Intracranial complications of acute sinusitis in children: The role of endoscopic sinus surgery

Increased incidence of intracranial complications following pediatric sinogenic and otogenic infections in the post-COVID-19 Era: A systematic review and meta-analysis

BACKGROUND

This systematic-review and meta-analysis aims to evaluate and summarize the prevalence of pediatric intracranial complications following sinogenic or otogenic infections before and after the COVID-19 pandemic.

METHODS

A literature search was performed using the PubMed, Scopus, and CINAHL databases to answer the question: In pediatric patients, was there an increase in the prevalence or severity of intracranial complications due to sinogenic or otogenic infections during and after the COVID-19 pandemic? Publications which included primary data on patients under the age of 18 years old, focusing on intracranial complications following otogenic and sinogenic infections were included.

RESULTS

Of 1025 abstracts screened, 18 studies were included. There were no significant differences in age or sex between the two cohorts. Compared to the pre-COVID era, post-COVID infections were more likely to have neurologic complications upon presentation [11.4 % (1.6-53.0) vs 50.1 % (13.9-86.2), p < 0.01], cerebral venous sinus thrombosis (CVST) [14.1 % (10.6-18.2) vs 40.5 % (25.2-56.9), p < 0.01], intraparenchymal abscess [40.3 % (43.9-72.2) vs 54.9 % (25.2-87.1), p < 0.01], and meningitis [10.6 % (0.0-39.4) vs 40.2 % (13.4-70.8), p < 0.01]. Metronidazole use [38.7 % (31.8-46.0) vs 71.9 % (51.3-88.6), p < 0.01], craniectomy [16.1 % (1.3-42.8) vs 37.4 % (2.9-83.0), p = 0.02], and burr holes [16.8 % (11.5-23.3) vs 26.6 % (12.7-43.3), p = 0.02] were increased in the post-COVID cohort.

CONCLUSION

There are considerable differences in neurologic deficits, CVST, intraparenchymal abscesses, meningitis, and treatment modalities in pre- and post-COVID cohorts of children with intracranial complications of otorhinogenic origin. Further research is required to determine the underlying mechanism for these differences.

Rhinosinusitis: Evidence and experience - 2024

It has been 10-years since the publication of Rhinosinusitis: evidence and experience, and since then a lot has changed in our understanding of the disease. Advances in pathophysiology, endotyping and new treatments such as biologics brought a new era in the management of our patients. This new guideline, developed jointly by ABR and ABORL-CCF, with the help of ASBAI presents an updated, evidence-based approach to the different forms of rhinosinusitis that aims to improve the diagnosis and treatment of this complex disease. The document covers a wide range of topics, including clear definitions of the different stages of acute sinusitis. It also introduces a new term called Prolonged Acute Viral Rhinosinusitis. Reviews phenotypes and endotypes of chronic rhinosinusitis, recommending methods for clinical and laboratory investigation, clinical and surgical treatment. We also discuss in detail fungal sinusitis and pediatric sinusitis. The objective of this updated Consensus is to clarify some already established and recent concepts, highlighting the importance of an accurate diagnosis to promote treatment approaches that reflect the best practices based on solid evidence. Therefore, we seek not only to improve the results of patients care, but also to guide thealth professionals through a clinical panorama that is in constant transformation.

Efficacy of endoscopic sinus surgery in patients under six years old

OBJECTIVES

To examine safety and efficacy of very young patients under the age of six who underwent endoscopic sinus surgery (ESS) at our institution for the indications of either complicated acute rhinosinusitis (ARS) or chronic rhinosinusitis (CRS).

METHODS

Retrospective cohort review of patients under six years old who underwent ESS for sinonasal pathology between 2016 and 2023 at a freestanding pediatric hospital. Age, sex, weight, diagnosis, laterality of disease, medications, types and number of surgical interventions, usage of image guidance, and outcomes were obtained from the medical record.

RESULTS

A total of 25 patients met inclusion criteria (range 1 month-5 years). Eighteen of the patients underwent surgery for an indication of complicated ARS and 7 patients underwent surgery for CRS. Ages were separated into three categories, <1 year (n = 1), 1-3 year (n = 3), 3-6 year (n = 21). Chi squared testing between these three age groups revealed no significant differences in revision rates. There were 5 children who required revision surgery, 3 of which had CRS. Ages of the children who required revision ranged from 2 to 4 years old. There was only one surgical complication observed.

CONCLUSIONS

Endoscopic sinus surgery has been increasingly considered safe in pediatric otolaryngology, however, our database in particular focuses on a very young subset of these patients in which there were very few (one) morbidities and no mortalities. Further study of this population should be continued to determine long term outcomes; however, it should be considered safe in acute situations.

LEVEL OF EVIDENCE

Level 4.

The impact of endoscopic sinus surgery in pediatric patients with sinogenic intracranial infection: A systematic review and meta-analysis

OBJECTIVE

This review aims to elucidate the role of endoscopic sinus surgery (ESS) on the outcomes of pediatric patients with sinogenic intracranial infections.

METHODS

MEDLINE, Embase, and the Cochrane library were searched for articles that described the outcomes in pediatric patients who had intracranial complications of acute rhinosinusitis (ARS) and underwent ESS with or without open neurosurgical approaches (ONA) or external sinus approaches (ESA). Primary outcomes of interest include mortality, revision surgery, length of stay and neurological sequelae. Random effects meta-analysis was performed.

RESULTS

Forty-eight articles met the final eligibility criteria, totaling 710 pediatric patients and 905 intracranial complications. The most common complications were subdural empyema (n = 261, 29 %), epidural abscess (n = 213, 24 %), and Pott's Puffy tumor (PPT) (n = 95, 10 %). When comparing patients who underwent ESS (alone or combined with ONA) to those who underwent ONA only, there was a decreased risk of revision surgery (RR = 0.66, 95 % CI = 0.38-1.12 and RR = 0.63, 95 % CI = 0.36-1.09, respectively) and decreased risk of neurological sequelae (RR = 0.65, 95 % CI = 0.15-2.74 and RR = 0.50, 95 % CI = 0.20-1.26, respectively), however these differences were not statistically significant. When patients who underwent combined intervention were compared to ESS only, the risk of revision surgery (RR = 1.04, 95 % CI = 0.62-1.72) and neurological sequelae (RR = 0.99, 95 % CI = 0.37-2.64) were similar. Risk of mortality was minimal and similar across all interventions.

CONCLUSION

The current study including primarily small retrospective studies found no statistically significant differences between children who received ESS alone, ESS with ONA or ONA alone, on mortality, revision surgery, length of stay and neurological sequelae. Although ESS may be beneficial for managing certain pediatric sinogenic intracranial infections, its true effectiveness is difficult to determine due to the variability in the types of intracranial complications and the inconsistent extent of ESS procedures reported in the literature.

A Scoping Review of the Intracranial Complications of Pediatric Sinusitis

OBJECTIVE

Intracranial complications of pediatric sinusitis are uncommon but are often associated with significant morbidity, especially when appropriate care is delayed. The present study aimed to identify commonalities for the development and progression of these complications in the pediatric population.

DATA SOURCES

CENTRAL, CINAHL, Citation searching, ClinicalTrials.gov, Embase, Google Scholar, MEDLINE, PsycINFO, PubMed, Scopus, Web of Science, and World Health Organization.

REVIEW METHODS

A comprehensive literature search was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses scoping review guidelines. Studies describing intracranial infections secondary to sinusitis in the pediatric population (age <18 years) were included. Studies in which adult and pediatric data were not separated and studies in which the pediatric cohort was fewer than 10 cases were excluded. Ultimately, 33 studies describing 1149 unique patient cases were included for data collection and analysis.

RESULTS

Our analysis revealed intracranial complications were more common in adolescent males. Most children presented with over 1 week of vague symptoms, such as headache and fever. The majority of complications were diagnosed radiographically with computed tomography. Subdural empyema and epidural abscess were the most common intracranial complications reported. On average, patients were admitted for over 2 weeks. Most children were treated with a combination of antibiotics and surgical intervention. Complications were rare, but when present, were often associated with significant morbidity.

CONCLUSION

This scoping review of the available literature has provided insight into commonalities among pediatric patients who develop intracranial complications of sinusitis, providing a foundation for further study to inform medical and surgical decision-making in this population.

[Acute rhinosinusitis in children requiring hospitalization between 2016 and 2022 - retrospective analysis]

Bevezetés: A rhinosinusitis az orr- és orrmelléküregek nyálkahártyájának váladékképződéssel és ödémás duzzanattal járó gyulladása. Az akut bakteriális rhinosinusitis főként szövődményes eseteiben gyakran szükséges fekvőbeteg-intézménybe való felvétel. Célkitűzés: A Szegedi Tudományegyetem Fül-Orr-Gégészeti és Fej-Nyaksebészeti Klinikájának fekvőbetegosztályára 2016 és 2022 között akut rhinosinusitis miatt felvett gyermekek anyagának retrospektív elemzése, illetve annak megállapítása, hogy a COVID–19-járvány befolyással volt-e a felvételt igénylő esetek arányára. Módszer: Demográfiai és klinikai adatok gyűjtése, az eredmények összehasonlítása hazai és nemzetközi irodalmi adatokkal. Eredmények: 497 gyermekből 471 beteg kezelése kizárólag ambulánsan történt. 26 gyermek, 17 fiú és 9 lány került felvételre (1 fő 2 alkalommal). Az átlagéletkor 7,65 év volt. A felvételek 52%-a a három téli hónapban, az összes felvétel 89%-a a novembertől áprilisig terjedő időszakban történt. 19 esetben akut ethmoiditis, 5 esetben akut sinusitis maxillaris, 2 esetben akut pansinusitis, 1 alkalommal akut sphenoiditis volt a felvételi diagnózis. A felvétel oka 19 gyermeknél a következményes szemhéjödéma, 7 esetben az alkalmazott terápia melletti progresszió volt, 1 betegnél intracranialis szövődmény igazolódott. Az átlagos hospitalizáció 4,2 nap volt. 16 esetben amoxicillin-klavulánsav, 11 esetben cefuroxim parenteralis adása történt. 9 esetben (8 orbitalis, 1 intracranialis szövődmény) elkerülhetetlen volt a műtét. Minden betegnél funkcionális endoszkópos beavatkozás történt. 2 alkalommal, orbitatályog miatt, külső megnyitásra is szükség volt, az intracranialis szövődménynél idegsebészeti műtét is történt. Megbeszélés: A vizsgált paraméterek korrelálnak az irodalmi adatokkal, a COVID–19-járványnak tulajdonítható esetszámváltozást nem tapasztaltunk. Következtetés: Az akut rhinosinusitis konzervatív terápiával általában gyógyítható, de előfordulhatnak súlyos, életet veszélyeztető szövődmények. Bár a kórházi felvételt igénylő esetek száma csökkent, a szövődmények aránya nem változott, ezért nagyon fontos azok gyors felismerése és hatékony kezelés. Orv Hetil. 2024; 165(19): 747–753.

Pediatric intracranial empyema complicating otogenic and sinogenic infection

OBJECTIVE

To describe and compare clinical and microbiological features, surgical and medical management, and outcomes of children with otogenic and sinogenic intracranial empyema (IE) in an institution with an established multidisciplinary protocol. To use the study findings to inform and update the institutional algorithm.

METHODS

Retrospective analysis was carried out on the electronic healthcare records of all children with oto-sinogenic IE admitted in a 5-year period.

RESULTS

A total of 76 patients were identified and treated according to an institutional protocol. Two distinct groups were identified: intracranial empyema related to otogenic infection (OI-IE, n = 36) or sinogenic infection (SI-IE, n = 40). SI-IE was seen in older children and had a significantly higher morbidity. Sub-dural IE was seen in a minority (n = 16) and only in SI-IE and required urgent collaborative ENT-neurosurgery. Extra-dural IE occurred more frequently and was seen in both SI-IE and OI-IE. No death and overall low morbidity were observed. Particularities found in SI-IE and OI-IE groups (as thrombosis, microbiology, antibiotic treatment, duration and outcome) permitted the delineation of these groups in our updated algorithm.

CONCLUSION

The presence of a collaborative multidisciplinary protocol permits the step-wise co-ordination of care for these complex patients in our institution. All patients received prompt imaging, urgent surgical intervention, and antibiotic treatment. Microbiological identification was possible for each patient and antibiotic rationalization was permitted through use of Polymerase chain reaction (PCR) testing in cases of sterile cultures. Of note, intracranial empyema related to sinogenic infection is shown to have significantly more severe clinical presentation, a higher morbidity, and a longer duration of antibiotic therapy than that related to otogenic infection. Study findings allowed for the update and clarification of the institutional protocol, which now clearly demarcates the clinical presentation, biological evidence, radiology, surgical and medical treatments in children with oto-sinogenic IE.

Management of Intracranial Sinusitis Complications in Children and Adolescents: Similarities and Differences Among Otolaryngology Subspecialists

The purpose of this study was to compare the management of intracranial sinusitis complications in pediatric patients between members of the American Rhinologic Society (ARS) and the American Society of Pediatric Otolaryngology (ASPO). A cross-sectional web-based survey was distributed twice to the ASPO and ARS membership over an 8-month period. The overall survey response rate was 12.1% (7.5% of ARS members and 17.3% of ASPO members). Recommended management was similar with respect to the use of intravenous antibiotics, nasal saline irrigations, topical decongestants, and nasal steroid sprays. Recommendations diverged with regards to systemic steroid use and urgent/emergent endoscopic sinus surgery (ESS). ARS members were more likely to recommend systemic corticosteroids. ASPO members were more likely to recommend immediate ESS. Based on survey responses, we found differences in practice patterns among subspecialists, which indicates additional collaborative research between societies is necessary to develop and disseminate evidence-based guidelines for these patients.

Level of Evidence: 4

Frontal Balloon Sinuplasty in Complicated Acute Pediatric Rhinosinusitis (ARS)

Utilization of frontal balloon sinuplasty in pediatric complicated acute rhinosinusitis (ARS) is demonstrated to be a safe and expedient alternative to other procedures such as trephination or functional endoscopic sinus surgery (FESS) in this case series. We performed a retrospective review of six pediatric cases of frontal balloon sinuplasty for ARS with intracranial complications at a tertiary academic center. Patients underwent unilateral (n = 5) or bilateral dilation (n = 1) in addition to functional endoscopic sinus surgery (FESS) including anterior ethmoidectomy (n = 5) and maxillary antrostomy (n = 6). This technique effectively addressed frontal sinus obstruction and served as an alternative to procedures such as trephination or functional endoscopic sinus surgery. No immediate or short-term complications of balloon dilation were observed in these cases. A larger cohort and extended follow-up are necessary to determine the use and long-term impact of this technique.

Concurrent management of suppurative intracranial complications of sinusitis and acute otitis media in children

OBJECTIVE

Intracranial complications of sinusitis and acute otitis media (AOM) are rare but life-threatening events. In children with suppurative intracranial complications, concurrent neurosurgical and otolaryngological (ORL) intervention has been recommended to optimize outcomes. The aim of this study was to investigate outcomes following concurrent neurosurgical and ORL intervention.

METHODS

A retrospective cohort study of children undergoing neurosurgical intervention for intracranial complications of sinusitis or AOM in two neurosurgical centres in Ireland was conducted.

RESULTS

65 children were identified. Mean age was 11.9 years. The most prevalent symptoms were headache, pyrexia, altered level of consciousness, facial swelling, and vomiting. Subdural empyema (n = 24, 36.9%) and extradural abscess (n = 17, 26.2%) were the most common complications. 54 underwent same admission ORL intervention; 47 (87%) were performed concurrently or earlier. For rhinogenic infections, 35 (64.8%) underwent endoscopic sinus surgery (ESS), 13 (24.1%) underwent frontal sinus trephine, and 5 (9.3%) underwent maxillary sinus washout alone. For otogenic infections, 10 (90.9%) underwent mastoidectomy and 7 (63.6%) underwent tympanostomy tube placement. 19 (29.2%) had post-operative neurological deficits, of which 2 (3.1%) were permanent. Streptococcus intermedius was the most common pathogen (n = 30, 46.2%). Concurrent intervention reduced the prevalence of residual collection (p = 0.018) and the need for revision neurosurgical intervention (p = 0.039) for sinogenic complications. The same trends did not achieve statistical significance for the otogenic group. Mortality was 0%.

CONCLUSION

Intracranial complications of sinusitis and AOM are best managed in a specialist centre with multidisciplinary input. Concurrent ORL and neurosurgical intervention reduces abscess recurrence and requirement for revision neurosurgery in sinogenic complications and should represent the standard of care. ESS is the ORL modality of choice in experienced hands.

Streptococcus anginosus group infections in hospitalised children and young people

AIM

The Streptococcus anginosus group (SAG) comprises three bacterial species colonising the mouth and gastrointestinal and genitourinary tracts and capable of serious pyogenic infections. Although well-described in adults, studies in children are limited. Here, we characterise paediatric SAG infections from a single Australian centre.

METHODS

Hospitalised patients aged ≤18 years with positive SAG cultures from January 2009 to December 2019 were identified from Pathology Queensland's Gold Coast Laboratory database and their medical records were reviewed.

RESULTS

Two-hundred children (62% male), median age 12 years (interquartile range 6-16), with positive SAG cultures were identified. Overall, 90% received intravenous antibiotics, 89% underwent surgical drainage, 23% were readmitted and 15% required additional surgery. The most common sites were the abdomen (39%), soft tissues (36%) and head and neck regions (21%). Since 2011, Pathology Queensland reported SAG at the species level (n = 133). Of these, S. anginosus was the most prevalent (39%), then S. constellatus (34%) and S. intermedius (27%). Compared with the other two species, S. intermedius was most commonly associated with head and neck infections (relative risk (RR) = 2.2, 95% confidence interval (CI) 1.4-3.5), while S. constellatus (RR = 1.7, 95% CI 1.2-2.4) and S. anginosus (RR = 1.5, 95% CI 1.0-2.0) were each associated with a higher risk of intra-abdominal infection than S. intermedius. Since February 2015, the number of children admitted with SAG-associated intra-abdominal infection per 1000 hospitalisations increased by 29% annually compared with an annual decline of 8% in previous years.

CONCLUSIONS

SAG infections occur at various anatomical sites. Despite antibiotics and surgical management, almost one-quarter are re-hospitalised for further treatment.

Management of orbital and brain complications of sinusitis: A practical algorithm

The aim of this work was to present a practical management algorithm for orbital and brain complications of sinusitis. According to the inclusion criteria, a sample of 68 patients was collected between 2008 and 2018 (39 males and 29 females). Among them, 44 were adults, with a mean age of 50.46 years, and 24 were pediatric patients, with a mean age of 10.33 years. Oral or intravenous antibiotic therapy was administered to all patients. Pharmacological resolution was observed in 14 cases. Early surgical treatment within 48 hours was necessary in 10 cases. Surgery consisted of abscess drainage, associated or not with functional endoscopic sinus surgery. Delayed surgery within 15-30 days was performed in 44 patients. The core procedure was functional endoscopic sinus surgery. Subsidiary procedures were abscess drainage, tooth extraction or cranial base repair. The combination of two or more of these procedures was case selected. Median follow-up was of 46.36 months. Sinusitis complications necessitate rapid diagnosis and prompt treatment. Antibiotic therapy alone is enough for mistreated rhinosinusitis with no anatomical predisposing factor. Surgery is mandatory for altered nasal and paranasal sinus anatomy or odontogenic infections.

Sinogenic Intracranial Suppuration in Children: Systematic Review and Meta-analysis

OBJECTIVE

To evaluate temporal trends in the management of sinogenic intracranial suppuration and its outcomes in children.

DATA SOURCES

A systematic search of databases was performed (Medline, Embase, Cochrane, ClinicalTrials.gov).

REVIEW METHODS

Studies in children (age <18 years) with sinogenic subdural empyema, extradural abscess, and intraparenchymal abscess were included. Data on treatment strategies were extracted. Primary outcome was death <90 days. Secondary outcomes were return to theater, neurologic disability at 6 months, and length of stay. Random effects meta-analysis and meta-regression were performed to investigate the effect of time and endoscopic sinus surgery (ESS) on these outcomes.

RESULTS

A total of 32 retrospective observational studies involving 533 patients recruited across a 45-year period (1975-2020) were included. The pooled estimates for 90-day mortality, permanent neurologic disability, and return to theater were 2.3% (95% CI, 1.1%-3.6%; I² = 0, P > .99), 21.3% (95% CI, 15.3%-27.3%; I² = 75.2%, P < .001), and 37.3% (95% CI, 29.5%-45%; I² = 71.2%, P < .001), respectively, with no significant differences found across the study period. The pooled estimate for ESS was 58.4% (95% CI, 44.2%-72.6%; I² = 97.1%, P < .001) with a significantly increasing trend in its use in the more recent years. ESS was not associated with improved mortality, reduced need for revision surgery, or neurologic disability.

CONCLUSION

The outcomes of sinogenic intracranial complications have not changed over the last 45 years, and ESS was not associated with improved patient outcomes. Further high-quality studies are required to determine the most appropriate treatment modalities to improve the burden of morbidity associated with sinogenic intracranial suppuration in children.

Suppurative Intracranial Complications of Pediatric Sinusitis: A Single-Center Experience

BACKGROUND

Suppurative intracranial complications of sinusitis are rare events in children and can lead to harmful neurologic sequelae and significant morbidity. We sought to review the presentation and management of patients admitted at our hospital with these conditions.

METHODS

This was a retrospective study of pediatric patients admitted to a quaternary children's hospital from 2007 to 2019 for operative management of sinusitis with intracranial extension. Clinical characteristics, including surgical and microbiological data, were collected and analyzed.

RESULTS

Fifty-four patients were included; the median age was 11.0 years, and there was a male predominance. Eighty-nine percent of patients had prior healthcare visits for the current episode of sinusitis; 46% of patients had an abnormal neurologic exam on admission. Epidural abscess and subdural empyema were the most common complications, and subdural empyema was associated with repeat surgical intervention. The dominant pathogens were Streptococcus anginosus group organisms (74%). The majority of patients completed treatment parenterally, with a median duration of therapy of 35 days. Neurological sequelae, including epilepsy or ongoing focal deficits, occurred in 22% of patients. History of seizure or an abnormal neurological exam at admission were associated with neurological sequelae.

CONCLUSIONS

Clinicians should consider intracranial complications of sinusitis in patients with symptoms of sinusitis for >1 week. Patients should undergo urgent neuroimaging, as neurosurgical intervention is essential for these patients. Subdural empyema was associated with repeat neurosurgical intervention. Neurological sequelae occurred in 22% of patients, and new onset seizure or an abnormal neurological exam at admission were associated with neurological sequelae.

Complicated acute frontal sinusitis in a child presenting with acute ischemic stroke

Acute stroke as a complication of sinusitis is exceedingly rare, and even more so in children. Here we present the case of a healthy 9-year-old male who had an acute stroke in the setting of severe acute pansinusitis. The patient was started on parenteral antibiotics and underwent urgent endoscopic sinus surgery and adenoidectomy, ultimately making a full neurologic recovery. Of the previously reported cases of stroke as a complication of sinusitis, all showed evidence of carotid artery pathology. This is the first report to our knowledge of acute sinusitis presenting as stroke with normal arterial anatomy and function.

Frontal Sinus Drainage in Acute Pediatric Sinusitis With Intracranial Complications

BACKGROUND

The indication for frontal sinus drainage is uncertain when managing pediatric acute sinusitis with intracranial complications.

OBJECTIVE

The primary objective was to determine if addressing the frontal sinus reduced need for subsequent surgical procedures in children presenting with acute sinusitis complicated by intracranial abscess.

METHODS

A case series with chart review was performed at a tertiary children's hospital between 2007 and 2019. Children under 18 years of age requiring surgery for complicated acute sinusitis that included the frontal sinus with noncontiguous intracranial abscess were included. Outcomes were compared among children for whom the frontal sinus was drained endoscopically, opened intracranially, or left undrained.

RESULTS

Thirty-five children with a mean age of 11.1 years (95% CI: 9.9-12.3) met inclusion. Most presented with epidural abscess (37%). Hospitalizations lasted 12.9 days (95% CI: 10.2-15.5), 46% required a second surgery, 11% required three or more surgeries, and 31% were readmitted within 60 days. Initial surgery for 29% included endoscopic frontal sinusotomy, 34% had a frontal sinus cranialization and 37% did not have any initial drainage of the frontal sinus. Groups were similar with respect to demographics, severity of infection, need for repeat surgery, length of stay, and readmissions (p > .05). Further, persistence of cranial neuropathies, seizures, or major neurological sequelae after discharge were no different among groups (p > .05).

CONCLUSION

Drainage of the frontal sinus, when technically feasible, was not associated with reduced surgical procedures or increased complications and there is unclear benefit on measured clinical outcomes.

Microbiology of orbital cellulitis with subperiosteal abscess in children: Prevalence and characteristics of Streptococcus anginosus group infection

Purpose: To evaluate the predominant pathogens and clinical course in pediatric patients with orbital cellulitis (OC) complicated by subperiosteal abscess (SPA).Methods: This is a single-center retrospective chart review evaluating pediatric patients with OC complicated by SPA treated at a tertiary care center in the Pacific Northwest. Data were analyzed for characteristics, rates of infection, and antibiotic resistance of the predominant pathogens in pediatric patients.Results: Twenty-seven children were identified with OC complicated by SPA and bacterial cultures drawn. The average age (SD) of the patients was 9.2 years (4.8), median 9.6; 15 range 5 months to 17.2 years. Seventeen (63.0%) were male. Sinusitis was present in all patients. Streptococcus species were the most common pathogen accounting for 52% (17/33) of isolates. Streptococcus anginosus group (SAG) was the predominant species and were isolated in 10 out of 27 (37%) children in the study. Twenty-one (78%) patients required surgery for the treatment of SPA. Among surgically treated patients, females tended to be younger than males (p = .068). Pediatric patients with SAG infections required more surgery than children without this isolate, 100% and 65%, respectively (p = .030). Female patients tended to have SAG infections more often than males (p = .063).Conclusions: Orbital infections caused by SAG require surgical management more often than those caused by other pathogens. Our results suggest a difference in pathogenic organisms in male and female patients with SPA. SAG is one of the most common pathogens isolated in orbital cellulitis complicated by SPA in children.

The risk factors of intracranial infection in patients with intracerebral hemorrhage undergone hematoma puncture: what should we care

BACKGROUND

Intracranial infection after puncture of cerebral hematoma in patients with intracerebral hemorrhage is very common in the department of neurosurgery, yet the relevant risks remain unknown. We attempted to analyze the risk factors of intracranial infection after puncture of cerebral hematoma, to provide insights into the management of patients with intracerebral hemorrhage after puncture of cerebral hematoma.

METHODS

Patients with intracerebral hemorrhage after puncture of cerebral hematoma treated in our hospital from January 2017 to January 2020 were selected, the related characteristics of intracranial infection and no infection patients were compared. Logistic regression analyses were conducted to analyze the risk factors for intracranial infection after puncture of cerebral hematoma.

RESULTS

A total of 925 patients with puncture of cerebral hematoma were included. The incidence of postoperative intracranial infection was 7.03%. There were significant statistical differences between the infected group and the no infection group in the American Association of Anesthesiologists (ASA) grade, length of hospital stay, consecutive operation, duration of surgery, extra-ventricular drainage (EVD) use (all p < 0.05). There was statistically significant difference in the duration of EVD between the infection and no infection groups (p = 0.002), and there was no significant difference in the frequency of EVD insertion between the two groups (p = 0.094). The length of hospital stay≥10 days (OR1.832, 1.062-3.158), consecutive operation (OR2.158, 1.358-3.430), duration of surgery≥4 h (OR1.581, 1.031-2.425), EVD use (OR1.694, 1.074-2.670), and duration of EVD ≥ 7 days (OR2.699, 1.689-4.311) were the risk factors of intracranial infection in patients with intracerebral hemorrhage after puncture of cerebral hematoma (all p < 0.05).

CONCLUSION

Clinical medical workers should take corresponding preventive measures against the different risk factors for prevention of intracranial infection in patient with puncture of cerebral hematoma.

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.

Management of complicated pediatric rhinosinusitis in the COVID-19 era

With the ongoing development of the COVID-19 pandemic, research continues to emerge regarding the pathophysiology, characteristics, and treatment considerations for patients with COVID-19. No reports have highlighted the specific challenges posed in the management of pediatric patients with COVID-19 who present with complicated rhinosinusitis. In this report, we discuss our preoperative, intraoperative, and postoperative multidisciplinary treatment strategy for these cases and provide two examples of complicated rhinosinusitis cases in COVID-19 patients, treated with two different approaches. Pearls, insights, and a brief review of the literature are discussed.

How to approach complications of acute rhinosinusitis in children?

Intraorbital and intracranial complications of acute rhinosinusitis (ARS) are uncommon, but potentially life threatening. Signs of progression of ARS should be recognized early to allow timely surgical treatment in order to avoid irreversible lesions such as vision loss and neurological deficits. In this case series, we provide an overview of 6 representative cases who presented at our tertiary center (2017-2018). The aim of this case series is (1) to draw new attention to the clinical manifestations and management of these complications, since even in highly-developed medical settings we still observe permanent sequellae due to delayed or inadequate treatment, (2) to give an updated analysis of the guidelines, stressing the low threshold for endoscopic sinus surgery, even in children, (3) to underline the benefits of a multidisciplinary approach in these young patients.

Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020

PURPOSE OF REVIEW

The purposes of the review are as follows: (1) to define acute rhinosinusitis (ARS) and their phenotypes, (2) to highlight the ARS management according to international guidelines, (3) to compare the physicians' management with the ARS guideline recommendations, and (4) to report ARS socioeconomic burden.

RECENT FINDINGS

Bacterial and non-bacterial ARS have similar symptoms, although they can be discriminated by using a combination of specific signs and symptoms. The prescription of antibiotics should be limited to clearly suspected bacterial ARS. There is an overuse of diagnosis tools and treatment prescriptions. The total cost per ARS episode in Europe is over €1000. ARS is mainly an inflammatory disease triggered by viral infection, and few cases end up developing bacterial infection. In most of the cases, it is a self-resolving disease which diagnosis is mainly clinical and the treatment symptomatic. The incidence of complications is low and independent of antibiotic use. There is a high socioeconomic burden associated to ARS.

Complications of sinusitis: An 80-case series from the ENT and neurosurgery departments of the Fann university hospital center of Dakar, Senegal

INTRODUCTION

Locoregional complications of sinusitis are dominated by oculo-orbital and/or cranioencephalic manifestations that may be life-threatening or jeopardize functional prognosis. The aim of this study was to report epidemiological, diagnostic and therapeutic aspects.

MATERIALS AND METHODS

A retrospective study included inpatients managed for sinusitis complications in the ENT and neurosurgery departments of the Fann university hospital center in Dakar, Senegal between January 1, 2005 and December 31, 2016.

RESULTS

In all, 80 files were collected. Mean age was 18.5 years, with male predominance. Mean time to treatment was 18.2 days. Cranio-encephalic complications were the most frequent (54 cases; 67.5%): mainly subdural empyema (30 cases) and brain abscess (10 cases). Seventeen patients (21.25%) had oculo-orbital complications: mainly orbital cellulitis (52.9%) and preseptal cellulitis (29.4%). Nine patients (11.25%) had both cranioencephalic and oculo-orbital complications. Acute sinusitis (82.5%) was the main cause of complications. 52.5% of patients showed pansinus involvement. Medical treatment consisted in broad-spectrum antibiotic therapy combining third-generation cephalosporins, metronidazole and gentamycin in cranio-encephalic complications and clavulanic acid and metronidazole in oculo-orbital complications. Thirty-four patients (42.5%) underwent surgical sinus drainage. Neurosurgical drainage was performed in 35 cases (43.75%). Post-treatment course was marked by 6.25% mortality (5 cases) and 16.25% sequelae.

CONCLUSION

With 6.25% mortality and a high rate of functional sequelae, complications of sinusitis are a serious concern in our region. Improving prognosis requires earlier management and better coordination between health professionals.

Intracranial complications of pediatric rhinosinusitis: Identifying risk factors and interventions affecting length of hospitalization

OBJECTIVE

To identify risk factors and interventions affecting length of hospitalization (LOH) and clinical outcome in children with intracranial complications of rhinosinusitis.

METHODS

Retrospective chart review of 12 children hospitalized at 2 academic medical centers for intracranial complications of rhinosinusitis over the past 5 years.

RESULTS

12 patients were identified with an average age at presentation of 13 years old. 92% were male and 75% were African American. The most common presenting symptoms were fever and headache. Localizing neurological symptoms including hemiparesis and aphasia, in addition to seizures occurred in 33% of patients and increased LOH significantly (33 versus 15 days, p = 0.03). Epidural (EA) and subdural abscesses (SA) were the most common intracranial complications. 58% of patients were initially treated with a combination of open neurosurgical (ON) intervention and endoscopic sinus surgery (ESS) and LOH was significantly shorter for these patients compared to those treated otherwise (14 versus 31 days, p = 0.02). Streptococcus species were the most common group of bacteria identified in 75% of cases, with S. anginosus accounting for 42% of cases. The overall average LOH was 21 days with 92% of patients having complete resolution of symptoms by time of discharge.

CONCLUSIONS

Treatment of intracranial complications of acute rhinosinusitis can have favorable outcomes after appropriate surgical management. Localizing neurologic symptoms and seizures portend longer hospital stay and recovery time. Shorter hospital stay was seen in those undergoing early combined ON and ESS interventions.

Hospital utilization for orbital and intracranial complications of pediatric acute rhinosinusitis

BACKGROUND

Orbital and intracranial complications of pediatric acute rhinosinusitis (ARS) are uncommon. With a risk of significant morbidity, hospital utilization and the financial burden of these entities are often high. We sought to assess utilization trends for complicated ARS and elucidate which factors influence cost.

METHODOLOGY

Analysis of Kids' Inpatient Database (2006, 2009 and 2012). Children were selected based on diagnosis codes for ARS and grouped as: uncomplicated ARS, orbital complications (OC), or intracranial complications (IC). Patients with IC were subdivided into abscess (ICa), meningitis, or sinus thrombosis. Length of stay (LOS), cost and management information were analysed. Data presented as median [IQR].

RESULTS

A weighted total of 20,775 children were included. OC and IC were observed in 10.9% and 2.7% of these patients. LOS was longer for IC compared to OC (9 [8] v 4 [3]days, p < 0.001). Daily cost for IC was greater than OC ($2861 [4044] v $1683 [1187], p < 0.001), likely due to differences in need for surgery (IC 66.3% v OC 37.1%, p < 0.001). Within the ICa group, patients who received both otolaryngologic (ENT) and neurosurgery, compared to neurosurgery alone, had higher total cost ($41,474 [41,976] v $32,299 [18,235], p < 0.001) but similar LOS (12 [10] v 11 [9] days, p = 0.783).

CONCLUSIONS

Children with IC required more surgery than their OC counterparts, resulting in a longer LOS and increased cost. Within the ICa group, the addition of ENT surgery to neurosurgery resulted in higher costs, but with a similar LOS. Considering the increased costs, the additional benefit of ENT surgery to those with children with IC should be investigated further.

Innovations in Endonasal Sinus Surgery in Children

Although there have been many advances in new tools and procedures for endonasal sinus surgery in children, the management and care for pediatric chronic rhinosinusitis has remained relatively unchanged. However, there have been advances in skull base surgery and tumor removal and new knowledge about perioperative concerns in children. This article discusses the role and risks of endoscopic sinus surgery, the use of balloon sinuplasty in children, management of complicated rhinosinusitis, and advances in skull base tumors and choanal atresia repair.

Impact of Sinus Surgery on Hospital Utilization for Complications of Sinusitis

BACKGROUND

Sinusitis complications are potentially lethal conditions that generally require extensive treatment and thus place a significant burden on the health-care system. The purpose of this study was to assess the impact of surgery on hospital utilization associated with treatment of sinusitis complications.

METHODS

Retrospective cohort study using a national hospital database. The 2012 to 2013 National Inpatient Sample was queried for adult patients with sinusitis and complications. Patients were grouped based upon the presence or absence of sinus procedures. Patient demographics and health status, hospital characteristics, length of stay (LOS), and charges were determined.

RESULTS

Of 1645 patients with sinusitis and associated complications, 232 (14%) underwent sinus procedures. These patients had higher LOS (8.0 ± 7.3 days vs 4.3 ± 5.2 days; P < .001) and charges (US$96 107 ± 108 089 vs US$30 661 ± 47 138; P < .001) than nonprocedure patients. Increased time to procedure in one operation patients (n = 209) of more than 2 days increased total LOS (11.4 ± 9.3 days vs 6.2 ± 5.5 days; P < .001) and charges (US$120 306 ± 112 748 vs US$76 923 ± 81 185; P = .005). Patients with multiple sinus procedures (n = 23) versus one had increased LOS and charges, despite no time difference from admission to first procedure (P = .35). On regression analysis, sinus procedure patients had excess LOS of 0.827 days and charges of US$36 949.

CONCLUSION

Although often necessary, sinus procedures lead to increased LOS and charges. As prolonged time to sinus procedure and revision operations also increase charges, shorter trials of medical therapy and earlier surgical intervention may improve outcomes and reduce costs.

Perioperative Risk Factors Associated With Morbidity and Mortality Following Pediatric Inpatient Sinus Surgery

OBJECTIVES:

Pediatric sinus surgery is indicated for a wide range of sinonasal and skull base pathologies, but it is most commonly performed for recalcitrant chronic rhinosinusitis or complicated acute sinusitis. The authors aim to report medical risk factors of morbidity and mortality following inpatient sinus surgery in the pediatric population.

METHODS:

Using data from the Kids' Inpatient Database from 2003 to 2012, patients with International Classification of Diseases, Ninth Revision, procedure codes for primary sinus surgery were identified. Mixed-effect multivariable logistic regression was used to identify risk factors of inpatient postoperative morbidity and mortality.

RESULTS:

The final sample included a weighted estimate of 4965 pediatric patients. The rates of inpatient morbidity and mortality were 6% and 1%, respectively. Respiratory complications (2.5%) were the most prevalent postoperative adverse events. The most prevalent comorbidities were chronic sinusitis (59.8%), acute sinusitis (27.8%), and cystic fibrosis (26.4%). Compared with patients who did not experience any morbidity, patients with inpatient morbidity had higher rates of pneumonia, mycoses, and nasal or paranasal benign neoplasm ( P < .05). The odds of inpatient morbidity and mortality were highest for patients with leukemia (odds ratio, 2.74; 95% confidence interval, 1.59-4.72; P < .001) and mycoses (odds ratio, 15.84; 95% confidence interval, 6.45-38.89; P < .001), respectively.

CONCLUSIONS:

This study is the first to report the national comorbidity burden and risk factors for postoperative adverse events following inpatient sinus surgery. Knowledge of the comorbidities and independent factors associated with morbidity and mortality will help in directing preoperative optimization and counseling.

LEVEL OF EVIDENCE:

2c.

Sphenoidal sinogenic extradural empyema associated with juvenile myelomonocytic leukemia

Intracranial empyema is a rare but serious complication of sinusitis in children. Myelodysplastic/myeloproliferative syndromes (MMS), including juvenile myelomonocytic leukemia (JMML), can lead to immunosuppression, thus favouring infections. We report the case of a sphenoid sinogenic retro-clival extradural empyema in a 14-year-old female patient associated with JMML. Treatment consisted in an endonasal transphenoidal drainage of the empyema associated with intravenous antibiotherapy. The patient was thereafter enrolled in chemotherapeutic treatment with Azacitidine. The disease progressed to blast phase, indicating bone marrow graft. This is the first reported case of an endocranial complication of bacterial sinusitis associated with MMS in a child.