Endocranial complications following acute ethmoiditis: a case report

¹Faculty of Medicine, Official University of Bukavu, Bukavu, Democratic Republic of Congo, ²Department of Paediatrics, University Hospital in Bukavu, Bukavu, Democratic Republic of Congo, ³Medical Research Circle, South Kivu, Bukavu, Democratic Republic of Congo, ⁴Research and Action for Medicine with a Social Impact, Bukavu, Democratic Republic of Congo, ⁵Ophthalmology Department, Bukavu University Clinics, Bukavu, Democratic Republic of Congo, ⁶Surgery Department, Bukavu University Clinics, Bukavu, Democratic Republic of Congo, ⁷Infectious Diseases Department, Institute of Biomedicine, University of Göteborg, Göteborg, Sweden, ⁸Departement de Pédiatrie, Centre Hospitalier de l'Ouest Guyanais Franck Joly (Saint-Laurent-du-Maroni), Guyane Française, France

^&Corresponding author
Kesheni Banyanga David, Department of Paediatrics, University Hospital in Bukavu, Bukavu, Democratic Republic of Congo

Introduction    

Acute ethmoiditis is an inflammation of the sinus mucosa located on the papyraceous blades [1]. It is generally a bacterial infection, the clinical diagnosis of which is usually made only when the infection is externalized at the palpebral level. Progression is better with treatment, and may be characterised by complications without treatment [2]. We report a case of an 11-year-old male child who was brought in consultation for a suppurative right blepharitis diagnosed in a hospital centre and followed up in a local referral general hospital.

Patient and observation     

Patient information: an 11-year-old male adolescent schoolchild was transferred to us from a local referral general hospital for better management of an abscess of the right upper eyelid. The patient's medical history included repeated consultations for chronic nasal discharge; the patient or those accompanying him did not disclose the place of treatment and the molecule regularly used.

Clinical findings: our examination reported headaches, chills, neck pain, photophobia and phonophobia. A temperature of 39°C on admission, with a continuity solution in the upper right eyelid measuring around 2 cm in diameter and leaking pus, and conjunctival hyperhaemia in the right eye. However, visual acuity was 6/6 in the right and left eyes, and the fundus was normal. Signs of meningeal irritation were noted, including a stiff neck with a positive Kernig sign and a negative Brezinski sign. The Glasgow score was 15/15, and the rest of the neurological examination was unremarkable.

Timeline of current episode: the abscess began about a month before our consultation, with a swelling of the palpebral area that started at the inner corner of the upper eyelid (Figure 1). This prompted the family to take him to an ophthalmology centre in the town, where he was diagnosed with an orbital abscess. A drainage incision was made, and a medical treatment of per os was combined with a medical treatment of cloxacillin tablet and tetracycline ointment and Anaflam tablet (a combination of ibuprofen and paracetamol), the dosage and duration of which were not specified. The evolution was marked by the persistence of fever and suppuration of the incision site; this would have motivated the family to abandon the conventional treatment initiated at the ophthalmological centre and to resort to traditional treatment and prayer sessions for about a week without success; this led to a new consultation at a local referral hospital, where a treatment consisting of clindamycin, gentamycin, metronidazole and anaflam was administered in hospital for a week, but to no avail, prompting a transfer to the Bukavu University Clinics for better care.

Diagnostic assessment: after our clinical evaluation, we considered the following differential diagnosis: acute meningitis complicating acute ethmoiditis initially externalized; a suppurated orbital abscess; fustilised frontal osteitis. The following laboratory and imaging tests were carried out while the patient was in hospital: analysis of cerebrospinal fluid (CSF); blood count, ion count, C-reactive protein (CRP); cerebral CT scan. The CSF analysis confirmed meningitis, probably bacterial, but no bacterial culture was performed to identify the causative germ (Table 1). The results of the CT scan confirmed Chandler stage 5 acute anterior ethmoiditis with a cerebral abscess, a right frontal pre-suppurative patch with right ventriculitis, frontal osteitis opposite with pansinusitis sparing the sphenoid (Figure 2). Haematological tests revealed a predominantly neutrophilic hyperleukocytosis with an increase in inflammatory markers (Table 2).

Diagnosis: following this approach, we concluded that the patient had acute anterior ethmoiditis complicated by orbital abscess, frontal osteitis, cerebral abscess and acute meningitis.

Therapeutic interventions and outcomes: we started a parenteral treatment with ceftriaxone 100mg/Kg or 1.5g per dose in two doses with Vancomycin 20mg/Kg or 200mg/ every 8 hours for a fortnight and Metronidazole 200mg every 8 hours for 10 days and Dexamethasone inj 0. 15mg/kg for 4 days, i.e. 4.5mg every 6 hours, Maxidrol eye drops 3x1 drop per day for 7 days, an antipyretic (Paracetamol 15mg/kg per dose, i.e. 450mg 3 times per day by direct intravenous injection). The incision was trimmed the orbital abscess drained again, and a daily dressing was applied for 2 days, then twice daily for 6 days.

Follow-up and outcomes of interventions: the evolution was marked by apyrexia after 3 days from the start of treatment, a drying up of the suppuration at the incision, a significant regression of the palpebral swelling (Figure 3) and signs of meningeal irritation. The patient was discharged on the 14^th day of hospitalisation, and an oral treatment of Augmentin tablet was prescribed for 30 days. On discharge, a follow-up programme was drawn up. One week later, the patient returned for a consultation, as scheduled; he had no particular complaints. We suggested a CT scan to the family, but unfortunately, this was not carried out due to a lack of funds.

Patient perspective: our patient and all his family reported that they were satisfied with the care and treatment he was receiving at the University clinics of Bukavu.

Informed consent: it was obtained from the patient´s family for the publication of this case report and any accompanying images.

Discussion     

Cases of ethmoiditis are becoming increasingly frequent in our study environment. Colombe et al. reported a case of ethmoiditis in a 14-year-old girl, one of the complications of which was cerebral empyema [2]. The male sex is retained by our case; however, numerous studies, including that of Colombe et al. [2] at the University Clinics of Bukavu in 2022. Also, Ben in Tunisia, report a predominance of females [3]. Diagnosis of ethmoiditis remains difficult as long as it does not become external. Most often, when it does appear, there is oedema of the internal angle of the eye [4] or it may cause an intracranial infection by passing through the sieve plates of the ethmoidal bone. A history of rhinitis and sinusitis is often found in the course of ethmoiditis [5] in our patient, there is evidence of frequent consultations for a runny nose, for which the therapeutic attitudes initiated by his carer were not revealed by those accompanying him.

Markers of inflammation are often elevated in our case, with a CRP of 57.84 mg/dl and hyperleukocytosis of 17 mils [5]. The culture of cerebrospinal fluid (CSF) [6], of pus during drainage or puncture most often found during ethmoiditis, Haemophilis influenza, Streptococcus pneumoniae, and Staphylococcus aureus [7]. In our case, no cultures were taken. Conventional radiography is an imaging examination that has been abandoned for acute ethmoiditis [8]. Computed tomography is the most appropriate examination, and shows lesions of periosteal reaction, osteitis, or neurological involvement such as cerebral abscess or empyema [3]. However, no follow-up imaging was performed in our case due to a lack of financial resources; the cost of a cranial scan is around US$200.

Antibiotic treatment for ethmoiditis should be early and empirical, combining a 3^rd generation cephalosporin with an intravenous glycopeptide. In the absence of any complication, intra-operative treatment can be continued from day 6 [7], or for at least 14 to 21 days, and imaging and blood tests should be carried out to assess the evolution of lesions. Anticoagulants in the case of cavernous thrombosis are not effective, whereas antibiotics are the rule [3]. Surgical treatment is instituted if the orbital abscess reaches or exceeds a diameter of approximately 3mm with involvement of the medial rectus muscle; and consists of incision and drainage of the collection [5].

Conclusion     

Acute ethmoiditis is an infrequent infectious disease in our environment and poses a real problem in terms of diagnosis and management. The prognosis is good when the diagnosis is made early and treatment is well administered. However, endocranial and extracranial complications in the event of late diagnosis or inadequate treatment remain formidable, and can threaten the patient's vital and functional prognosis. The poverty of the population and the mystico-religious beliefs in our environment remain an obstacle to the best management of this pathology.

Competing interests     

The authors declare no competing interest.

Authors' contributions     

Patient management: Kesheni Banyanga David, Carmel Mbalo Walemba, Kitambala Charles and Heri Nabuloho Erick. Data collection: Manga Opondjo Fernand and Irenge Bisimwa Gloire. Manuscript drafting: Feza Bianga Vivianne and Kesheni Banyanga David. Manuscript revision: Archippe Muhandule Birindwa and Carmel Mbalo Walemba. All authors approved final version of the manuscript conceptualization. All authors approved final version of the manuscript conceptualization. They equally read and agreed to the final manuscript.

Tables and figures     

Table 1: results of cerebrospinal fluid analysis

Table 2: haematological tests

Figure 1: right palpebral swelling at onset of symptoms

Figure 2: cerebral CT scan: A) brain abscess located in the frontal lobe; B) frontal osteitis with pansinusitis and exophthalmos; C,D) parenchymal oedema with ventriculitis

Figure 3: frontal swelling subsiding and the suppuration at the incision subsiding

Aknowledgment     

The authors acknowledge the cooperation they got from the patient and his family

References