Scand J Infect Dis 24: 353-356, 1992
Septic Complications to Sphenoidal Sinus Infection OLAV 0KTEDALEN' and FINN LILLEAS'
Scand J Infect Dis Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
From Depar/mentr of ' M e d m n e , Section of Infectious D u e a ~ e sand 'Neurorudiology, Ullevil University Hospital, Oslo, Norway
Sphenoid sinusitis is an uncommon infection, but an early diagnosis and appropriate treatment is important because of its serious complications. We report 4 patients (28,28,37 and 28 years old) admitted to a department of infectious diseases with meningitis, sepsis and orbital cellulitis as complications of acute sphenoidal cavity infection. The cases illustrate the value of computed tomography (CT) scan of the sphenoid sinus in the evaluation of patients with rlinical features suspicious of sphenoid sinusitis.
0. Qktedalen, MD, PhD, Department of Medicine, Section of Infectious Diseases, Ullevd University Hospital, Oslo, Norway
INTRODUCTION Many physicians are unfamiliar with the diagnosis of sphenoid sinusitis. The infection is not common ( 1 ) . and is often misdiagnosed. Located deep in the cranium the sphenoid sinus is not accessible to direct physical examination, and the history is often difficult to interpret. Most patients experience headache and facial pains as initial symptoms, and the diagnosis is often mistaken for common headache, migraine headache or trigeminal neuralgia. The diagnosis and treatment are delayed, and the risk of complications associated with serious morbidity and high mortality is increased. Many of these patients are not thoroughly examined until other neurologic deficits become apparent, and the infection has spread to adjacent vital structures as the dura mater, optic canals o r cavernous sinus. Sphenoid sinusitis is mostly a diagnosis of interest for the family physician and the otorhinolaryngologist. but the internist should also be aware of its existence because of its serious complications that might bring these patients to medical departments. We present 4 patients who during a period of 4 months were admitted to our department of infectious diseases with symptoms of meningitis, sepsis or orbital cellulitis, and where the focus of infection was the sphenoidal sinus. The cases illustrate the necessity for computed tomography scan and that plain roentgenography of the sphenoidal sinus is not reliable in the evaluation of these patients. CASE REPORTS Caw 1 A 28-year-old man had a 7 day history of fever, freezing, headache, nausea. frequent coughing and general muscle pain. For 2 days he was treated orally by his family doctor with erythromycin in ordinary doses. However, the patient's condition worsened. and he was examined by a general physician who found neck stiffness compatible with meningeal irritation. On admission, he was conscious, normotensive with tcmpcraturc of 41.3"C, showed purpuric rash on the arms, and stiffness of the back and neck. Blood tests showed a sedimentation rate (ESR) of 68, C-reactive protein (CRP) 117, leucocytes 6.5 x 10'/1 with 70% polynuclear and 6% rods, hyperglycemia (8.8 mmolll), no bacterial growth from blood cultures and normal flora from the throat and nose. Cerebrospinal fluid (CSF) revealed pleocytosis with 170x 10hcells/l.mostly mononuclear, but no bacterial growth. Plain X-rays of the paranasal sinuses werc normal (Fig. 1A). while computed tomography of the sinuses and the cerebrum performed the day after arrival showed massive and moderate opacification of the right and left sphenoidal sinus respectively
23'
Scand J Infect Dis Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
354 0. (aktedalen and F: Lillecis
Fig. 1 A P l m X-ray shows no significant opacification of the Sinuses. opacification of the right rphenoid sinus
Scand J Infect Dis 24
-
B. CT-scan shows massive
(Fig. JB). In addition, the left maxilla sinus had a thickened mucosa. The brain showed signs of moderate edema. The diagnosis of primary sphenoidal sinusitis with complicating reactive meningitis was made. He was treated with ampicillin, was later followed as an outpatient and showed no neurological sequelae.
Case 2 A previously healthy man. 28 years of age. had a 4-day history of high fever and headache. He lived alone and was twice examined by a general clinician who recommended analgetics and antipyretics. A few hours before arrival he developed a left side periorbital edema and was found unconscious in his flat. On admission, hc was mentally confused and excited. The left eye showed periorbital swelling, injected conjunctivae, slight exophthalmos. normal reaction of the pupil and normal movement of the bulbus. A pronounced stiffness of the neck and columna was found. ESR was 23, C R P 225, leucocytes 26.5 x 10y/l,pleocytosis of the CSF with 8300X lo6cells/l and > 40% polynuclear. Furthermore, the CSF showed elevated levels of protein (0.62 g/l) and a decreased fraction of glucose (0.07). Microscopic investigation of the fluid revealed Gram-positive diplococci with capsule, and microbiological tests showed growth of Streptococcus pneumoniae. In addition. S. pneumoniae was grown from 2 of 3 blood cultures. Plain X-rays of the thorax was normal. and C T scan of the sinuses performed some hours after arrival revealed massive and slight opacification of the left sinus sphenoidalis and the left sinus ethmoidalis, respectively. C T scan of the orbita showed slight retrobulbar edema on the left side, and a small degree of exophthalmos. A diagnosis of acute sphenoidal cavity infection with complicating bacterial meningitis was made. H e responded well to penicillin, and an otorhinolaryngologist found no indication for surgical intervention. Therc were no signs of somatic sequelae in later controls. Case 3
A 37-ycar-old woman was previously healthy. The last 7 days she had felt ill with fever, frontal headache
and frequent coughing. The last 3 days the condition worsened with freezing. high fever, nausea and vomiting. She was twice seen by a general physician. O n admission, she was mentally oriented, febrile and septic. No rash and no stiffness of the back or neck was noted. ESR was 75, C R P 448, leucocytes 19.8 x 10y/l with 75% polynuclear and 15% rods. The CSF was normal. There was no growth in 6 blood cultures. moderate growth of S. pneumoniae from the nasal cavity, and normal flora from the throat. Plan X-rays of the sinuses were normal, while C T scan of the sinuses performed 2 days later disclosed massive opacification of both the sphenoidal and the ethmoidal sinus on the right side. The patient presented a condition of septicemia with the infective focus in the sphenoidal sinus. She was initially
Sc;~nd I Infect Dis
21
Sphenoidal sit1ids iris 35 5
trea1c.d with ccfuroxime and tobramycin in combination. which was later changed to penicillin tablets. and the condition improved rapidly.
Scand J Infect Dis Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
C'crsr
1
A man. 28 years of age, was HIV-infected 3 yews earlier. H e had previously been treated for Pneuinocystis carinii pulmonary infection and was in addition controlled for chronical diarrhoea. He had daily intake of azidothymidine and acyclovir for the HIV infection. The last 4 days he noticed a swelling around the left eye, and the last few hours he developed fever. started freezing and complained of headache. On arrival, he was mentally oriented and did not look seriously ill. The left eye showed pcriotbital edema and injected conjunctivae. The hulbus was painful at palpation. but there w a s no exophthalmos and n o purulent discharge from the eye. ESK was 42, C R P 13, leucocytes 1.8 X 10"A with 44% polynuclcar, and CD4 as low as 0.04 X l(I''/l. Spinal puncture was not performed. No bacterial growth was obtained in 6 blood cultures, no bacterial growth from the conjunctiva: massive growth. however. of S. pneumoniae and Haemophilus influenzae from the nose. Plain X-rays of the sinuses were negative. However, CT scan of the sinuses showed massive opacification of the left side sinus sphenoidalis and a slight opacification of the right side sinus cthmoidalis. The condition was evaluated as an acute infection of the sinus sphenoidalis with complicating orbital cellulitis. He was intially treated with cefuroxirnc which was later changed to tablets of erythromycin, and he responded well.
DISCUSSION
Sphenoid sinusitis is an uncommon infection that should be taken into account because of its scrious complications as meningitis, blindncss. sepsis, intra- or extracranial abscesses, lesions of cranial nerves and thrombosis of the cavernous sinus. Our cases illustrate that the diagnosis is difficult and that repeated examinations are required. All our paticnts showed a history of fever and headache which are the most common initial symptoms of the disease ( I . 2). Progressive headache in combination with nasal discharge. visual disturbances and hyper- o r hypoesthesia of the branches of thc fifth cranial nerve are symptoms pointing to sphenoidal cavity infection with beginning sprcad. and should hasten further evaluation and intervention (2). Characteristically, the diagnoses and treatment of our patients were delayed until they presented symptoms of Complications as meningitis, sepsis or orbital cellulitis. One patient (case 2) in particular was critically ill on presentation. However, the diagnosis was quickly established through CT scan of the paranasal sinuses. Interestingly, 3 o f 4 referred patients showed normal sinuses in plain sinus radiographs, and the diagnosis of acute sphenoidal sinusitis was made by C T scan. The observation is compatible with previous reports that plain X-rays of the sinus are not reliable in the diagnosis of sphenoidal cavity infection and that CT scan is indicated (1, 3-5). I t appears important to establish an early diagnosis and start appropriate treatment t o niinimise the risk of serious complications and permanent sequelae. Our patients had a short history of infection which could have attributed to the happy outcome of the treatment. They responded well to antibiotics. were repeatedly examined by otorhinolaryngologists, CT scans were repeated b u t there was no indication for surgical evacuation of the sinus. The case reports should remind the internist of the possibility of sphenoid sinusitis as a primary focus of infection when evaluating patients with serious bacterial diseases in the head. REFERENCES I . L.ew D, Southwick FS. Montgomery WW, Webcr AL. Raker AS. Sphenoid sinusitis. N Engl J Med 309: 1 149-1 154. 1983.
356 0. 0ktedalen and E Lilleis
Scand J lnfect Dis 24
Scand J Infect Dis Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
2. Wyllie JW, Kern EB, Djalilian M. Isolated sphenoid sinus lesions. Laryngoscope 83: 1252-1265, 1973. 3. Mizoguchi K, Jojima H, Tanaka M. Hotta M, Yano H, Toyomasu T. Shoji H, Kaji M, Kondo M. Sphenoid sinusitis associated with meningitis, visual disturbances and total ophthalmoplegia. Kurume Med J 35: 211-215, 1988. 4. McAlister WH, Lusk R , Muntz HR. Comparison of plain radiographs and coronal CT scans in infants and children with recurrent sinusitis. AJR 153: 1259-1264, 1989. 5. Roberts C , Nylander AE, Jayaramachandran S. Orbital cellulitis complicating isolated unilateral sphenoidal sinusitis: importance of the CT scan. Br J Ophthalmol 73: 769-770, 1989.
Septic Complications to Sphenoidal Sinus Infection OLAV 0KTEDALEN' and FINN LILLEAS'
Scand J Infect Dis Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
From Depar/mentr of ' M e d m n e , Section of Infectious D u e a ~ e sand 'Neurorudiology, Ullevil University Hospital, Oslo, Norway
Sphenoid sinusitis is an uncommon infection, but an early diagnosis and appropriate treatment is important because of its serious complications. We report 4 patients (28,28,37 and 28 years old) admitted to a department of infectious diseases with meningitis, sepsis and orbital cellulitis as complications of acute sphenoidal cavity infection. The cases illustrate the value of computed tomography (CT) scan of the sphenoid sinus in the evaluation of patients with rlinical features suspicious of sphenoid sinusitis.
0. Qktedalen, MD, PhD, Department of Medicine, Section of Infectious Diseases, Ullevd University Hospital, Oslo, Norway
INTRODUCTION Many physicians are unfamiliar with the diagnosis of sphenoid sinusitis. The infection is not common ( 1 ) . and is often misdiagnosed. Located deep in the cranium the sphenoid sinus is not accessible to direct physical examination, and the history is often difficult to interpret. Most patients experience headache and facial pains as initial symptoms, and the diagnosis is often mistaken for common headache, migraine headache or trigeminal neuralgia. The diagnosis and treatment are delayed, and the risk of complications associated with serious morbidity and high mortality is increased. Many of these patients are not thoroughly examined until other neurologic deficits become apparent, and the infection has spread to adjacent vital structures as the dura mater, optic canals o r cavernous sinus. Sphenoid sinusitis is mostly a diagnosis of interest for the family physician and the otorhinolaryngologist. but the internist should also be aware of its existence because of its serious complications that might bring these patients to medical departments. We present 4 patients who during a period of 4 months were admitted to our department of infectious diseases with symptoms of meningitis, sepsis or orbital cellulitis, and where the focus of infection was the sphenoidal sinus. The cases illustrate the necessity for computed tomography scan and that plain roentgenography of the sphenoidal sinus is not reliable in the evaluation of these patients. CASE REPORTS Caw 1 A 28-year-old man had a 7 day history of fever, freezing, headache, nausea. frequent coughing and general muscle pain. For 2 days he was treated orally by his family doctor with erythromycin in ordinary doses. However, the patient's condition worsened. and he was examined by a general physician who found neck stiffness compatible with meningeal irritation. On admission, he was conscious, normotensive with tcmpcraturc of 41.3"C, showed purpuric rash on the arms, and stiffness of the back and neck. Blood tests showed a sedimentation rate (ESR) of 68, C-reactive protein (CRP) 117, leucocytes 6.5 x 10'/1 with 70% polynuclear and 6% rods, hyperglycemia (8.8 mmolll), no bacterial growth from blood cultures and normal flora from the throat and nose. Cerebrospinal fluid (CSF) revealed pleocytosis with 170x 10hcells/l.mostly mononuclear, but no bacterial growth. Plain X-rays of the paranasal sinuses werc normal (Fig. 1A). while computed tomography of the sinuses and the cerebrum performed the day after arrival showed massive and moderate opacification of the right and left sphenoidal sinus respectively
23'
Scand J Infect Dis Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
354 0. (aktedalen and F: Lillecis
Fig. 1 A P l m X-ray shows no significant opacification of the Sinuses. opacification of the right rphenoid sinus
Scand J Infect Dis 24
-
B. CT-scan shows massive
(Fig. JB). In addition, the left maxilla sinus had a thickened mucosa. The brain showed signs of moderate edema. The diagnosis of primary sphenoidal sinusitis with complicating reactive meningitis was made. He was treated with ampicillin, was later followed as an outpatient and showed no neurological sequelae.
Case 2 A previously healthy man. 28 years of age. had a 4-day history of high fever and headache. He lived alone and was twice examined by a general clinician who recommended analgetics and antipyretics. A few hours before arrival he developed a left side periorbital edema and was found unconscious in his flat. On admission, hc was mentally confused and excited. The left eye showed periorbital swelling, injected conjunctivae, slight exophthalmos. normal reaction of the pupil and normal movement of the bulbus. A pronounced stiffness of the neck and columna was found. ESR was 23, C R P 225, leucocytes 26.5 x 10y/l,pleocytosis of the CSF with 8300X lo6cells/l and > 40% polynuclear. Furthermore, the CSF showed elevated levels of protein (0.62 g/l) and a decreased fraction of glucose (0.07). Microscopic investigation of the fluid revealed Gram-positive diplococci with capsule, and microbiological tests showed growth of Streptococcus pneumoniae. In addition. S. pneumoniae was grown from 2 of 3 blood cultures. Plain X-rays of the thorax was normal. and C T scan of the sinuses performed some hours after arrival revealed massive and slight opacification of the left sinus sphenoidalis and the left sinus ethmoidalis, respectively. C T scan of the orbita showed slight retrobulbar edema on the left side, and a small degree of exophthalmos. A diagnosis of acute sphenoidal cavity infection with complicating bacterial meningitis was made. H e responded well to penicillin, and an otorhinolaryngologist found no indication for surgical intervention. Therc were no signs of somatic sequelae in later controls. Case 3
A 37-ycar-old woman was previously healthy. The last 7 days she had felt ill with fever, frontal headache
and frequent coughing. The last 3 days the condition worsened with freezing. high fever, nausea and vomiting. She was twice seen by a general physician. O n admission, she was mentally oriented, febrile and septic. No rash and no stiffness of the back or neck was noted. ESR was 75, C R P 448, leucocytes 19.8 x 10y/l with 75% polynuclear and 15% rods. The CSF was normal. There was no growth in 6 blood cultures. moderate growth of S. pneumoniae from the nasal cavity, and normal flora from the throat. Plan X-rays of the sinuses were normal, while C T scan of the sinuses performed 2 days later disclosed massive opacification of both the sphenoidal and the ethmoidal sinus on the right side. The patient presented a condition of septicemia with the infective focus in the sphenoidal sinus. She was initially
Sc;~nd I Infect Dis
21
Sphenoidal sit1ids iris 35 5
trea1c.d with ccfuroxime and tobramycin in combination. which was later changed to penicillin tablets. and the condition improved rapidly.
Scand J Infect Dis Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
C'crsr
1
A man. 28 years of age, was HIV-infected 3 yews earlier. H e had previously been treated for Pneuinocystis carinii pulmonary infection and was in addition controlled for chronical diarrhoea. He had daily intake of azidothymidine and acyclovir for the HIV infection. The last 4 days he noticed a swelling around the left eye, and the last few hours he developed fever. started freezing and complained of headache. On arrival, he was mentally oriented and did not look seriously ill. The left eye showed pcriotbital edema and injected conjunctivae. The hulbus was painful at palpation. but there w a s no exophthalmos and n o purulent discharge from the eye. ESK was 42, C R P 13, leucocytes 1.8 X 10"A with 44% polynuclcar, and CD4 as low as 0.04 X l(I''/l. Spinal puncture was not performed. No bacterial growth was obtained in 6 blood cultures, no bacterial growth from the conjunctiva: massive growth. however. of S. pneumoniae and Haemophilus influenzae from the nose. Plain X-rays of the sinuses were negative. However, CT scan of the sinuses showed massive opacification of the left side sinus sphenoidalis and a slight opacification of the right side sinus cthmoidalis. The condition was evaluated as an acute infection of the sinus sphenoidalis with complicating orbital cellulitis. He was intially treated with cefuroxirnc which was later changed to tablets of erythromycin, and he responded well.
DISCUSSION
Sphenoid sinusitis is an uncommon infection that should be taken into account because of its scrious complications as meningitis, blindncss. sepsis, intra- or extracranial abscesses, lesions of cranial nerves and thrombosis of the cavernous sinus. Our cases illustrate that the diagnosis is difficult and that repeated examinations are required. All our paticnts showed a history of fever and headache which are the most common initial symptoms of the disease ( I . 2). Progressive headache in combination with nasal discharge. visual disturbances and hyper- o r hypoesthesia of the branches of thc fifth cranial nerve are symptoms pointing to sphenoidal cavity infection with beginning sprcad. and should hasten further evaluation and intervention (2). Characteristically, the diagnoses and treatment of our patients were delayed until they presented symptoms of Complications as meningitis, sepsis or orbital cellulitis. One patient (case 2) in particular was critically ill on presentation. However, the diagnosis was quickly established through CT scan of the paranasal sinuses. Interestingly, 3 o f 4 referred patients showed normal sinuses in plain sinus radiographs, and the diagnosis of acute sphenoidal sinusitis was made by C T scan. The observation is compatible with previous reports that plain X-rays of the sinus are not reliable in the diagnosis of sphenoidal cavity infection and that CT scan is indicated (1, 3-5). I t appears important to establish an early diagnosis and start appropriate treatment t o niinimise the risk of serious complications and permanent sequelae. Our patients had a short history of infection which could have attributed to the happy outcome of the treatment. They responded well to antibiotics. were repeatedly examined by otorhinolaryngologists, CT scans were repeated b u t there was no indication for surgical evacuation of the sinus. The case reports should remind the internist of the possibility of sphenoid sinusitis as a primary focus of infection when evaluating patients with serious bacterial diseases in the head. REFERENCES I . L.ew D, Southwick FS. Montgomery WW, Webcr AL. Raker AS. Sphenoid sinusitis. N Engl J Med 309: 1 149-1 154. 1983.
356 0. 0ktedalen and E Lilleis
Scand J lnfect Dis 24
Scand J Infect Dis Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
2. Wyllie JW, Kern EB, Djalilian M. Isolated sphenoid sinus lesions. Laryngoscope 83: 1252-1265, 1973. 3. Mizoguchi K, Jojima H, Tanaka M. Hotta M, Yano H, Toyomasu T. Shoji H, Kaji M, Kondo M. Sphenoid sinusitis associated with meningitis, visual disturbances and total ophthalmoplegia. Kurume Med J 35: 211-215, 1988. 4. McAlister WH, Lusk R , Muntz HR. Comparison of plain radiographs and coronal CT scans in infants and children with recurrent sinusitis. AJR 153: 1259-1264, 1989. 5. Roberts C , Nylander AE, Jayaramachandran S. Orbital cellulitis complicating isolated unilateral sphenoidal sinusitis: importance of the CT scan. Br J Ophthalmol 73: 769-770, 1989.
