Post on 01-Jan-2017
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Complications of Pediatric Sinusitis
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
22 January 2007
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Outline
1. Paranasal sinus anatomy2. Definitions3. Indications for imaging4. Imaging modalities5. Patient presentation6. Summary
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Sinus Anatomy
Essential Clinical Anatomy, 2002
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Sinus Plain Films
http://xray.20m.com/photo.html
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Sinus Development
Age (years)Sinus Appearance Maturity
Maxillary Embryo 12-20
Ethmoid Birth 12
Sphenoid 1-3 7-14
Frontal 1-4 ≥
12
Kronemer and McAlister, 1997
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Acute vs Chronic Sinusitis
Acute • Bacterial infection of the paranasal sinuses• Symptoms last less than 30 days • Complete resolution
Chronic• Inflammation of the paranasal sinuses • Symptoms last more than 90 days • Persistent residual respiratory symptoms of cough,
rhinorrhea and nasal obstruction
American Academy of Pediatrics, 2001
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Complications of Sinusitis
Reid, 2004
Orbital Intracranial1. Edema2. Preseptal cellulitis3. Postseptal cellulitis4. Subperiosteal abscess5. Orbital abscess6. Cavernous sinus
thrombosis
1. Epidural empyema2. Subdural empyema3. Meningitis4. Cerebritis5. Parenchymal abscess6. Mycotic aneurysm7. Brain infarction
Subgaleal1. Pott’s puffy tumor2. Osteomyelitis
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Indications for Imaging
1. Purulent nasal discharge >10 days2. Recurrent or persistent clinical sinusitis3. Preoperative evaluation for functional
endoscopic sinus surgery (FESS)4. Suspected complication5. Complex sinus disease 6. Suspected fungal sinusitis
*Imaging is not recommended for uncomplicated acute sinusitis
American College of Radiology, 2006
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Imaging Modalities to Diagnose Chronic Sinustis
Plain Film Radiograph• Low sensitivity and therefore seldom used• Caldwell (anteroposterior) - frontal, ant ethmoid• Normal lateral – sphenoid• Waters (occipitomental) - maxillary, ethmoid
CT• High sensitivity and therefore the test of choice• Coronal projection most accurate view of sinus anatomy• Bone window on bone algorithm for sinus views• Contrast for intracranial pathology• Imaging for functional endoscopic sinus surgery (FESS)• Radiation exposure
American College of Radiology, 2006
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Imaging Modality for Complications of Sinusitis
T1 Anatomy
T1 + Gadolinium Vasculature, malignancy
T2 Inflammation/fluid
FLAIR Inflammation
Diffusion weighted Ischemia
Angiography Vasculature
MRI• Intracranial pathology and complex sinus disease• Lacks bony detail of sinus anatomy• Long image collection time may require sedation• No radiation
American College of Radiology, 2006 and Boyle, 2006
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Abnormal Sinuses in
Children
Incidence of abnormal sinus CT in children with no history of sinusitis
• 55% had abnormal sinuses• 33% had air fluid levels in sinuses
High incidence (62%) of viral URI symptoms or allergic rhinitis within the past 2 weeks
Maning et al, 1996
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Modified Lund-Mackay
Staging System
Correlation of clinical symptoms of chronic sinusitis with CT radiographs
• Paranasal sinuses opacification0 none, 1 partial, 2 completeAssign score independently to left and right paranasal sinuses
• Osteomeatal complex0 not occluded, 2 occluded
• Sinus not developed: 0
Score: 0-2 no disease, 3-4 equivocal, ≥5 chronic sinusitis
Bhattacharyya et al, 2004
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Patient Presentation
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Patient BE
• 11 year old previously healthy girl
• 4 day history of headache, lethargy, fever, malaise and sinus congestion
• Seizure during transfer from OSH
• No significant past medical history
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Patient BE: Sinusitis on CT
Coronal CT Bone Window
Courtesy of Dr Hines-Peralta
1
2
3
4
4. Near total opacification of the frontal sinuses
1. Opacification of the ethmoid sinuses2. Opacification of the right maxillary sinus3. Concha bullosa a normal variant
Axial CT Bone Window
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Differential of
Opacified Sinsuses1. Sinusitis
• GERD• Immune deficiency
syndrome• URI
2. Trauma• Hemorrhage• Edema
3. Allergy4. Cystic fibrosis
5. Inflammatory mass• Mucocele• Cyst• Pyocele• Polyp
6. Malignancy • Burkitt Lymphoma• Osteoma
7. Granulomatous Disease• Sarcoidosis• Tuberculosis
8. Dysfunctional cilia• Kartagener’s syndrome• Immotile cilia syndrome
Reeder, 2003
Naana Afua Jumah, HMS IIIGillian Lieberman, MD `
Axial CT Bone Window Axial MR T2
Courtesy of Dr Hines-Peralta
1. Opacification of the ethmoid sinuses2. Opacification of the sphenoid sinuses3. Fluid in the right mastoid air cells
4. Chronic sinusitis in the maxillary sinuses5. Frothy appearance of acute sinusitis in
the maxillary sinus
2
3
1 45
Patient BE: Sinusitis on CT and MRI
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
MR T1 Pre-contrast MR T1 Post-contrast
Courtesy of Dr Hines-Peralta
1. Low signal areas in the anterior and left lateral temporal lobes indicating regions of restricted diffusion suggestive of edema or fluid
1
1
2
2
2. Low signal areas in the anterior and left lateral temporal lobe surrounded by a rim of enhancement consistent with empyema
Patient BE: Subdural Empyema on Axial MRI
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Courtesy of Dr Hines-Peralta
Coronoal MR T1 with Contrast2. Low signal areas surrounded by
a rim of enhancement consistent with empyema on sagittal section
1
12
Patient BE: Subdural Empyema on MRI
1. Low signal areas surrounded by a rim of enhancement consistent with empyema on coronal section
Sagittal MR T1 with Contrast
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Courtesy of Dr Hines-Peralta
Patient BE: Meningitis on MRI
Axial MR T1 with Contrast
1
1. Focal areas of subtle enhancement of the meninges consistent with meningitis
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Companion Patient 1: Meningitis on MRI
http://www.math.uno.edu/~jensen/L/neuropath/images.htm
Axial MR T1 Pre-contrast Axial MR T1 Post-contrast
1 2
2. Ring of enhancement surrounding the cerebellum consistent with meningitis
1. Meninges appear as a ring of low signal intensity
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Patient BE: Cerebral Edema
on MRI
Courtesy of Dr Hines-Peralta
Axial MR T1 Pre-contrast
1. Midline shift
2. Compression of the anterior horn of the lateral ventricle
3. Compression of the left posterior horn of the lateral ventricle
4. Diffuse effacement of the cortical gyri shown best in the left parietal lobe
2
1
4
3
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Patient BE: Cerebral Edema
Courtesy of Dr Hines-Peralta
Axial MR T1 Post-contrast Axial MR T2-weighted1. Low signal areas indicating restricted
diffusion in the frontal lobes bilaterally and the temporal lobe suggestive of edema or a fluid collection
2. High signal areas that follow the pattern of the gyri in the frontal lobes bilaterally and the temporal lobe more suggestive of edema than a fluid collection
1 2
on MRI
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Patient BE: Cerebral Ischemia on Diffusion-Weighted Imaging
Courtesy of Dr Hines-Peralta
Axial MR Diffusion-Weighted Image
1. High signal areas that follow the pattern of the gyri in the frontal lobes bilaterally and the temporal lobe localizing areas of cerebral ischemia
1
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Patient BE: Shunt &
Craniectomy on CT
Courtesy of Dr Hines-Peralta
Axial CT Brain Window
1
2
3
1. Intraventricular shunt
2. Craniectomy site and herniation of the left cerebral hemisphere beyond the skull margin
3. Post surgical aberrant air collections
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Brain Abscess on CT & MRI
Courtesy of Dr Hines-Peralta and Nadalo and Hunter, 2004
Companion Patient 2: Axial MR T1 with Contrast
Patient BE: Follow-up Axial CT Brain Window
1
2
3
1. Site of second craniectomy
2. Suspected abcess in left parietal lobe. Finding needs to be confirmed on MRI
3. Pair of rim enhancing lesions with low signal intensity indicating the presence of an intraparenchymal abscess
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Summary of Patient BE
• 11 year old girl with symptoms of sinusitis suspected of having complications
• Coronal CT showed opacification of the paranasal sinuses
• MRI showed subdural empyema, meningitis, cerebral edema and cerebral ischemia
• An interventricular shunt was placed and a craniectomy was performed
• CT showed a second craniectomy site and the development of a possible parenchymal abscess and
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Companion Patients
Companion patients are shown to illustrate the following radiographic findings:
• Orbital cellulitis and subperiosteal abscess - the most common complication of sinusitis
• Cavernous sinus thrombosis - a must not miss diagnosis
• Pott’s Puffy Tumor
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Orbital Cellulitis & Subperiosteal Abscess on CT
Kirsch and Turbin, 2005 and Reid, 2004
Companion Patient 4: Axial CT with Contrast Soft Tissue Window
Companion Patient 3: Coronal CT with Contrast Soft Tissue Window
2
16
5
3
4
1. Opacification of the ethmoid sinuses
2. Air-fluid level in the right maxillary sinus
3. Periobital soft tissue edema
4. Hypoplasia of the left maxillary sinus
5. Proptosis of the right orbit
6. Lentiform region of low signal with rim enhancement consistent with abscess. Lateral deviation of the medial rectus.
Naana Afua Jumah, HMS IIIGillian Lieberman, MD
Cavernous Sinus Thrombosis on MRI
Zimmer et al, 2006
Companion Patient 5: MR Angiogram
Companion Patient 5: Coronal MR T1 Post-contrast
12
1. Cavernous sinus thrombosis 2. Wall thickening of the right cavernous sinus
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Pott’s Puffy Tumor on MRI
Ghorayeb, 2006 and Thomson Health, 2006
Companion Patient 6: MR T1 with Contrast
Companion Patient 7
1. Sagittal view of opacified frontal sinus with fistula to soft tissue overlying the frontal bone and soft tissue edema
2. Axial view showing the same
12
Naana Afua Jumah, HMS IIIGillian Lieberman, MD Summary
Sinusitis, complications and correlation with imaging
Coronal CT MR T1 ±
contrast MR T2 & T2 weighted
Naana Afua Jumah, HMS IIIGillian Lieberman, MD References
1. American College of Radiology. 2006. ACR Appropriateness Criteria, Sinusitis – Child.2. KL Moore and AMR Agur. Essential Clinical Anatomy, 2nd ed. Baltimore: Lippincott Willams & Wilkins,
2002. p 577.3. SJ Zinreich. 2006. Progress in sinonasal imaging. Ann Oto Rhino Laryn. 115(9)Suppl 196:61-65.4. JR Reid. 2004. Complications of pediatric paranasal sinusitis. Pediatr Radiol. 34:933-942.5. N Bhattacharrya, DT Jones, M Hill and NL Shapiro. 2004. The diagnostic accuracy of computed
tomography in pediatric chronic sinusitis. Arch Otolaryngol Head Neck Surg. 130:1029-1032.6. Welcome to radiography reporting. http://xray.20m.com/photo.html. Accessed 18 January 2007.7. S Maning, MJ Biavati and DL Philips. 1996. Correlation of clinical sinusitis signs and symptoms to
imaging findings in pediatric patients. Int J Pediatr Otorhinolaryn. 37:65-74.8. GE Boyle, M Ahern, J Cooke, NP Sheehy, and JF Meaney. 2006. An Interactive Taxonomy of MR
Imaging Sequences. Radiographics. 26:e24 9. KA Kronemer and WH McAlister. 1997. Sinusitis and its imaging in the pediatric population. Pediatr
Radiol. 27:837-846.10. Congental malformations, hydroencephaly, and herniation.
http://www.math.uno.edu/~jensen/L/neuropath/images.htm. Accessed 18 January 2007.11. J Zimmer, J Bhatt, JH Conway, M Edwards-Brown, DK Sokol. 2006. Is it all in his head?. Internet J
Pediatr Neonat. 6(1) .12. BY Ghorayeb. 2006. Otolaryngology Houston. Accessed 18 January 2007.
http://www.ghorayeb.com/PottsPuffyTumor.html13. Thomson Healthcare. 2006. Sinusitis. PDR Health.
http://www.pdrhealth.com/patient_education/BHG01ID21.shtml. Accessed 19 January 2007. 14. American Academy of Pediatrics. 2001. Clinical practice guideline: management of sinusitis.
Pediatrics. 108:798-808.15. LA Nadalo and LK Hunter. 2004. Brain Abscess. http://www.emedicine.com/radio/topic91.htm.
Accessed 20 January 2007.16. CFE Kirsch and R Turbin. 2005. Orbit, Infections. eMedicine.
http://www.emedicine.com/radio/topic490.htm. Accessed. 20 January 2007. 17. MM Reeder. Reeder and Felson’s Gamuts in Radiology, 4th ed. New York: Springer, 2003, p 133.
Naana Afua Jumah, HMS IIIGillian Lieberman, MD With Thanks to . . .
Andrew Hines-Peralta, MDNeil Bhattacharyya, MD FACSGillian Lieberman, MDPamela LepkowskiLarry Barbaras, Webmaster