Complications of Pediatric Sinusitis - Naana Afua Jumah, HMS III Gillian Lieberman, MD doc

Naana Afua Jumah, HMS III Gillian Lieberman, MD Complications of Pediatric Sinusitis Naana Afua Jumah, HMS III Gillian Lieberman, MD 22 January 2007 Naana Afua Jumah, HMS III Gillian Lieberman, MD Outline Paranasal sinus anatomy Definitions Indications for imaging Imaging modalities Patient presentation Summary Naana Afua Jumah, HMS III Gillian Lieberman, MD Sinus Anatomy Essential Clinical Anatomy, 2002 Naana Afua Jumah, HMS III Gillian Lieberman, MD Sinus Plain Films http://xray.20m.com/photo.html Sinus Development Naana Afua Jumah, HMS III Gillian Lieberman, MD Sinus Age (years) 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 III Gillian 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 III Gillian Lieberman, MD Complications of Sinusitis Orbital Intracranial 6 Edema Preseptal cellulitis Postseptal cellulitis Subperiosteal abscess Orbital abscess Cavernous sinus thrombosis Epidural empyema Subdural empyema Meningitis Cerebritis Parenchymal abscess Mycotic aneurysm Brain infarction Subgaleal Pott’s puffy tumor Osteomyelitis Reid, 2004 Naana Afua Jumah, HMS III Gillian Lieberman, MD Indications for Imaging Purulent nasal discharge >10 days Recurrent or persistent clinical sinusitis Preoperative evaluation for functional endoscopic sinus surgery (FESS) Suspected complication Complex sinus disease Suspected fungal sinusitis *Imaging is not recommended for uncomplicated acute sinusitis American College of Radiology, 2006 Naana Afua Jumah, HMS III Gillian 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 III Gillian Lieberman, MD Imaging Modality for Complications of Sinusitis MRI • Intracranial pathology and complex sinus disease • Lacks bony detail of sinus anatomy • Long image collection time may require sedation • No radiation T1 Anatomy T1 + Gadolinium Vasculature, malignancy T2 Inflammation/fluid FLAIR Inflammation Diffusion weighted Ischemia Angiography Vasculature American College of Radiology, 2006 and Boyle, 2006 Naana Afua Jumah, HMS III Gillian Lieberman, MD Patient BE: Meningitis on MRI Axial MR T1 with Contrast Focal areas of subtle enhancement of the meninges consistent with meningitis Courtesy of Dr Hines-Peralta Naana Afua Jumah, HMS III Gillian Lieberman, MD Companion Patient 1: Meningitis on MRI Axial MR T1 Pre-contrast Axial MR T1 Post-contrast Meninges appear as a ring of low signal intensity Ring of enhancement surrounding the cerebellum consistent with meningitis http://www.math.uno.edu/~jensen/L/neuropath/images.htm Naana Afua Jumah, HMS III Gillian Lieberman, MD Patient BE: Cerebral Edema on MRI Axial MR T1 Pre-contrast Midline shift Compression of the anterior horn of the lateral ventricle Compression of the left posterior horn of the lateral ventricle Diffuse effacement of the cortical gyri shown best in the left parietal lobe Courtesy of Dr Hines-Peralta Naana Afua Jumah, HMS III Gillian Lieberman, MD Patient BE: Cerebral Edema on MRI Axial MR T1 Post-contrast Axial MR T2-weighted Low signal areas indicating restricted diffusion in the frontal lobes bilaterally and the temporal lobe suggestive of edema or a fluid collection 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 Courtesy of Dr Hines-Peralta Naana Afua Jumah, HMS III Gillian Lieberman, MD Patient BE: Cerebral Ischemia on Diffusion-Weighted Imaging Axial MR Diffusion-Weighted Image High signal areas that follow the pattern of the gyri in the frontal lobes bilaterally and the temporal lobe localizing areas of cerebral ischemia Courtesy of Dr Hines-Peralta Patient BE: Shunt & Craniectomy on CT Naana Afua Jumah, HMS III Gillian Lieberman, MD Axial CT Brain Window Intraventricular shunt Craniectomy site and herniation of the left cerebral hemisphere beyond the skull margin Post surgical aberrant air collections Courtesy of Dr Hines-Peralta Naana Afua Jumah, HMS III Gillian Lieberman, MD Brain Abscess on CT & MRI Patient BE: Follow-up Axial CT Brain Window Companion Patient 2: Axial MR T1 with Contrast Site of second craniectomy Suspected abcess in left parietal lobe Finding needs to be confirmed on MRI Pair of rim enhancing lesions with low signal intensity indicating the presence of an intraparenchymal abscess Courtesy of Dr Hines-Peralta and Nadalo and Hunter, 2004 Naana Afua Jumah, HMS III Gillian 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 III Gillian 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 III Gillian Lieberman, MD Orbital Cellulitis & Subperiosteal Abscess on CT Companion Patient 3: Coronal CT with Contrast Soft Tissue Window Opacification of the ethmoid sinuses Air-fluid level in the right maxillary sinus Periobital soft tissue edema Hypoplasia of the left maxillary sinus Companion Patient 4: Axial CT with Contrast Soft Tissue Window Proptosis of the right orbit Lentiform region of low signal with rim enhancement consistent with abscess Lateral deviation of the medial rectus Kirsch and Turbin, 2005 and Reid, 2004 Naana Afua Jumah, HMS III Gillian Lieberman, MD Cavernous Sinus Thrombosis on MRI Companion Patient 5: MR Angiogram Cavernous sinus thrombosis Companion Patient 5: Coronal MR T1 Post-contrast Wall thickening of the right cavernous sinus Zimmer et al, 2006 Naana Afua Jumah, HMS III Gillian Lieberman, MD Pott’s Puffy Tumor on MRI Companion Patient 6: MR T1 with Contrast Companion Patient Sagittal view of opacified frontal sinus with fistula to soft tissue overlying the frontal bone and soft tissue edema Axial view showing the same Ghorayeb, 2006 and Thomson Health, 2006 Summary Naana Afua Jumah, HMS III Gillian Lieberman, MD Sinusitis, complications and correlation with imaging Coronal CT MR T1 ± contrast MR T2 & T2 weighted Naana Afua Jumah, HMS III Gillian Lieberman, MD 10 11 12 13 14 15 16 17 References American College of Radiology 2006 ACR Appropriateness Criteria, Sinusitis – Child KL Moore and AMR Agur Essential Clinical Anatomy, 2nd ed Baltimore: Lippincott Willams & Wilkins, 2002 p 577 SJ Zinreich 2006 Progress in sinonasal imaging Ann Oto Rhino Laryn 115(9)Suppl 196:61-65 JR Reid 2004 Complications of pediatric paranasal sinusitis Pediatr Radiol 34:933-942 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 Welcome to radiography reporting http://xray.20m.com/photo.html Accessed 18 January 2007 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 GE Boyle, M Ahern, J Cooke, NP Sheehy, and JF Meaney 2006 An Interactive Taxonomy of MR Imaging Sequences Radiographics 26:e24 KA Kronemer and WH McAlister 1997 Sinusitis and its imaging in the pediatric population Pediatr Radiol 27:837-846 Congental malformations, hydroencephaly, and herniation http://www.math.uno.edu/~jensen/L/neuropath/images.htm Accessed 18 January 2007 J Zimmer, J Bhatt, JH Conway, M Edwards-Brown, DK Sokol 2006 Is it all in his head? Internet J Pediatr Neonat 6(1) BY Ghorayeb 2006 Otolaryngology Houston Accessed 18 January 2007 http://www.ghorayeb.com/PottsPuffyTumor.html Thomson Healthcare 2006 Sinusitis PDR Health http://www.pdrhealth.com/patient_education/BHG01ID21.shtml Accessed 19 January 2007 American Academy of Pediatrics 2001 Clinical practice guideline: management of sinusitis Pediatrics 108:798-808 LA Nadalo and LK Hunter 2004 Brain Abscess http://www.emedicine.com/radio/topic91.htm Accessed 20 January 2007 CFE Kirsch and R Turbin 2005 Orbit, Infections eMedicine http://www.emedicine.com/radio/topic490.htm Accessed 20 January 2007 MM Reeder Reeder and Felson’s Gamuts in Radiology, 4th ed New York: Springer, 2003, p 133 Naana Afua Jumah, HMS III Gillian Lieberman, MD With Thanks to Andrew Hines-Peralta, MD Neil Bhattacharyya, MD FACS Gillian Lieberman, MD Pamela Lepkowski Larry Barbaras, Webmaster ... Score: 0-2 no disease, 3-4 equivocal, ≥5 chronic sinusitis Bhattacharyya et al, 2004 Naana Afua Jumah, HMS III Gillian Lieberman, MD Patient Presentation Naana Afua Jumah, HMS III Gillian Lieberman,. .. Afua Jumah, HMS III Gillian Lieberman, MD Sinusitis, complications and correlation with imaging Coronal CT MR T1 ± contrast MR T2 & T2 weighted Naana Afua Jumah, HMS III Gillian Lieberman, MD 10.. .Naana Afua Jumah, HMS III Gillian Lieberman, MD Outline Paranasal sinus anatomy Definitions Indications for imaging Imaging modalities Patient presentation Summary Naana Afua Jumah, HMS III Gillian