Prior antibiotic therapy for acute sinusitis in children and the development of subperiosteal orbital abscess

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

Hospitalizations and severe complications following acute sinusitis in general practice: a registry-based cohort study

OBJECTIVES

To investigate complication rates of acute sinusitis in general practice, and whether antibiotic prescribing had an impact on complication rate.

METHODS

All adult patients diagnosed with sinusitis in Norwegian general practice between 1 July 2012 and 30 June 2019 were included. GP consultation data from the Norwegian Control and Payment for Health Reimbursements Database were linked with antibiotic prescriptions (Norwegian Prescription Database) and hospital admissions (Norwegian Patient Registry). Main outcomes were sinusitis-related hospitalizations and severe complications within 30 days. Logistic regression was used to estimate associations between antibiotic prescriptions, prespecified risk factors, individual GP prescribing quintile, and outcomes.

RESULTS

A total of 711 069 episodes of acute sinusitis in 415 781 patients were identified. During the study period, both annual episode rate (from 30.2 to 21.2 per 1000 inhabitants) and antibiotic prescription rate (63.3% to 46.5%; P < 0.001) decreased. Yearly hospitalization rate was stable at 10.0 cases per 10 000 sinusitis episodes and the corresponding rate of severe complications was 3.2, with no yearly change (P = 0.765). Antibiotic prescribing was associated with increased risk of hospitalization [adjusted OR 1.8 (95% CI 1.5-2.1)] but not with severe complications. Individual GP prescribing quintile was not associated with any of the outcomes, whereas risk factors such as previous drug abuse, or head injury, skull surgery or malformations, and being immunocompromised were significantly associated with increased risk of both outcomes.

CONCLUSIONS

Severe complications of acute sinusitis were rare and no protective effect of high prescribing practice among GPs was found. Recommendations to further reduce antibiotic prescribing are generally encouraged, except for high-risk groups.

Management of post-septal complications of acute rhinosinusitis in children: A 14-year experience in a tertiary hospital

INTRODUCTION

Acute rhinosinusitis accounts for most of the cases of orbital infections and is the most common cause of periorbital oedema in children. Up to 10% of patients with orbital complications of acute rhinosinusitis may experience vision loss and other complications such as meningitis, intracranial abscess or even death. Therefore, these patients require prompt diagnosis and proper treatment.

OBJECTIVES

This study aims to report the clinical presentation and management of post-septal orbital complications of acute rhinosinusitis in the paediatric population.

MATERIALS AND METHODS

A retrospective medical chart review of all children aged under 18 years old who were diagnosed with post-septal orbital complications of acute rhinosinusitis at a tertiary academic hospital, between 01/2007 and 12/2020. Patients were grouped according to the Chandler Classification (groups 2-5).

RESULTS

Fifty-five children (mean age of 6.91 ± 4.61 years) fulfilled the entry criteria for post-septal orbital complications of acute rhinosinusitis, based on clinical evaluation by an otorhinolaryngologist and CT-scan findings. Forty (72.72%) patients were also evaluated by an ophthalmologist. Most patients were male (76.36%). Twenty-four patients had post-septal cellulitis (43.63%), 21 patients had a subperiosteal abscess (38.18%) and 10 patients had an orbital abscess (18.18%). Eyelid swelling was the most frequent sign, followed by fever. Microbiology varied considerably and gram-positive agents were clearly predominant. Eighteen (32.73%) patients had been treated with oral antibiotics prior to hospital admission, exhibiting a significantly higher risk of recurrence of orbital infection (p = 0.020). Ethmoid and maxillary sinuses were the most involved paranasal sinuses (90.91%). Thirty-three patients (60%) were successfully treated medically, and 22 patients (40%) required surgical drainage. Seven patients (12.73%) developed further complications and six recovered without sequelae. The mean length of hospital stay was 8.0 ± 5.0 days and recurrence of orbital infection occurred in six patients (10.91%). The absolute neutrophil blood count was significantly different amongst Chandler groups (p = 0.021), with higher counts in patients with subperiosteal abscess. The duration of hospitalization was significantly higher in patients submitted to surgery (p < 0.001).

CONCLUSION

Post-septal orbital complications of acute rhinosinusitis are infrequent but dangerous events in the paediatric population. Close collaboration with Ophtalmology is paramount, as the child's vision is at risk. Eyelid swelling and proptosis are early signs. CT-scan imaging plays an invaluable role in the diagnosis and decision-making. Predictive indicators for surgery were not found. However, emergency endoscopic nasal surgery with abscess drainage should be considered whenever vision is at risk, if there is no improvement after aggressive medical treatment, and in cases of intracranial complications.

Pediatric subperiosteal orbital abscess characterization and prediction of size, location, and management

INTRODUCTION

Subperiosteal orbital abscess (SPOA) is a serious suppurative complication of pediatric sinusitis. The objective of this study is to stratify patient selection into those best treated medically versus surgically based on clinical outcomes.

METHODS

This is a retrospective review of patients diagnosed with SPOA complicating sinusitis treated at a tertiary care pediatric hospital from 2002 through 2016. SPOA was diagnosed by CT scan. Characteristics evaluated include demographics, abscess size, location, and measurements, length of hospital stay, medical and surgical interventions, presenting symptoms, and complications.

RESULTS

A total of 108 total SPOA secondary to sinusitis patients were included. A majority, 72.2%, were male with an average age at presentation of 6.8 years. The mean ± standard deviation abscess cubic volume was 0.98 ± 1.27 cm³ (median(range) = 0.44(0.01-7.34 cmcm³)). With an abscess volume of 0.510 cm³, there was a sensitivity of 71.2% and a specificity of 84.4% for needing surgical drainage. Those with large abscesses at our volume threshold were 13 times more likely to require surgery than those with small abscesses, OR: 13.41, 95%CI: 5.02-35.86, p < .001. Patients that required surgery had an abscess closer to the orbital apex with the majority, 25 (61.0%), being the most proximal to the apex, p = .004. The likelihood of surgery decreased with increased distance from the orbital apex in medial abscesses (OR:.92, 95%CI: 0.86-0.98, p = .009).

CONCLUSION

In the pediatric population, SPOA is a serious consequence of sinusitis. This study provides evidence supporting that larger abscess size is a significant risk factor for requiring surgery. The appeal of our study is that it provides evidence and support that employ clinical parameters already assessed as standard practice in evaluating these patients. In summarizing the clinical translational relevance of our study, when determining whether to treat a patient with surgery and antimicrobial/medical therapy vs. non-surgical medical therapy alone, the clinician should focus on size of 0.510 cm³ or larger for abscesses in any location as a relative indication for surgery.

Orbital complications of acute bacterial rhinosinusitis in the pediatric population: A systematic review and meta-analysis

OBJECTIVES

Assess characteristics and outcomes of orbital complications of acute bacterial rhinosinusitis (ABRS) in the pediatric population and evaluate trends over time.

METHODS

A literature search of pediatric orbital complications was performed in the following databases: Ovid MEDLINE, Scopus, and Cochrane Database of Systematic Reviews. Studies reporting data for at least 10 subjects with orbital complications of sinusitis under 18 years old were included. Studies were grouped by publication year; before 2010 and after and including 2010. Studies that only included patients with subperiosteal abscess (SPA) were grouped in a separate category. Data collected include demographics, Chandler class complications, intra-operative culture, treatment, and outcomes. Meta-analysis of proportion was performed to compare data from studies published before 2010 and data published in 2010 and after.

RESULTS

Thirty-five studies met inclusion criteria. No significant difference was observed over time in gender of subjects in the all Chandler complications or SPA only groups (P > 0.72). The proportion of subjects presenting with Chandler IV complications decreased from 6.8% to 2.9% in recent studies (P = 0.019). The proportion of subjects treated surgically decreased from 45.2% to 21.7% in the all Chandler complications group (P < 0.0001) and from 90.0% to 47.9% in the SPA only group, P < 0.0001. The proportion of S. pneumoniae positive cultures decreased from 20.5% to 9.1% (P = 0.02).

CONCLUSION

The demographics of pediatric patients treated for orbital complications of ABRS in published literature has been stable. Patients reported in more recently published studies are less likely to present with orbital abscess and more likely to receive conservative treatment. The proportion of positive Streptococcus pneumoniae cultures have decreased.

Pediatric Subperiosteal Abscess Secondary to Acute Sinusitis: A Systematic Review and Meta-analysis

OBJECTIVES/HYPOTHESIS

The surgical versus medical management of subperiosteal abscess can be controversial. The purpose of this study was to summarize current literature and provide pooled analyses to help direct management decisions.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Patients <18 years old with subperiosteal abscess secondary to acute sinusitis were reviewed, and a meta-analysis was conducted. Studies including five or more patients written in English were the primary search focus.

RESULTS

Thirty-eight studies met inclusion criteria for the systematic review, and seven studies contained sufficient data for the meta-analysis. A total of 1,167 patients between the ages of 10 days and 18 years were included. Eleven sign/symptom categories were identified, with restricted ocular motility (n = 289, 45.9%), proptosis (n = 277, 44%), and fever (n = 223, 35.4%) being most frequent. Staphylococcus aureus was the most common pathogen isolated from cultures. Patients with abscess volume greater than the threshold specified in each individual study were over three times more likely to require surgical intervention compared to those with smaller abscess volume (pooled risk ratio [RR] = 3.61, 95% confidence interval [CI]: 2.40-5.44). Proptosis and gaze restriction also significantly predicted surgical intervention (pooled RR = 1.65: 95% CI: 1.29-2.12 for proptosis/pooled RR = 1.90; 95% CI: 1.20-3.00 for gaze restriction).

CONCLUSIONS

Approximately half of patients with a subperiosteal abscess undergo surgical drainage. Abscess volume appears to be the most significant predictive risk factor. Detailed data from future studies regarding radiologic and ophthalmologic parameters are needed to provide more definitive values predictive of which patients are likely to fail medical therapy.

LEVEL OF EVIDENCE

2a Laryngoscope, 2020.

Urgent Infections of the Head and Neck

Infections of the head and neck are common and appropriately managed by primary care providers in most cases. However, some infections are associated with significant morbidity and require urgent recognition and management by specialty services. These include deep neck space infections originating in the oral cavity, pharynx, and salivary glands, as well as complicated otologic and sinonasal infection. This article provides a review of these conditions, including the pathophysiology, presenting features, and initial management strategy.

Management of pediatric orbital cellulitis: A systematic review

OBJECTIVES

Orbital complications account for 74-85% of all complications from acute sinusitis, more often affect the pediatric population, and can result in devastating consequences. Therefore these patients require prompt diagnosis and proper management. We review and summarize the current literature to determine the appropriate management of each stage of pediatric orbital cellulitis and offer a new comprehensive literature-based algorithm.

METHODS

Data sources were PubMed/MEDLINE, and Google Scholar. Studies relevant to the management of each subcategory of the Chandler criteria in the pediatric population, limited to the period 1997 through Jan 2018, were compiled and interpreted. Seventy-one studies were reviewed in total.

RESULTS

Pre-septal and post-septal cellulitis can generally be managed non-surgically, while orbital abscess and cavernous sinus thrombosis are managed surgically. For subperiosteal abscess, non-surgical medical management has been successful in certain patients. Results of the literature review were summarized, and subsequently developed into a comprehensive algorithm for management, including criteria for age, location, and volume of abscess on imaging.

CONCLUSIONS

Orbital cellulitis, particularly subperiosteal abscesses, in children is not an absolute indication for immediate surgical intervention. Conservative measures can be safe and effective if appropriately used, depending on patient characteristics, clinical course, and imaging.

Microbiology and antibiotic therapy of subperiosteal orbital abscess in children with acute ethmoiditis

OBJECTIVE

The objective of this study was to investigate the microbiological cultures and the management of acute ethmoiditis complicated by subperiosteal orbital abscess (SPOA) in a pediatric population.

METHODS

The medical records of children under 18 years old was performed in a tertiary referral pediatric center from January 2009 to April 2017. Clinical examination, computed tomography scans, medical and surgical treatments were reviewed and compared to other studies in literature.

RESULTS

One hundred and twenty-nine children were hospitalized for acute ethmoiditis. Among them, forty eight were complicated by SPOA. The mean age of these children were 7 years (range 10 months-16 years). Thirtyfour underwent surgical drainage; for the others the medical treatment was sufficient. Microbiological samples were obtained during the surgical intervention and were contributive in 91% of cases. Streptococcus spp was the most frequently encountered bacteria (60% of cases). We also found anaerobic bacteria (12%), and Staphylococcus aureus (12%). 94% of children received two intravenous antibiotics (a third-generation cephalosporin and metronidazole) for a mean duration of four days. Then the oral treatment was based on amoxicillin-clavulanate during about 8.5 days. All children were cured without sequelae.

CONCLUSIONS

For five years Streptococcus milleri, Staphylococcus spp and anaerobic bacteria are on the rise in acute ethmoiditis complicated by SPOA. That is why antibiotics must be adapted to these bacteria even in children under ten years old.

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.

Radiographic Findings and Clinical Correlates in Pediatric Periorbital Infections

OBJECTIVE

To review radiographic studies of pediatric patients presenting with periorbital infections and to evaluate sinonasal anatomical factors and clinical course related to this disease process.

METHODS

Retrospective study review of computed tomography (CT) scans in 100 patients less than 18 years old, admitted to a tertiary children's hospital with the diagnosis of an orbital infection. CT scans were reviewed for anatomic variants and Lund-Mackay scores were calculated. An independent chart reviews of the treatment course and need for surgical intervention was performed.

RESULTS

Of 100 patients, 67% were male, 60% had left-sided infections, and 30% of patients were treated with surgical drainage. Adenoid hypertrophy (61%), inferior turbinate hypertrophy (80%) and septal deviation (47%) were common, but did not show statistical correlation with the need for surgical intervention. Dehiscence of the lamina papyracea was identified in 21% of patients treated without surgery and in 76% of those requiring surgery (P 0.0048). The average overall Lund-Mackay score was 11.8 and did not correlate with the need for surgical intervention.

CONCLUSIONS

To our knowledge, this is the first study to evaluate the incidence of sinonasal anatomic abnormalities in children presenting with periorbital infections. This study also demonstrated that lamina papyracea dehiscence is a common finding and is associated with higher rates of surgical intervention. Such findings may have an important role in the diagnosis, surveillance and management of sinus disease in the pediatric population.

Complicated sinusitis in a developing country, a retrospective review

OBJECTIVES

The aim of our study was to assess the incidence rate, mode of presentation, treatment and outcome measures associated with complicated sinusitis in our developing world setting. Additionally we had hope to identify possible patterns or predisposing factors that may assist us in decreasing the significant morbidity and mortality associated with this serious disease.

METHOD

A retrospective chart review was performed on all patients treated for complicated sinusitis at 3 referral hospitals in Durban South Africa between January 2006 and September 2009.

RESULTS

A total of 220 patients were identified including 138 patients with orbital complications only and 82 with intracranial complications with or without orbital manifestations. We report on the demographics, mode of presentation, microbiology, impact on resources, management and mortality of the study group. The incidence rate was found to be 5.83 per million, the most common risk factors associated with intracranial complications, a persistent headache beyond 1 week and referral from a rural rather than urban area (OR 3.24). We found a high mortality rate of 20.7% in those patients with intracranial complications of their sinusitis.

CONCLUSIONS

Complicated sinusitis is still far too common in the developing world with young adolescent males most at risk. A high index of suspicion must be maintained in detecting orbital as well as intracranial extension of disease and appropriate referral for investigation and management swift and aggressive in preventing extensive morbidity and mortality.

[Consensus document on the aetiology, diagnosis and treatment of sinusitis]

The Spanish National Consensus (Spanish Society of Pediatric Infectious Diseases, Spanish Association of Primary Care Pediatrics, Spanish Society of Pediatric Outpatient and Primary Care, Spanish Society of Otorhinolaryngology and Cervical-Facial Pathology) on Sinusitis is presented. Rhinosinusitis is a difficult to diagnose and often unrecognised disease. The document discusses the aetiology, the clinical signs and symptoms, and the diagnostic criteria. A proposal for treatment is made based on the epidemiological situation in our country. Oral amoxicillin is the treatment of choice (80mg/kg/day divided every 8hours). Alternative treatment is proposed in special cases and when amoxicillin is not sufficient. The main complications are reviewed.

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

OBJECTIVE

Subperiosteal orbital abscesses (SPOAs) secondary to acute sinusitis are rare occurrences in the pediatric age group, more so in the neonatal period. Here, a rare case of SPOA in a 38-day-old newborn later drained via endoscopic sinus surgery is included also. This review describes the demographic data, clinical history, treatment, microbiology results, complications, and outcome.

METHODS

The admission records for all the patients who were admitted to the Pediatric Surgical Ward in Sarawak General Hospital, Kuching, Malaysia, between January 2004 and May 2009 were retrospectively reviewed. Records of patients who presented with preseptal cellulitis, orbital cellulitis, subperiosteal abscess (extraconal), orbital abscess (intraconal), and cavernous sinus thrombosis were closely studied. Ophthalmology consultations were obtained in all these cases. Ultimately, 3 patients having SPOA secondary to acute sinusitis were selected for this review.

RESULTS

All patients were male with rapid onset of periorbital signs, absence of purulent rhinorrhea, and presence of significant thrombocytosis (exceeding 500 × 10(9)/L). The 38-day-old newborn had mixed infection of methicillin-resistant coagulase-negative Staphylococcus bacteremia and local Acinetobacter eye infection with Staphylococcus aureus in the SPOA. All had medially located SPOA that was adequately drained via endoscopic sinus surgery, resulting in full recovery.

CONCLUSION

Newborns with preexisting risk factors and immature immunity are at risk of severe and rare infections. Contrast-enhanced paranasal sinus computed tomographic scan is mandatory and reliable to differentiate preseptal and postseptal orbital infection, as both conditions can present similarly and rapidly deteriorate. In the contrast-enhanced computed tomography-demonstrable SPOA, endoscopic sinus surgery drainage of the abscess proved to be safe and reliable as the main treatment modality. All patients recovered well without complications.

Timing of rhinosinusitis complications in children

BACKGROUND

Acute rhinosinusitis in a child with signs and symptoms of a cold that persist beyond 10 days is recommended to be treated with antimicrobials. One reason for this recommendation is to prevent the complications of sinus infection. We wanted to find out whether there is any evidence to support this.

METHODS

We reviewed retrospectively all the medical records of children treated in our hospital from February 1996 to March 2006 for complications related to rhinosinusitis.

RESULTS

Twenty children had such complications. Their symptoms of uncomplicated acute respiratory infection had lasted for an average of 5.1 days before the appearance of the complication, and only 3 children had respiratory symptoms lasting longer than 10 days.

CONCLUSIONS

Complications of rhinosinusitis in children appear during the first few days of acute upper respiratory infection. This finding does not support the recommendation that antibiotics should be started if upper respiratory symptoms have lasted longer than 10 days in children. Even though patients with findings suggesting invasive periorbital infection require immediate antimicrobial treatment, we should be critical in our recommendations as to when antibiotics need to be given to patients with only prolonged upper respiratory infections.