SYNUSOGENIC COMPLICATIONS IN CHILDREN Mr. Dr. Emine Ramku, Mr. Dr. Vahidin Haxhijaha, Dr. Lirim Ukimeraj, Mr. Dr. Flamur Ukaj, Dr. Selver Hudut, Dr. Shkelzen Kuqi
ABSTRACT ď Ž
BECKGRAUND; The ethmoid and the maxillary sinuses form in the third to fourth gestational month and, accordingly, are present at birth. The sphenoid sinuses are generally pneumatized by 5 years of age; the frontal sinuses appear at age 7 to 8 years but are not completely developed until late adolescence. The para nasal sinuses are a common site of infection in children and adolescents. These infections are important as a cause of frequent morbidity and rarely may result in life-threatening complications. It may be difficult to distinguish children with uncomplicated viral upper respiratory infections or adenoiditis from those with an episode of acute bacterial sinusitis. Most viral infections of the upper respiratory tract involve the nose and the par nasal sinuses (viral rhino sinusitis). However, bacterial infections of the par nasal sinuses do not usually involve the nose. When the patient with bacterial infection of the par nasal sinuses has purulent (thick, colored, and opaque) nasal drainage, the site of infection is the par nasal sinuses; the nose is simply acting as a conduit for secretions produced in the sinuses.
Sinus development
DEFINITION
Acute bacterial sinusitis; Bacterial infection of the par nasal sinuses lasting less than 30 days in which symptoms resolve completely. Sub acute bacterial sinusitis: Bacterial infection of the par nasal sinuses lasting between 30 and 90 days in which symptoms resolve completely. Recurrent acute bacterial sinusitis: Episodes of bacterial infection of the par nasal sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic. Chronic sinusitis: Episodes of inflammation of the par nasal sinuses lasting more than 90 days. Patients have persistent residual respiratory symptoms such as cough, rhino rhea, or nasal obstruction. Acute bacterial sinusitis superimposed on chronic sinusitis: Patients with residual respiratory symptoms develop new respiratory symptoms. When treated with antimicrobials, these new symptoms resolve, but the underlying residual symptoms do not.
OBJECTIVE
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ď Ž
The aim of this study is to investigate fifty-six children with sinusogenic complications treated in University Hospital in Prishtina. MATERIAL AND METHODS; In this report we present 56 cases witch was treated in ENT clinic in Prishtina.6 of them underwent sinus surgery and 50 of them were treated with medicament therapy. All of them prepared with x-Ray of sinuses, CT scan, blood analyses and microbiology findings, oftalmological and neurological examination.
X-Ray ,CT foundings
RESULTS ď Ž
RESULTS; The total number of this study was 56 patients. 6 (10.71)of them underwent sinus surgery and 50(89.29) of them were treated with medicament therapy. The first group was children from 2-7 years old with 10 cases. Second group was children from 8-12 years old with 16 cases. Third group was children from 13-18 years old with 30 cases. 21(37.5) of them was female and 35(62.5) male. All of them were treated with antibiotics (amoxicllav or ceftriaxon) because in microbiological founding were gram positive bacteria. The median stay of hospitalization for patients with operative treatment was 21 days and for conservative treatment was 10.5 days. 3(5.36) of them was with more than one sinus infection, orbital cellulites and retro orbital abscessus.3 other was with only one sinus infection, orbital cellulites and retro orbital abscesses. The most often bacteria isolated was staphylococcus aureus with 16 cases (28.57%).20(35.7) of total number was without bacteriological result because they was treated with antibiotics previously.
Table 1. Sinusogenic complication in children by gender Years
Female
Male
Total
%
2000
2
2
4
7.14
2001
3
1
4
7.14
2002
0
2
2
3.57
2003
0
1
1
1.79
2004
2
4
6
10.71
2005
4
4
8
14.29
2006
3
4
7
12.50
2007
2
7
9
16.07
2008
5
10
15
26.79
21
35
56
100.00
37.5
62.5
100
Total %
Chart 1: Sinusogenic complication in children by gender
%
Males
100 90 80 70 60 50 40 30 20 10 0
100.0
Females 100.0
77.8 66.7
66.7 57.1
50.0
50.0
25.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
Table 2.Sinusogenic complication in children by method of treatment Years
Operations
Cons. treatm.
Total
%
2000
0
4
4
7.14
2001
1
3
4
7.14
2002
1
1
2
3.57
2003
0
1
1
1.79
2004
0
6
6
10.71
2005
3
5
8
14.29
2006
1
6
7
12.50
2007
0
9
9
16.07
2008
0
15
15
26.79
6
50
56
100.00
10.71
89.29
100
Total %
Chart 2: Sinusogenic complication in children by method of treatment Operations
% 100
Cons. treatm.
90 80
50.0
70
62.5 75.0
60 50
85.7
100.0
100.0
100.0
100.0
100.0
2007
2008
40 30
50.0
20
37.5 25.0
10
14.3
0 2000
2001
2002
2003
2004
2005
2006
Tab. & Chart 3. Sinusogenic complication in children by age Age
cases
%
2-7 years
10
17.86
8-12 years
16
28.57
13-18 years
30
53.57
56
100.00
Total %
100.0 80.0 60.0
53.57
40.0 20.0
28.57 17.86
0.0 2-7 years
8-12 years
13-18 years
Table & Chart 4. Sinusogenic complication in children by type of intervention Type of interv.
cases
%
Fronto eth. ext. cum evacuatio absc. Periorb.
3
50.00
Eth. ext. cum evacuatio absc. Periorb.
3
50.00
Total
6
100.00
%
%
100.0 80.0 60.0
50.0
50.0
Fronto eth. ext. cum evacuatio absc. Periorb.
Eth. ext. cum evacuatio absc. Periorb.
40.0 20.0 0.0
Tab. & Chart 5. Sinusogenic complication in children by method of diagnostication CT and X-Ray faundings Operative treated Conservative treated
Nr.
%
One sinus
3
5.36
More than one sinus
3
5.36
One sinus
30
53.57
More than one sinus
20
35.71
56
100.00
Total
100.0 80.0 60.0 40.0 20.0 0.0
% 53.6 5.4
5.4
One sinus
More than one sinus
One sinus
35.7
More than one sinus
Tab. & Chart 6. Sinusogenic complication in children by microbiologic founding’s Types of bacteria
cases
%
Staphylococcus aurus
16
28.57
Streptococcus β hemolyticus
14
25.00
6
10.71
No result found
20
35.71
Total
56
100.00
Branhamelal catarhalis
%
% 100.0 80.0 60.0 40.0
28.6
35.7
25.0 10.7
20.0 0.0 Staphylococcus aurus
Streptococcus β hemolyticus
Branhamelal catarhalis
No result found
DISCUSION ď Ž
ER Wald et al.Correlate the clinical, radiographic, and bacteriologic findings in maxillary sinusitis in 30 children who had both upper-respiratory-tract symptoms and abnormal maxillary radiographs. Cough, nasal discharge, and fetid breath were the most common signs, but fever was present inconsistently. Facial pain or swelling and headache were prominent symptoms in older children. Bacterial colony counts of greater than or equal to 10(4) colony-forming units per milliliter were found in 34 of 47 sinus aspirates obtained from 23 children. The most common species recovered were Streptococcus pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis. No anaerobic bacteria were isolated. Viruses were isolated from only two sinus aspirates. There was a poor correlation between the predominant species of bacteria recovered from either the nasopharyngeal or throat culture and the bacteria isolated from the sinus aspirate. This study demonstrates that children with both upper-respiratory-tract symptoms and abnormal sinus radiographs are likely to harbor bacteria in their sinuses, suggesting that such children have bacterial sinusitis.
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In Zinkin AN et al study we can see clinical features and diagnostic and prognostic values of systemic inflammatory response syndrome (SIRS) were studied in 158 children with rhino-sinusogenic orbital and intracranial complications. Patients, whose condition was more severe, showed more SIRS markers and more often needed surgical removal of the primary infectious process in paranasal sinuses (31%). Increase of the SIRS symptoms led to an increase of organic dysfunction from 3.3% to 53.3%. The main targets for shock are the brain and meninges, with the lungs being often the second target and the hemostasis system being also often involved. Complicated rhinosinusitis should be regarded as septic if in addition to the primary infectious process the child has two or more SIRS symptoms and signs of organic dysfunctions. This approach to the diagnosis and treatment of sepsis results in recovery of 98.5 of children with this condition.
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MCcLay et al. study review the demographic, microbiologic, and outcome data for children with complications of acute sinusitis. STUDY DESIGN AND SETTING: Retrospective review of children admitted with complications of acute sinusitis from January 1995 to July 2002 to a tertiary care children's hospital. RESULTS: One hundred four patients were reviewed with the following complications: orbital cellulitis (51), orbital abscesses (44), epidural empyemas (7), subdural empyemas (6), intracerebral abscesses (2), meningitis (2), cavernous sinus thrombosis (1), and Pott's puffy tumors (3). Sixty-six percent were males (P < 0.001), and 64.4% presented from November to March (P < 0.001). Patients with isolated orbital complications were younger than patients with intracranial complications (mean, 6.5 versus 12.3 years), had a shorter stay (mean, 4.2 versus 16.6 days), and had shorter duration of symptoms (mean, 5.4 versus 14.3 days; all P < 0.0001). Complete resolution was documented for 54/55 patients with restricted ocular motility, 7/8 with visual loss, 3/3 patients with a nonreactive pupil, 7/7 with neurological deficits, and 2/4 with seizures. The most common organism isolated was Streptococcus milleri (11/36 patients with surgical cultures). No mortalities occurred, and persistent morbidity occurred in 4 patients (3.8%). CONCLUSIONS: Despite significant deficits on presentation, permanent morbidity was low. Streptococcus milleri is a common pathogen with complications of sinusitis in children.
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Jerzy Kuczkowski et al.show a retrospective review of children diagnosed and treated for suppurative complications of paranasal sinusitis was undertaken to describe clinical presentation, microbiology, and treatment. This review includes children with subgaleal abscess and osteomyelitis of the frontal bone, subdural empyema, frontal lobe abscess, meningitis, and encephalitis. Staphylococcus aureus and group C Ă&#x;-hemolytic Streptococcus were isolated agents. All children were treated with intravenous antibiotics with drainage of both the sinus and extracranial and intracranial suppurations. Results of treatment in the series support the opinion that combined aggressive surgical and antibiotic treatment is a preferred method in complicated sinusitis in children.
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In a clinical practice guideline formulates recommendations for health care providers regarding the diagnosis, evaluation, and treatment of children, ages 1 to 21 years, with uncomplicated acute, subacute, and recurrent acute bacterial sinusitis. It was developed through a comprehensive search and analysis of the medical literature. Expert consensus opinion was used to enhance or formulate recommendations where data were insufficient. Several other groups (including members of the American College of Emergency Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Asthma, Allergy and Immunology, as well as numerous national committees and sections of the American Academy of Pediatrics) have reviewed and revised the guideline. Three specific issues were considered: 1) evidence for the efficacy of various antibiotics in children; 2) evidence for the efficacy of various ancillary, nonantibiotic regimens; and 3) the diagnostic accuracy and concordance of clinical symptoms, radiography (and other imaging methods), and sinus aspiration.
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It is recommended that the diagnosis of acute bacterial sinusitis be based on clinical criteria in children 6 years of age who present with upper respiratory symptoms that are either persistent or severe. Although controversial, imaging studies may be necessary to confirm a diagnosis of acute bacterial sinusitis in children >6 years of age. Computed tomography scans of the paranasal sinuses should be reserved for children who present with complications of acute bacterial sinusitis or who have very persistent or recurrent infections and are not responsive to medical management. There were only 5 controlled randomized trials and 8 case series on antimicrobial therapy for acute bacterial sinusitis in children. However, these data, plus data derived from the study of adults with acute bacterial sinusitis, support the recommendation that acute bacterial sinusitis be treated with antimicrobial therapy to achieve a more rapid clinical cure. Children with complications or suspected complications of acute bacterial sinusitis should be treated promptly and aggressively with antibiotics and, when appropriate, drainage. Based on controversial and limited data, no recommendations are made about the use of prophylactic antimicrobials, ancillary therapies, or complementary/alternative medicine for prevention and treatment of acute bacterial sinusitis. Conduct more and larger studies correlating the clinical findings of acute bacterial sinusitis with findings of sinus aspiration, imaging, and treatment outcome.
AREAS FOR FUTURE RESERCH
1. Develop noninvasive strategies to accurately diagnose acute bacterial sinusitis in children. 2. Correlate cultures obtained from the middle meatus of the maxillary sinus of infected individuals with cultures obtained from the maxillary sinus by puncture of the antrum. 3. Develop imaging technology that differentiates bacterial infection from viral infection or allergic inflammation. 4. Develop rapid diagnostic methods to image the sinuses without radiation. 5. Determine the optimal duration of antimicrobial therapy for children with acute bacterial sinusitis. 6. Determine the causes and treatment of subacute and recurrent acute bacterial sinusitis.
7. Determine the efficacy of prophylaxis with antimicrobials to prevent recurrent acute bacterial sinusitis. 8. Determine the impact of bacterial resistance among S pneumoniae, H influenzae, and M catarrhalis on outcome of treatment with antibiotics by the performance of randomized, double-blind, placebo-controlled studies in well-defined populations of patients. 9. Determine the role of adjuvant therapies (mucolytics, decongestants, antihistamines, etc) in patients with acute bacterial sinusitis by the performance of prospective, randomized, clinical trials. 10. Determine the role of complementary and alternative medicine strategies in patients with acute bacterial sinusitis by performing systematic, prospective, randomized clinical trials. 11. Assess the effect of the pneumococcal conjugate vaccine on the epidemiology of acute bacterial sinusitis. 12. Develop new bacterial and viral vaccines to reduce the incidence of acute bacterial sinusitis.
CONCLUSION ď Ž
By 9 years of evaluation, we conclude that most of childrenâ&#x20AC;&#x2122;s sinus infection could managing with high dosage of antibiotic and prevent the surgical intervention. And that combined aggressive surgical and antibiotic treatment is a preferred method in complicated sinusitis in children.
REFERENCES
1. ER Wald, GJ Milmoe, A Bowen, Acute maxillary sinusitis in children 2. Zinkin AN Syndrome of systemic inflammatory response in children with septic pyogenic complications of rhinosinusitis. 3. MCcLay et al .Complications of acute sinusitis in children. 4. Jerzy Kuczkowski, Waldemar Narozny, Boguslaw Mikaszewski,,Suppurative Complications of Frontal Sinusitis in Children 5. Management of Sinusitis .Subcommittee on Management of Sinusitis and Committee on Quality Improvement.American academy of pedijatrics. Pedijatrics Vol. 108 No. 3 September 2001, pp. 798-808 6. Lusk RP, Stankiewicz JA Pediatric rhinosinusitis. Otolaryngol Head Neck Surg 1997; 117:S53S57 7. Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK Computed tomographic study of the common cold. N Engl J Med 1994; 330:25-30
8. Fireman P Diagnosis of sinusitis in children: emphasis on the history and physical examination . J Allergy Clin Immunol 1992; 90:433-436 9. Aitken M, Taylor JA Prevalence of clinical sinusitis in young children followed up by primary care pediatricians . Arch Pediatr Adolesc Med 1998; 152:244-248 10. Ueda D, Yoto Y The ten-day mark as a practical diagnostic approach for acute paranasal sinusitis in children. Pediatr Infect Dis J 1996; 15:576-579 11. Wald ER, Guerra N, Byers C Upper respiratory tract infections in young children: duration of and frequency of complications. Pediatrics 1991; 87:129-133 12. McCaig LF, Hughes JM Trends in antimicrobial drug prescribing among office-based physicians in the United States [published erratum in JAMA. 1998;11:279] . JAMA. 1995; 273:214-219 13. Parsons DS, Wald ER Otitis media and sinusitis: similar diseases. Otolaryngol Clin North Am 1996; 29:11-25 14. Gwaltney JM Jr, Scheld WM, Sande MA, Sydnor A The microbial etiology and antimicrobial therapy of adults with acute community-acquired sinusitis: a fifteen-year experience at the University of Virginia and review of other selected studies. J Allergy Clin Immunol 1992; 90:457462
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