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

Invasive Streptococcus intermedius Infections in Children: Two Cases from a Pediatric Infectious Diseases Unit in Italy

In recent years, an increasing number of reports have described invasive infections caused by bacteria from Streptococcus anginosus group (SAGs). S. intermedius seems to be more related with pleuropulmonary infections and abscess of the brain and deep soft tissues, and it is more likely to cause suppurative and non-bacteremic infections compared to other members of the same genus. We present two clinical cases of invasive S. intermedius infections in pediatric patients: a liver abscess case and a pansinusitis case associated with bilateral otomastoiditis and parapharyngeal abscess complicated by acute mediastinitis, thrombophlebitis of the cavernous sinus, and thrombosis of the cranial tract of the ipsilateral jugular vein. In both cases, prompt broad-spectrum antibiotic therapy and operative drainage of the collections resulted in a good clinical response with full recovery.

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.

Drainage of middle cranial fossa epidural abscess through mastoidectomy: Our experience and review of the literature

Background

Otitis media (OM) can uncommonly lead to intracranial complications. Epidural abscesses represent a large proportion of cases; however, literature regarding the optimal surgical management of otogenic epidural abscesses is sparse. Favorably located epidural abscesses may be amenable to drainage through a transmastoid approach because the tegmen mastoideum lies immediately inferior to the middle cranial fossa (MCF).

Case Description

We report 3 pediatric patients with OM complicated by epidural abscesses of the MCF. The ages ranged from 3 to 6 years old, with 2 females and 1 male. All 3 patients had acute mastoiditis with an abscess of the MCF ranging from 1.6 cm to 6.3 cm at the largest dimension. All patients underwent canal wall-up mastoidectomy with the evacuation of the MCF abscess through a small window, 0.7 × 0.7 cm or less, created in the tegmen mastoideum. All patients were successfully treated through this approach and had complete resolution of their infection on follow-up imaging. There were no postoperative temporal lobe encephaloceles.

Conclusion

This is one of the few descriptions of the treatment of an otogenic epidural abscess of the MCF through a transmastoid approach. Collaboration with neurosurgery is vital because their familiarity with the intracranial space helped to guide the accurate direction of dissection. This highlights the importance of a multidisciplinary approach in the treatment of epidural intracranial abscess of the MCF through this approach. The risk of postoperative temporal lobe encephalocele was minimized due to the small tegmen defect size.

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.

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.

A 20-Year Study of Intracranial Pyogenic Complications of Sinusitis in Children

BACKGROUND

Intracranial pyogenic complications of sinusitis in children can lead to serious sequelae. We characterize the clinical, epidemiologic and microbiologic characteristics of children with such complications over a 20-year period.

METHODS

Single-center retrospective chart review. Cases were identified based on International Classification of Diseases diagnostic codes (ICD)-9 and ICD-10 depending on the year and by reviewing all intracranial microbiologic samples.

RESULTS

A total of 104 cases of complicated sinusitis were included after review of 1591 charts. Median age was 12 (IQR 9-14); 72 were male (69%). The most frequent complications were epidural empyema (n = 50, 48%), subdural empyema (n = 46, 44%) and Pott's puffy tumor (n = 27, 26%). 52% (n = 54) underwent neurosurgery and 46% (n = 48) underwent otolaryngologic surgery. The predominant pathogen isolated from sterile site specimens was Streptococcus anginosus (n = 40, 63%), but polymicrobial growth was common (n = 24; 38%). The median duration of intravenous antibiotic therapy was 51 days (IQR 42-80). Persistent neurologic sequelae (or death, n = 1) were found in 24% (n = 25) and were associated with the presence of cerebritis and extensive disease on neuroimaging ( P = 0.02 and P = 0.04, respectively).

CONCLUSIONS

Intracranial complications of sinusitis continue to cause significant morbidity in children. Polymicrobial infections are common, which reinforces the need for broad-spectrum empiric antibiotic therapy and cautious adjustment of the antibiotic regimen based primarily on sterile site cultures. The association of neurologic sequelae with the presence of cerebritis and extensive intracranial involvement on neuroimaging suggest that delayed diagnosis may be a contributor to adverse outcome.

Identification of mutations resulting in derepression of the intermedilysin gene by sequential mutagenesis of its promoter region in Streptococcus intermedius

Streptococcus intermedius secretes the human-specific cytolysin intermedilysin (ILY), a crucial factor in the pathogenicity of this bacterium. Previously, we reported that a lactose phosphotransferase repressor (LacR) represses ily expression, and that its mutation increases ILY production. Interestingly, UNS40, a strain isolated from a liver abscess, produces high levels of ILY despite the absence of mutations in the lacR promoter and coding regions. Our results showed that a G > A mutation at the -90th position from the transcription start point in the UNS40 ily promoter region increased hemolytic activity and decreased the binding ability to LacR. To elucidate the regions involved in the repression of ily expression, we generated mutant strains, in which point or deletion mutations were introduced into the ily promoter region, and then compared their hemolytic activity. Among the point mutations, -120 C > A and -90 G > A and their flanking mutations increased hemolytic activity. These results indicated that these mutations may increase the virulence of S. intermedius.

Clinical characteristics and outcomes of children with non-sinogenic Brain infections

BACKGROUND

Central Nervous System (CNS) suppurative infections are serious but rare conditions in the paediatric population. Data on long-term neurocognitive and quality of life outcomes in children recovering from these infections are lacking.

METHODS

A retrospective cohort review of children <16 years with non-sinogenic infections undergoing neurosurgery was conducted. Data for patients admitted to Children's Health Ireland at Temple St between 2008-2021 were analysed for clinical and microbiological profiles. Follow-up reviews evaluating neurological and academic sequelae and quality of life were performed. Categorical variables were analysed for unfavourable outcome with a p < 0.05 significance value.

RESULTS

Forty patients were included with a mean age of 4.5 years and equal gender distribution. Fever (68%) and vomiting (58%) were the most common presenting complaints. Only fourteen (35%) patients presented with the classic triad of fever, headache, and focal neurological deficit. Meningitis/Encephalitis was the most common cause of suppurative infection (40%). Predisposing factors included congenital heart disease (18%), prematurity (15%) and immunocompromised status (10%). More patients received an initial Burr hole aspiration (73%) than Craniotomy (27%). The re-operation rate was higher in the craniotomy group (45%) compared to the burr hole group (34%), but this was not statistically significant (p = 0.522). Four patients died (10%) including two intra-hospital deaths (5%). Male gender (p = 0.047) and multiple abscesses (p = 0.041) were associated with unfavourable outcome at discharge. Mobility impairment was the most affected determinant of quality of life.

CONCLUSION

CNS suppurative infections are associated with long-term neurocognitive sequelae in children. Multiple abscesses and male gender are associated with unfavourable GOS on discharge. Children are still left with mobility impairment (25%), personality changes (23%) and intellectual disability (18%) at an average of 5 years. Long-term follow up with multidisciplinary input is required. Further research should focus on evaluating long-term HRQoL in children.

Prospective Study of the Detection of Bacterial Pathogens in Pediatric Clinical Specimens Using the Melting Temperature Mapping Method

The melting temperature (Tm) mapping method is a novel technique that uses seven primer sets without sequencing to detect dominant bacteria. This method can identify pathogenic bacteria in adults within 3 h of blood collection without using conventional culture methods. However, no studies have examined whether pathogenic bacteria can be detected in clinical specimens from pediatric patients with bacterial infections. Here, we designed a new primer set for commercial use, constructed a database with more bacterial species, and examined the agreement rate of bacterial species in vitro. Moreover, we investigated whether our system could detect pathogenic bacteria from pediatric patients using the Tm mapping method and compared the detection rates of the Tm mapping and culture methods. A total of 256 pediatric clinical specimens from 156 patients (94 males and 62 females; median age, 2 years [<18 years of age]) were used. The observed concordance rates between the Tm mapping method and the culture method for both positive and negative samples were 76.4% (126/165) in blood samples and 79.1% (72/91) in other clinical specimens. The Tm mapping detection rate was higher than that of culture using both blood and other clinical specimens. In addition, using the Tm mapping method, we identified causative bacteria in pediatric clinical specimens quicker than when using blood cultures. Hence, the Tm mapping method could be a useful adjunct for diagnosing bacterial infections in pediatric patients and may be valuable in antimicrobial stewardship for patients with bacterial infections, especially in culture-negative cases. IMPORTANCE This study provides novel insights regarding the use of the melting temperature (Tm) mapping method to identify the dominant bacteria in samples collected from pediatric patients. We designed a new set of primers for commercial use and developed a database of different bacteria that can be identified using these primers. We show that the Tm mapping method could identify bacteria from blood samples and other clinical specimens. Moreover, we provide evidence that the Tm mapping method has a higher detection rate than that of the culture-based methods and can achieve a relatively high agreement rate. We believe that our study makes a significant contribution to this field because rapid identification of the source of bacterial infections can drastically improve patient outcomes and impede the development of antibiotic-resistant bacteria.