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Case report

Maxillary sinusitis complicated by stroke

C. Fabre a,∗ , I. Atallah a,b,c , I. Wroblewski b,c,d , C.A. Righini a,b,c
a
Service hospitalo-universitaire d’ORL et chirurgie cervico-faciale, CHU Michalon CS 10217, 38043, Grenoble cedex 9, France
b
Faculté de médecine, universités des Alpes, Grenoble, France
c
UGA/UMR/CNRS 5309/Inserm 1209, institut Albert-Bonniot, Grenoble, France
d
Réanimation et surveillance continue pédiatrique, pôle Couple Enfant, CHU de Grenoble, Grenoble, France

a r t i c l e i n f o a b s t r a c t

Keywords: Introduction: Neurological complications of acute sinusitis are exceptional, but potentially serious.
Diabetes mellitus Case report: The authors report the case of a 6-year-old diabetic girl who presented with middle cerebral
Sinusitis artery ischemic stroke secondary to inflammatory arteritis of the left internal carotid artery in a context
Arteritis
of bilateral acute maxillary sinusitis. MRI confirmed ischaemic stroke associated with carotid arteritis
Ischaemic stroke
and complete obstruction of the maxillary sinuses. A favourable outcome was observed after endoscopic
drainage of the sinuses associated with broad-spectrum antibiotic therapy.
Discussion: This complication was probably due to spread of an infectious inflammatory reaction of the
intrapetrosal carotid artery and its branches via the pterygoid venous plexus. To our knowledge, this is
the first published case report of maxillary sinusitis complicated by stroke.
© 2018 Elsevier Masson SAS. All rights reserved.

1. Introduction
Acute maxillary sinusitis is a common, generally benign dis-
ease. However, inadequate treatment can lead to serious and
life-threatening intracranial complications. The main intracranial
complications of sinusitis are infectious (meningitis, empyema,
brain abscess) and/or vascular (cavernous sinus thrombosis, cere-
bral ischaemia) [1]. Only one case of ischaemic stroke, without
associated meningitis, has been reported in the literature [2]. We
report a case of ischaemic stroke, without meningitis, associated
with bilateral acute maxillary sinusitis in a 6-year-old diabetic girl.
The pathophysiology of this complication is discussed in the light
of a review of the literature.
2. Case report
A 6-year-old girl with poorly controlled type 1 diabetes expe-
rienced, at home, an episode of enuresis accompanied by sudden
headache with spatial and temporal disorientation and gait disor-
ders. As blood glucose was normal, her parents put her back to bed.
On the following day, the child presented muteness, hemiplegia,
and right facial palsy and was brought to the paediatric emer-
gency department. Neurological examination on arrival revealed:
right hemiplegia associated with sensory loss and right hemibody
∗ Corresponding author.
E-mail addresses: cfabre2@chu-grenoble.fr, christol.fabre@gmail.com (C. Fabre).
neglect. Clinical interview revealed that the child had been treated
by the family doctor, two weeks previously, for afebrile rhinitis and
bronchitis, by amoxicillin (50 mg/kg/day) for 7 days. The labora-
tory work-up performed in the emergency department (CBC, serum
electrolytes, liver function tests, blood glucose, CRP) was normal.
Gadolinium-enhanced MRI revealed left middle cerebral artery
ischaemic stroke (Fig. 1B). Ipsilateral maxillary sinusitis and carotid
arteritis were not diagnosed at this stage (Fig. 1A). CT angiography
was performed and suggested left intrapetrosal carotid artery dis-
section, which was subsequently excluded after review of the scans
by two expert neuroradiologists. Lumbar puncture, performed after
imaging, was normal.
The girl was admitted to the paediatric intermediate care unit
and continuous heparin infusion was initiated, with a switch to oral
acetylsalicylic acid (100 mg/day) on day 4. After multidisciplinary
consultation (pediatricians and neuroradiologists), a diagnosis
of segmental left intrapetrosal internal carotid arteritis was
adopted.
As the neurological signs had regressed on day 4, the child was
transferred to the pediatric rehabilitation unit.
On day 6, hemiplegia worsened and subsequently became
complete. MRI revealed: (1) extension of the ischaemia to the
lentiform and caudate nuclei, and corona radiata (Fig. 2A); (2)
extensive circumferential high-intensity signal of the left internal
carotid artery, starting at its bifurcation, with tight stenosis of the
cavernous segment (Fig. 2B, C), the M1 segment of the middle
cerebral artery and the A1 segment of the anterior cerebral artery
(ACA); (3) bilateral maxillary sinusitis and partial obstruction of

https://doi.org/10.1016/j.anorl.2018.07.004
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Please cite this article in press as: Fabre C, et al. Maxillary sinusitis complicated by stroke. European Annals of Otorhinolaryngology,
Head and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2018.07.004
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ANORL-792; No. of Pages 3 ARTICLE IN PRESS
2 C. Fabre et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2018) xxx–xxx

Fig. 1. Emergency MRI. (A). MRI diffusion-weighted sequence: left middle cerebral artery ischaemic stroke involving the left lentiform and left caudate nuclei. (B). MRI T2
Fast Spin Echo sequence. Thick arrow: undiagnosed left maxillary sinusitis. Thin arrow: thickened left internal carotid artery wall indicating the presence of carotid arteritis.

Fig. 2. MRI performed on Day 6 after the first stroke following deterioration of the patient’s neurological status. (A). MRI FLAIR sequence: extension of left middle cerebral
artery ischaemia to the internal capsule and pallidum. (B). Top: MRI T2 Fast Spin Echo sequence: decreased arterial calibre compared to Figure 1b. Note bilateral extension
of maxillary sinusitis. Bottom: MRI, gadolinium-enhanced T1-weighted sequence: minimal passage of contrast agent due to the tight left carotid artery stenosis. (C). MR
angiography: arrow-showing disappearance of the entire intracranial and cervical course of the left internal carotid artery.

the left sphenoid sinus (Fig. 2A). The child was re-admitted to
the pediatric intensive care unit and treatment with intravenous
®
acetylsalicylic acid (5 mg/kg/day) and Solumédrol (methylpred-
nisolone) 2 mg/kg/day was initiated. No antibiotic therapy was
initiated, as the child did not present any symptoms of sinusitis.
On day 15, clinical examination and follow-up MRI remained
unchanged (Fig. 3). Laboratory assessments of auto-immunity,
liver function tests, and platelet count were normal. Transthoracic
echocardiography did not reveal any signs of infective endocardi-
tis. Sinusitis was then proposed as the origin of internal carotid
arteritis.
Bilateral middle meatal antrostomy and left sphenoidotomy
were performed, revealing bilateral obstructed purulent maxil-
lary sinusitis with no pus in the sphenoid sinus. Bacteriological
samples were taken, but no bacteria were isolated. Empirical antibi-
otic therapy with cefotaxime (200 mg/kg/day) and metronidazole
(50 mg/kg/day) was administered for 5 days, followed by amox-
icillin and clavulanic acid (50 mg/kg/day) for 10 days. Treatment
with acetylsalicylic acid was continued at the same dose for 3
®
months and Solumédrol (methylprednisolone) was suspended.
The postoperative course was uneventful and the child was trans-
ferred to the paediatric rehabilitation unit. The child’s neurological
status slowly improved with partial resolution of hemiplegia. The
follow-up MRI on Day 45 revealed increased calibre of the left
internal carotid, left middle cerebral and left anterior cerebral
arteries.
3. Discussion
Paranasal sinus infection in this diabetic girl remained sub-
clinical, resulting in a rare complication: initially segmental
carotid arteritis, responsible for the first stroke. Cerebral ischaemia

Please cite this article in press as: Fabre C, et al. Maxillary sinusitis complicated by stroke. European Annals of Otorhinolaryngology,
Head and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2018.07.004
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C. Fabre et al. / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2018) xxx–xxx
Fig. 3. Preoperative MRI, T2-weighted sequence showing obstructed bilateral max-
illary sinusitis with thickening of the walls of the left sphenoid sinus (thick arrow)
and inflammatory thickening of the left carotid artery wall in the carotid canal
(dashed arrow).
subsequently worsened due to the absence of treatment of sinusi-
tis, extending to the entire wall over the entire length of the left
internal carotid artery and part of its branches. Several cases of
bacterial sphenoid sinusitis responsible for ischaemic stroke have
been reported in the literature. However, in the majority of cases,
sphenoid sinusitis was associated with meningitis and/or ipsilat-
eral cavernous sinus thrombosis [3–6]. The microorganisms most
commonly isolated are Staphylococcus aureus and Streptococcus
pneumoniae. One publication reported 4 cases of ischaemic stroke,
including one case in a child, secondary to asymptomatic acute
sphenoid sinusitis with no identified bacteria, in the absence of
meningitis, in a context of tight stenosis and/or occlusion of the
internal carotid artery [7]. Rochat et al. reported a case of stroke
secondary to unilateral pansinusitis in a 10-year-old child without
meningitis or cavernous sinus thrombosis treated by endoscopic
surgery and broad-spectrum antibiotics. The authors concluded on
vascular spasm of the internal carotid artery in contact with the
sphenoid sinus infection [2]. Diabetes is known to be associated
with an increased infectious risk related to immune dysfunction [8].
In the present case, diabetes was not only predisposed to paranasal
sinus infection, but was also probably responsible for the asymp-
tomatic nature of this infection.
Please cite this article in press as: Fabre C, et al. Maxillary sinusitis complicated by stroke. European Annals of Otorhinolaryngology,
Head and Neck diseases (2018), https://doi.org/10.1016/j.anorl.2018.07.004
3
Venous drainage of the maxillary sinus is partly ensured by the
facial vein and retromandibular vein, but also the pterygoid venous
plexus in the infratemporal fossa, which is valveless in children,
and which drain into the cavernous sinus [9]. In the case reported
here, in view of the absence of sphenoid sinusitis responsible for
carotid arteritis, maxillary sinusitis was probably responsible for
infratemporal (pericarotid) venous thrombosis extending to the
cavernous sinus, not visible on CT scan, with contiguous inflam-
mation of the carotid artery wall (carotid arteritis), responsible for
the first stroke. Untreated sinusitis then led to deterioration and
propagation of pericarotid inflammation. The presence of sinusi-
tis must therefore be investigated in patients managed for stroke
with no cardiovascular risk factors. In the presence of sinusitis and
after excluding any other aetiology, emergency surgery combined
with broad-spectrum empirical antibiotic therapy, subsequently
adapted to the culture results of intraoperative bacteriological sam-
ples is recommended [10]. To the best of our knowledge, this is the
first published case of stroke secondary to maxillary sinusitis.
4. Conclusion
In this case, stroke was very likely due to carotid arteritis sec-
ondary to thrombophlebitis of pericarotid veins that participate
in the venous drainage of the maxillary sinus. To the best of our
knowledge, this is the first published case of ischaemic stroke asso-
ciated with maxillary sinusitis. The proposed pathophysiological
hypothesis appears to be the most likely mechanism, but cannot
be formally confirmed.
Disclosure of interest
The authors declare that they have no competing interest.
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