SYNUSOGENES COMPLICATIONS IN CHILDREN_23 prill 09

SYNUSOGENIC SYNUSOGENIC COMPLICATIONS IN COMPLICATIONS IN

CHILDREN CHILDREN Mr. Dr. Emine Ramku, Mr. Dr. Mr. Dr. Emine Ramku, Mr. Dr. Vahidin Haxhijaha, Dr. Lirim Vahidin Haxhijaha, Dr. Lirim

Ukimeraj, Mr. Dr. Flamur Ukaj, Dr. Ukimeraj, Mr. Dr. Flamur Ukaj, Dr. Selver Hudut, Dr. Shkelzen KuqiSelver Hudut, Dr. Shkelzen Kuqi

ABSTRACTABSTRACT BECKGRAUND; The ethmoid and the maxillary sinuses form in the BECKGRAUND; The ethmoid and the maxillary sinuses form in the

third to fourth gestational month and, accordingly, are present at third to fourth gestational month and, accordingly, are present at birth. The sphenoid sinuses are generally pneumatized by 5 years of 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 age; the frontal sinuses appear at age 7 to 8 years but are not completely developed until late adolescence. The para nasal sinuses completely developed until late adolescence. The para nasal sinuses are a common site of infection in children and adolescents. These are a common site of infection in children and adolescents. These infections are important as a cause of frequent morbidity and rarely infections are important as a cause of frequent morbidity and rarely may result in life-threatening complications. It may be difficult to may result in life-threatening complications. It may be difficult to distinguish children with uncomplicated viral upper respiratory distinguish children with uncomplicated viral upper respiratory infections or adenoiditis from those with an episode of acute infections or adenoiditis from those with an episode of acute bacterial sinusitis. Most viral infections of the upper respiratory tract bacterial sinusitis. Most viral infections of the upper respiratory tract involve the nose and the par nasal sinuses (viral rhino sinusitis). involve the nose and the par nasal sinuses (viral rhino sinusitis). However, bacterial infections of the par nasal sinuses do not usually However, bacterial infections of the par nasal sinuses do not usually involve the nose. When the patient with bacterial infection of the par involve the nose. When the patient with bacterial infection of the par nasal sinuses has purulent (thick, colored, and opaque) nasal nasal sinuses has purulent (thick, colored, and opaque) nasal drainage, the site of infection is the par nasal sinuses; the nose is drainage, the site of infection is the par nasal sinuses; the nose is simply acting as a conduit for secretions produced in the sinuses.simply acting as a conduit for secretions produced in the sinuses.

Sinus developmentSinus development

DEFINITIONDEFINITION Acute bacterial sinusitis; Bacterial infection of the par nasal sinuses Acute bacterial sinusitis; Bacterial infection of the par nasal sinuses

lasting less than 30 days in which symptoms resolve completely. lasting less than 30 days in which symptoms resolve completely. Sub acute bacterial sinusitis: Bacterial infection of the par nasal sinuses Sub acute bacterial sinusitis: Bacterial infection of the par nasal sinuses

lasting between 30 and 90 days in which symptoms resolve completely. lasting between 30 and 90 days in which symptoms resolve completely. Recurrent acute bacterial sinusitis: Episodes of bacterial infection of the Recurrent acute bacterial sinusitis: Episodes of bacterial infection of the

par nasal sinuses, each lasting less than 30 days and separated by par nasal sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic. intervals of at least 10 days during which the patient is asymptomatic.

Chronic sinusitis: Episodes of inflammation of the par nasal sinuses Chronic sinusitis: Episodes of inflammation of the par nasal sinuses lasting more than 90 days. Patients have persistent residual respiratory lasting more than 90 days. Patients have persistent residual respiratory symptoms such as cough, rhino rhea, or nasal obstruction. symptoms such as cough, rhino rhea, or nasal obstruction.

Acute bacterial sinusitis superimposed on chronic sinusitis: Patients with Acute bacterial sinusitis superimposed on chronic sinusitis: Patients with residual respiratory symptoms develop new respiratory symptoms. residual respiratory symptoms develop new respiratory symptoms. When treated with antimicrobials, these new symptoms resolve, but the When treated with antimicrobials, these new symptoms resolve, but the underlying residual symptoms do not.underlying residual symptoms do not.

OBJECTIVEOBJECTIVE

The aim of this study is to investigate fifty-six children with The aim of this study is to investigate fifty-six children with

sinusogenic complications treated in University Hospital in sinusogenic complications treated in University Hospital in Prishtina.Prishtina.

MATERIAL AND METHODS; In this report we present 56 cases witch MATERIAL AND METHODS; In this report we present 56 cases witch was treated in ENT clinic in Prishtina.6 of them underwent sinus was treated in ENT clinic in Prishtina.6 of them underwent sinus surgery and 50 of them were treated with medicament therapy. surgery and 50 of them were treated with medicament therapy. All of them prepared with x-Ray of sinuses, CT scan, blood All of them prepared with x-Ray of sinuses, CT scan, blood analyses and microbiology findings, oftalmological and analyses and microbiology findings, oftalmological and neurological examination. neurological examination.

X-Ray ,CT foundingsX-Ray ,CT foundings

RESULTSRESULTS RESULTS; The total number of this study was 56 patients. 6 RESULTS; The total number of this study was 56 patients. 6

(10.71)of them underwent sinus surgery and 50(89.29) of them (10.71)of them underwent sinus surgery and 50(89.29) of them were treated with medicament therapy. The first group was were treated with medicament therapy. The first group was children from 2-7 years old with 10 cases. Second 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 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 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 female and 35(62.5) male. All of them were treated with antibiotics (amoxicllav or ceftriaxon) because in microbiological antibiotics (amoxicllav or ceftriaxon) because in microbiological founding were gram positive bacteria. The median stay of founding were gram positive bacteria. The median stay of hospitalization for patients with operative treatment was 21 days hospitalization for patients with operative treatment was 21 days and for conservative treatment was 10.5 days. 3(5.36) of them and for conservative treatment was 10.5 days. 3(5.36) of them was with more than one sinus infection, orbital cellulites and retro was with more than one sinus infection, orbital cellulites and retro orbital abscessus.3 other was with only one sinus infection, orbital orbital abscessus.3 other was with only one sinus infection, orbital cellulites and retro orbital abscesses. The most often bacteria cellulites and retro orbital abscesses. The most often bacteria isolated was staphylococcus aureus with 16 cases isolated was staphylococcus aureus with 16 cases (28.57%).20(35.7) of total number was without bacteriological (28.57%).20(35.7) of total number was without bacteriological result because they was treated with antibiotics previously.result because they was treated with antibiotics previously.

Table 1. Sinusogenic complication in children by Table 1. Sinusogenic complication in children by gendergender

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

Total 21 35 56 100.00

% 37.5 62.5 100  

Chart 1: Sinusogenic complication in children by Chart 1: Sinusogenic complication in children by gendergender

50.0

25.0

100.0 100.0

66.7

50.057.1

77.8

66.7

0102030405060708090

100

2000 2001 2002 2003 2004 2005 2006 2007 2008

% Males Females

Table 2.Sinusogenic complication in children by Table 2.Sinusogenic complication in children by method of treatmentmethod 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

Total 6 50 56 100.00

% 10.71 89.29 100  

Chart 2: Sinusogenic complication in children by Chart 2: Sinusogenic complication in children by method of treatmentmethod of treatment

25.0

50.037.5

14.3

100.0

75.0

50.0

100.0 100.0

62.5

85.7100.0 100.0

0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006 2007 2008

% Operations Cons. treatm.

Tab. & Chart 3. Sinusogenic complication in Tab. & Chart 3. Sinusogenic complication in children by agechildren by age

AgeAge casescases %%

2-7 years2-7 years 1010 17.8617.86

8-12 years8-12 years 1616 28.5728.57

13-18 years13-18 years 3030 53.5753.57

TotalTotal 5656 100.00100.00

17.86

28.57

53.57

0.0

20.0

40.0

60.0

80.0

100.0

2-7 years 8-12 years 13-18 years

%

Table & Chart 4. Sinusogenic complication in Table & Chart 4. Sinusogenic complication in children by type of interventionchildren by type of intervention

Type of interv.Type of interv. casescases %%

Fronto eth. ext. cum evacuatio absc. Fronto eth. ext. cum evacuatio absc. Periorb.Periorb. 33 50.0050.00

Eth. ext. cum evacuatio absc. Periorb.Eth. ext. cum evacuatio absc. Periorb. 33 50.0050.00

TotalTotal 66 100.00100.00

50.0 50.0

0.0

20.0

40.0

60.0

80.0

100.0

Fronto eth. ext. cum evacuatio absc. Periorb. Eth. ext. cum evacuatio absc. Periorb.

% %

Tab. & Chart 5. Sinusogenic complication in children Tab. & Chart 5. Sinusogenic complication in children by method of diagnosticationby method of diagnostication

CT and X-Ray faundingsCT and X-Ray faundings Nr.Nr. %%

Operative treatedOperative treatedOne sinus One sinus 33 5.365.36

More than one sinusMore than one sinus 33 5.365.36

Conservative Conservative treatedtreated

One sinus One sinus 3030 53.5753.57

More than one sinusMore than one sinus 2020 35.7135.71

TotalTotal 5656 100.00100.00

5.4 5.4

53.635.7

0.020.040.060.080.0

100.0

One sinus More than one sinus One sinus More than one sinus

%

Tab. & Chart 6. Sinusogenic complication in children Tab. & Chart 6. Sinusogenic complication in children by microbiologic founding’sby microbiologic founding’s

28.6 25.010.7

35.7

0.0

20.0

40.0

60.0

80.0

100.0

Staphylococcus aurus Streptococcus βhemolyticus

Branhamelal catarhalis No result found

% %

Types of bacteriaTypes of bacteria casescases %%

Staphylococcus aurusStaphylococcus aurus 1616 28.5728.57

Streptococcus Streptococcus β hemolyticusβ hemolyticus 1414 25.0025.00

Branhamelal catarhalisBranhamelal catarhalis 66 10.7110.71

No result foundNo result found 2020 35.7135.71

TotalTotal 5656 100.00100.00

DISCUSIONDISCUSION

ER WaldER Wald et al.Correlate the clinical, radiographic, and bacteriologic et al.Correlate the clinical, radiographic, and bacteriologic findings in maxillary sinusitis in 30 children who had both upper-findings in maxillary sinusitis in 30 children who had both upper-respiratory-tract symptoms and abnormal maxillary radiographs. respiratory-tract symptoms and abnormal maxillary radiographs. Cough, nasal discharge, and fetid breath were the most common signs, Cough, nasal discharge, and fetid breath were the most common signs, but fever was present inconsistently. Facial pain or swelling and but fever was present inconsistently. Facial pain or swelling and headache were prominent symptoms in older children. Bacterial colony headache were prominent symptoms in older children. Bacterial colony counts of greater than or equal to 10(4) colony-forming units per 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 milliliter were found in 34 of 47 sinus aspirates obtained from 23 children. The most common species recovered were Streptococcus children. The most common species recovered were Streptococcus pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis. No pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis. No anaerobic bacteria were isolated. Viruses were isolated from only two anaerobic bacteria were isolated. Viruses were isolated from only two sinus aspirates. There was a poor correlation between the predominant sinus aspirates. There was a poor correlation between the predominant species of bacteria recovered from either the nasopharyngeal or throat species of bacteria recovered from either the nasopharyngeal or throat culture and the bacteria isolated from the sinus aspirate. This study culture and the bacteria isolated from the sinus aspirate. This study demonstrates that children with both upper-respiratory-tract demonstrates that children with both upper-respiratory-tract symptoms and abnormal sinus radiographs are likely to harbor bacteria symptoms and abnormal sinus radiographs are likely to harbor bacteria in their sinuses, suggesting that such children have bacterial sinusitis.in their sinuses, suggesting that such children have bacterial sinusitis.

In Zinkin AN et al study we can see clinical features and diagnostic In Zinkin AN et al study we can see clinical features and diagnostic and prognostic values of systemic inflammatory response and prognostic values of systemic inflammatory response syndrome (SIRS) were studied in 158 children with rhino-syndrome (SIRS) were studied in 158 children with rhino-sinusogenic orbital and intracranial complications. Patients, whose sinusogenic orbital and intracranial complications. Patients, whose condition was more severe, showed more SIRS markers and more condition was more severe, showed more SIRS markers and more often needed surgical removal of the primary infectious process in often needed surgical removal of the primary infectious process in paranasal sinuses (31%). Increase of the SIRS symptoms led to an paranasal sinuses (31%). Increase of the SIRS symptoms led to an increase of organic dysfunction from 3.3% to 53.3%. The main increase of organic dysfunction from 3.3% to 53.3%. The main targets for shock are the brain and meninges, with the lungs being targets for shock are the brain and meninges, with the lungs being often the second target and the hemostasis system being also often the second target and the hemostasis system being also often involved. Complicated rhinosinusitis should be regarded as often involved. Complicated rhinosinusitis should be regarded as septic if in addition to the primary infectious process the child has septic if in addition to the primary infectious process the child has two or more SIRS symptoms and signs of organic dysfunctions. two or more SIRS symptoms and signs of organic dysfunctions. This approach to the diagnosis and treatment of sepsis results in This approach to the diagnosis and treatment of sepsis results in recovery of 98.5 of children with this condition. recovery of 98.5 of children with this condition.

MCcLay et al. study review the demographic, microbiologic, and MCcLay et al. study review the demographic, microbiologic, and outcome data for children with complications of acute sinusitis. STUDY outcome data for children with complications of acute sinusitis. STUDY DESIGN AND SETTING: Retrospective review of children admitted with DESIGN AND SETTING: Retrospective review of children admitted with complications of acute sinusitis from January 1995 to July 2002 to a complications of acute sinusitis from January 1995 to July 2002 to a tertiary care children's hospital. RESULTS: One hundred four patients tertiary care children's hospital. RESULTS: One hundred four patients were reviewed with the following complications: orbital cellulitis (51), were reviewed with the following complications: orbital cellulitis (51), orbital abscesses (44), epidural empyemas (7), subdural empyemas (6), orbital abscesses (44), epidural empyemas (7), subdural empyemas (6), intracerebral abscesses (2), meningitis (2), cavernous sinus thrombosis intracerebral abscesses (2), meningitis (2), cavernous sinus thrombosis (1), and Pott's puffy tumors (3). Sixty-six percent were males (P < (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). 0.001), and 64.4% presented from November to March (P < 0.001). Patients with isolated orbital complications were younger than patients Patients with isolated orbital complications were younger than patients with intracranial complications (mean, 6.5 versus 12.3 years), had a 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 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 symptoms (mean, 5.4 versus 14.3 days; all P < 0.0001). Complete resolution was documented for 54/55 patients with restricted ocular 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 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 with neurological deficits, and 2/4 with seizures. The most common organism isolated was Streptococcus milleri (11/36 patients with organism isolated was Streptococcus milleri (11/36 patients with surgical cultures). No mortalities occurred, and persistent morbidity surgical cultures). No mortalities occurred, and persistent morbidity occurred in 4 patients (3.8%). CONCLUSIONS: Despite significant deficits occurred in 4 patients (3.8%). CONCLUSIONS: Despite significant deficits on presentation, permanent morbidity was low. Streptococcus milleri is on presentation, permanent morbidity was low. Streptococcus milleri is a common pathogen with complications of sinusitis in children. a common pathogen with complications of sinusitis in children.

Jerzy Kuczkowski et al.show a retrospective review of children Jerzy Kuczkowski et al.show a retrospective review of children diagnosed and treated for suppurative complications of paranasal diagnosed and treated for suppurative complications of paranasal sinusitis was undertaken to describe clinical presentation, sinusitis was undertaken to describe clinical presentation, microbiology, and treatment. This review includes children with microbiology, and treatment. This review includes children with subgaleal abscess and osteomyelitis of the frontal bone, subdural subgaleal abscess and osteomyelitis of the frontal bone, subdural empyema, frontal lobe abscess, meningitis, and encephalitis. empyema, frontal lobe abscess, meningitis, and encephalitis. Staphylococcus aureus and group C ß-hemolytic Streptococcus Staphylococcus aureus and group C ß-hemolytic Streptococcus were isolated agents. All children were treated with intravenous were isolated agents. All children were treated with intravenous antibiotics with drainage of both the sinus and extracranial and antibiotics with drainage of both the sinus and extracranial and intracranial suppurations. Results of treatment in the series intracranial suppurations. Results of treatment in the series support the opinion that combined aggressive surgical and support the opinion that combined aggressive surgical and antibiotic treatment is a preferred method in complicated sinusitis antibiotic treatment is a preferred method in complicated sinusitis in children.in children.

In a clinical practice guideline formulates recommendations for In a clinical practice guideline formulates recommendations for health care providers regarding the diagnosis, evaluation, and health care providers regarding the diagnosis, evaluation, and treatment of children, ages 1 to 21 years, with uncomplicated treatment of children, ages 1 to 21 years, with uncomplicated acute, subacute, and recurrent acute bacterial sinusitis. It was acute, subacute, and recurrent acute bacterial sinusitis. It was developed through a comprehensive search and analysis of the developed through a comprehensive search and analysis of the medical literature. Expert consensus opinion was used to enhance medical literature. Expert consensus opinion was used to enhance or formulate recommendations where data were insufficient. or formulate recommendations where data were insufficient. Several other groups (including members of the American College Several other groups (including members of the American College of Emergency Physicians, American Academy of Otolaryngology-of Emergency Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Asthma, Allergy Head and Neck Surgery, American Academy of Asthma, Allergy and Immunology, as well as numerous national committees and and Immunology, as well as numerous national committees and sections of the American Academy of Pediatrics) have reviewed sections of the American Academy of Pediatrics) have reviewed and revised the guideline. Three specific issues were considered: and revised the guideline. Three specific issues were considered: 1) evidence for the efficacy of various antibiotics in children; 2) 1) evidence for the efficacy of various antibiotics in children; 2) evidence for the efficacy of various ancillary, nonantibiotic evidence for the efficacy of various ancillary, nonantibiotic regimens; and 3) the diagnostic accuracy and concordance of regimens; and 3) the diagnostic accuracy and concordance of clinical symptoms, radiography (and other imaging methods), and clinical symptoms, radiography (and other imaging methods), and sinus aspiration. sinus aspiration.

It is recommended that the diagnosis of acute bacterial sinusitis be based 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 on clinical criteria in children 6 years of age who present with upper respiratory symptoms that are either persistent or severe. Although respiratory symptoms that are either persistent or severe. Although controversial, imaging studies may be necessary to confirm a diagnosis of controversial, imaging studies may be necessary to confirm a diagnosis of acute bacterial sinusitis in children >6 years of age. Computed acute bacterial sinusitis in children >6 years of age. Computed tomography scans of the paranasal sinuses should be reserved for tomography scans of the paranasal sinuses should be reserved for children who present with complications of acute bacterial sinusitis or children who present with complications of acute bacterial sinusitis or who have very persistent or recurrent infections and are not responsive who have very persistent or recurrent infections and are not responsive to medical management. There were only 5 controlled randomized trials to medical management. There were only 5 controlled randomized trials and 8 case series on antimicrobial therapy for acute bacterial sinusitis in and 8 case series on antimicrobial therapy for acute bacterial sinusitis in children. However, these data, plus data derived from the study of adults children. However, these data, plus data derived from the study of adults with acute bacterial sinusitis, support the recommendation that acute with acute bacterial sinusitis, support the recommendation that acute bacterial sinusitis be treated with antimicrobial therapy to achieve a more bacterial sinusitis be treated with antimicrobial therapy to achieve a more rapid clinical cure. Children with complications or suspected rapid clinical cure. Children with complications or suspected complications of acute bacterial sinusitis should be treated promptly and complications of acute bacterial sinusitis should be treated promptly and aggressively with antibiotics and, when appropriate, drainage. Based on aggressively with antibiotics and, when appropriate, drainage. Based on controversial and limited data, no recommendations are made about the controversial and limited data, no recommendations are made about the use of prophylactic antimicrobials, ancillary therapies, or use of prophylactic antimicrobials, ancillary therapies, or complementary/alternative medicine for prevention and treatment of complementary/alternative medicine for prevention and treatment of acute bacterial sinusitis. Conduct more and larger studies correlating the acute bacterial sinusitis. Conduct more and larger studies correlating the clinical findings of acute bacterial sinusitis with findings of sinus clinical findings of acute bacterial sinusitis with findings of sinus aspiration, imaging, and treatment outcome. aspiration, imaging, and treatment outcome.

AREAS FOR FUTURE RESERCHAREAS FOR FUTURE RESERCH

1. Develop noninvasive strategies to accurately diagnose 1. Develop noninvasive strategies to accurately diagnose acute bacterial sinusitis in children. acute bacterial sinusitis in children.

2. Correlate cultures obtained from the middle meatus of the 2. Correlate cultures obtained from the middle meatus of the maxillary sinus of infected individuals with cultures obtained maxillary sinus of infected individuals with cultures obtained from the maxillary sinus by puncture of the antrum. from the maxillary sinus by puncture of the antrum.

3. Develop imaging technology that differentiates bacterial 3. Develop imaging technology that differentiates bacterial infection from viral infection or allergic inflammation. infection from viral infection or allergic inflammation.

4. Develop rapid diagnostic methods to image the sinuses 4. Develop rapid diagnostic methods to image the sinuses without radiation. without radiation.

5. Determine the optimal duration of antimicrobial therapy 5. Determine the optimal duration of antimicrobial therapy for children with acute bacterial sinusitis. for children with acute bacterial sinusitis.

6. Determine the causes and treatment of subacute and 6. Determine the causes and treatment of subacute and recurrent acute bacterial sinusitis. recurrent acute bacterial sinusitis.

7. Determine the efficacy of prophylaxis with antimicrobials to 7. Determine the efficacy of prophylaxis with antimicrobials to prevent recurrent acute bacterial sinusitis. prevent recurrent acute bacterial sinusitis.

8. Determine the impact of bacterial resistance among S 8. Determine the impact of bacterial resistance among S pneumoniae, H influenzae, and M catarrhalis on outcome of pneumoniae, H influenzae, and M catarrhalis on outcome of treatment with antibiotics by the performance of randomized, treatment with antibiotics by the performance of randomized, double-blind, placebo-controlled studies in well-defined double-blind, placebo-controlled studies in well-defined populations of patients. populations of patients.

9. Determine the role of adjuvant therapies (mucolytics, 9. Determine the role of adjuvant therapies (mucolytics, decongestants, antihistamines, etc) in patients with acute decongestants, antihistamines, etc) in patients with acute bacterial sinusitis by the performance of prospective, randomized, bacterial sinusitis by the performance of prospective, randomized, clinical trials. clinical trials.

10. Determine the role of complementary and alternative 10. Determine the role of complementary and alternative medicine strategies in patients with acute bacterial sinusitis by medicine strategies in patients with acute bacterial sinusitis by performing systematic, prospective, randomized clinical trials. performing systematic, prospective, randomized clinical trials.

11. Assess the effect of the pneumococcal conjugate vaccine on 11. Assess the effect of the pneumococcal conjugate vaccine on the epidemiology of acute bacterial sinusitis. the epidemiology of acute bacterial sinusitis.

12. Develop new bacterial and viral vaccines to reduce the 12. Develop new bacterial and viral vaccines to reduce the incidence of acute bacterial sinusitis.incidence of acute bacterial sinusitis.

CONCLUSIONCONCLUSION By 9 years of evaluation, we conclude that most of children’s sinus By 9 years of evaluation, we conclude that most of children’s sinus

infection could managing with high dosage of antibiotic and infection could managing with high dosage of antibiotic and prevent the surgical intervention. And that combined aggressive prevent the surgical intervention. And that combined aggressive surgical and antibiotic treatment is a preferred method in surgical and antibiotic treatment is a preferred method in complicated sinusitis in children.complicated sinusitis in children.

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pyogenic complications of rhinosinusitis.pyogenic complications of rhinosinusitis. 3. MCcLay et al .Complications of acute sinusitis in children. 3. MCcLay et al .Complications of acute sinusitis in children. 4. Jerzy Kuczkowski, Waldemar Narozny,4. Jerzy Kuczkowski, Waldemar Narozny, Boguslaw MikaszewskiBoguslaw Mikaszewski,,,Suppurative ,Suppurative

Complications of Frontal Sinusitis in Children Complications of Frontal Sinusitis in Children 5. Management of Sinusitis .Subcommittee on Management of Sinusitis and 5. Management of Sinusitis .Subcommittee on Management of Sinusitis and

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10. Ueda D, Yoto Y The ten-day mark as a practical diagnostic approach for acute 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 paranasal sinusitis in children. Pediatr Infect Dis J 1996; 15:576-579

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14. Gwaltney JM Jr, Scheld WM, Sande MA, Sydnor A The microbial etiology and 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-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 year experience at the University of Virginia and review of other selected studies. J Allergy Clin Immunol 1992; 90:457-462 Allergy Clin Immunol 1992; 90:457-462

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