Complications of sinusitis

Elexacaftor/tezacaftor/ivacaftor improves chronic rhinosinusitis detected by magnetic resonance imaging in children with cystic fibrosis on long-term therapy with lumacaftor/ivacaftor

INTRODUCTION

Previous studies using magnetic resonance imaging (MRI) demonstrated early onset and progression of chronic rhinosinusitis (CRS) from infancy to school age, and response to lumacaftor/ivacaftor (LUM/IVA) therapy in children with cystic fibrosis (CF). However, the effect of elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) on CRS detected by MRI in children with CF and at least one F508del mutation, and potential incremental effects of ELX/TEZ/IVA compared to LUM/IVA in F508del homozygous children have not been studied.

METHODS

30 children with CF with at least one F508del mutation underwent three longitudinal paranasal sinus MRI before (MRI1), without (n = 16) or with LUM/IVA therapy (n = 14, MRI2), and with ELX/TEZ/IVA therapy (MRI3, mean age at therapy initiation 11.1 ± 3.4y, range 6-16y). MRI were evaluated using the CRS-MRI score.

RESULTS

After therapy initiation with ELX/TEZ/IVA, the prevalence and in maxillary and sphenoid sinuses the dominance of mucopyoceles decreased (35% vs. 0 %, p<0.001 and 26% vs. 8 %, p < 0.05, respectively). This leads to a reduction in mucopyocele subscore (-3.4 ± 1.9, p < 0.001), and sinus subscores in MRI3 (maxillary sinus: -5.3 ± 3.1, p < 0.001, frontal sinus: -1.0 ± 1.9, p < 0.01, sphenoid subscore: -2.8 ± 3.5, p < 0.001, ethmoid sinus: -1.7 ± 1.9, p < 0.001). The CRS-MRI sum score decreased after therapy initiation with ELX/TEZ/IVA by -9.6 ± 5.5 score points (p < 0.001). The strength in reduction of mucopyoceles subscore and CRS-MRI sum score was independent of a pretreatment with LUM/IVA from MRI1-MRI2 (p = 0.275-0.999).

CONCLUSIONS

ELX/TEZ/IVA therapy leads to improvement of CRS in eligible children with CF. Our data support the role of MRI for comprehensive monitoring of CRS disease severity and response to therapy in children with CF.

Artificial Intelligence Automation of Proptosis Measurement: An Indicator for Pediatric Orbital Abscess Surgery

INTRODUCTION

To evaluate the ability of artificial intelligence (AI) software to quantify proptosis for identifying patients who need surgical drainage.

METHODS

We pursued a retrospective study including 56 subjects with a clinical diagnosis of subperiosteal orbital abscess (SPOA) secondary to sinusitis at a tertiary pediatric hospital from 2002 to 2016. AI computer software was developed to perform 3D visualization and quantitative assessment of proptosis from computed tomography (CT) images acquired at the time of hospital admission. The AI software automatically computed linear and volume metrics of proptosis to provide more practice-consistent and informative measures. Two experienced physicians independently measured proptosis using the interzygomatic line method on axial CT images. The AI software and physician proptosis assessments were evaluated for association with eventual treatment procedures as standalone markers and in combination with the standard predictors.

RESULTS

To treat the SPOA, 31 of 56 (55%) children underwent surgical intervention, including 18 early surgeries (performed within 24 h of admission), and 25 (45%) were managed medically. The physician measurements of proptosis were strongly correlated (Spearman r = 0.89, 95% CI 0.82-0.93) with 95% limits of agreement of ± 1.8 mm. The AI linear measurement was on average 1.2 mm larger (p = 0.007) and only moderately correlated with the average physicians' measurements (r = 0.53, 95% CI 0.31-0.69). Increased proptosis of both AI volumetric and linear measurements were moderately predictive of surgery (AUCs of 0.79, 95% CI 0.68-0.91, and 0.78, 95% CI 0.65-0.90, respectively) with the average physician measurement being poorly to fairly predictive (AUC of 0.70, 95% CI 0.56-0.84). The AI proptosis measures were also significantly greater in the early as compared to the late surgery groups (p = 0.02, and p = 0.04, respectively). The surgical and medical groups showed a substantial difference in the abscess volume (p < 0.001).

CONCLUSION

AI proptosis measures significantly differed from physician assessments and showed a good overall ability to predict the eventual treatment. The volumetric AI proptosis measurement significantly improved the ability to predict the likelihood of surgery compared to abscess volume alone. Further studies are needed to better characterize and incorporate the AI proptosis measurements for assisting in clinical decision-making.

Does Adenoid Hypertrophy Increase the Risk of Orbital Complication in Children with Acute Sinusitis?

Adenoid hypertrophy (AH) plays a role as a reservoir for bacterial growth and decreases mucociliary clearance which might contribute to the development of an infection. To compare the presence of AH in the pediatric population presenting with orbital complications as a result of ABRS and the control group radiologically. Patients who were diagnosed with OC as a result of ABRS labeled as case group, and the patients who had undergone computed tomography (CT) for indications other than sinonasal diseases were assigned as control group. Both groups were retrospectively reviewed to measure the adenoid, nasopharynx, and adenoid/nasopharynx ratio (ANR) in the axial and mid-sagittal planes. We compared 52 patients from case group to 57 control group. In the CT axial plane, adenoid length was greater in the OC group compared to the control group, with a significant difference (p-value = 0.02) of 14.2 ± 3.5 mm compared to 11.2 ± 7 mm, respectively. The ANRs were 2.9 in the OC group and 2.8 in the control group, with a p-value of 0.089. In the mid-sagittal plane, only the anteroposterior length was significantly greater in the OC group, with a mean of 19.9 ± 5.3 mm compared to 15.2 ± 8.8 mm in the control group (p-value = 0.007). The process of inflammation increased the anteroposterior length of the adenoids. However, the ANR was similar between the two groups, indicating that adenoid hypertrophy is not directly related as a risk factor for OC in pediatric patients with ARBS.

Long-term effects of lumacaftor/ivacaftor on paranasal sinus abnormalities in children with cystic fibrosis detected with magnetic resonance imaging

Introduction: Chronic rhinosinusitis (CRS) usually presents with nasal congestion, rhinorrhea and anosmia impacts quality of life in cystic fibrosis (CF). Especially mucopyoceles pathognomonic for CRS in CF may cause complications such as spread of infection. Previous studies using magnetic resonance imaging (MRI) demonstrated early onset and progression of CRS from infancy to school age in patients with CF, and mid-term improvements of CRS in preschool and school-age children with CF treated with lumacaftor/ivacaftor for at least 2 months. However, long-term data on treatment effects on paranasal sinus abnomalities in preschool and school-age children with CF are lacking. Methods: 39 children with CF homozygous for F508del (mean age at baseline MRI 5.9 ± 3.0 years, range 1-12 years) underwent MRI before (MRI1) and about 7 months after starting lumacaftor/ivacaftor and then annually (median 3 follow-up MRI, range 1-4) (MRI2-4). MRI were evaluated using the previously evaluated CRS-MRI score with excellent inter-reader agreement. For intraindividual analysis ANOVA mixed-effects analysis including Geisser-Greenhouse correction and Fisher's exact test, and for interindividual group analysis Mann-Whitney test were used. Results: The CRS-MRI sum score at baseline was similar in children starting lumacaftor/ivacaftor in school age and children starting therapy at preschool age (34.6 ± 5.2 vs.32.9 ± 7.8, p = 0.847). Mucopyoceles were the dominant abnormality in both, especially in maxillary sinus (65% and 55%, respectively). In children starting therapy in school age the CRS-MRI sum score decreased longitudinally from MRI1 to MRI2 (-2.1 ± 3.5, p < 0.05), MRI3 (-3.0 ± 3.7, p < 0.01) and MRI4 (-3.6 ± 4.7, p < 0.01), mainly due to a decrease in the mucopyoceles subscore (-1.0 ± 1.5, p = 0.059; -1.2 ± 2.0, p < 0.05; -1.6 ± 1.8, p < 0.01; and -2.6 ± 2.8, p = 0.417, respectively). In children starting lumacaftor/ivacaftor in preschool age, the CRS-MRI sum score remained stable under therapy over all three follow-up MRI (0.6 ± 3.3, p = 0.520; 2.4 ± 7.6, p = 0.994; 2.1 ± 10.5, p > 0.999 and -0.5 ± 0.5, p = 0.740; respectively). Conclusion: Longitudinal paranasal sinus MRI shows improvements in paranasal sinus abnormalities in children with CF starting lumacaftor/ivacaftor therapy at school age. Further, MRI detects a prevention of an increase in paranasal sinus abnormalities in children with CF starting lumacaftor/ivacaftor therapy at preschool age. Our data support the role of MRI for comprehensive non-invasive therapy and disease monitoring of paranasal sinus abnormalities in children with CF.

Automated delineation of orbital abscess depicted on CT scan using deep learning

OBJECTIVES

To develop and validate a deep learning algorithm to automatically detect and segment an orbital abscess depicted on computed tomography (CT).

METHODS

We retrospectively collected orbital CT scans acquired on 67 pediatric subjects with a confirmed orbital abscess in the setting of infectious orbital cellulitis. A context-aware convolutional neural network (CA-CNN) was developed and trained to automatically segment orbital abscess. To reduce the requirement for a large dataset, transfer learning was used by leveraging a pre-trained model for CT-based lung segmentation. An ophthalmologist manually delineated orbital abscesses depicted on the CT images. The classical U-Net and the CA-CNN models with and without transfer learning were trained and tested on the collected dataset using the 10-fold cross-validation method. Dice coefficient, Jaccard index, and Hausdorff distance were used as performance metrics to assess the agreement between the computerized and manual segmentations.

RESULTS

The context-aware U-Net with transfer learning achieved an average Dice coefficient and Jaccard index of 0.78 ± 0.12 and 0.65 ± 0.13, which were consistently higher than the classical U-Net or the context-aware U-Net without transfer learning (P < 0.01). The average differences of the abscess between the computerized results and the experts in terms of volume and Hausdorff distance were 0.10 ± 0.11 mL and 1.94 ± 1.21 mm, respectively. The context-aware U-Net detected all orbital abscess without false positives.

CONCLUSIONS

The deep learning solution demonstrated promising performance in detecting and segmenting orbital abscesses on CT images in strong agreement with a human observer.

Lesion-Mapping Software for the Measurement of Subperiosteal Abscess Volume for Pediatric Orbital Cellulitis: A Retrospective Chart Review

Introduction

Our objective was to assess the utility of using lesion-mapping software to calculate precise orbital volumes to predict patients who would benefit from early surgical intervention.

Methods

We retrospectively reviewed patients diagnosed with subperiosteal orbital abscess (SPOA) secondary to sinusitis at a tertiary pediatric hospital from 2005 to 2016. Diagnoses were confirmed by CT scans. Lesion-mapping software was used to measure SPOA volume using initial CT images. Data collected included patient demographics, length of hospital stay, and subsequent medical or surgical treatment.

Results

Thirty-three (52%) patients ultimately underwent surgical intervention, while 30 (48%) were managed medically. Between the surgical and medical groups, there were no differences in gender, age, or comorbidities. The surgical group had larger abscess volumes than the medically managed group (0.94 mL vs. 0.31 mL, p < 0.01). Overall, increased SPOA volume was associated with increased age (Pearson’s coefficient = 0.374, p ≤ 0.01) and increased total days of intravenous (IV) antibiotic administration (Pearson’s coefficient = 0.260, p = 0.039). Patients who underwent surgery on the day of admission had 25% shorter hospital stay than patients who had delayed surgery (p < 0.01). Our calculated sensitivity-optimized SPOA volume cutoff of 0.231 mL yielded sensitivity of 90.9% and specificity of 70.0%.

Conclusions

This is the first study to use lesion-mapping software for precise calculation of SPOA volumes, which can help refine indications for early surgical intervention and help decrease length of hospital stay.

Risk factors of orbital complications in outpatients presenting with severe rhinosinusitis: A case-control study

OBJECTIVES

We assessed associations of potential factors with orbital complications in acute rhinosinusitis (ARS) patients.

DESIGN

An unmatched case-control study.

SETTING

A tertiary referral hospital in Thailand.

PARTICIPANTS

Consecutive outpatients of any age with severe ARS (visual analog scale ≥ 7) with and without orbital complications.

MAIN OUTCOME MEASURES

Patients were enrolled from January 2013 to December 2018. Forty-three ARS patients (55.8% female, median age 45.6, (range 2.0-93.0) years) were included, with 19 patients in the complicated group and 24 in the uncomplicated group. Patient characteristics (gender, age, diabetes, immune status), symptoms and signs, site of infection and type of pathogenic bacteria were recorded and assessed their associations with orbital complications by univariable and multivariable logistic regression analyses. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

The most common orbital complication was subperiosteal abscess (42.1%), followed by orbital cellulitis (15.8%) and cavernous sinus thrombosis (10.5%). Multivariable logistic regression analysis demonstrated a positive association with orbital complications (pseudo R² 0.4) for ethmoid sinusitis (OR 31.1, 95% CI [2.3-430.6]) and a short duration of symptoms (OR 0.9, 95% CI [0.8-0.9]).

CONCLUSIONS

Orbital complications were associated with ethmoid sinusitis with a short duration of ARS symptoms.

Pediatric Ethmoid Mucoceles in Cystic Fibrosis: Long-Term Follow-up of Reported Cases

Ethmoid mucocele, a condition that usually affects adults, can be found in both children and infants with cystic fibrosis. We have cared for two patients with cystic fibrosis and ethmoid mucoceles. Because we could find no references to the prognosis or any long-term follow-up data for this disorder, we contacted the physicians and families of six of the seven patients with this condition previously reported in the English literature to determine how they were managed surgically and the incidence of recurrence. Regardless of the mode of therapy, none of the mucoceles recurred.

Will we ever cure nasal polyps?

BACKGROUND

Nasal polyposis is a benign hyperplastic growth of nasal mucosa. There is a paucity of evidence on the prevalence and incidence of nasal polyposis. Although nasal polyps can be asymptomatic, they can cause a spectrum of nasal problems including nasal obstruction, rhinorrhoea, nasal congestion, anosmia resulting in ageusia. Nasal polyps are mostly associated with chronic rhinosinusitis, The current management of chronic rhinosinusitis with nasal polyps is controversial and is not curative.

METHODS

A Medline search was conducted, using the keywords 'rhinosinusitis', 'sinusitis', 'classification' and ''aetiology.

FINDINGS

The current treatment of nasal polyposis in chronic rhinosinusitis with nasal polyps is still challenging. Emerging research through endotypes profiling aims to better understand the complexities of this heterogeneous disease to personalise treatment and provide a cure. Randomised controlled trials aim to provide robust evidence for current management options.

Allergic Rhinitis as a Risk Factor for Orbital Complication of Acute Rhinosinusitis in Children

The purpose of this article is to determine allergic rhinitis and age as potential risk factors for the development of orbital complications of acute rhinosinusitis in children. One hundred two children presenting with orbital swelling were investigated by computed tomography (CT) of the paranasal sinuses and the orbit as well as for underlying allergic rhinitis. Sixty (58.8%) patients had orbital complications of clinical and radiological acute rhinosinusitis. They were grouped accordingly: preseptal cellulitis (n = 24), periostitis (n = 10), and subperiosteal abscess (n = 26). No abscess within the orbit or cavernous sinus thrombosis was found. Thirty-four (56.7%) of the 60 patients underwent allergy investigation. Allergic rhinitis was found in 9 (64.3%) of 14 children with preseptal cellulitis, in 1 (25%) out of 4 children with periostitis, and in 13 (76.5%) out of 17 children with subperiosteal abscess. The prevalence of allergic rhinitis was significantly higher in patients presenting in pollen season from February to August (17:4) than in patients presenting in the period between September and January (6:7). Thus, allergic rhinitis may be a cofactor in the pathogenesis of orbital complications of acute rhinosinusitis. According to our study population, age only influences the type of orbital complication of acute rhinosinusitis in the sense that older children are more likely to develop subperiosteal abscess, whereas younger children develop preseptal cellulitis.

Pediatric allergy medications: review of currently available formulations

BACKGROUND

Allergy affects about 50% of the pediatric population globally. Allergic rhinitis (AR), one form of allergy, causes considerable impairment in quality of life, including disruption of sleep and, in children, interference with school attendance and performance.

SCOPE

Traditional formulations and delivery systems - tablets, capsules, or intranasal sprays - successfully used by adults for treatment of AR may not be as easily administered in children. Liquid oral medications are more readily taken by children but contain sugars and excipients; they can also be inconvenient with less accurate dosing and are associated with dental caries and gastrointestinal upset.

METHODOLOGY

This review evaluated medications for treatment of AR currently available for pediatric patients and identified the attitudes of parents and health care professionals toward these medications. Guidelines from international organizations and governmental websites were reviewed for recommendations and product labeling requirements. A Medline search was conducted using the terms dyes, excipients, palatability, prescribing habits, sugar, among others.

FINDINGS

In recent years, governmental regulatory agencies and professional organizations in Europe and the United States have recommended avoidance of sugar in pediatric medicines and required stricter labeling of their ingredients. Public awareness about the adverse effects of sugar and some excipients has also increased, and parents more frequently express the desire for safer and more convenient medicines for their children. In response, more sugar-free, dye-free liquid medicines and other formulations, such as granules, filmstrips, chewable tablets, fast-dissolving tablets, and drops, are becoming available for pediatric use.

LIMITATIONS

Data from well-designed trials conducted in children for the treatment of AR are lacking. In addition, the possibility of a social response bias may exist for parents and physicians about sugar and other ingredients in children's medications.

CONCLUSION

Treatment for AR is often long-term, particularly in persistent AR; therefore, safety, tolerability, convenience, and patient/parental acceptance are important considerations when deciding which medication to prescribe.

Pathogenesis of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a heterogenous disorder and represents a major public health problem. Although insights into the pathophysiology of CRS have largely expanded over the last two decades, the exact etiology and mechanism of persistence is still unrevealed. CRS is a multifactorial disease, and, with variable evidence, impaired ostial patency, mucociliary impairment, allergy, bacterial or fungal infection (or triggering), immunocompromised state, and environmental and genetic factors have been suggested to be associated or risk factors. Pathomechanisms in CRS are better understood currently, allowing us to characterize and differentiate the heterogeneous pathology of chronic sinonasal inflammation based on histopathology, inflammatory pattern, cytokine profile, and remodeling processes. In nasal polyposis (NP), but not CRS without NP, an abundant eosinophilic inflammation and local immunoglobulin E production could be demonstrated, and Staphylococcus-derived superantigens may at least modulate disease severity and expression. These findings question the current assumption that NP is a subgroup of CRS, but suggest that CRS and NP should probably be considered as distinct disease entities.

Preseptal and orbital cellulitis: a 10-year review of hospitalized patients

BACKGROUND

Preseptal and orbital cellulitis range in severity from minor to potentially severe complications. The purpose of this study is to describe the clinical features of patients with preseptal or orbital cellulitis in one medical center in Taiwan, and to assess the effectiveness of treatments and the complications.

METHODS

Patients admitted between 1996 and 2005 to Taipei Veterans General Hospital under the diagnosis of preseptal or orbital cellulitis were retrospectively reviewed. The demographics, administrative history, past history, clinical presentations, treatments, and complications were analyzed.

RESULTS

In total, 94 patients fulfilling the diagnostic criteria for preseptal or orbital cellulitis were identified (67 had preseptal cellulitis, 27 had orbital cellulitis). While paranasal sinus disease was the most common predisposing cause in orbital cases, skin lesions in children and dacryocystitis in adults were the most common in preseptal cases. Microbiologic investigations showed variable results, but the most common pathogen isolated was Staphylococcus aureus. Cultures from eye swabs and local abscesses gave the highest positive yield. Blood cultures were taken in some patients, but the positive rate was extremely low. Treatments included intravenous antibiotics alone, or intravenous antibiotics combined with surgical drainage. Only one case had permanent ocular motility impairment after removal of the orbital foreign body.

CONCLUSION

Despite the past history of potential morbidity and even mortality from orbital cellulitis, early diagnosis and prompt treatment with proper antibiotics and/or surgical intervention can achieve a good prognosis.

Nosocomial sinusitis: a unique subset of sinusitis

PURPOSE OF REVIEW

Nosocomial sinusitis is a complication of critically ill patients that is frequently not considered as a cause of fever and infection. While this disease has been described in the literature there have been few recent citations on this subject. This brief review will familiarize the reader with the current state of the art with regard to diagnosis complications and treatment of this problem.

RECENT FINDINGS

Nasal and oral tubes have been the prime inciting events. Other risk factors have been facial trauma, inability to mobilize the patient and prior sinus disease. Patients usually present while in the intensive care unit; and there are few signs that suggest sinusitis to the critical care team. A number of complications including direct extension to the brain, lung and blood stream, as well as sepsis and even death have been described. The diagnosis is usually made with the help of specific radiographs or computed tomography scans when these modalities are used. The microbiology is quite different than sinusitis in the community. Staphylococcus spp., Pseudomonas spp. and other nosocomial organisms are frequently isolated when specific cultures are obtained. Treatment usually consists of removal of the tubes mobilizing the patient and institution of broad-spectrum antibiotics aimed at the offending organisms.

SUMMARY

Nosocomial sinusitis continues to be a major problem causing morbidity and occasionally mortality in critically ill patients. Recent findings have suggested that a careful search for this disease and appropriate treatment if found can decrease both morbidity, mortality and subsequent other nosocomial infections.

Guidelines for the management of periorbital cellulitis/abscess

Orbital and periorbital swelling secondary to acute sinusitis is relatively common. Distinguishing between preseptal and orbital involvement can be difficult based on clinical observations alone. A delay in diagnosis and appropriate treatment may result in serious complications including blindness. The literature is reviewed and simple guidelines suggested to manage such patients, including their initial assessment, investigations with particular reference to the indications and timing of CT scanning, antimicrobial therapy and the type of surgery. These guidelines have been approved across disciplines in our unit and trialled successfully for 2 years.

Upper Eyelid Fistula Caused by Chronic Frontal Sinusitis

A chronic upper eyelid fistula stemming from frontal sinus infection was found in a 21-year-old male patient. The diagnosis and treatment approach to this interesting case that remained undiagnosed for a long time are presented in detail.

Severe rhinosinusitis

Rhinosinusitis is diagnosed frequently in clinical practice, but the term may in fact encompass a wide spectrum of diseases. Inflammation of the nasal and sinus mucosa can arise from various causes and lead to different sequelae. Moreover, the term rhinosinusitis is more accurate than sinusitis. Causes range from a viral infection leading to the common cold to an invasive, fungal infection. An accurate diagnosis is important because effective therapy is available if recognized early and if specific therapy is used. Importantly, there is a close relationship between upper and lower airway disease and each have unique structural and functional differences that make an understanding of rhinosinusitis important not only for upper airway disease, but also for the management of asthma. All too often, rhinosinusitis becomes chronic and this becomes a challenge because medical therapy may not be sufficient to control disease. Finally, we should note that the differential diagnosis of rhinosinusitis is extensive and physicians should place heavy emphasis not only on the history, but also on appropriate imaging studies. A normal exam does not rule out the possibility of rhinosinusitis. Finally, we should emphasize that effective treatment is dependent on the etiology of the symptoms but also dependent on whether it is acute or chronic.

Complicações orbitárias em pacientes com sinusite aguda

Introdução: As complicações orbitárias das sinusites permanecem como tópico importante dentro da otorrinoloringologia, a despeito do decréscimo de sua prevalência observado após o advento da antibioticoterapia. Objetivo: Tendo por objetivo determinar as características clínicas e terapêuticas nos casos de sinusites complicadas. Forma de estudo: Clínico prospectivo randomizado. Material e método: Realizamos um estudo retrospectivo de 128 pacientes internados nos últimos 15 anos na Divisão de Clínica Otorrinolaringológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A maior parte destes pacientes eram crianças ou adultos jovens (82,81% dos pacientes tinham menos de 30 anos de idade) e 57,81% eram do sexo masculino. Todos os pacientes apresentaram evolução satisfatória, sem seqüelas tardias. Conclusão: Observamos que o diagnóstico precoce destas patologias é importante, bem como o é a instituição de terapêutica adequada e agressiva (clínica ou cirúrgica). É a ação conjunta destes dois fatores que irá promover uma diminuição da morbimortalidade destas afecções.

Bilateral ethmoidal mucocele in cystic fibrosis: report of a case

The purpose of this study is to report a rare and interesting case of a 10-month-old boy who presented a bilateral ethmoidal mucocele associated with cystic fibrosis and to discuss, according to the literature, the sinonasal involvement in this disease. Only nine pediatric patients with both disorders have been reported previously in literature, and all of these cases were older than 1 year 4 months and presented with a unilateral mucocele.

Do primary care physicians or specialists provide more efficient care?

Sinusitis is a common health complaint and expenditures for its treatment are high; thus, it is necessary to promote efficient practice behaviours in managing patient care. This study compares resource utilization between primary care physicians and specialists in the treatment of Medicaid sinusitis patients in Virginia. Physician-level data from Virginia Medicaid claim files for 1993 were analysed. The efficiency frontier, representing the best achievable performance in the use of resources for treating sinusitis, is identified using Data Envelopment Analysis. Resource utilization (primary care physician visits, specialist visits, emergency room usage, prescriptions and laboratory tests) and corresponding costs are compared between generalists and otolaryngologists. It was concluded from this study that there are no discernible differences in technical efficiency between generalists and specialists in the treatment of sinusitis. Nevertheless, otolaryngologists are found to be more costly than generalists in treating sinusitis. Variation in both caseload and patient mix might explain variation in use of resources.

Sinusitis and carotid artery stroke

The relationship between sinusitis and ischemic stroke is unexplored. The anatomic proximity between the paranasal sinuses and the internal carotid artery suggests that inflammation of the sinuses could easily extend to the intracranial vasculature. We report 4 patients with acute ischemic stroke and extensive disease of the paranasal sinuses. All patients had large vessel stroke involving the internal carotid artery territory. All patients had extensive disease of the sphenoid and other sinuses. The sinus disease was demonstrated by magnetic resonance imaging. These case report observations suggest a relationship between inflammation of the paranasal sinuses, particularly sphenoid sinusitis, and ischemic stroke.

Epidural and pericranial abscesses complicating frontal sinusitis in a comatose child

Most complications of sinusitis have a significant risk of severe morbidity and possibly mortality. Therefore a keen awareness of the subtle signs and symptoms of bacterial spread beyond the paranasal sinuses must be maintained. This increased awareness is especially important in mentally retarded and psychomotor handicapped children because they can develop a rapidly fatal course despite the absence of any warning signs.

Potential infectious disease complications of upper respiratory tract infections

Upper respiratory tract infections (URTIs), particularly otitis media and sinusitis, are prevalent among children. With recurrent URTIs there is an increased likelihood of sequelae. Suppurative complications associated with URTIs, although rare, must be treated rapidly to prevent serious morbidity and mortality. Further, increase in antimicrobial resistance may be accompanied by an increased risk for complications because infecting pathogens may be more difficult to eradicate.

Sinusitis-associated epidural abscess presenting as posterior scalp abscess--a case report

Complications of paranasal sinusitis constitute true surgical and medical emergencies. These complications appear to be more prevalent and seem to present in a more fulminant manner in the pediatric age group. The most common complication of paranasal sinusitis is orbital cellulitis followed collectively by all the intracranial complications. These include meningitis, subdural empyema, intracerebral abscess, epidural abscess and rarely cavernous or superior sagittal sinus thrombosis. We report the case of a 7-year old boy who presented with posterior scalp cellulitis and abscess as a complication of minimally symptomatic paranasal sinusitis. A combined neurosurgical and otolaryngologic approach was required to treat a unilateral ethmoid and frontal sinusitis associated with an epidural abscess abutting the length of the superior sagittal sinus and a posterior subgaleal abscess. The pertinent anatomy allowing for the development of this disease process is discussed. The danger of neurologic sequellae resulting from thrombosis of the superior sagittal sinus is emphasized. Aggressive treatment utilizing a multi-disciplinary surgical approach as well as broad spectrum antibiotics is paramount to obtain the best chance for a full recovery.

Complications of frontal sinusitis in adolescents: case presentations and treatment options

Frontal sinusitis in adolescents can be a serious condition because of the severity of potential complications and rapid progression of disease. These complications may arise as a result of extension of the infection intracranially, to the frontal bone, and to the orbit. Infection may spread hematogenously or by direct extension. A series of seven adolescent patients with complications of frontal sinusitis is presented. Surgical options are necessitated by the location and extent of infection and include trephination, frontal sinus obliteration, and craniotomy. Recent advances in endoscopic sinus surgery have provided surgeons another access to the frontal recess. However, a combined otolaryngological/neurosurgical approach is essential for patients with intracranial complications.

Ptosis associated with sinusitis

An adolescent male developed eye pain and a drooping lid. Imaging revealed adjacent pansinusitis and a swollen levator palpebrae and superior rectus muscle. Compression of a branch of the oculomotor nerve is the postulated cause because vertical eye movements were normal.

Erosion of the wall of the frontal sinus caused by mucopyocele in cystic fibrosis

Three patients with cystic fibrosis had complete erosion of one of the walls of a frontal sinus caused by a mucopyocele. Only fibrous tissue then separated the purulent contents of the sinus from the orbit or central nervous system. Initial surgery was unsuccessful, but two patients have remained free of symptoms after a second obliterating procedure. Sinus mucocele must be excluded by appropriate radiographic techniques when patients with cystic fibrosis have severe frontal headache and acute ophthalmologic symptoms.

Orbital complications of sinusitis: avoid delays in diagnosis

Orbital cellulitis and abscess formation are uncommon complications of sinusitis. Early diagnosis and treatment are important to prevent blindness and intracranial complications. We present four consecutive cases referred over 2 years which demonstrate how diagnostic delays may occur and suggest a protocol to avoid similar delays.