Acute bacterial sinusitis in children

Tonsillitis and Sinusitis: A Narrative Review of Pathogenesis, Diagnosis, and Management

The review aims for a comprehensive examination of tonsillitis and sinusitis, covering their pathophysiology, diagnosis, and management, with a focus on recent breakthroughs and therapeutic practices. Tonsillitis, marked by inflammation of the tonsils, can result from viral or bacterial infections, particularly Streptococcus pyogenes, with attention to antibiotic resistance trends. This review discusses clinical manifestations, diagnostic criteria, and the importance of distinguishing viral from bacterial causes. Therapeutic interventions like antibiotics and tonsillectomy indications are evaluated within evolving guidelines. Regarding sinusitis, it explores its origins, contributing factors, and classification based on duration and pathophysiology. Viral infections, allergens, and structural anomalies' roles in pathogenesis are highlighted. Diagnostic modalities like imaging and endoscopic exams are assessed for their efficacy in guiding management decisions. The importance of precise diagnosis through clinical examination, microbiological testing, and imaging is emphasized for informed treatment choices. This review also delves into minimally invasive surgical procedures, particularly endoscopic sinus surgery and tonsillectomy, showcasing progress in these areas. In summary, it provides insights into tonsillitis and sinusitis, offering perspectives on their aetiology, diagnosis, and treatment while integrating current research and clinical standards to enhance patient care and healthcare resource utilization.

A randomized, open-label, phase 3 study evaluating safety and immunogenicity of 13-valent pneumococcal conjugate vaccine in Chinese infants and children under 6 years of age

Streptococcus pneumoniae causes a considerable disease burden among children in China. Many isolates exhibit antimicrobial resistance but are often serotypes covered by the 13-valent pneumococcal conjugate vaccine (PCV13). Because the approved infant immunization schedule in China allows PCV13 vaccination only for those 6 weeks to 15 months of age, this phase 3 study was conducted to evaluate PCV13 immunogenicity and safety in unvaccinated older infants and children. Eligible participants were stratified by age into four cohorts: Cohort 1 (n = 125), 6 weeks-2 months; Cohort 2 (n = 354), 7-<12 months; Cohort 3 (n = 250), 1 -<2 years; Cohort 4 (n = 207), 2-<6 years. Cohort 1 received PCV13 at ages 2, 4, and 6 months; older cohorts were randomized 2:1 to PCV13 or Haemophilus influenzae type b (Hib) vaccine using age-appropriate schedules. Within-group immune responses were assessed by immunoglobulin G (IgG) concentrations and opsonophagocytic activity (OPA) titers. Safety evaluations included solicited reactogenicity events and adverse events (AEs). IgG geometric mean concentrations and OPA geometric mean titers for all 13 PCV13 serotypes increased for all participants vaccinated with PCV13, but not those vaccinated with Hib. Immune responses in Cohorts 2-4 were generally comparable with those in Cohort 1 (the infant series) for most serotypes. PCV13 was well tolerated across cohorts, with reported AEs consistent with expectations in these age groups; no new safety signals were identified. These results suggest that PCV13 administered as a catch-up regimen to infants and children 7 months-<6 years of age in China will effectively reduce vaccine-type pneumococcal disease in this population. NCT03574389.

Efficacy of Adenoidectomy for the Management of Chronic Rhinosinusitis in Children Older Than 7 Years of Age

OBJECTIVES

While adenoidectomy is the first-line surgical management of chronic rhinosinusitis (CRS) in young children, evidence regarding its utility in older children is lacking. This study aimed to assess the efficacy of adenoidectomy in children 7 to 18 years old with regard to symptom control, postoperative medication use, and the need for additional surgery.

METHODS

Single-institution retrospective chart review of patients ages 7 to 18 undergoing adenoidectomy for CRS from 2009 to 2019. Patients with cystic fibrosis and ciliary disorders were excluded. Comorbidities, preoperative and postoperative symptoms (rhinorrhea, congestion, anosmia, and facial pain), medication use (antibiotics, antihistamines, nasal steroids, and irrigations), and Lund-Mackay scores were extracted. McNemar's or Wilcoxon Rank Sum Tests were used to assess rates of symptom control and medication use. Fisher's exact or Chi-square tests were used to assess for factors associated with symptom persistence.

RESULTS

Ninety-seven patients with a mean age of 9 years (range 7-18) were identified. Patients were shown to experience significantly decreased rates of rhinorrhea (64.9% vs 20.6%, <.001), congestion (95.9% vs 26.8%, <.001), facial pain (17.5% vs 3.1%, .001), use of nasal steroids (79.4% vs 36.1%, <.001), antihistamines (47.4% vs 20.6%, <.001), and number of antibiotics (median 1 vs 0, <.001) after adenoidectomy. No patient or disease factors were associated with symptom persistence. Nine patients (9.3%) required additional nasal surgery.

CONCLUSION

In this cohort of older children with CRS with limited follow up, additional surgery is not routinely done following adenoidectomy, the results suggest that adenoidectomy alone may provide adequate symptom control and medication reduction.

Biological basis of child health 11: anatomy, physiology and development of the senses

This article, the 11th in the Biological basis of child health series, focuses on the senses. There are five basic senses in humans: hearing, sight, touch, smell and taste. Several congenital and acquired conditions can affect the senses and may have significant negative effects on a child's development and ability to communicate with others. This article explores each of the five senses, discussing their anatomy, physiology and embryological development, as well as common conditions affecting sensory function in children. It aims to provide children's nurses with an understanding of the role of the senses in supporting children to make sense of the world, and how knowledge of this can be linked to clinical practice.

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.

Early experience with feasibility of balloon sinus dilation in complicated pediatric acute frontal rhinosinusitis

BACKGROUND/OBJECTIVE

Complicated acute rhinosinusitis in the pediatric population is an uncommon problem that may affect the orbit or brain and is life-threatening. This condition requires surgical intervention with endoscopic sinus surgery for source control, and prior studies have demonstrated the safety of balloon sinuplasty in chronic frontal sinusitis.

METHODS/RESULTS

We present our approach with a balloon sinus dilation hybrid procedure to resolve four distinct types of complicated acute frontal sinusitis in pediatric patients, including intracranial manifestations, intraorbital complications, and recurrent disease. All four patients were able to be managed operatively with frontal balloon sinuplasty.

CONCLUSIONS

Prior efficacy has been demonstrated for chronic frontal sinusitis in the pediatric population. We demonstrate that frontal balloon sinuplasty is also feasible in the proper clinical setting for acute frontal sinusitis, even in the presence of regional complications or recurrent disease.

LEVEL OF EVIDENCE

4.

Acute rhinosinusitis among pediatric patients with allergic rhinitis: A nationwide, population-based cohort study

Background

While chronic rhinosinusitis is a common complication of allergic rhinitis, the link between acute rhinosinusitis and allergic rhinitis is unclear. The aim of this study was to evaluate the risk of incident acute rhinosinusitis among pediatric patients with allergic rhinitis, using a nationwide, population-based health claims research database.

Methods

Newly diagnosed allergic rhinitis patients aged 5–18 years were identified from the health claim records of the Longitudinal Health Insurance Database 2000 of Taiwan’s National Health Insurance Research Database. A comparison cohort was assembled by randomly selecting patients from the same database with frequency matching by sex, age group, and index year. All patients were followed until a diagnosis of acute rhinosinusitis or the end of the follow-up period. Cox proportional hazards model was used to assess the association between allergic rhinitis and acute rhinosinusitis.

Results

Of the 43,588 pediatric patients included in this study, 55.4% were male and 43.9% were between the ages of 5.0–7.9 years. The risk of acute rhinosinusitis was significantly higher in pediatric patients with allergic rhinitis compared to those without the condition (adjusted hazard ratio = 3.03, 95% confidence interval = 2.89–3.18). Similar hazard ratios were observed between male and female pediatric patients.

Conclusions

This secondary cohort study using a nationwide, population-based health claim data of the Taiwan’s NHIRD showed that allergic rhinitis was significantly associated with a higher risk of acute rhinosinusitis among pediatric patients.

The Microbiology of Complicated Acute Sinusitis among Pediatric Patients: A Case Series

OBJECTIVE

The microbiology of pediatric complicated acute rhinosinusitis (ARS) has evolved, and our current understanding of pathogenic organisms is limited. The objectives of this study are to describe the incidence of pathogens causing complicated ARS requiring surgical intervention at our institution over a 10-year period as well as their associated treatment outcomes.

STUDY DESIGN

Retrospective cohort study.

SETTING

A single tertiary care children's hospital.

SUBJECTS AND METHODS

Data were reviewed from all patients who underwent surgery for complicated ARS and had positive culture data from 2006 to 2016. Associations among pathogens, complications, and outcomes were analyzed with Pearson χ² and Wilcoxon rank-sum tests.

RESULTS

Eighty-nine patients met criteria. Complications included orbital infections (78%), intracranial infections (48%), Pott's puffy tumor (13%), and cavernous sinus thrombosis (9.0%). Bacterial isolates were majority polymicrobial (55%) and included Streptococcus species (58%), Staphylococcus species (49%; including methicillin-resistant S aureus [MRSA], 11%), and anaerobic bacteria (35%). S pneumoniae (9.0%), Haemophilus species (4.5%), and Moraxella catarrhalis (1.1%) were relatively uncommon. Bacterial isolates were similar among patients with all types of complications.

CONCLUSION

Among a large cohort of pediatric patients with complicated ARS, most bacterial isolates were polymicrobial, with Streptococcus and Staphylococcus species contributing to the majority of cases. S aureus species, including MRSA and anaerobic pathogens, were common. The pattern of bacterial isolates was similar among patients with all types of complications of ARS. We suggest treatment for complicated ARS with broad-spectrum antibiotics with coverage for Streptococcus species, Staphylococcus species including MRSA, and anaerobic bacteria.

Chronic Rhinosinusitis in Children: Pathophysiology, Evaluation, and Medical Management

PURPOSE OF REVIEW

Pediatric chronic rhinosinusitis (CRS) is a common disorder that carries significant morbidity. The diagnosis requires sinus symptoms that persist despite standard medical therapy greater than 3 months. Viral infections, allergies, and anatomic differences in children lead to chronic obstruction of the osteomeatal complex.

RECENT FINDINGS

Chronic rhinosinusitis as a diagnosis is a conglomeration of multiple phenotypes and endotypes. As such, the diagnosis and management are complex. New survey studies provide some consensus on prevalence and management of this disease in children. In this review, we highlight the differential diagnosis of pediatric CRS, including non-eosinophilic/infectious variants, eosinophilic variants with and without nasal polyps, allergic fungal sinusitis, aspirin-exacerbated respiratory disease, primary immunodeficiency, and disorders of mucociliary clearance. Further, we detail treatment options that should be considered. Finally, we feature emerging potential treatment options of CRS, including anti-immunoglobulin E, interleukin-5, and interleukin-4 receptor alpha subunit.

Pediatric Rhinosinusitis

Rhinosinusitis, is defined as an inflammation of the paranasal and nasal sinus mucosae. Chronic rhinosinusitis (CRS)is a common problem in the pediatric age group and the diagnosis and treatment are challenging due to the chronicity and similarity of symptoms with allergic rhinitis and adenoid hypertrophy. Although it is less common than acute rhinosinusitis, CRS is becoming more frequent and significantly affects the quality of life in children and can substantially impair daily function. CRS is characterized by sinus symptoms lasting more than 3 months despite medical therapy. Many factors are involved in the pathogenesis of this disease and include a primary insult with a virus followed bybacterial infection and mucosal inflammation, along with predisposition to allergies. The standard treatment of pediatricacute bacterial rhinosinusitis (ABRS) is nasal irrigation and antibiotic use. Medical treatment of pediatric CRS includes avoidance of allergens in allergic patients (environmental or food) and therapy with nasal irrigation, nasal corticosteroids sprays, nasal decongestants, and antibiotics directed at the most common sinonasalorganisms (Haemophilusinfluenzae, Streptococcus pneumoniae, and Moraxella catarrhalis). Surgical therapy is rarely needed after appropriate medical therapy. Referral to an otolaryngologist and allergy specialist is recommended in case of failure of medical treatment.

Pediatric Acute Bacterial Sinusitis: Diagnostic and Treatment Dilemmas

Acute bacterial sinusitis (ABS) is a common complication of a simple upper respiratory infection. Acute bacterial sinusitis and an upper respiratory infection, however, have different management plans. This article will help clinicians establish when a diagnosis of ABS can be made based on the latest guidelines from the American Academy of Pediatrics. Also covered will be the pathophysiology of ABS, the role of diagnostic imaging, the recognition of complications of ABS, and treatment options.

Balloon frontal sinuplasty for intracranial abscess in a pediatric acute sinusitis patient

A case of balloon frontal sinuplasty in a 12-year old male with intracranial abscess from acute sinusitis is presented. The patient experienced photophobia, fever, headache, nausea and vomiting. Frontal sinusitis with intracranial abscess was diagnosed on imaging. The patient was taken to the operating room for drainage with left frontal balloon sinuplasty. The patient showed immediate clinical improvement, did not suffer from any complications of surgery and was further managed with long term intravenous antibiotics. We believe that balloon frontal sinuplasty is potentially safe and effective in the treatment of complicated acute frontal sinus obstruction in children.