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© Borgis - New Medicine 2/2003, s. 26-29
Małgorzata Dębska, Eliza Brożek, Anna Bielicka, Mieczysław Chmielik
Complications of sinusitis in children hospitalised between 1994 and 2002
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik M.D.
Summary
Acute sinusitis is a quite commonly occurring disease, although complications have rarely been reported in recent years. Children admitted to the Paediatric Otolaryngology Department of the Medical University in Warsaw between 1994-2002 due to a complicated course of sinusitis were analyzed. The management required, the course of treatment, and length of stay were taken into consideration. The most frequently – occurring complications among orbital, bone and intracranial complications were inflammatory oedema of the eyelids.
INTRODUCTION
Sinusitis and its complications in children are quite frequently discussed. It is very important to follow information in this field in order to apply the most efficient management. The occurrence of complicated sinusitis depends on the anatomical structure of the nasal cavities and sinuses, and but also on the immunological processes responsible for both the local and general immunity of the developing system. Knowledge of sinus development in a child is particularly important in appropriate interpretation of radiological examination, thus facilitating a differential diagnosis.
THE DEVELOPMENT AND ANATOMICAL RELATIONS OF THE PARANASAL SINUSES
Paranasal sinus growth occurs due to the pneumatization process i.e. the enlargement of mucosal recesses in the facial skeleton and a bone resorption process. Two stages of pneumatization are distinguished, primary involving the maxillary sinuses, anterior and posterior ethmoid cells and frontal sinus, and secondary, covering all the sinuses including the sphenoid sinus (1).
Of particular importance in the development of sinuses are the anterior ethmoid cells, for they appear first viz. between the 2nd and 3rd month of foetal life and at birth their dimensions are 5x2x3 mm (2). They reach their final shape around the 12th year of age. They drain into the nasal cavities in the upper part of the middle meatus through the ethmoidal infundibulum. Next, the posterior ethmoid cells appear about the 6th month of foetal life, and in a newborn their size is approximately 5x4x2 mm (2). They drain into the superior meatus. Their growth ends simultaneously with the anterior ethmoid cells. It is clinically important that the ethmoid cells are better developed in infancy than other sinuses, and that they lie close to the orbital tissues. The orbital wall is thinnest in the area of the lamina papyracea. This means that ethmoiditis in newborns and infants always implies the possibility of an inflammatory spread in the orbital tissues. Sinusitis expansion through continuity may occur due to the existence of bony dehiscences in the wall of the orbit, most commonly existing in the area of the above-mentioned lamina papyracea.
The 3rd month of foetal life brings the onset of development of the maxillary sinuses. At delivery, their size is 7x3x5mm, bilaterally. These narrow fissures, lying on the sides of the nasal cavities and reaching the infraorbital canal, are filled with tooth buds and cancellous bone. The gradual growth of the maxillary sinuses depends on the process of teeth eruption. The beginning of secondary dentition (about the 7th year of age) allows the maxillary sinus to enlarge effectively. It reaches its final size at age twenty. In the beginning, it communicates with the nasal cavity through an aperture 4mm long and 1mm wide, finally forming the ethmoidal infundibulum. Until the 6th-8th year of age, the bottom of the sinuses lies above the bottom of the nasal cavities, which is important in clinical practice when performing a sinus puncture (1).
The frontal sinus either does not exist in a newborn, or only forms a minute frontal recess, which does not present any particular growth features until the 6th year. The chance of ethmoiditis spreading towards the frontal sinus and on towards the brain is small, due to sufficiently thick bony structures. The risk of acquiring meningitis this way is very rare. In the literature we can find a few cases of frontal sinusitis complicated with subperiosteal abscess formation in the orbital wall. Their occurrence was probably connected with the existence of bony dehiscence in other places than the lamina papyracea (3). The frontal sinus reaches its final size and shape at age twenty.
Similarly, the sphenoid sinus shows a late onset of development. From originally being a small recess, it starts to have a lumen at the age of 4, and it grows until the 15th or 16th year. Some paricular structures lie close to the sinus; viz: cranial nerves II-IV, the internal carotid artery, cavernous sinus, spheno-palatine nerve and ganglion, pituitary gland and dura mater. Cadaver studies show that the bone between the sinus and the optic nerve is less than 0.5 mm thick and in 4 % of the study group there was bony dehiscence (4). Such anatomy favours the complications, especially the loss of vision.
Paranasal sinus hypoplasia may occur in diseases such as: pituitary microsomia, Down´s syndrome, hemifacial hypoplasia but also may exist as an isolated form.
It is worth mentioning the vascular system, especially the veins joining the maxillary sinuses, the frontal sinus and the ethmoid cells with the orbit and middle cranial fossa. These veins are important for their lack of valves, which allows an easy way of communication between the above-mentioned structures.
COMPLICATIONS OF SINUSITIS
Complications of sinusitis can be divided into orbital, bone (osteomyelitis), and intracranial complications. The classification in the first group has been changing since 1937 when Hubert specified five groups relative to the intensity and scope of inflammatory changes:
1. Oedematous eyelids with or without orbital tissue oedema,
2. Subperiosteal abscess with eyelid oedema and purulent excudate,
3. Orbital abscess,
4. Orbital cellulitis and phlebitis,
5. Thrombophlebitis of the cavernous sinus.
In course of time the above classification has been modified. It is worth mentioning that each category is not a separate disease, but together they present a certain continuity, giving the idea of an advancing inflammatory process. At the moment the greatest interest is focused on Chandler´s classification (1970) (table 1).
Table 1. Complications of the sinuses after Chandler.
Group 1Eyelid oedema in the preseptal area without the loss of either eyeball motility or visual acuity
Group 2Orbital cellulitis without subperiosteal abscess formation
Group 3Orbital cellulitis with a subperiosteal abscess formed between the periosteum and the bone forming the orbital cavity
Group 4Orbital cellulitis associated with an abscess in the orbital fat - proptosistranslocating the eyelid forwards, severe limitation of mobility and loss ofvision due to optic neuropathy
Group 5Cavernous thrombophlebitis - phlebitis in the orbital cavity, involving the cavernous sinus, and spreading on the opposite side through the basilar venous plexus resulting in bilateral changes
The orbital complications described usually occur unilaterally, although the literature has provided us with a case of bilateral occurrence without affecting the cavernous and basilar venous plexus (6). A subperiosteal abscess in a child´s orbit has also been described in the superolateral part, as a complication of frontal sinusitis (3).
Complicated sinusitis in children also covers maxillary osteomyelitis and frontal osteomyelitis (with Pott´s puffy tumour). The spongy substance in the frontal bone and in the upper jaw of younger children contains vessels called Brechet veins. Due to their structure, they favour thrombus formation close to the wall of the vessel, thus leading to osteomyelitis. Maxillary osteomyelitis is characteristic of the presence of inflammatory infiltration in the buccal region, which may spread towards the palate and alveolar processes and lead to the formation of an alveolar fistula. An inflammatory condition involving the zygomatic process may spread in the supratemporal or pterygopalatine fossa. Inflammation involving the anterior wall of the frontal sinus may produce a subperiosteal abscess, continuing to the soft tosues of the forehead, with skin oedema, i.e. Pott´s puffy tumour.

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New Medicine 2/2003
Strona internetowa czasopisma New Medicine