.
Gallagher RM, Gross CW, Phillips CD. Suppurative intracranial complications of sinusitis. Laryngoscope 1998;108:1635-42.  Back to cited text no. 14
    
15.
Albu S, Tomescu E, Bassam S, Merca Z. Intracranial complications of sinusitis. Acta Otorhinolaryngol Belg 2001;55:265-72.  Back to cited text no. 15
    
16.
Tsou TP, Lee PI, Lu CY, Chang LY, Huang LM, Chen JM, et al. Microbiology and epidemiology of brain abscess and subdural empyema in a medical center: A 10-year experience. J Microbiol Immunol Infect 2009;42:405-12.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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