MR sialographic assessment of the masseter muscle and the ductal kinking in patients with recurrent parotitis

Dysfunction of the masseter muscle may cause pathological kinking of the parotid duct leading to parotitis; MR sialography is a non-invasive radiological examination that allows to evaluate dynamically the ductal system of the parotid glands. In the present study we aimed to assess the relationships between Stensen's duct and masseter muscle and their implications in the aetiopathogenesis of recurrent parotitis secondary to masseter muscle dysfunction. Forty-one patients with recurrent unilateral parotitis and nine with bilateral recurrent parotitis, all with a clinical suspicious of masseter muscle hypertrophy due to bruxism were enrolled. They underwent ultrasonography as a first line examination and then MR sialography and sialendoscopy. Different anatomical features were studied. Involved parotid glands had a wider duct compared to contralateral unaffected parotid glands of patients with recurrent parotitis (p = 0.00134); male subjects with parotitis had a longer duct compared to the salivary glands of healthy patients (p = 0.00943 for affected glands and p = 0.00629 for the contralateral). A concordance between the evidence of an acute duct angle during sialendoscopy and a wider duct in patients with parotitis was observed although not statistically significant. These initial findings suggest that the masticatory muscle dysfunction related to bruxism seems to condition alteration of parotid duct course and anatomy thus favouring the occurrence of recurrent parotitis. A specific diagnostic iter based on clinical evaluation, dynamic ultrasonography and MR sialography, is therefore, mandatory to confirm the relationship between masseter muscle anatomy and parotid duct anomalies; this is the premise for an adequate therapeutic approach to underlying masticatory muscle disorder.

Multidisciplinary Decision-Making-ITAlian Consensus After Two Years of Real Practice on the Management of Severe Uncontrolled CRSwNP by Biologics (ITACA Study)

PURPOSE OF REVIEW

We aimed to reach an Italian multidisciplinary consensus on some crucial aspects of treatment decision making in CRSwNP, following 2 years of clinical experience in order to support specialists in the management of CRSwNP in clinical practice. We addressed issues relating to therapeutic decision-making and shared criteria for the treatment choice, as well as appropriate timing and criteria for evaluating treatment response, and highlighted the need for repeated multidisciplinary assessments.

RECENT FINDINGS

A national survey has been conducted recently to understand how rhinology practice has changed in Italy with the advent of biologics and how this affects patients with uncontrolled, severe CRSwNP. Despite the many published consensus documents, practical recommendations, and protocols on the use of biologics in CRSwNP, heterogenous behaviors in practice are still observed mainly conditioned by the novelty of the topic. The consensus procedure followed a modified Delphi approach. The scientific board included 18 otorhinolaryngologists and 8 allergists, who selected the 4 main topics to be addressed and developed overall 20 statements. Consensus on these statements was sought by a larger group of 48 additional experts, through two rounds of voting, the first web-based, the second in presence with discussion and possible refinement of the statements. The statements reaching an average score ≥ 7 at the second voting round were approved. Five statements were proposed for each of the following topics: baseline evaluation of patients eligible for biologic therapy; choice between different therapeutic options; assessment of the response to biologic treatment; multidisciplinary management. At the first voting round, 19 out of the 20 statements reached a mean score ≥ 7. Following the discussion and a few consequent amendments, at the second round of voting all the 20 statements were approved.

Acute otitis media diagnosis in childhood: still a problem in 2023?

BACKGROUND

Diagnosis of acute otitis media (AOM) in children can be challenging, given that symptoms are often non-specific or absent, and that the direct observation of the tympanic membrane in its entirety through otoscopy can sometimes be difficult. The aim of this study is to assess the diagnostic concordance in detection of AOM episodes between primary care paediatricians and physicians especially trained in paediatric otoscopy, and to characterize the most misleading elements in diagnostic failure.

METHODS

Consecutive clinical charts of children regularly followed for recurrent AOM (RAOM, i.e.: >3 episodes in 6 months or > 4 episodes in 1 year) at our Otitis Media paediatric outpatient clinic were retrospectively screened, in order to collect any diagnosis of AOM episode (and the related clinical findings/middle ear complaints) performed by primary care paediatricians/emergency room paediatricians. Diagnosis of AOM episode was validated by the same experienced physician (FF) in case of otoscopic relief of a bulging eardrum with at least one of the following: hyperaemia or yellow-like colour. The diagnostic concordance in detection of AOM episodes between primary care/emergency room paediatricians and our internal validator was expressed as the percentage of matching diagnosis.

RESULTS

One hundred and thirty-four single AOM episodes occurring in 87 children (mean age: 26.9 +/- 18.9 months) were included in the analysis. Diagnostic concordance in detection of AOM episodes between primary care/emergency room paediatricians and our internal validator was reported in 72.4% of cases. The most common pitfall found in our study was the misleading diagnosis of AOM in case of hyperaemic tympanic membrane without bulging (32/37 out of non-validated diagnoses).

CONCLUSIONS

AOM diagnosis still represents a relevant issue among paediatricians in our country, and the presence of tympanic membrane hyperaemia without concomitant bulging can be confusing.

Topical administration of S. salivarius 24SMB-S. oralis 89a in children with adenoidal disease: a double-blind controlled trial

Chronic adenoiditis (CA) is generally sustained by some infectious foci mainly located within the nasopharynx or in the deep adenoidal pads and it is characterized by a complex interplay between bacterial species. The aim of this study was to assess the efficacy and safety of the topical nasal administration of a probiotic compound based on S. salivarius 24SMB and S. oralis 89a in children with CA in terms of reduction in: the number of acute adenoidal infections (primary outcome), and in the blockage of the nasopharynx space by hypertrophic adenoids (secondary outcome). A prospective, double-blind, 1:1 randomized controlled study was performed to test the effectiveness of a 90-day treatment with Rinogermina spray (DMD ITALIA s.r.l, Rome), 1 puff each nostril twice a day for 90 days, to nasal spray placebo in children with CA (in terms of number of acute exacerbations and blockage of nasopharynx space assessed after 90 days of treatment- T1, and 90 days later- T2). The final analysis was based on 152 children (males = 48.0%; mean age = 49.2 ± 14.1 months). Compared to the baseline, no significant differences in terms of number of acute exacerbations at T1 and T2 follow-up visits were detected in both groups. After treatment, a significant reduction in the blockage of nasopharynx space by hypertrophic adenoids (0.002 < p-value < 0.007) compared to the baseline was attested in the study group at T1 and T2, but not in the control group.

CONCLUSIONS

Our findings document a positive effect of Rinogermina spray in achieving reduction in the blockage of nasopharynx space by hypertrophic adenoids, thus suggesting that its use into the integrated therapeutic management of children with CA could be of a certain utility.

WHAT IS KNOWN

• Chronic adenoiditis in children results from an imablance in baterial homeostasis at the nasophaynx, with impairment in respiratory microbiota. • The modulatory effect of target transnasal bacteriotheray by means of S. salivarius has been considered in children with chronic adenoiditis in children with recurrent acute otitis media with preliminary positive results.

WHAT IS NEW

• This randomized controlled study, specifically designed on a cohrt of children with chronic adenoiditis, documents a certain effectiveness of the probiotic treatment in achieving a reduction in the grade of adenoidal hypertropy, compared to placebo.

Chronic Rhinosinusitis with Nasal Polyps: A Survey on Routine Management and Evaluation of Disease Control in Practice

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease with a significant impact on quality of life. The overall goal of CRSwNP management, as with other chronic conditions, is to achieve "disease control", and for that reason, a definition of control of disease is pivotal in deciding the best treatment strategy. Although many staging systems have already been developed to evaluate the disease, disease control is not yet to be standardized, and a specific tool that is consistently applied and accepted by all practitioners is still missing in daily clinical practice. To gain an overview of the implementation and limitations of existing guidelines and to shed light on real-life definitions of control and disease severity, we conducted a nationwide survey of otorhinolaryngologists routinely treating CRSwNP to identify unmet clinical needs in Italy. The results showed homogeneous responses regarding the knowledge contained in international guidelines while highlighting the difficulty of their implementation in day-to-day practice. Respondents called attention to the importance of clinical symptoms, giving more weight to the patient's perspective. Among the symptoms to be considered, respondents emphasized nasal obstruction, followed by loss of sense of smell and rhinorrhea. Others also believe that the physician's perspective should be considered, and the inclusion of endoscopy as a measure of control was warranted by many. The need for a specific tool that is able to unequivocally ascertain disease control is increasingly pivotal in this new era of biologics for treating CRSwNP.

Practical recommendations for managing severe chronic rhinosinusitis with nasal polyps in the era of biologics

Objective

We conducted a national survey to understand how rhinology practice has changed with the advent of biologics and how this affected patients with uncontrolled, severe chronic rhinosinusitis with nasal polyps (CRSwNP). We aimed to analyse the results of the survey and infer practical recommendations for clinical practice.

Methods

A group of ear, nose, and throat specialists (ENTs) experienced in the management of CRSwNP developed a 74-question survey. ENTs from rhinology centres authorised to prescribe biologics in the context of the national health system were invited to answer it between 01/05/2022 and 31/07/2022. The responses underwent descriptive analyses, and the authors discussed the results and derived practical recommendations for clinical practice.

Results

ENTs working in rhinology centres changed their practices coinciding with the advent of biologics. CRSwNP evaluations have become more complex because they involve diagnostic confirmation, determining the patients' immunologic profile, and other factors. We observed heterogenous behaviours in practice that may be conditioned by the novelty of the topic. The results of the survey were used to develop practical recommendations for ENTs and are summarised herein.

Conclusions

Clinical practice in rhinology outpatient clinics has changed profoundly in the era of biologics. Our practical recommendations for clinicians working in rhinology centres are expected to help standardise practice and improve care.

Dupilumab in the treatment of severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP): A multicentric observational Phase IV real-life study (DUPIREAL)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is associated with significant morbidity and reduced health-related quality of life. Findings from clinical trials have demonstrated the effectiveness of dupilumab in CRSwNP, although real-world evidence is still limited.

METHODS

This Phase IV real-life, observational, multicenter study assessed the effectiveness and safety of dupilumab in patients with severe uncontrolled CRSwNP (n = 648) over the first year of treatment. We collected data at baseline and after 1, 3, 6, 9, and 12 months of follow-up. We focused on nasal polyps score (NPS), symptoms, and olfactory function. We stratified outcomes by comorbidities, previous surgery, and adherence to intranasal corticosteroids, and examined the success rates based on current guidelines, as well as potential predictors of response at each timepoint.

RESULTS

We observed a significant decrease in NPS from a median value of 6 (IQR 5-6) at baseline to 1.0 (IQR 0.0-2.0) at 12 months (p < .001), and a significant decrease in Sino-Nasal Outcomes Test-22 (SNOT-22) from a median score of 58 (IQR 49-70) at baseline to 11 (IQR 6-21; p < .001) at 12 months. Sniffin' Sticks scores showed a significant increase over 12 months (p < .001) compared to baseline. The results were unaffected by concomitant diseases, number of previous surgeries, and adherence to topical steroids, except for minor differences in rapidity of action. An excellent-moderate response was observed in 96.9% of patients at 12 months based on EPOS 2020 criteria.

CONCLUSIONS

Our findings from this large-scale real-life study support the effectiveness of dupilumab as an add-on therapy in patients with severe uncontrolled CRSwNP in reducing polyp size and improving the quality of life, severity of symptoms, nasal congestion, and smell.

Bilateral Sensorineural Hearing Loss Related to a Skull Base Spontaneous Cerebrospinal Fluid Leak: A Case Report and Literature Review

Spontaneous intracranial hypotension (SIH) is a rare condition characterized by orthostatic headache, pulsatile tinnitus, vertigo, nausea, and fluctuating hearing loss; this latter seems to be due to the development of cochlear endolymphatic hydrops following negative cerebrospinal fluid (CSF) pressure transmitted to the perilymphatic space through a patent cochlear aqueduct. We here describe a case of bilateral progressive sensorineural hearing loss (SNHL) due to intracranial hypotension caused by an undiagnosed spontaneous CSF leak from a skull base defect in a middle-aged woman. To the best of our knowledge, this is the first report describing a SNHL in a patient affected by SIH secondary to sphenoidal CSF leak.

An Unusual Retained Choanal Foreign Body: A Possible Complication of COVID-19 Testing With Nasopharyngeal Swab

Testing for coronavirus disease 2019 is critical in controlling the pandemic all over the world. Diagnosis of severe acute respiratory syndrome coronavirus-2 infection is based on real-time polymerase chain reaction performed on nasopharyngeal swab. If not adequately performed, the viral specimen collection can be painful and lead to complications. We present a complication occurred during a nasopharyngeal swab collection performed in a noncooperative patient where the plastic shaft of the swab fractured during the procedure, resulting in swab tip retention deep into the nasal cavity. The foreign body was found endoscopically, stuck between the nasal septum and the superior turbinate tail at the upper level of the left choana and removed under general anesthesia in a negative pressure operating room with the health care personnel wearing personal protective equipment. Unpleasant complications like the one described can happen when the swab is collected without the necessary knowledge of nasal anatomy or conducted inappropriately, especially in noncooperative patients. Moreover, the design of currently used viral swabs may expose to accidental rupture, with risk of foreign body retention in the nasal cavities. In such cases, diagnosis and treatment are endoscopy-guided procedures performed in an adequate setting to minimize the risk of spreading of the pandemic.

Chronic Rhinosinusitis: T2r38 Genotyping and Nasal Cytology in Primary Ciliary Dyskinesia

OBJECTIVES

Chronic rhinosinusitis (CRS) is a major hallmark of primary ciliary dyskinesia (PCD). We investigated the possible correlation between some severity markers of CRS and several clinical features of the disease. We further studied the bitter taste receptor TAS2R38 polymorphisms to identify the genotypes associated with more severe disease.

METHODS

We included 39 adult PCD patients with (CRSwNP) and without nasal polyposis (CRSsNP); a sample for nasal cytology was obtained and clinical cytological grading (CCG) was determined. The SNOT-22 and Lund-Mackay scores were recorded. A sample of DNA was extracted from peripheral blood to investigate TAS2R38 polymorphisms.

RESULTS

CRSwNP patients had features of more severe disease: indeed, they had statistically significantly higher frequency of previous sinus surgery, higher SNOT-22, LM scores, and CCG than CRSsNP patients. Upon genotyping of TAS2R38 polymorphisms, we observed that the AVI-AVI genotype, associated to homozygous nonfunctional bitter TAS2R38 receptor, was more prevalent among CRSwNP (100%) than in CRSsNP patients (0%); furthermore, AVI-AVI subjects showed statistically significantly worse SNOT-22 and CCG scores than PAV-PAV and PAV-AVI subjects. The group of AVI-AVI patients also had more frequent respiratory exacerbations, Gram-negative infections, and Pseudomonas aeruginosa colonization than PAV-PAV and PAV-AVI patients.

CONCLUSION

Our findings indicate for the first time that PCD patients with CRSwNP display a more severe disease than those with CRSsNP. Genotyping of TAS2R38 polymorphisms demonstrated that in PCD patients, the AVI-AVI genotype is strikingly more prevalent among CRSwNP than in CRSsNP, while the PAV-PAV genotype might be protective against Gram-negative infections and respiratory exacerbations.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:248-254, 2023.

Acute otitis media-related facial nerve palsy in a child: a case report and a literary review

BACKGROUND

Acute otitis media has become a rare cause of facial palsy in children. A high index of suspicion is essential to achieve the diagnosis and to properly treat this condition to avoid permanent neurological sequelae.

CASE PRESENTATION

A case of acute otitis media-related facial nerve palsy in an 18 months-old child is described and a review of the recent literature about the clinical presentation, diagnosis, and management of this condition is performed.

CONCLUSIONS

Facial paralysis is an uncommon complication of acute otitis media that requires appropriate care. As highlighted in our report, the treatment of facial nerve palsy secondary to otitis media should be conservative, using antibiotics and corticosteroids. The role of antiviral is still a matter of debate. Myringotomy and a ventilation tube should be added when spontaneous perforation of the tympanic membrane is not present. More aggressive surgical approach should be considered only when there is no significant improvement.

Proposal for a Structured Outpatient Clinic for Dupilumab Treatment in Chronic Rhinosinusitis with Nasal Polyps in the First Year of Treatment

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common disease of the nose and paranasal sinuses with important economic and sanitary burdens, as well as having a great impact on patients’ quality of life. In this field, a new therapeutic approach for those patients who have been described as affected by severe uncontrolled CRSwNP, resistant to medical and best surgical treatment, is represented by subcutaneous human monoclonal antibodies (including dupilumab) that block specific targets involved in the type 2 inflammatory pathway which most commonly drives CRSwNP pathophysiology. This paper aims to report our experience in the management of severe uncontrolled CRSwNP and, in particular, describe our diagnostic workup including baseline evaluation and follow-up visits in the first year of treatment. We also describe into detail our multidisciplinary approach to the disease. We finally report the outcomes of treatment in a real-life setting. In this outpatient real-life setting, our results confirmed the effectiveness of dupilumab in reducing the volume of nasal polyps and restoring nasal obstruction and sense of smell, as well as improving patients’ quality of life. The adherence to the dupilumab treatment was very high. The dose of administration was never modified in patients in the first year of treatment. All the patients respected the plan of the visits at proposed time points. We believe that the structural organization of our outpatient clinic appears to be functional: it allows us to study patients thoroughly before starting treatment and to make a proper follow-up after it starts. We believe that sharing both our strict clinical flowchart and growing experience with dupilumab with the medical community can lead to more standardized and effective pathways of care for CRSwNP patients.

Immunological profiles of children with recurrent otitis media with or without spontaneous tympanic membrane perforation and of children with recurrent respiratory infections

OBJECTIVES

The primary aim of this study was to compare the immunological profiles of children affected by recurrent acute otitis media (rAOM) with and without spontaneous tympanic membrane perforation (STMP). The secondary aim was to compare immunological features of children without parameters outside the normal range and affected by either rAOM or recurrent respiratory tract infections (rRTI).

METHODS

In this study, otherwise healthy children (<10 years of age) with rAOM or rRTI were included. Data on perinatal history, vaccination status, presence of risk factors for rAOM or rRTI (including personal or family history of allergy) and number of infectious episodes in the previous 12 months were retrospectively obtained. Furthermore, data on immunological profile (blood cell count, circulating IgA, IgG, IgM and total IgE, IgG subclasses and lymphocyte subpopulations) were collected. The immune profile of children affected by rAOM with and without STMP were compared. Among children with parameters within normal range, we compared the levels of the immunological parameters of children affected by rAOM (with and without STMP) and rRTI.

RESULTS

The study involved a total of 751 children: 566 (75.3%) with rAOM and 185 (24.7%) with rRTI. Among the 566 children with rAOM, 39.7% had uncomplicated rAOM and 60.3% had rAOM with STMP. The mean age of the study population was 34.9 (SD 20.5) months. The frequency of children with parameters outside the normal range was similar among children with rAOM with (4.9%) and without STMP (6.1%). Among subjects without parameters outside the normal range, children with uncomplicated rAOM had significantly lower serum IgG, lymphocyte CD8⁺ and CD19⁺ and significantly higher IgG2 levels than children affected by rAOM with STMP. Finally, children with rAOM had lower levels of IgA, IgM and IgG2 and higher levels of IgG, lymphocyte CD19⁺ and CD16/56+ compared to children with rRTI.

CONCLUSIONS

A low (<6.5%) percentage of children with rAOM with or without STMP present parameters outside the normal range. Among subjects without parameters outside the normal range, children with uncomplicated rAOM have a different immune profile as compared to those with STMP and rRTI. New prospective studies are needed to further explore the immune features of children affected by rAOM with and without STMP.

Unilateral silent sinus syndrome: A case report

Silent sinus syndrome (SSS) is a rare clinical condition, commonly unilateral, secondary to the obstruction of the osteomeatal complex, subsequent negative pressure in the maxillary sinus, and collapse of the orbit floor and sinus walls. We describe a case of unilateral SSS treated by means of functional endoscopic sinus surgery.

Upper Eyelid Retraction in Graves' Ophthalmopathy: Our Surgical Experience on 153 Cases of Full-Thickness Anterior Blepharotomy with Mullerectomy

BACKGROUND

We present our experience on 153 cases of full-thickness anterior blepharotomy with mullerectomy (FTABM) in the treatment of upper eyelid retraction (UER) related to Graves' ophthalmopathy (GO).

METHODS

We included all the patients who underwent a graded FTABM between 1^st January 2015 and 30^th June 2020 for UER GO-related. The analysis included: pre-/post-operative conjunctival symptoms, epiphora, GO-Quality of Life Questionnaire (QoL), lagophthalmos, marginal reflex distance (MRD-1) index, eyelid symmetry within 1mm. The statistical analysis was designed to detect postoperative improvement in objective and subjective clinical features. Outcomes were analysed through Chi-squared test for dichotomous variables and through Wilcoxon-Mann-Whitney test for continuous variables.

RESULTS

Of the 111 patients, 42 underwent a bilateral procedure, while 69 a monolateral. Conjunctival symptoms were reported in 32% of cases before surgery and in 12.4% after FTABM (p < 0.001). Epiphora was complained by 29.6% of patients preoperatively and in 12.4% postoperatively (p < 0.001). Preoperative lagophthalmos was found in 12.4% (mean value of 0.34 ± 0.76 mm) of eyelids, and in 2.6% (mean value 0.05 ± 0.19 mm) eyelids (p = not significant) postoperatively. Pre-operative GO-QoL was 24.9 ± 4.4 mm; while post-operative GO-QoL was 35.3 ± 5.5 mm (p < 0.001). The MRD-1 varied from 10.12 ± 2.1 mm preoperatively, to 4.3 ± 0.6 mm (p < 0.001) after surgery. Asymmetric palpebral fissure was noted in 94 (84.7%) patients before surgery and in 7 (6.3%) after the procedure (p < 0.001).

CONCLUSION

FTABM is an effective procedure to treat UER GO-related. The technique manages to prevent complications of UER and determine good aesthetics.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Level IV, therapeutic study.

Otitis Media Practice During the COVID-19 Pandemic

The global coronavirus disease-2019 (COVID-19) pandemic has changed the prevalence and management of many pediatric infectious diseases, including acute otitis media (AOM). Coronaviruses are a group of RNA viruses that cause respiratory tract infections in humans. Before the COVID-19 pandemic, coronavirus serotypes OC43, 229E, HKU1, and NL63 were infrequently detected in middle ear fluid (MEF) specimens and nasopharyngeal aspirates in children with AOM during the 1990s and 2000s and were associated with a mild course of the disease. At times when CoV was detected in OM cases, the overall viral load was relatively low. The new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the causative pathogen responsible for the eruption of the COVID-19 global pandemic. Following the pandemic declaration in many countries and by the World Health Organization in March 2020, preventive proactive measures were imposed to limit COVID-19. These included social distancing; lockdowns; closure of workplaces; kindergartens and schools; increased hygiene; use of antiseptics and alcohol-based gels; frequent temperature measurements and wearing masks. These measures were not the only ones taken, as hospitals and clinics tried to minimize treating non-urgent medical referrals such as OM, and elective surgical procedures were canceled, such as ventilating tube insertion (VTI). These changes and regulations altered the way OM is practiced during the COVID-19 pandemic. Advents in technology allowed a vast use of telemedicine technologies for OM, however, the accuracy of AOM diagnosis in those encounters was in doubt, and antibiotic prescription rates were still reported to be high. There was an overall decrease in AOM episodes and admissions rates and with high spontaneous resolution rates of MEF in children, and a reduction in VTI surgeries. Despite an initial fear regarding viral shedding during myringotomy, the procedure was shown to be safe. Special draping techniques for otologic surgery were suggested. Other aspects of OM practice included the presentation of adult patients with AOM who tested positive for SARS-2-CoV and its detection in MEF samples in living patients and in the mucosa of the middle ear and mastoid in post-mortem specimens.

A Strong Decline in the Incidence of Childhood Otitis Media During the COVID-19 Pandemic in the Netherlands

Introduction

Recent reports have highlighted the impact of the COVID-19 pandemic on the incidence of infectious disease illnesses and antibiotic use. This study investigates the effect of the pandemic on childhood incidence of otitis media (OM) and associated antibiotic prescribing in a large primary care-based cohort in the Netherlands.

Material and Methods

Retrospective observational cohort study using routine health care data from the Julius General Practitioners’ Network (JGPN). All children aged 0-12 registered in 62 practices before the COVID-19 pandemic (1 March 2019 - 29 February 2020) and/or during the pandemic (1 March 2020 - 28 February 2021) were included. Data on acute otitis media (AOM), otitis media with effusion (OME), ear discharge episodes and associated antibiotic prescriptions were extracted. Incidence rates per 1,000 child years (IR), incidence rate ratios (IRR) and incidence rate differences (IRD) were compared between the two study periods.

Results

OM episodes declined considerably during the COVID-19 pandemic: IR pre-COVID-19 vs COVID-19 for AOM 73.7 vs 27.1 [IRR 0.37]; for OME 9.6 vs 4.1 [IRR 0.43]; and for ear discharge 12.6 vs 5.8 [IRR 0.46]. The absolute number of AOM episodes in which oral antibiotics were prescribed declined accordingly (IRD pre-COVID-19 vs COVID-19: -22.4 per 1,000 child years), but the proportion of AOM episodes with antibiotic prescription was similar in both periods (47% vs 46%, respectively).

Discussion

GP consultation for AOM, OME and ear discharge declined by 63%, 57% and 54% respectively in the Netherlands during the COVID-19 pandemic. Similar antibiotic prescription rates before and during the pandemic indicate that the case-mix presenting to primary care did not considerably change. Our data therefore suggest a true decline as a consequence of infection control measures introduced during the pandemic.

Prevention of recurrent respiratory infections : Inter-society Consensus

Recurrent respiratory infections (RRIs) are a common clinical condition in children, in fact about 25% of children under 1 year and 6% of children during the first 6 years of life have RRIs. In most cases, infections occur with mild clinical manifestations and the frequency of episodes tends to decrease over time with a complete resolution by 12 years of age. However, RRIs significantly reduce child and family quality of life and lead to significant medical and social costs.Despite the importance of this condition, there is currently no agreed definition of the term RRIs in the literature, especially concerning the frequency and type of infectious episodes to be considered. The aim of this consensus document is to propose an updated definition and provide recommendations with the intent of guiding the physician in the complex process of diagnosis, management and prevention of RRIs.

Management of upper retropharyngeal abscesses in children: Two case reports of a troublesome situation

Management of upper retropharyngeal abscesses in children is challenging. In surgical cases, ultrasound-assisted intra-operative procedures may be helpful to reach peculiar locations, thus reducing surgical morbidity and complications rate.

Outcomes of balloon dilation for paediatric laryngeal stenosis

Objective

Balloon dilation (BD) is a minimally invasive endoscopic treatment for paediatric laryngeal stenosis (LS) with reduced morbidity compared to open surgery. We retrospectively describe our experience in a cohort of children with chronic LS.

Methods

Fourteen children (median age: 28.5; range: 2-81 months) with chronic LS (multilevel in 8) were treated with tubeless total intravenous anaesthesia under spontaneous ventilation.

Results

Grade III LS was preoperatively detected in 12 children; the remaining 2 had grade IV stenosis. Six had prior tracheotomy, and one received it during the first intervention. Dilation laryngoplasty was the primary treatment in 11 children and was used as an adjuvant treatment in 3 after open reconstructive surgery. The median number of dilations was 2 (range: 1-6). There were no postoperative complications. At the end of the follow-up (median: 20.5; range: 2-46 months), detectable laryngeal lumen widening and/or respiratory improvement occurred in 12 children. Two of 7 patients with tracheostomy were decannulated.

Conclusions

Balloon laryngoplasty is a valuable therapeutic option to improve laryngeal patency in children with chronic multilevel LS, both as a primary and secondary adjuvant treatment after reconstructive surgery.

Has Otitis Media Disappeared during COVID-19 Pandemic? A Fortuitus Effect of Domestic Confinement

Background: To measure patient flow at our Pediatric Emergency Department (PED) during the Italian lockdown, with particular care in terms of otolaryngological (ENT)-related diagnoses. Methods: A retrospective evaluation of electronic charts of children admitted to our PED in the City Center of Milan (Italy) for any disease. The outcome was to compare distribution of diagnoses performed at our PED during 21 February–3 May 2019 (period 1) to 21 February–3 May 2020 (period 2). Results: A total of 4538 children were evaluated during period 1 compared to 1310 during period 2. A statistically significant overall effect on diagnosis between the study periods was attested (p-value < 0.001; pseudo R2 = 0.010), ENT-related diagnoses being more frequently documented in period 1 (80.4% vs. 19.5%; p-value < 0.001), as well as those related to middle ear infections (92.8% vs. 7.2%; p-value < 0.001). Non-complicated acute otitis media more frequently occurred in period 1 (92.0% vs. 8.0%; p-value < 0.001); no significant difference in the number of complicated middle ear infections occurred (95.8% vs. 4.2%). Conclusions: The exceptional circumstances of the Italian lockdown resulted in a significant decrease in patients’ attendance to our PED, especially when considering diagnoses related to any ENT disorder, middle ear disease, and non-complicated middle ear infection.

COVID-19 isolation drape for sialendoscopy-assisted transfacial approach to parotid gland

Surgical procedures requiring close contact with saliva, such as salivary gland surgery, may determine the risk of spreading the SARS-CoV-2 infection. The use of PPE and isolation settings are mandatory to protect health workers.

Unrevealed foreign body in the deep neck space: A case report

Clinical data provided by the patient are not always reliable or could be difficult to collect. In this case, a difficult history collection resulted in a diagnostic delay. Major complications were avoided performing an urgent surgical intervention.

Nasopharyngeal Microbiota Analysis in Healthy and Otitis-prone Children: Focus on History of Spontaneous Tympanic Membrane Perforation

BACKGROUND

Recurrent acute otitis media (RAOM) is common in children, and it may result in spontaneous tympanic membrane perforation (STMP), management of which is often challenging. In the upper respiratory tract (URT), resident microorganisms play a pivotal role in otitis media pathogenesis and prevention, as they are able to inhibit the colonization process and otopathogens growth. In particular, Dolosigranulum spp. and Corynebacterium spp. have been associated with respiratory health in several studies. This study aims at comparing both nasopharyngeal microbiota of children with RAOM versus matched controls and nasopharyngeal microbiota of children with a history of RAOM with STMP.

METHOD

Nasopharyngeal swabs were collected from 132 children, median age 3.51 (2.13-4.72), including 36 healthy children, 50 with RAOM without STMP, and 46 with RAOM with STMP. Bacterial DNA was subsequently extracted and 16S rRNA gene V3-V4 regions were polymerase chain reaction amplified and sequenced using Illumina MiSeq technology.

RESULTS

A higher relative abundance of Dolosigranulum and Corynebacterium genera was detected in the nasopharynx of healthy children (16.5% and 9.3%, respectively) in comparison with RAOM without STMP (8.9% and 4.3%, respectively) and RAOM with STMP (5.2% and 2.8%, respectively). A decreasing pattern in relative abundance of these 2 pivotal genera through disease severity was detected. In all groups, the most abundant genera were Moraxella, Streptococcus and Haemophilus, followed by Dolosigranulum and Corynebacterium.

CONCLUSIONS

Our study provides a characterization of the URT microbiota in otitis-prone children with and without history of recurrent STMP, suggesting that the role of Dolosigranulum and Corynebacterium in regulating the healthy URT microbiota should be further studied.

Abscess of the clivus in an adolescent with complicated acute rhinosinusitis: a case report

Background

Complications of acute sinusitis affecting multiple sites are very uncommon, and generally develop for a delayed diagnosis of the primary infection, with possible severe and life-threatening evolution. Patients can have variable presentations according to the site and extent of the infection. Multiple forms generally include the coexistence of orbital manifestations and intracranial infections. We here present a case with unusual multiple sites locations (i.e.: intraorbital intraconic abscess, sigmoid sinus thrombosis, preclival abscess, multiple splanchnocranium osteomyelitic processes).

Case presentation

A 13-year-old male presented at our hospital with right progressive orbital oedema with eyesight worsening and signs of meningitis. Computed tomography and magnetic resonance (MRI) demonstrated right intraorbital intraconic abscess, left sphenoidal sinusitis, transverse and sigmoid sinus thrombosis. Ophthalmologic evaluation documented a right optic nerve sufferance. Endoscopic and superior right trans-palpebral surgical decompression was performed, and the abscess was drained. Microbiological analysis revealed the presence of multi-sensitive Streptococcus Intermedius. Subsequent prolonged antibiotic and anti-thrombotic treatments were started. In the following two-weeks the sinusal and ophthalmologic clinical conditions improved, whereas the patients complained of mild to moderate cervical pain and suffered from intermittent pyrexia. Control MRI documented clival abscess extending up to preclival soft tissues posterior to the nasopharynx, associated with mandible osteomyelitis, occipital condyles and anterior part of the temporal bone hyper intensity. Endoscopic trans-nasal surgical approach to the clival compartment with neurosurgery navigation-guided achieved preclival abscess drainage. Complete clinical and radiological recovery was achieved after 45 days of medical treatment.

Conclusions

Multiple sites complicated rhinosinusitis is uncommon, and its management is challenging. A proper history and thorough clinical examination along with a radiological evaluation are key factors in the final diagnosis of patients with complicated multiple sites acute rhinosinusitis. A quick multidisciplinary approach is always necessary to avoid unwanted life-threatening complications.

ENT management of children with adenotonsillar disease during COVID-19 pandemic. Ready to start again?

Clinical manifestations of COVID-19 in children are milder, but the real burden of disease is unknown. After the lockdown, in our Region Lombardia we have been requested to progressively resume medical services including outpatient assessment and priority surgery. Therefore, we screened surgical waiting lists with identification of 47 children candidates to priority surgery (among 358). No homogeneous national health surveillance/screening programs are ongoing or have been conceived to test susceptible population among children/healthcare workers in preparation of coming down to routinely daily activities, and diagnostic strategies are not completely accurate in children. So, restoring medical services now might be untimely.

Cationic drugs and COVID-19

Given the sharp spreading of COVID-19 pandemic all around the world, our attention was brought to consider that that many cationic drugs (i.e. those characterized by the presence, at physiological pH value, of one or more cationic groups, both primary, secondary, tertiary and guanidinic aminic groups) could have any effect in impairing SARS-CoV2 entry in the host cell. This could open to new therapeutic chances against COVID-19.

Pediatric otogenic cerebral venous sinus thrombosis: a case report and a literature review

Background

Cerebral venous sinus thrombosis in children is a rare but potentially fatal complication of acute mastoiditis, one of the most common pediatric infectious diseases. Due to its subtle clinical presentation, suspicion is essential for a prompt diagnosis and appropriate management. Unfortunately, no standard treatment options are available. To discuss the possible clinical presentation, microbiology, and management, we here report the case of a child with otogenic cerebral venous sinus thrombosis and perform a literature review starting from 2011.

Case presentation

The child, a 10-months-old male, presented clinical signs of right acute otitis media and mastoiditis. Brain computed tomography scan detected right sigmoid and transverse sinus thrombosis, as well as a subperiosteal abscess. Fusobacterium necrophorum and Haemophilus Influentiae were detected on cultural sampling. A multidisciplinary approach along with a combination of medical and surgical therapy allowed the patient’s full recovery.

Conclusion

Cerebral venous sinus thrombosis is a rare but severe complication of acute otitis media and mastoiditis. The management of this pathological condition is always challenging and an interdisciplinary approach is frequently required. Current therapeutic options include a combination of medical and surgical therapy. A patient-centered approach should guide timing and treatment management.

Upper Respiratory Tract Microbiome and Otitis Media Intertalk: Lessons from the Literature

Otitis media (OM) is one of the most common diseases occurring during childhood. Microbiological investigations concerning this topic have been primarily focused on the four classical otopathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pyogenes) mainly because most of the studies have been conducted with culture-dependent methods. In recent years, the introduction of culture-independent techniques has allowed high-throughput investigation of entire bacterial communities, leading to a better comprehension of the role of resident flora in health and disease. The upper respiratory tract (URT) is a region of major interest in otitis media pathogenesis, as it could serve as a source of pathogens for the middle ear (ME). Studies conducted with culture-independent methods in the URT and ME have provided novel insights on the pathogenesis of middle ear diseases through the identification of both possible new causative agents and of potential protective bacteria, showing that imbalances in bacterial communities could influence the natural history of otitis media in children. The aim of this review is to examine available evidence in microbiome research and otitis media in the pediatric age, with a focus on its different phenotypes: acute otitis media, otitis media with effusion and chronic suppurative otitis media.

Diagnosis of SARS-CoV-2 by RT-PCR Using Different Sample Sources: Review of the Literature

Objective:

The most widely used diagnostic technique for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is real-time reverse transcriptase-polymerase chain reaction (RT-PCR). It can be done on different samples: nasopharyngeal swabs (NPS) or oropharyngeal swabs (OPS), and self-collected saliva. However, negative findings do not rule out infection.

Methods:

A review was conceived to discuss advantages and limitations of the available diagnostic modalities for nonserologic diagnosis of SARS-CoV-2 based on RT-PCR; the article also proposes some practical suggestions to improve diagnostic reliability.

Results:

A total of 16 papers (corresponding to 452 patients) of the 56 initially identified were included. Most of the papers describe findings from different samples obtained in limited case series; comparative studies are missing.

Conclusions:

Diagnostic accuracy of NPS and OPS is suboptimal and the risk of contaminated aerosol dispersal is not negligible. The SARS-CoV-2 RNA can be found in self-collected saliva specimens of many infected patients within 7 to 10 days after symptom onset. There is an urgent need for comparative trials to define the diagnostic modality of choice. Adequate education and training of health care personnel is mandatory.

A goitrous model for Bartolomeo Vivarini (1432-1499)

INTRODUCTION

Bartolomeo Vivarini (Venezia 1432c.-Venezia 1499c.) was an Italian painter during the Renaissance. The artist was widely influenced by Andrea Mantegna, whose opera was characterized by personages with anatomical details meticulously described.

MATERIALS AND METHODS

Some of the most valued paintings of Bartolomeo Vivarini were analyzed. Purpose of the present article is to describe these artworks focusing on female personages represented with thyroid swelling.

RESULTS

A recurring female model in Vivarini's artworks is portrayed with a goitrous neck. This might display a real prevalence of thyroid diseases among young women in the Renaissance age (e.g. postpartum thyroiditis).

CONCLUSIONS

Representation of goiter in the artworks of Vivarini and Mantegna reflects the increased anatomic accuracy and knowledge developed in art since Renaissance and Baroque.

THU0221 EVIDENCE FOR A PATHOGENIC ROLE OF EXTRA-FOLLICULAR, IL-10 PRODUCING CCR6+B-HELPER T-CELLS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

IL-10 plays a key role in systemic lupus erythematosus (SLE) pathogenesis, promoting B-cell response. IL10 is mainly secreted by regulatory T-cells, but follicular helper T-cells (TFH), also produce it. We previously identified a subset of CCR6+IL-7R+T-cells in human tonsils providing IL-10-dependent B-cell help. These CCR6+T-cells were able to produce IL-10, inducing IgG production.

Objectives:

to investigate a possible role of CD4+CCR6+IL7R+T-cells in SLE pathogenesis.

Methods:

37 patients fulfilling the ACR criteria for SLE have been included. Disease activity was assessed by 2k-SLEDAI. PBMC were analyzed by flow cytometry, using specific lineage markers. CCR6+IL7R+T-cells purified from total PBMC of SLE patients or healthy donors (HD) were co-cultured with autologous CD20+B-cells. IL-10, Il-17, total IgG and anti-dsDNA antibodies titers in patients serum and culture supernatants were assessed by ELISA. Embedded sections of lymph nodes from 8 SLE patients were analyzed by immunofluorescence (IF).

Results:

IL10 levels were significantly higher in SLE patients (Fig 1A). CD4+CCR6+IL7R+T-cells were significantly increased in SLE, in particular in those with higher disease activity and higher IL10 levels. CD4+CCR6+IL7R+T-cells levels associated with anti-dsDNA positivity. CCR6+IL7R+T-cells of SLE patients induced production of IgG and anti-dsDNA IgG (in anti-dsDNA + patients) from autologous B-cells, providing spontaneous help for autoantibody productionex vivo(Fig 1B-C). The IF study of lymph nodes of SLE patients showed that IL-10-producing CCR6+T-cells were highly abundant and co-localized with B-cells at follicle margins.

Fig 1

Conclusion:

our study revealed a novel population of extra-follicular B-helper T-cells, which produce IL-10 and could play a prominent pathogenic role in SLE. Further studies will clarify if this potentially pathogenic cell population might represent a possible future therapeutic target.

References:

[1]Facciotti F. J Allergy Clin Immunol. 2016; Geginat J. Semin Immunol. 2019; Tsokos GC. Nat Rev Rheumatol. 2019

Tab 1:

SLE patients characteristics

(n=37)DemographicsFemale/Male, n37/5Age, years, median (IQR)44 (38-49)Disease duration, years, median (IQR)19 (11-26)Lab testsANA86%*anti-dsDNA (%)46% medium/high titre41%Disease activity and clinical manifestations SLEDAI-2K, median (min-max)3.5 (0-24) Moderate/high activity19%Ongoing therapyPrednisone dose mg/day, median (IQR)7,5 mg (2,5 – 20)hydroxychloroquine78%Immunosuppressants87%Fig 2

Disclosure of Interests: :

Maria Gerosa: None declared, Federica Facciotti: None declared, Paola Larghi: None declared, Roberto Bosotti: None declared, Chiara Vasco: None declared, Nicola Gagliani: None declared, Chiara Cordiglieri: None declared, Elsa Rottoli: None declared, Alessandra Emiliana Penatti: None declared, Lorenza Maria Argolini: None declared, Bhavna Karnani: None declared, Yasushi Kobayashi: None declared, Mauro Bombaci: None declared, Jan Piet Van Hamburg: None declared, Roberta Gualtierotti: None declared, Stefano Gatti: None declared, Sara Torretta: None declared, Lorenzo Pignataro: None declared, Sander W. Tas: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Sergio Abrignani: None declared, Massimiliano Pagani: None declared, Fabio Grassi: None declared, Pier Luigi Meroni: None declared, Richard Flavell: None declared, Jens Geginat: None declared

Nonserologic test for COVID-19: How to manage?

Background

Diagnosis of Severe Acute Respiratory Coranavirus‐2 (SARS‐CoV‐2) infection is currently based on real‐time PCR (RT‐PCR) performed on either nasopharyngeal (NPS) or oropharyngeal (OPS) swabs; saliva specimen collection can be used, too. Diagnostic accuracy of these procedures is suboptimal, and some procedural mistakes may account for it.

Methods and results

The video shows how to properly collect secretions from the upper airways for nonserologic diagnosis of COVID‐19 by nasopharyngeal swab (NPS), oropharyngeal swab (OPS), and deep saliva collection after throat‐cleaning maneuver, all performed under videoendoscopic view by a trained ENT examiner.

Conclusions

We recommend to perform NPS after elevation of the tip of the nose in order to reduce the risk of contamination from the nasal vestible, and to let it flow over the floor of the nasal cavity in parallel to the hard palate in order to reach the nasopharynx. Then the tip of the swab should be left in place for few seconds, and then rotated in order to achieve the largest absorption of nasopharyngeal secretions. Regards OPS, gentle anterior tongue depression should be used to avoid swab contamination from the oral cavity during collection of secretions from the posterior pharyngeal wall. These procedural tricks would enhance diagnostic reliability.

Exacerbations and Pseudomonas aeruginosa colonization are associated with altered lung structure and function in primary ciliary dyskinesia

BACKGROUND

Recurrent bacterial infections of the respiratory tract are one of the major clinical features of the primary ciliary dyskinesia (PCD), a rare genetic disease due to malfunctioning of motile cilia. Chronic infections and persistent inflammation of the respiratory system result in progressive lung disease. Aim of the study was to highlight the main factors associated with clinical, functional and anatomical deterioration in PCD patients.

METHODS

We retrospectively analyzed data from 58 patients with PCD, 37 adults and 21 children. The demographic and clinical data, forced expiratory volume at 1 s (FEV1) and forced vital capacity (FVC), sputum microbiology and imaging results (chest CT scores-modified Bhalla) were recorded. Patients were stratified according to the number of exacerbations (< 2/year vs ≥ 2/year) and chronic Pseudomonas aeruginosa (PA) colonization. The possible correlations between lung function and chest CT scores were assessed; we also evaluated the correlation between these parameters and the severity scores for bronchiectasis (BSI, FACED and e-FACED).

RESULTS

Chest CT scores showed a significant correlation with FEV1 (p = 0.0002), age (p <  0.0001), BMI (p = 0.0002) and number of lung lobes involved (p <  0.0001). PA colonization had an overall prevalence of 32.6%: no significant difference in FEV1 between PA colonized and non-colonized patients was found (p = 0.70), while chest CT score was significantly worse in chronic PA colonized patients (p = 0.009). Patients with a high number of exacerbation (≥ 2/year) were older (p = 0.01), had lower FEV1 (p = 0.03), greater number of lobes involved (p < 0.001) and worse CT score than patients with low number of exacerbations (p = 0.001); they also had higher prevalence of PA chronic bronchial infection (33.3% versus 13.6%, p = 0.10). Multivariable linear regression analyses adjusted for gender, age and BMI showed positive associations between PA colonization and number of exacerbations with severity of disease (number of lobes involved, CT score, BSI, FACED, and e-FACED).

CONCLUSIONS

In our PCD population the number of exacerbations (≥ 2/year) and PA colonization were the two most relevant factors associated with severity of disease.

3D video-assisted trans-oral removal of deep hilo-parenchymal sub-mandibular stones

The aim of this paper is to describe the intra-operative findings and surgical results of the first application of 3D high-definition (HD) endoscopic support to the trans-oral surgical treatment of five patients with deep hilo-parenchymal sub-mandibular stones who underwent clinical and ultrasonographic (US) follow-up examinations at one month after the procedure. Five patients undergoing 2D-HD video-assisted transoral surgery for the same condition were used as controls. The results were classified as successful (US - demonstrated complete clearance) or unsuccessful (US - demonstrated total or partial persistence). Visual analogue scales (VAS) were used post-surgically to evaluate the sharpness and brightness of the 2D and 3D images on the screen and stereoscopic depth perception (SDP) of the 3D-HD endoscope. Successful stone removal and significant subjective improvement (lack of obstructive symptoms) was obtained in all but one of the patients in the 3D group, in whom the one-month US evaluation revealed a residual 3 mm asymptomatic hilo-parenchymal stone that was successfully treated by sialendoscopy-assisted intra-corporeal laser lithotripsy. Wharton’s duct and the lingual nerve were identified and preserved in all cases. The mean 3D-HD VAS results were brightness 7 (range 6-8), sharpness 7.8 (range 7-9) and SDP 8.2 (range 8-9); the mean 2D-HD results were brightness 7.8 (range 7-9) and sharpness 7 (range 7-8). Our findings confirm the safety and efficacy of conservative transoral surgical treatment of hilo-parenchymal sub-mandibular stones. From a surgeon’s perspective, 3D-HD guided exploration of the oral floor seems to provide a better view of Wharton’s duct and the lingual nerve, especially near the sub-mandibular parenchyma. The 3D-HD video-assisted transoral removal of deep hilo-parenchymal sub-mandibular stones can therefore be considered a useful new means of preserving the function of an obstructed salivary gland.

Otogenic temporomandibular septic arthritis in a child: a case report and a review of the literature

Background

Acute otitis media is one of the most common infectious diseases in the paediatric age and although its complications such as acute mastoiditis have become rare thanks to improvements in therapeutic approaches, possible serious complications such as septic arthritis of the temporomandibular joint may develop. A prompt diagnosis and adequate treatment are essential to achieving the best outcome and avoiding serious sequelae. We describe a case occurring in a previously healthy 6-year-old female and review the literature currently available on this topic.

Case presentation

The patient presented a right temporomandibular septic arthritis with initial mandibular bone involvement secondary to acute otitis media. She presented with torcicollis, trismus, right preauricular swelling over the temporomandibular joint and was successfully treated with antibiotic treatment alone.

Conclusions

Septic arthritis of the temporomandibular joint is a rare complication of acute otitis media or acute mastoiditis in children. It should be suspected in patients presenting with trismus, preauricular swelling or fever. No guidelines on the diagnosis and treatment of this infectious disease are currently available.

Surgical Treatment of Paediatric Chronic Rhinosinusitis

Rhinosinusitis (RS) is a common disease in children, significantly affecting their quality of life. Chronic rhinosinusitis (CRS) is frequently linked to other respiratory diseases, including asthma. Children affected by CRS may be candidates for surgery in the case of failure of maximal medical therapy comprising three to six weeks of broad-spectrum systemic antibiotics with adjunctive therapies. Although endoscopic sinus surgery (ESS) is the surgical treatment of choice in adult patients with CRS, different surgical procedures are scheduled for refractory paediatric CRS and include adenoidectomy, paediatric ESS (PESS), and balloon catheter sinuplasty (BCS). The present paper discusses the indications and limitations of each treatment option in children with CRS. Given the amount of current evidence, it is reasonable to suggest that, in young and otherwise healthy children with refractory CRS, an adenoidectomy (eventually combined with BCS) should be offered as the first-line surgical treatment. Nevertheless, this approach may be considered ineffective in some patients who should be candidates for traditional ESS. In older children, those with asthma, or in the case of peculiar conditions, traditional ESS should be considered as the primary treatment.

Role of Biofilms in Children with Chronic Adenoiditis and Middle Ear Disease

Chronic adenoiditis occurs frequently in children, and it is complicated by the subsequent development of recurrent or chronic middle ear diseases, such as recurrent acute otitis media, persistent otitis media with effusion and chronic otitis media, which may predispose a child to long-term functional sequalae and auditory impairment. Children with chronic adenoidal disease who fail to respond to traditional antibiotic therapy are usually candidates for surgery under general anaesthesia. It has been suggested that the ineffectiveness of antibiotic therapy in children with chronic adenoiditis is partially related to nasopharyngeal bacterial biofilms, which play a role in the development of chronic nasopharyngeal inflammation due to chronic adenoiditis, which is possibly associated with chronic or recurrent middle ear disease. This paper reviews the current evidence concerning the involvement of bacterial biofilms in the development of chronic adenoiditis and related middle ear infections in children.

Multidisciplinary management of congenital giant head and neck masses: Our experience and review of the literature

BACKGROUND

Large fetal head and neck (HN) masses can be life-threatening at birth and postnatally owing to airway obstruction. The two most frequent congenital masses that may obstruct the airway are lymphatic malformation (LM) and teratoma. The aim of this paper was to evaluate the results of our experience in the management of giant congenital HN masses and to conduct a literature review.

METHODS

The study involved a consecutive series of 13 newborns (7 females) affected by giant HN masses. Prenatal diagnosis was achieved by means of ultrasound (US) and fetal magnetic resonance imaging (MRI). Delivery was performed by means of EXIT procedure in case of radiological evidence of airway obstruction. In the postnatal period all feasible therapeutic options (surgery, sclerotherapy, medical therapy) were discussed and adopted by a multidisciplinary team. Twelve patients underwent surgery and one received Rapamycin for one month, with consequent surgical resection owing to increasing size of the mass.

RESULTS

The histopathological diagnosis was LM in 11 cases and teratoma in 2 cases. Airway obstruction was solved in 11 cases; 2 LM patients required a tracheotomy because of persistent airway obstruction. Major complications were flap necrosis (one patient) and facial nerve palsy (2 cases). Recurrence occurred in 5 patients.

CONCLUSIONS

The management of congenital HN masses is always challenging and necessarily requires an interdisciplinary approach. Current therapeutic options include surgery, sclerotherapy, medical therapy or a combination of them. When they are large enough to obstruct the airway, a patient-centered approach should guide timing and modality of treatment.

LEVEL OF EVIDENCE

IV.

Surgical treatment of non-tuberculous mycobacterial lymphadenitis in children: Our experience and a narrative review

Non-tuberculous mycobacterial lymphadenitis (NTML) accounts for about 95% of the cases of head-and-neck mycobacterial lymphadenitis, and its prevalence has been increasing in the Western world. The diagnostic work-up can be challenging, and differential diagnoses such as tuberculous and suppurative lymphadenitis need to be considered. It may, therefore, not be diagnosed until the disease is in a late stage, by which time it becomes locally destructive and is characterized by a chronically discharging sinus. The treatment options include a medical approach, a wait-and-see policy, and surgery, with the last being considered the treatment of choice despite the high risk of iatrogenic nerve lesions. The aim of this article is to provide an overview of pediatric, head-and-neck NTML based on the literature and our own experience, with particular emphasis on the impact and limitations of surgery.

Microbiological Aspects of Acute and Chronic Pediatric Rhinosinusitis

The microbiology of acute and chronic rhinosinusitis has been extensively studied, but there are still some differences of view concerning the etiology of the former, and many disagreements regarding the microbiology of the latter. Establishing the concomitant distribution of the causative micro-organisms in cases that involve multiple sinuses is scientifically and practically important. The main problems are the variety of aerobes and anaerobes that may be involved, and the fact that different tracts of the sinuses of the same patient may be simultaneously affected. Rhinosinusitis may also involve the formation of biofilm, which may play a significant role in its pathogenesis and persistence. Biofilms have a number of advantages in terms of bacterial survival, and their perpetuation can create a certain degree of instability in host-bacteria interactions. Sinonasal microflora may further complicate pathogenesis and the identification of the pathogen(s) involved. Furthermore, the concentration, uniformity, and type/number of strains of nasal microbiota may vary from one site to another. The relative and total micro-organism counts can also be affected by various factors, and microbiota can modulate the course of both acute and chronic rhinosinusitis.

Sinonasal-Related Orbital Infections in Children: A Clinical and Therapeutic Overview

Sinonasal-related orbital infections (SROIs) are typically pediatric diseases that occur in 3⁻4% of children with acute rhinosinusitis. They are characterised by various clinical manifestations, such as peri-orbital and orbital cellulitis or orbital and sub-periosteal abscesses that may develop anteriorly or posteriorly to the orbital septum. Posterior septal complications are particularly dangerous, as they may lead to visual loss and life-threatening events, such as an intracranial abscess and cavernous sinus thrombosis. Given the possible risk of permanent visual loss due to optic neuritis or orbital nerve ischemia, SROIs are considered ophthalmic emergencies that need to be promptly recognised and treated in an urgent-care setting. The key to obtaining better clinical outcomes in children with SROIs is a multi-disciplinary assessment by pediatricians, otolaryngologists, ophthalmologists, radiologists, and in selected cases, neurosurgeons, neurologists, and infectious disease specialists. The aim of this paper is to provide an overview of the pathogenesis, clinical manifestations, diagnosis, and treatment of pediatric SROIs, and to make some practical recommendations for attending clinicians.