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Título

Central Nervous System Involvement in Complicated Rhinosinusitis: Case Report

RESUMO

Case presentation: male, 16 years old, illicit drug user, symptoms of headache, mental confusion, bilateral eyelid edema, eye pain, blurred vision and fever after upper airway infection. Exams showing leukocytosis and cerebrospinal fluid indicative of bacterial meningitis. Broad-spectrum antibiotic therapy was started. Pulse therapy with methylprednisone was also performed to help reduce proptosis and visual symptoms. Magnetic Resonance Imaging (MRI) of the brain was requested, which showed intracranial collection starting in the medial temporal region adjacent to the cavernous sinus and extending to the posterior fossa, bypassing the right cerebellar hemisphere, suggestive of subdural empyema. He underwent neurosurgical drainage by posterior fossa craniotomy, without complications. Post-surgical control MRI showed thrombosis of the right sigmoid sinus, probable intraorbital collection on the right, in addition to reduced proptosis and peri-orbital soft tissue edema, and it was decided to maintain antibiotic therapy and start anticoagulation. After a month of antibiotic therapy, a new orbital MRI showed an abscess next to the superior rectus muscle, and ophthalmic surgery was chosen for drainage, which occurred without intercurrences. After almost two months of hospitalization and with clinical improvement, the patient was discharged with mild restriction of right orbit eye movements, being followed up as an outpatient. Discussion: the patient in question presented rare and serious complications of rhinosinusitis, both ophthalmic and intracranial. Anatomical factors that explain this infectious dissemination are: close relationship between the orbital contents and the ethmoidal labyrinth, which is separated from the orbit by the papyraceous lamina; the existence of a large number of sutures and neurovascular foramina in the medial wall of the orbit; the optic canal which is closely adjacent to the posterior ethmoid and sphenoid sinuses; and valved ophthalmic veins that communicate with vessels inside the orbit and directly with the cavernous sinus, presenting a direct blood flow, facilitating hematogenous dissemination. The presence of eyelid edema and headache are warning symptoms for a more attentive investigation of rhinosinusitis, in addition to intravenous antibiotic therapy. Final comments: the importance of anatomical knowledge is emphasized for understanding the routes of spread of facial and intracranial infections.