Indian Journal of Otolaryngology and Head & Neck Surgery

INTRACRANIALCOMPLICATIONS OF FRONTAL SINUSITIS BY DIRECT SPREAD –

A CASE REPORT
--Manuscript Draft--

Manuscript Number: IJOO-D-22-00251

Full Title: INTRACRANIALCOMPLICATIONS OF FRONTAL SINUSITIS BY DIRECT SPREAD – A
CASE REPORT
Article Type: Clinical Report
Keywords: Frontal sinusitis; subdural abscess; CSF leak; meningitis; draff procedure
Corresponding Author: Sri Varshini kanjula, MBBS
Dr Pinnammaneni Siddhartha Institute of Medical Sciences and Research Foundation INDIA

Corresponding Author Secondary

Information:
Corresponding Author's Institution: Dr Pinnammaneni Siddhartha Institute of Medical Sciences and Research Foundation
Corresponding Author's Secondary
Institution:
First Author: satish chandra tripuraneni
First Author Secondary Information:
Order of Authors: satish chandra tripuraneni
Sri Varshini kanjula, MBBS
murthy p.s.n
sudhakar rao madala
sameera gera
Order of Authors Secondary Information:
Funding Information:
Abstract: Complications of frontal sinusitis though rare, still develop even with the advent of widespread
antibiotics. Complications of rhinosinusitis are caused by either local or distant spread. Direct
routes of spread are through the neurovascular foramina and diploic veins of frontal, sphenoid,
ethmoid bones. Posterior spread of frontal sinusitis can cause acute intracranial infections.
Subdural empyema is the most common intracranial complication of frontal sinusitis. Here we
are reporting an interesting case that initially presented with seizures, on evaluation patient was
diagnosed to have subdural empyema secondary to frontal sinusitis. In this article, we want to
share our experience of diagnosing and managing successfully.

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Title Page

Title: “ INTRACRANIAL COMPLICATION OF FRONTAL SINUS BY DIRECT SPREAD ”

- Case Report

1st author
Dr.T.Satish Chandra, MS ENT
Professor
Dept.of ENT
Dr.Pinnamaneni Siddhartha Institute of Medical sciences & Research Foundation, Gannavaram Mail:
sctripuraneni@yahoo.com
Ph:9440535769
ORCID iD :- 0000-0002-1813-4758

Corresponding author
Dr.K.SRI VARSHINI MBBS
2nd year Post Graduate
Dept.of ENT
Dr.Pinnamaneni Siddhartha Institute of Medical sciences & Research Foundation, Gannavaram. Mail:
varshinir2896@gmail.com
Ph: 9063392716
ORCID iD: 0000-0003-0455-7810
.

2nd author:
Dr.PSN Murthy, MS DLO
Professor of ENT
Dr.Pinnamaneni Siddhartha Institute of Medical sciences & Research Foundation, Gannavaram Mail:
drmurtypsn@gmail.com
Ph :9963176545
ORCID iD : 0000-0002-4294-7118

3rd author:
Dr.M.Sudhakar, MS ENT
Professor
Dept.of ENT
Dr.Pinnamaneni Siddhartha Institute of Medical sciences & Research Foundation, Gannavaram Mail:
sudhakarraomadala@gmail.com
Ph:9000200333
ORCID iD :- 0000-0001-8955-3485

4th author:
Dr.G.Sameera, MS ENT
Assistant professor
Dept.of ENT
Dr.Pinnamaneni Siddhartha Institute of Medical sciences & Research Foundation, Gannavaram.
Mail:sameeragera@gmail.com
Ph: 9966897799
ORCID iD: 0000-0001-8582-5797
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INTRACRANIALCOMPLICATIONS OF FRONTAL SINUSITIS BY DIRECT SPREAD – A CASE REPORT

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4 ABSTRACT:
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Complications of frontal sinusitis though rare, still develop even with the advent of widespread antibiotics.
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Complications of rhinosinusitis are caused by either local or distant spread. Direct routes of spread are through
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the neurovascular foramina and diploic veins of frontal, sphenoid, ethmoid bones. Posterior spread of frontal
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sinusitis can cause acute intracranial infections. Subdural empyema is the most common intracranial complication
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of frontal sinusitis. Here we are reporting an interesting case that initially presented with seizures, on evaluation
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patient was diagnosed to have subdural empyema secondary to frontal sinusitis. In this article, we want to share
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our experience of diagnosing and managing successfully.
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18 KEYWORDS: Frontal sinusitis, subdural abscess, CSF leak, meningitis, draff procedure.
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20 INTRODUCTION:
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23 Paranasal sinuses were first identified in the bones of the skull by ancient Egyptians [1]. The maxillary
24 sinus was first discovered and illustrated by Leonardo da Vinci. Studies show that 0.5% of upper respiratory
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26 infections may lead to sinusitis. Even though not every upper respiratory infection leads to sinusitis, the possibility
27 of sinusitis remains. Incidence of acute rhinosinusitis is about 6-15% following upper respiratory infection.
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29 chronic rhinosinusitis affects 5-12% of general population. Incidence of complications due to sinusitis has
30 decreased over the years with increased use of early antibiotics. Even after availability of antibiotics,
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32 complications are still occurring may predisposing condition vary.Complications of rhinosinusitis classified as
33 orbital, intracranial and osseous involvement with an incidence of about 60-80%, 15-20% and 5% respectively.
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EPOS 2020 guidelines reiterate that usage of oral antibiotics have not shown significant beneficial effect in
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prevention of complications.
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39 The extension of the infection from the frontal sinus to the anterior cranial fossa leads to intracranial
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41 complications such as meningitis, epidural empyema, subdural abscess, brain abscess and cavernous sinus
42 thrombosis[8]. Morbidity and mortality of these complications are decreasing recently with the use of new
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44 generations of antibiotics, endoscopic sinus surgeries.
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Here we want to share our experience in managing one of the rare presentations of complications secondary to
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48 frontal sinusitis.
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CASE REPORT:
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55 A 62-year-old male was brought to the Emergency Department (ED) with complaints of altered sensorium. The
56 patient had a recent history of upper respiratory symptoms along with fever 2 days ago. Initial vital signs were BP
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58 170/90 mm Hg, HR 90 bpm, oral temperature 96.7o F, and oxygen saturation 100% on room air, with Glasgow
59 Coma Scale on the arrival of 12/15. On physical examination, the patient was found to have a near-normal CNS
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 examination. Initial laboratory investigations are within normal limits, except glycated hemoglobin-14%. He had
1 episodes of focal seizures each lasting for 10-15 min and 3 episodes per day for one day. The neurosurgeon has
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3 started him on antiepileptic treatment. Even after medication he still had episodes of seizures repeatedly.
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A magnetic resonance imaging scan was ordered with and without contrast and T1 and T2 images were generated
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in multiple planes, which revealed a left frontal subdural, epidural empyema with leptomeningitis with left acute
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8 pansinusitis.
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48 Fig 1: MRI BRAIN - Left frontal subdural empyema
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30 Fig 2: MRI BRAIN – Left acute pansinusitis
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The neurosurgeon performed a craniotomy to clear the abscess. Even after surgical clearance patient had episodes
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of seizures so he was paralyzed and ventilated for 48hrs. Antibiotic coverage was given as per the meningitis
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protocol. Culture and sensitivity report of pus came positive for enterococcus faecium, sensitive to vancomycin
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39 and linezolid. Appropriate antibiotic coverage was changed. Repeated episodes of focal seizures persisted till
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41 postoperative craniotomy day 3 which later subsided slowly by day 5.
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43 He was referred to the otorhinolaryngology department in view of sinusitis on the left side.
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An unenhanced CT scan of the brain and paranasal sinuses was obtained that demonstrated erosion of the lower
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part of the posterior wall the frontal sinus extending onto the roof of the left ethmoidal sinus with communication
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48 to subdural space, left sinusitis, and left frontal cerebritis with subdural empyema.
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34 Fig 3 -CT PNS -coronal plane- left pansinusitis
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Fig 4-CT PNS-sagittal plane -defect in the posterior wall of the frontal sinus.
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24 We planned endoscopic surgery where we cleared sinusitis from all the sinuses on the left side. Draff 2 was done
25 on the left side to expose the defect in the Basi-frontal region and identified a 3*2 mm defect near the posterior
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27 table of the frontal sinus and cribriform plate.
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29 Fascia Lata was taken from the lateral aspect of the right thigh along with part of vastus lateralis muscle and the
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31 muscle is tucked into the defect which is covered with fascia Lata by bath plug technique. Proper sealing of the
32 defect was confirmed by the Valsalva maneuver. The left nasal cavity was packed with merocele and the anterior
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34 nasal dressing was done.
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36 Merocele in nasal cavity was removed on postoperative day 2 and the patient was under observation till day 5 and
37 was uneventful.
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40 The patient was discharged on the 6th post-operative day.
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42 The patient is under regular follow up and is doing well
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DISCUSSION:
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Complications of bacterial rhinosinusitis are subdivided into orbital, extracranial, and intracranial[1]. The
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intracranial complications include meningitis, epidural or subdural empyema, cerebral abscess, and dural venous
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sinus thrombosis. Complications of sinusitis are more common in the Pediatric age group and persons with
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53 immunosuppression.
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Complications of sinusitis, rare with the advent of antibiotics, still persist leading to significant morbidity and
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57 mortality [2]. Complications of frontal sinusitis include orbital complications through the roof of the orbit,
58 mucocele/ pyocele, Potts puffy tumor, and intracranial complications [3]. Intracranial complications from frontal
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60 sinus occur either by Direct spread by the erosion of the sinus wall or through preformed pathways and the natural
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 skull foramina. A more commonly known mechanism is the indirect spread via retrograde septic
thrombophlebitis
1 of valveless emissary veins[6].
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Fairbanks et al. state that either superior longitudinal sinus thrombosis or subdural empyema precedes a rhinogenic
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abscess [4]. Usually, all these complications are preceded by signs and symptoms suggestive of sinusitis. Very
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rarely they do present directly with symptoms of intracranial complications.
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9 CECT is the initial investigation of choice whenever we are suspecting intracranial complications. MRI is the
10 gold standard in diagnosing intracranial infections [5]. Lumbar puncture is contraindicated in cases of suspected
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12 or confirmed any form of brain abscess as it can lead to tentorial herniation and sometimes even death.
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The patient with established intracranial complications has to be treated for complications first. Once the patient
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is stabilized, we have to treat the sinusitis component.
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18 In our case, once the intracranial components were treated and the patient was stabilized, we did the procedure.
19 The patient was having left frontal sinusitis with a defect in the posteroinferior wall of the frontal sinus. We did
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21 draff 2 and cleared the frontal sinus of the disease and closed the defect with a muscle graft.
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Defects in the posteroinferior wall of frontal sinus always possess a challenge in exposure being the narrowest
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area. Draff procedures do provide excellent exposure which helps us in maneuvering that area with straight
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26 instruments.
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28 Incidence of intracranial complications secondary to direct bony defect without a history of previous trauma is
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30 very rare.
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In our case adult male with an immunocompetent state and spread of sinusitis is by direct erosion of the posterior
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table of the frontal sinus. Here we managed this case successfully in coordination with the neurosurgeon.
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CONCLUSION:
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Even with the advent and use of antibiotics, the fatal complications of frontal sinusitis still develop. It is important
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to diagnose and manage the complications as soon as possible. Multidisciplinary treatment with radiologists,
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neurosurgeons, otorhinolaryngology, ophthalmology, and anesthesia is very important in the management of a
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case with frontal sinus [10]. Draff procedure does provide very good exposure as far as the posterior table of
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frontal sinus by which we can avoid open procedures.
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53 STATEMENTS:
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55 Conflict of interest: no conflict of interest.
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Ethical approval: In accordance with the ethical standards of the institution.

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2 REFERENCES:
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4 [1] Evolution of the paranasal sinuses' anatomy through the ages
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Alexandra Mavrodi and George Paraskevas, 2013 Dec, 46(4): 235–238.
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9 [2] Barry L. Wenig, Mark N. Goldstein and Allah L. Abramson. Frontal sinusitis and its intracranial
10 complications. International Journal of Pediatric Otorhinolaryngology, 5 (1983) 285-302.
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[3] Bluestone, C.D., and Steiner, R.E., Intracranial complications of acute frontal sinusitis. South. med.J.,58
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16 [4] Fairbanks, D.N.F., Vander Veen, T.S. and Bordley, J.E., Intracranial complications of frontal sinusitis. In G.M.
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18 English (Ed.), otolaryngology, Williams and Wilkin’s, Philadelphia, 1981, vol. 2, Chap. 38, pp. 1-28.
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20 [5] Dolan RW, Chowdhury K. Diagnosis and treatment of intracranial complications of paranasal sinus infections.
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24 [6] Roche M, Humphreys H, Smyth E, Phillips J, Cunney R, McNamara E, et al. A twelve-year review of central
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[7] Bruner DI, Littlejohn L, Pritchard A (2012) Subdural empyema presenting with seizure, confusion, and focal
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31 [8] Osborn MK, Steinberg JP (2007) Subdural empyema and other suppurative complications of paranasal
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35 [9] Waseem M, Khan S, Bomann S (2008) Subdural empyema complicating sinusitis. J Emerg Med 35: 277-281
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37 [10] Szyfter W, Bartochowska A, Borucki L, Maciejewski A, Kruk-Zagajewska A. Simultaneous treatment of
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39 intracranial complications of paranasal sinusitis. Eur Arch Otorhinolaryngol 2018;275:1165-73.
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