Complicated Sinusitis in Children: Should We Increase Awareness After the Pandemic?

To the Editors: We read with great interest the manuscript written by Smiljkovic et al,1 about intracranial suppurative complications of sinusitis in children. Acute bacterial sinusitis is common in children, and despite being mostly a disorder with a favorable course, a percentage ranging from 3.7% to 8.8% may present serious complications.2 Furthermore, as outlined by Smiljkovic et al,1 there is a risk of persistent neurological sequelae, especially in children with extensive intracranial involvement. We retrospectively analyzed data of 38 children admitted to our Hospital from January 2013 to December 2023 due to complicated sinusitis. About 65.8% were males (25/38) with a median age of 10 (interquartile ranges: 7–13) years. Most of them had been hospitalized for isolated orbital complications (29/38, 76.3%), and of these 14/29 had postseptal cellulitis. Intracranial complications were identified in 9/38 children (23.7%), including 3/9 epidural empyema, 3/9 subdural empyema, 1/9 meningitis and 2/9 intracerebral abscesses; one of the children diagnosed with intracerebral abscesses had also cavernous sinus thrombosis and preseptal cellulitis. While Smiljkovic reported a rate of neurological sequelae of 24% with 1 out of 104 cases resulting in death (1%), in our cohort, which also included patients with orbital complications, the long-term neurological and visual outcome were favorable, expect for the one with the cavernous sinus thrombosis who deceased.1 None of these children had preexisting medical conditions or immunological deficits. The surgical approach was significantly more common in the group of patients with intracranial complications (8/9, 88.9% vs. 9/29, 31%; P = 0.002), with functional endoscopic sinus surgery being performed in 77% of cases, compared to 17.2% of patients with orbital complications (P = 0.0006). In children undergoing surgery, culture test or polymerase chain reaction on purulent drainage material was positive for Streptococcus spp. in 7/17 cases (41%), with no differences observed between groups. Moreover, a positive blood culture was more frequently obtained in children with intracranial complications (P = 0.04). In patients with intracranial complications, the duration of intravenous antibiotic therapy was significantly longer [28 (20.5–42) days vs. 11 (9–16.5) days, P < 0.0001], and intravenous steroids were also more frequently prescribed (P = 0.03). Beside provide insights into the management of complicated sinusitis, our purpose is also to highlight that since 2021, concomitantly with the gradual easing of restrictions against SARS-CoV-2, our hospital registered a remarkable increase in complicated sinusitis (Fig. 1). The prevalence of complications rose to 0.55% in 2021, then slightly decreased to 0.39% and 0.38% in 2022 and 2023, respectively, maintaining a higher trend compared to the years before SARS-CoV-2 pandemic. This trend aligns with the reported rise in severe invasive infections during the post-lockdown period, attributed primarily to the concept of "immunity debt."3,4 During the pandemic, the interventions adopted to limit SARS-CoV-2 spread, led to a concomitant decrease in several infections. Reduced exposure to bacterial and viral pathogens, along with the negative impact on vaccination coverage, could have adversely affected immune system training and increased the percentage of children susceptible to infections.4 Pediatricians need to be alerted about the potential increase of severe infections in the coming years, and the epidemiologic surveillance network should be further implemented.FIGURE 1.: Prevalence of complicated sinusitis over the past decade.