Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
Citations 0
Special Feature
March 1, 2010

Picture of the Month—Diagnosis

Author Affiliations



Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2010

Arch Pediatr Adolesc Med. 2010;164(3):290-291. doi:10.1001/archpediatrics.2010.2-b
Denouement and Discussion: Sinusitis Complicated by Epidural Abscess

The MR image showed a large fluid-filled collection overlying the apical aspect of both cerebral hemispheres (Figure 2), consistent with epidural abscess. An MR venogram showed significant compression of the superior sagittal sinus by the abscess (Figure 3), prompting urgent burr hole drainage of the collection in conjunction with frontal sinus surgery. A postoperative MR venogram showed that venous circulation had been successfully restored. Following surgery, a combination of ticarcillin disodium and clavulanate potassium was initiated intravenously. Cultures of pus drained intraoperatively grew Streptococcus intermediussusceptible to penicillin, ampicillin, and cephalexin. The patient made an uneventful recovery and was discharged without neurological sequelae after 2 weeks. A computed tomographic scan after 6 weeks of intravenous antibiotic therapy showed complete resolution of the intracranial and extracranial pathology, as well as improvement of the osteolytic changes.

Figure 2.
Image not available

T2-weighted (A) and T1-weighted (B) cranial magnetic resonance images. The findings are described in detail in the “Denouement and Discussion” section.

Figure 3.
Image not available

Magnetic resonance venogram showing displacement and compression of the superior sagittal sinus (arrows) caused by the epidural abscess.

Bacterial sinusitis is a common infection that generally resolves without sequelae.1Intracranial complications associated with sinusitis are thought to be rare, although definitive data are lacking. One large multicenter study2reported intracranial complications in 3.7% of patients hospitalized with sinusitis. However, because these represent the severe end of the disease spectrum, the overall incidence is likely to be considerably lower.

The spectrum of suppurative intracranial complications associated with sinusitis includes meningitis, intracerebral (parenchymal) abscess, subdural empyema, and epidural abscess. Epidural abscess is thought to result from retrograde bacterial spread into the epidural space via diploic skull veins.3Coexisting osteomyelitis of the skull, which was also present in the case described herein, is commonly observed.3

The absence of characteristic features associated with epidural abscess often makes the diagnosis difficult. Most patients have nonspecific symptoms, frequently consisting of only fever and headache; in contrast to intracerebral abscess, focal neurological symptoms are rare.1,2,4Signs of meningeal irritation, such as nuchal rigidity and Kernig and Brudzinski signs, are rarely present, whereas these are common in patients with subdural empyema.5

A broad range of bacteria can cause intracranial complications associated with sinusitis, including streptococci, Staphylococcus aureus, Haemophilus influenzae, enterococci, and anaerobic bacteria such as Peptostreptococcusspecies, Bacteroidesspecies, and Fusobacteriumspecies.1Bacteria of the Streptococcus millerigroup, which includes S intermedius, Streptococcus constellatus,and Streptococcus anginosus, are generally overrepresented.1,2,4,6,7These bacteria are part of the normal commensal respiratory and gastrointestinal flora.8However, unlike other viridans streptococci, they have a propensity to cause deep-seated abscesses and are responsible for 56% to 81% of central nervous system abscesses.8,9The majority of clinical S millerigroup isolates are susceptible to penicillin and most cephalosporins, although isolates with multiple resistance have been reported.9,10

Thrombosis of the cavernous sinus or intracranial dural sinuses are further potential intracranial complications of sinusitis.2The patient described herein was at considerable risk of sagittal sinus thrombosis given the proximity of this structure to an area of inflammation in conjunction with marked compression. The MR venogram provided valuable additional information that helped to guide management decisions toward a surgical rather than a conservative approach.

Most patients with epidural abscess make a full recovery7if appropriate management is initiated in a timely fashion. However, cases with poor outcome and long-term neurological sequelae have been described.11

This report highlights that inadequate treatment of sinusitis can result in severe suppurative intracranial complications, which may present with only nonspecific clinical features.

Return to Quiz Case.

Back to top
Article Information

Correspondence:Marc Tebruegge, MRCPCH, MD, Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, Victoria 3052, Australia (

Accepted for Publication:November 30, 2009.

Author Contributions:Study concept and design: Tebruegge, Curtis, and Bryant. Acquisition of data: Tebruegge and Bryant. Analysis and interpretation of data: Tebruegge, Wallace, Starr, and Bryant. Drafting of the manuscript: Tebruegge, Curtis, and Bryant. Critical revision of the manuscript for important intellectual content: Tebruegge, Curtis, Wallace, Starr, and Bryant. Study supervision: Tebruegge, Curtis, Wallace, Starr, and Bryant.

Financial Disclosure:None reported.

Osborn  MKSteinberg  JP Subdural empyema and other suppurative complications of paranasal sinusitis. Lancet Infect Dis 2007;7 (1) 62- 67
Clayman  GLAdams  GLPaugh  DRKoopmann  CF  Jr Intracranial complications of paranasal sinusitis: a combined institutional review. Laryngoscope 1991;101 (3) 234- 239
Giannoni  CMStewart  MGAlford  EL Intracranial complications of sinusitis. Laryngoscope 1997;107 (7) 863- 867
Gallagher  RMGross  CWPhillips  CD Suppurative intracranial complications of sinusitis. Laryngoscope 1998;108 (11, pt 1) 1635- 1642
Dill  SRCobbs  CGMcDonald  CK Subdural empyema: analysis of 32 cases and review. Clin Infect Dis 1995;20 (2) 372- 386
Kombogiorgas  DSeth  RAthwal  RModha  JSingh  J Suppurative intracranial complications of sinusitis in adolescence: single institute experience and review of literature. Br J Neurosurg 2007;21 (6) 603- 609
Legrand  MRoujeau  TMeyer  PCarli  POrliaguet  GBlanot  S Paediatric intracranial empyema: differences according to age. Eur J Pediatr 2009;168 (10) 1235- 1241
Belko  JGoldmann  DAMacone  AZaidi  AK Clinically significant infections with organisms of the Streptococcus millerigroup. Pediatr Infect Dis J 2002;21 (8) 715- 723
Ruoff  KL Streptococcus anginosus(“Streptococcus milleri”): the unrecognized pathogen. Clin Microbiol Rev 1988;1 (1) 102- 108
Aracil  BGomez-Garces  JLAlos  JI A study of susceptibility of 100 clinical isolates belonging to the Streptococcus millerigroup to 16 cephalosporins. J Antimicrob Chemother 1999;43 (3) 399- 402
González-López  JJGórgolas  MMuñiz  JLópez-Medrano  FBarnés  PRFernández Guerrero  ML Spontaneous epidural abscess: analysis of 15 cases with emphasis on diagnostic and prognostic factors. Eur J Intern Med 2009;20 (5) 514- 517