Pediatric subperiosteal orbital abscess secondary to acute sinusitis: a 5-year review

Bilateral orbital abscess secondary to pediatric acute rhinosinusitis: a case report and literature review

A 13-month-old boy presented with bilateral periorbital swelling accompanied by rhinorrhea and fever. Nasal endoscopy revealed middle meatus edema and purulent discharge. He was diagnosed with bilateral preseptal cellulitis and treated with intravenous antibiotics. Continuous fever and new-onset proptosis with extraocular muscle restriction the next day prompted imaging, which revealed sinusitis with bilateral subperiosteal abscesses. He underwent endoscopic sinus surgery with bilateral abscess drainage and recovered uneventfully. Bilateral orbital complications of acute sinusitis are exceedingly rare occurrences and nearly always require surgical treatment.

Aspergillosis Causing Orbital Subperiosteal Abscess in an Immunocompetent Child: A Rare Presentation

Orbital abscesses are primarily seen in children as complication of ethmoid bacterial sinusitis. We report a case of invasive aspergillosis causing orbital abscess in an immunocompetent child which resolved with surgery followed by antifungal therapy. This case highlights need for histopathological, and microbiological examination, including fungal culture in such cases.

Infantile orbital abscess caused by methicillin-resistant Staphylococcus aureus: a case report and literature review

Objective

To report and review infantile orbital abscess caused by methicillin-resistant Staphylococcus aureus (MRSA).

Methods

We report a case of MRSA-induced infantile orbital abscess accompanied by sepsis, pneumonia, and purulent meningitis. We systematically review cases of MRSA-induced infantile orbital abscess published in PubMed, Web of Science and ScienceDirect until April 2023.

Results

We reviewed 14 patients [our patient + 13 patients (10 papers) identified via literature searches]. There were nine boys and five girls; nine neonates and five older infants; and 8 full-term births and 1 preterm birth. The gestational age at birth was unknown for five infants. The right and left orbits were affected in 10 and 4 patients, respectively. The clinical presentation included periorbital soft-tissue edema or redness (11 patients), fever (7 patients), exophthalmos (10 patients), limited eye movement (4 patients), purulent eye secretions (2 patients), and skin abscess and convulsion (1 patient each). The source of infection was sinusitis (8 patients), vertical transmission, gingivitis, dacryocystitis, upper respiratory tract infection (1 patient each), and unknown (2 patients). MRSA was detected in blood (6 patients) or pus culture (8 patients). Vancomycin or linezolid were used for 11 patients; corticosteroids were administered to only 1 patient. Surgical drainage was performed for 13 infants (external drainage, 11 patients; endoscopic drainage, 2 patients). Two patients initially had pulmonary and intracranial infections. Except for one patient with neurological dysfunction at discharge, all other infants had no sequelae or complications.

Conclusion

Early aggressive anti-infective treatment and timely drainage are essential for managing MRSA-induced infantile orbital abscess.

Transnasal endoscopic drainage of neonatal orbital abscess

Neonatal orbital complications are rare and potentially fatal, demanding prompt diagnosis and adequate treatment. A 25-day-old neonate presented with rapidly progressive orbital complications as evidenced by proptosis, chemosis, lid oedema and restricted eye movements, developing within 3 days. There was no significant medical history or risk factors for developing infection. An initial conservative approach with antimicrobial therapy failed to show any resolve. An MRI brain, orbits and paranasal sinuses demonstrated that there were features suggestive of right orbital cellulitis with possibility of abscess formation with right ethmoidal mucoinflammatory disease and mass effect on the optic nerve causing stretching and compression by the surrounding inflammation.The patient was treated successfully with transnasal endoscopic drainage and decompression. Endoscopic access was challenging owing to the restrictive anatomy. Postoperatively, the patient showed improvement, with gradual decrease in proptosis and resolve in eye movements.

[Children's rhinosinusitis orbital complications]

The number of cases of children's sinogenic orbital complications does not reduce in spite of the advanced methods of paranasal sinuses visualization, wide use of antibacterial therapy against sinusitis, and preventive vaccination against pneumococcal disease. Orbital complications are more common with children than with adults, the basic reason of their development being ethmoiditis. The prevailing classification of orbital complications proposed by J. Chandler et al. divides these into preceptal and postceptal forms and gives description to 5 development stages of orbital complications in the order of their increasing severity. At an early age preceptal and orbital cellulites prevail, and these commonly need conservative treatment only. In case of orbital cellulitis, the major treatment method is endovenous antibiotic therapy in which the chosen antibiotic is to cover the whole spectrum of aerobic and anaerobic microbes often extracted in such cases. At small subperiostal abscesses (<0.5-1 ml), conservative treatment during 24-48 hours is possible. If there is no positive dynamics, or abscess grows in size, or eye symptoms progress, abscess and affected sinuses drain is recommended. Orbital abscess is to be given surgical treatment; at the same time endoscopic management of paranasal sinuses might by complemented with external surgical approaches (lateral and medial orbitotomy).

The difference in pathogenic bacteria between chronic rhinosinusitis in patients with and without Sjogren's syndrome: a retrospective case-control study

Background

Chronic rhinosinusitis (CRS) affects the quality of life of many people worldwide and can cause comorbidities. Our previous research proved that Sjogren’s syndrome (SS) is a predisposing factor for CRS, with a 2.5-fold associated risk. Antibiotics are important in CRS treatment; however, there is a paucity of research on the pathogenic bacteria of SS-CRS in the past. We conducted this study to investigate the pathogenic difference of SS-CRS and non-SS-CRS and aimed to give clinicians references when selecting antibiotics to treat SS-CRS.

Materials and methods

A total of 14,678 patients hospitalized for CRS operation from 2004 to 2018 were identified from the Chang Gung Research Database. These CRS cases were classified as either SS-CRS or non-SS-CRS. We analyzed their bacterial distribution by studying the results of the pus cultures performed alongside surgery.

Results

The top three facultative anaerobic or aerobic isolated bacteria in the SS-CRS group were coagulase-negative Staphylococcus (CoNS: 34.3%), Pseudomonas aeruginosa (28.6%), methicillin-sensitive Staphylococcus aureus (MSSA: 20%), and Staphylococcus epidermidis (20%). In the non-SS-CRS group, S. epidermidis (29.3%), CoNS (25.7%), and MSSA (14.2%) were identified. The top three anaerobic bacterial genera were Cutibacterium (54.3%), Peptostreptococcus (11.4%), and Fusobacterium (11.4%) in the SS-CRS group and Cutibacterium (53.8%), Peptostreptococcus (25%), and Prevotella (12.9%) in the non-SS-CRS group.

Conclusions

P.aeruginosa is a major pathogen in SS-CRS patients. In addition, physicians should be aware of potential Fusobacterium and antibiotic-resistant bacterial infection in patients with SS-CRS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07652-4.

Acute bacterial sinusitis in children: an updated review

Background

In the pediatric age group, approximately 7.5% of upper respiratory tract infections (URIs) are complicated by acute bacterial sinusitis (ABS). Despite its prevalence, ABS is often overlooked in young children. The diagnosis and management present unique challenges in primary care. This is an updated narrative review on the evaluation, diagnosis, and management of ABS.

Methods

A PubMed search was performed using the key term ‘acute sinusitis’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies, and reviews. The search was restricted to the English literature and children.

Results

Haemophilus influenzae (non-typeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the major pathogens in uncomplicated ABS in otherwise healthy children. In complicated ABS, polymicrobial infections are common. The diagnosis of acute sinusitis is mainly clinical and based on stringent criteria, including persistent symptoms and signs of a URI beyond 10 days, without appreciable improvement; a URI with high fever and purulent nasal discharge at onset lasting for at least 3 consecutive days; and biphasic or worsening symptoms.

Conclusion

Data from high-quality studies on the management of ABS are limited. The present consensus is that amoxicillin-clavulanate, at a standard dose of 45 mg/kg/day orally, is the drug of choice for most cases of uncomplicated ABS in children in whom antibacterial resistance is not suspected. Alternatively, oral amoxicillin 90 mg/kg/day can be administered. For those with severe ABS or uncomplicated acute sinusitis who are at risk for severe disease or antibiotic resistance, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) is the drug of choice.

Spectrum of Orbital Cellulitis on Magnetic Resonance Imaging

Introduction Orbital infection is an ophthalmological emergency as it can lead to blindness and intracranial spread. Imaging is needed to determine the extent of the infection, to localize an abscess, and for surgical planning. The role of magnetic resonance imaging (MRI) is well established in the evaluation of orbital pathologies, including orbital cellulitis and abscess, mainly due to its ability to evaluate early intracranial involvement. The objective of the study was to highlight the spectrum of MR imaging findings and the pattern of spread in fifteen patients with orbital cellulitis. Methods A prospective study was conducted in a tertiary care hospital. Fifteen patients of all age groups, of either sex, presenting with clinical findings suggestive of orbital cellulitis, referred for MRI of orbits, were included in the study. Written informed consent was obtained prior to the study. Patients' demographic data such as age and gender, associated co-morbidities, complications, and the pattern of spread of disease on MRI were recorded and evaluated. Descriptive statistics were used. Results Orbital/periorbital abscess was found to be the most common complication of orbital cellulitis (eight cases, 53.3%), followed by optic neuritis/perineuritis (four cases, 26.67%), intracranial involvement (four cases, 26.67%), dacryoadenitis (three cases, 20%) and cavernous sinus thrombophlebitis (three cases, 20%). Seven cases (46.67%) had right orbital involvement. Sinusitis was found to be the most common predisposing factor. Amongst the cases associated with sinusitis, the commonest inflamed paranasal sinus was found to be the ethmoid sinus (twelve cases). Amongst the fifteen cases of orbital/periorbital cellulitis, there were only two cases of isolated preseptal cellulitis (13.33%), five cases of postseptal cellulitis (33.33%) and eight cases of both preseptal and postseptal orbital cellulitis (53.33%). Conclusion MRI is the imaging modality of choice in the evaluation of orbital cellulitis because of its superior soft tissue and contrast resolution. It is vital to evaluate the extent of the orbital infection, underlying paranasal sinus involvement, as well as detect complications of orbital cellulitis, especially intracranial spread.

Pediatric trochleitis associated with paranasal sinusitis: a case report

Background

Trochleitis is trochlear pain with evidence of inflammation in the trochlear area on radiologic examination. The etiology of trochleitis is mostly idiopathic. Secondary trochleitis is rare, and trochleitis associated with paranasal sinusitis in children has not yet been reported.

Case presentation

An 8-year-old boy presented with left periorbital pain for a week. His visual acuity and eye movement were normal. There was point tenderness on palpitation over the left trochlear region without swelling or redness. Orbital magnetic resonance imaging showed focal enhancement on the left trochlea and paranasal sinusitis on the left side. The patient’s symptoms and signs were completely resolved after empirical treatment for sinusitis. There was no need to inject a local steroid.

Conclusion

Although rare, sinusitis should be considered when diagnosing and treating trochleitis in children with periorbital pain.

Surgical Treatment of Rhinosinusitis-Related Orbital Complications: Factors Affecting Irreversible Blindness

If left untreated, rhinosinusitis can rarely cause a devastating complication irreversible blindness (IB). Despite new technologies in endoscopic sinus surgery and use of new broad-spectrum antibiotics, IB outcome is still a problem for surgically treated orbital complication of paranasal sinus infection (OCPSI) patients, and factors leading to IB outcome are not actually known. The aim of this study was to assess the factors leading to the IB outcome for surgically treated OCPSI patients. Results of 25 surgically treated OCPSI patients in our clinic were combined with surgically treated OCPSI patients reported through the PubMed database search from the year 2007. Patients were divided into 2 groups: IB group and recovery group. Patients having at least 1 immune status-related additional risk factor (ARF) were more common in the IB group, having an at least 1 ARF had 1.683 risk value of IB outcome (RR: 1.683, P = 0.006). IB patients had statistically significant higher mean (21.87 ± 40.35, P = 0.005) time interval (days) (TI) between onset of ophthalmological symptoms and surgical intervention compared to recovery group patients (2.92 ± 2.53). ROC curve analysis for an estimation of IB outcome according to the TI value demonstrated that a cut-off value of ≥2.5 days had the ideal sensitivity (87.5%) and specificity (71.9%) that resulted in IB outcome. (80.5% power, P = 0.008) IB and recovery group patients did not differ according to orbital complication type according to Chandler's classification (P = 0.492) and white blood cell count status (P = 0.584). In conclusion, OCPSI patients with ARFs and delayed admission after onset of orbital symptoms have a higher risk of IB outcome. These patients deserve prompt evaluation and early surgical intervention to prevent blindness. With future studies, new surgical criteria, including the ARF status and onset of ophthalmological symptoms (≥2.5 days) may be added to classical surgical criteria to prevent IB for OCPSI cases.

Image-guided system endoscopic drainage of orbital abscess caused by methicillin-resistant Staphylococcus aureus in an infant

•

Orbital abscess in infant requires prompt treatment.

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MRSA is an increasingly common organism causing orbital abscess in infants.

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Surgical drainage of orbital abscess is indicated when presence of persistent infection clinically or radiologically despite systemic antimicrobial therapy.

•

Image-guided endoscopic drainage of orbital abscess in infant provides a safer surgical technique.

Introduction

The management of orbital abscesses in neonates and infants is very challenging. Surgical drainage of the abscess is aimed at removing the pus and preventing blindness. We describe a case of orbital abscess in an infant that was caused by methicillin-resistant Staphylococcus aureus and that was successfully drained with image-guided endoscopic surgery.

Presentation of case

A 39-day-old infant presented with progressive right maxillary swelling complicated by methicillin-resistant Staphylococcus aureus orbital abscess. Tooth bud abscess was the most likely primary cause and a combination of intravenous antibiotics was initially prescribed. The collection of intra-orbital pus was removed using image-guided system-aided endoscopic surgical drainage.

Discussion

Prompt diagnosis and management are very crucial. Endoscopic drainage of these abscesses in children has been described. Image-guided drainage of the orbital abscess is a newer technique that has been reported in a teenager and in adult patients. This is the first reported case of endoscopic orbital drainage surgery in an infant. The procedure was performed successfully. This approach provides for better identification of the anatomical structures in a very young patient. Injuries to the medial rectus, globe and optic nerve can be avoided with this technique.

Conclusion

Aggressive management of orbital abscesses in infants is mandatory. Image-guided endoscopic orbital drainage offers precise visualization and a safer technique in a relatively smaller orbit.

Orbital complications associated with paranasal sinus infections - A 10-year experience in Israel

OBJECTIVE

Orbital involvement is the most common complication of sinus infections. The epidemiology of the disease is continuously changing in the antibiotic era.

MATERIALS AND METHODS

Data on patients who were hospitalized due to acute sinusitis and orbital complications were retrospectively collected and analyzed from four medical centers in Israel during the years 2002-2012.

RESULTS

288 patients were included in the study, the average age was 14.4 years, 180 were males, and 220 were children. No significant annual increase in the number of patients was noted. The lowest number of patients was found during the summer 19.4%. A linear direct correlation was found between older age and prolonged hospital stay. Children were presented with a significantly higher Chandler score than adults. No patient had cavernous sinus thrombosis. 101 (35%) patients received antibiotics before hospital admission. Their average hospital stay was similar to those who were not treated prior to admission. 106 patients (39.8%) had fever. A direct correlation was found between older age and the presence of fever. 102 (35.4%) patients had leukocytosis. The difference in white blood cell count between patients younger than two years of age to the other groups was statistically significant. Forty four (15.3%) patients underwent surgical intervention. A direct correlation was found between leukocytosis and older age to surgery.

CONCLUSIONS

Periorbital cellulitis occurs mainly in children and males and is less frequent in the summer. Children tend to have worse orbital involvement with lower temperatures than adults. Older age and leukocytosis are associated with surgical intervention.

Microbiology and choice of antimicrobial therapy for acute sinusitis complicated by subperiosteal abscess in children

OBJECTIVES

Review past studies of the microbiology of subperiosteal abscesses (SPOA) complicating sinusitis in children and their implications of the antimicrobials administered to treat the infection.

METHODS

Literature search was conducted of the Cochrane Library, EMBASE, TRIP, EMBASE, and MEDLINE databases from their inception.

RESULTS

The most common pathogens isolated from studies of SPOA complicating sinusitis are aerobic (Streptococcus pneumoniae, Streptococcus spp., Haemophilus spp., Eikenella corrodens), anaerobic (Peptostreptococcus, Fusobacterium, Prevotella, Porphyromonas, Bacteroides, and Veillonella spp.), and micoaerophilic streptococci (Streptococcus anginosus/Streptococcus milleri group), all members of the oropharyngeal flora. S. pneumoniae and S. aureus were more frequently recovered in children >7 years old, while polymicrobial aerobic-anaerobic flora were more often isolated from those >15 years. The introduction of pneumococcal vaccine reduced the rate of isolation of S. pneumoniae, and correlated with increase of recovery of S. aureus including methicillin resistant strains, as well as Streptococcus pyogenes and S. anginosus/milleri group.

CONCLUSIONS

The microbiology and consequently the treatment of respiratory infections including sinusitis and its complications has evolved over the past decades. Establishing the microbiology of SPOA by obtaining appropriate cultures for both aerobic and anaerobic bacteria are essential for proper antimicrobial selection.

Blindness resulting from orbital complications of ophthalmic zoster

Herpes zoster ophthalmicus occurs when the latent varicella zoster virus (VZV) reactivates in the trigeminal ganglion and ophthalmic branch of the trigeminal nerve. In the elderly, there is a sharp increase in the tendency of secondary skin bacterial infections occurrence due to the deterioration of capabilities of self-care and changed sanitation. We present a case of patient who developed phlegmon of the orbit, which resulted with complete unilateral blindness. Varicella zoster virus infection in the elderly may have a severe course due to the progressive weakening of the immune system related to the age. Moreover, skin lesions around the eye socket require special care in prevention of bacterial superinfections due to the extremely high risk of life-threatening complications or disability. Neuralgia resistant to pharmacological treatment present in the course of ophthalmic zoster and difficulty in caring about skin lesions predispose to the occurrence of complications.

Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis

In patients with acute bacterial rhinosinusitis severe orbital and intracranial complications can occur. This review will illustrate the anatomic relationship between the paranasal sinuses and the orbital and intracranial compartments. Subsequently, the spectrum of orbital and intracranial complications of rhinosinusitis and related imaging findings will be discussed and illustrated by case material from daily practice.

TEACHING POINTS

• Acute bacterial rhinosinusitis can cause severe orbital and intracranial complications. • If orbital or intracranial complications are suspected, cross-sectional imaging is mandatory. • Infection can spread from the ethmoid sinus to the orbit through the lamina papyracea. • Frontal sinusitis can spread intracranially through dehiscences or osteomyelitis. • Radiologists must recognize imaging findings of complications of acute bacterial rhinosinusitis.

Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis

PURPOSE

Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss.

METHODS

All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed.

RESULTS

Thirty patients met inclusion criteria. Average age was 28.7 ± 24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p = 0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p = 0.03) and maximum restriction (-2.5 ± 1.2 vs. -0.9 ± 0.7, p = 0.008) were associated with SPA. Temperature at presentation (37.9 ± 0.9 vs. 37.1 ± 0.4, p = 0.04), relative proptosis (5.8 ± 3.3 mm vs. 2.1 ± 1.1, p = 0.002) and abscess volume (4.3 ± 1.3 mm(3) vs. 0.7 ± 0.5 mm(3), p = 0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology.

CONCLUSIONS

Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.

Acute MRSA sinusitis with intracranial extension and marginal vancomycin susceptibility

Methicillin resistant Staphylococcus aureus (MRSA) is increasingly being described as a cause of acute sinusitis. We present a patient with acute MRSA sinusitis complicated by rapid intracranial extension, marginal vancomycin susceptibility (MIC = 2 mg/L), delayed drainage of intracranial abscess, and subsequent development of rifampin resistance. Given the relatively high risk of intracranial extension of severe acute bacterial sinusitis and high mortality associated with invasive MRSA infections, we suggest early surgical drainage of intracranial abscesses in these circumstances. We believe this is important given the limited intracranial penetration of currently available treatment options for MRSA, especially those with a vancomycin minimal inhibitory concentration (MIC) of ≥2 mg/L.

Neonatal orbital abscess

Orbital abscess is life-threatening and rare in children. Reported herein is a term male neonate who had methicillin-resistant Staphylococcus aureus orbital abscess, and a literature review of this disease. A total of 16 neonates diagnosed with neonatal orbital abscess are reported in the literature. There is a mild male predilection and two neonates were delivered prematurely. Leukocytosis, fever, ethmoiditis and associated upper respiratory tract infection were found in approximately half of them. Eight neonates had sepsis and 14 patients underwent surgical intervention. One patient died. Staphylococcus aureus was identified in 14 out of 17 patients. Neonatal orbital abscess is rarely encountered but may be fatal. Although streptococci are prevalent in childhood orbital infection, S. aureus was predominant in neonatal orbital abscess in the present series. Appropriate antimicrobial therapy against S. aureus is essential in treating neonatal orbital abs ess. This case suggests that a higher initial dose of vancomycin may be an effective and safe strategy for severe S. aureus infection in neonates.

[Orbital complications of sinusitis]

PURPOSE

Orbital complications of sinusitis are rare but serious, with potential functional and even fatal consequences. The purpose of this work is to study the epidemiological, clinical and paraclinical features of the orbital complications of sinusitis, as well as the various treatment modalities and clinical course.

PATIENTS AND METHODS

We report the results of a retrospective study of 34 cases of orbital complications of sinusitis, collected between 1998 and 2009.

RESULTS

Mean age was 19 years 3 months, with a clear male predominance. No predisposing factors were found. All patients presented with periorbital edema. In addition to periorbital edema, ophthalmological examination also revealed: proptosis in 19 patients, decreased visual acuity in eight patients and ocular motility disturbances in 10 patients. All patients underwent emergent facial CT, two patients underwent orbital ultrasound, and one underwent magnetic resonance imaging. Initial treatment was based on empiric intravenous antibiotic therapy. Orbital drainage was performed in 20 patients. Sinus drainage was performed in 16 patients (14 cases during the acute phase) with a middle meatotomy in all cases. The initial response was favorable in 97.5% of cases. One patient had a recurrence. Mean follow-up was 11 months.

CONCLUSION

Orbital complications of sinusitis are a diagnostic and therapeutic emergency. Imaging helps guide management. Directed treatment and early management can improve mortality and morbidity.

Orbital abscess arising from an odontogenic infection

AIM

Presenting a rare complication of an odontogenic infection extending to the orbit.

BACKGROUND

A 45-year-old male patient reported with periorbital swelling of eyelids, of the left eye, foul smelling nasal discharge and a pus draining sinus on the left lower eyelid area.

CASE DESCRIPTION

The patient gave history of pain in the left upper first molar tooth 1 week back. His intraoral examination showed poor oral hygiene with tenderness on percussion on the left maxillary first molar. Investigations showed possible extension of infection from left maxillary molar root to maxillary sinus and to the orbital floor.

CONCLUSION

A case of periapical infection of a maxillary left molar resulting in an orbital abscess is presented. Identification of odontogenic source of infections, institution of drainage, removal of offending teeth and appropriate antimicrobial therapy are mandatory in preventing loss of vision and cerebral extensions. The pathways of spread of the infection, treatment aspects, are discussed and complications are reviewed.

Management of acute rhinosinusitis

Acute rhinosinusitis (ARS) is one of the most common reasons for physician visits and for significant school absenteeism, although precise data on its prevalence and incidence are still lacking. RS is defined as acute if there are symptoms lasting <12 wk with complete resolution. Superinfection by bacteria following a viral infection is the most important mechanism of ARS. Diagnosis of ARS should be made on clinical grounds alone. Typically, acute bacterial RS is self-limited and goes through spontaneous recovery within 4 wk. Recognizing the occurrence of bacterial superinfections of the sinuses during a common viral respiratory infection is fundamental to making the decision to start an appropriate antibiotic treatment. Topical treatments such as saline irrigation, nasal decongestants, steroids, antihistamines, and fungicides are all in widespread pediatric use, but analyzing the literature gives poor evidence of efficacy, except for topical steroids. RS is a multifactorial condition that poses a diagnostic and management challenge to infectivologist and ear-nose-throat specialists as well as to pediatricians.