Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era.

BACKGROUND: COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes. MATERIAL AND METHODS: An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up. RESULTS: Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%. CONCLUSIONS: These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

[The Relevance of Abducent Nerve Palsy in ENT]. / Abduzensparese mit Ursache im HNO-Fachgebiet.

Patients suffering from abducent nerve palsy are usually primary seen by a conservative medical Specialist. In most cases the ENT specialist is secondary involved for treatment. In the majority of cases abducent nerve palsy is a temporary symptom associated with neurologic or vascular diseases. Rarely inflammation, neoplasm or fracture of the skull base cause this symptom and lead to an intervention done by the ENT surgeon. This case series describes retrospectively the abducent palsy seen through the eyes of an ENT surgeon. From 2008 to 2011 15 patients suffering from abducent nerve palsy. One patient suffering from a temporal bone fracture has been treated conservatively while 14 patients needed surgery. 6 patients had a complicated inflammation of the skull base. In 7 patients skull base neoplasms were found in endoscopic surgery. In one case the underlying pathology remained unclear. 2 third of the patients that suffered from complications of inflammatory diseases completely recovered after a combined operative and conservative therapy. The patients who suffered from neoplasms of the skull base partially recovered in only one third, none, achieved full recovery. The patient with the temporal bone fracture achieved a partial recovery after 3 months. If the leading symptom of abducent palsy is caused by a severe extracranial inflammation, neoplasm or trauma an experienced skull base surgeon is mandatory. The recovery rate of abducent palsy in our case series was 60 %. The prognosis of abducent palsy in skull base inflammation is much better compared to patients with skull base neoplasm.

Fusobacterium necrophorum otitis and mastoiditis in infants and young toddlers.

There is an increased recovery of Fusobacterium necrophorum from cases of otitis media and mastoiditis in the pediatric population. These infections may be highly severe, causing local osteomyelitis, bacteremia, and Lemierre's syndrome. The severity and difficulties in providing optimal treatment for these infections may be especially difficult in this age group due to immunological immaturity and delayed presentation. In this review of literature, we present and analyze the clinical presentation, management, and outcome of otic infections caused by F. necrophorum in infants and young toddlers less than 2 years old. Search in Pubmed was conducted for reported cases in the English literature for the time period of the last 50 years. Twelve well-described cases were retrieved with F. necrophorum otitis and mastoiditis and complications reported in all cases. Treatment included both intravenously with antimicrobial agents (beta lactams plus metronidazole) and mastoidectomy. Lemierre's syndrome and Lemierre's syndrome variants developed in 60 % of the patients. Dissemination of the infection as distal osteomyelitis and septic shock were also reported. The outcome was favorable in all the cases. Otitis and mastoiditis infections in children less then 2 years old are invasive infections, and severe complications can occur.

Chronic Invasive Aspergillus Sinusitis and Otitis with Meningeal Extension Successfully Treated with Voriconazole.

Invasive aspergillosis (IA) is a severe disseminated fungal disease that occurs mostly in immunocompromised patients. However, central nervous system IA, combining meningitis and skull base involvement, does not occur only in groups with classic risk factors for IA; patients with chronic renal failure and diabetes mellitus are also at risk for more chronic forms. In both of our proven IA cases, voriconazole monotherapy was effective without surgery, and cerebrospinal fluid and serum 1,3-ß-d-glucan test results were initially positive, in contrast to galactomannan antigen results.

[The assessment of the clinical effectiveness of fenspiride for the treatment of acute obstruction of the Eustachian tube].

The objective of the present study was to estimate the clinical effectiveness of fenspiride used to correct the obstruction of the Eustachian tube in 80 patients presenting with acute tubootitis and exudative otitis media. The algorithm of the examination included the evaluation of the severity of subjective clinical symptoms based on the relevant analog-visual scale, results of tonal audiometry, and tympanometry. The control group was comprised of 34 patients treated with antibacterial preparations, topical decongestants, and transtubal administration of glucocorticoids. The study group included 46 patients who received fenspiride at a dose of 80 mg thrice daily in addition to the above pharmacotherapy. The severity of clinical symptoms in the patients treated with fenspiride decreased faster than in the control subjects. The frequency analysis of dynamics of the air-bone gaps on the audiometric curves revealed the significantly more intensive recovery of the hearing function in the patients treated by basal pharmacotherapy in the combination with fenspiride. Type A tympanograms predominated on day 7 after the onset of the conservative treatment with the use of fenspiride whereas type C tympanograms continued to predominate in the patients of the control group. It is concluded that the introduction of fenspiride into combined therapy of acute tubootitis and exudative otitis media promotes the normalization of the ventilation and drainage functions and relieves the severity of subjective clinical symptoms.

Neighbourhood air quality and snoring in school-aged children.

The prevalence of habitual snoring has been extensively explored in paediatric populations. Although exposure to cigarette smoke increases the risk of habitual snoring in a dose-dependent fashion, the potential contribution of air quality to habitual snoring remains unclear. 6000 questionnaires were distributed to 6- to 12-year-old children attending public schools in five distinct neighbourhoods within the city of Tehran, Iran, that were preselected based on air quality measures. Habitual snoring was defined as loud snoring ≥3 nights per week. Information regarding clinical and family-related habitual snoring risk factors was also obtained. Descriptive statistics followed by adjusted risk assessments were conducted. Among the 4322 (72%) completed datasets, the prevalence of habitual snoring was 11.6%. Partition of habitual snoring rates according to neighbourhood air quality characteristics revealed significantly higher habitual snoring frequencies among children residing in neighbourhoods with greatest pollution (24.5% and 12.1% in South and Central neighbourhoods versus 7.0% and 7.7% in North and East neighbourhoods, respectively). The regional variance in habitual snoring was primarily accounted for by an integrated measure of air quality, even after controlling for other risk factors. Environmental air quality emerges as a significant and potentially modifiable contributor to the risk for developing habitual snoring during childhood.

From the Netherlands to Japan: communicating psychiatric practice in the 1830s.

This article explores an example of the transmission of Dutch psychiatric knowledge to Japan in the Edo period (1600-1868), through the translation of a case study first published by Schroeder van der Kolk in 1826. The translation appeared in an innovative new journal of Western medicine edited by the Japanese rangaku (Dutch-learning) scholar, Mitsukuri Genpo. The case study describes the symptoms and treatment of a woman who experienced delusions following an ear infection, in terms largely familiar to the Japanese doctors of the time. This translation provides opportunities to consider the globalization and localization of psychiatric knowledge, the medicalization of mental health care in Japan, and the growing interest in Western psychiatry before its official introduction to Japan after 1868.

Allergic rhinitis as a possible risk factor for malocclusion: a case-control study in children.

BACKGROUND: Prolonged oral respiration is known to cause postural alterations, which can lead to dental malocclusions. Allergic rhinitis, a common cause of upper airway obstruction in children, must therefore be seen as a possible risk factor in the development of malocclusions. AIM: Aim of this study was to investigate the association between allergic rhinitis and malocclusions in primary and early-mixed dentition. DESIGN: A case-control study was carried out involving 275 Italian children aged 5-9. The case group and the control group were composed of 125 individuals affected by malocclusions and by 150 healthy patients, respectively. Through a questionnaire, we assessed the presence of professionally diagnosed allergic rhinitis. Data were analysed to identify associations between these variables and the presence of malocclusions. RESULTS: Children with a history of allergic rhinitis had a threefold increased risk to develop one or more dento-skeletal alterations [OR = 3.16; 95% CI (1.79-5.58), P < 0.001]. Statistically significant associations were found between allergic rhinitis and the development of posterior crossbite and increased overjet. No significant association was found for anterior openbite. CONCLUSIONS: Allergic rhinitis is a significant risk factor for the development of malocclusions in general and is associated with the development of posterior crossbite and increased overjet.

[Vertigo in children and adolescents. Part 1: Epidemiology and diagnosis of peripheral vestibular disorders]. / Schwindel bei Kindern und Jugendlichen. Teil 1: Epidemiologie und Diagnostik peripher-vestibulärer Schwindelsyndrome.

Migraine equivalents are the most common cause of vertigo in children and adolescents. Vertigo and balance disorders occur frequently in children during the course of otitis media, middle ear effusion and viral infections. If otitis media is associated with reduced hearing and vertigo, labyrinthitis must be considered. Craniocerebral injury is another important cause of vertigo in children. In contrast, spontaneous benign paroxysmal positional vertigo is rare among children. The isolated cases of endolymphatic hydrops that occur in children are usually secondary. Perilymph fistula can have congenital, infectious or trauma-related causes. The following characteristics are useful for differentiating between different vertiginous syndromes: type and duration of vertigo, triggering/aggravating/alleviating factors and accompanying symptoms. A neuro-ophthalmologic examination is essential to rule out central vestibular disorders.

The oxidative and antioxidative status of simple febrile seizure patients.

OBJECTIVE: To evaluate the oxidative status following a seizure in children experiencing a simple febrile seizure. METHODS: The cross-sectional study was conducted at Harran University, Turkey, between January and September 2011. It comprised 32 paediatric patients who, within the preceding 8 hours, had experienced a seizure due to upper respiratory tract infection and had been diagnosed with simple febrile seizure, and 30 healthy children as the control group. Blood was taken from the patients 8 hours after the seizure. Total oxidant level and Total anti-oxidant level were measured according to the Erel technique and the oxidative stress index was calculated. Data was analysed using SPSS 11.5. RESULTS: The mean values of the total oxidant level and the oxidative stress index of the cases were found to be significantly high compared to the controls and the total anti-oxidant level was found to be significantly low (p < 0.01, p < 0.01, p < 0.03 respectively). CONCLUSION: The increased total oxidant level and decreased total anti-oxidant level resulting in increased oxidative stress associated with febrile seizure patients may increase the risk of experiencing febrile seizures.

[Assessment of hypoacusis]. / Mise au point d'une hypoacousie.

Hypoacusis is a common complaint among young and older patients. This common symptom addressed in general medicine is often but not always due to a benign disease; sometimes, life-threatening emergencies occur and must be recognised. Moreover, hypoacusis is known to lead to social isolation and nervous breakdown among old people, and to slow down speech learning among children. Unfortunately, the general practitioner is not tooled to assess accurately the hard-of-hearing patient, but nevertheless, he can get easily a first differential diagnosis. First of all, comprehensive history and clinical exam can be quickly carried out. In particular cases, specialised investigations and ENT consultations are indicated. That is why this article is built to answer basic questions to frequent clinical problems involving a reduced audition, and to suggest first-line recommendations.

Oridonin employs interleukin 1 receptor type 2 to treat noise-induced hearing loss by blocking inner ear inflammation.

NOD-like receptor protein 3 (NLRP3) inflammasomes trigger the inflammatory cascades and participate in various inflammatory diseases, including noise-induced hearing loss (NIHL) caused by oxidative stress. Recently, the anti-inflammatory traditional medicine oridonin (Ori) has been reported to provide hearing protection in mice after noise exposure by blocking the NLRP3-never in mitosis gene A-related kinase 7 (NEK7)-inflammasome complex assembly. Using RNA sequencing analysis, we further elucidated that interleukin 1 receptor type 2 (IL1R2) may be another crucial factor regulated by Ori to protect NIHL. We observed that IL1R2 expression was localized in spiral ganglion neurons, inner and outer hair cells, in Ori-treated mouse cochleae. Additionally, we confirmed that ectopic overexpression of IL1R2 in the inner ears of healthy mice using an adeno-associated virus delivery system significantly reduced noise-induced ribbon synapse lesions and hearing loss by blocking the "cytokine storm" in the inner ear. This study provides a novel theoretical foundation for guiding the clinical treatment of NIHL.

Persistent foramen of Huschke: Clinical manifestations and complications, systematic review.

BACKGROUND: Foramen of Huschke is a bone defect with wide clinical symptoms which ca can be responsible for severe complications. Clinical history and imaging are unspecific, it is therefore essential to recognize and treat the pathology related to the persistence of this foramen, to avoid destruction of the TMJ, chronic pain or OBJECTIVE: The aim of this review was to summarise the clinical manifestations and complications of persistent foramen of Huschke in adult patients, through a review of the cases reported in the literature. METHODS & MATERIALS: A literature search of the PubMed, Cochrane Library, ScienceDirect and Embase databases was conducted for all articles published up to November 2022 to identify studies and case reports concerning clinical manifestations and complications of persistent foramen of Huschke in adult patients, with the key words "foramen of Huschke" or "foramen tympanicum". RESULTS: 74 papers where firstly identify, and 21 were selected. This correspond to 46 patients with the additional case from our department. Symptoms mostly reported consisted of otitis (63%, 29/46), otorrhea (28.26%, 13/46), and masticatory tinnitus (19.57%, 9/46). Diagnosis was priority made by CT-scan (95.65%, 44/46). Surgery was the most performed treatment (28.26%, 13/46). In our case, the use of FLUOBEAM® NIR camera was help-full for TMJ surgery. CONCLUSION: Persistent foramen of Huschke should be suspected in the presence of otitis, otorrhea and masticatory tinnitus. Knowledge of this anatomical variation could help to treat certain pathology like TMJ disorders or TMJ septic arthritis.

Infections in postmenopausal women with osteoporosis treated with denosumab or placebo: coincidence or causal association?

UNLABELLED: Serious adverse events of infections that occurred in subjects receiving denosumab or placebo in the Fracture Reduction Evaluation of Denosumab in Osteoporosis every 6 Months (FREEDOM) study were examined in detail. Serious adverse events of infections in denosumab subjects had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab. INTRODUCTION: Denosumab reduces the risk for new vertebral, hip, and nonvertebral fractures compared with placebo. In the pivotal phase 3 fracture trial (FREEDOM), the overall safety profile and incidence of adverse events including adverse events of infections were similar between groups. Serious adverse events of erysipelas and cellulitis were more frequent in denosumab-treated subjects. In this report, we further evaluate the details of infectious events in FREEDOM to better understand if RANKL inhibition with denosumab influences infection risk. METHODS: FREEDOM was an international multicenter, randomized, double-blind, placebo-controlled study in postmenopausal women with osteoporosis randomly assigned to receive placebo (n = 3,906) or denosumab 60 mg every 6 months (n = 3,902). The incidence of adverse events and serious adverse events categorized within the Medical Dictionary for Regulatory Activities system organ class, "Infections and Infestations," was compared between the placebo and denosumab groups by body systems and preferred terms. The temporal relationship between occurrence of serious adverse events of infections of interest and administration of denosumab was explored. RESULTS: Serious adverse events of infections involving the gastrointestinal system, renal and urinary system, ear, and endocarditis were numerically higher in the denosumab group compared with placebo, but the number of events was small. No relationship was observed between serious adverse events of infections and timing of administration or duration of exposure to denosumab. CONCLUSIONS: Serious adverse events of infections that occurred with denosumab treatment had heterogeneous etiology, with no clear clinical pattern to suggest a relationship to time or duration of exposure to denosumab.

Doxycycline treatment of otosyphilis with hearing loss.

OBJECTIVES: The recommended treatment of otosyphilis is intravenous penicillin therapy. The response rate varied between 23% and 31%. This treatment needs hospitalisation and is costly, inconvenient and time consuming. Oral doxycycline was tested for its efficacy in otosyphilis. METHOD: The authors reviewed 19 patients diagnosed as having otosyphilis with hearing loss at the outpatient unit between 2004 and 2008 by oral doxycycline 400 mg/day for 21 days. RESULTS: Of those enrolled patients, 12 patients were male and the mean age is 69.4 years. The hearing was improved in nine patients (47.3%) and the audiogram of seven patients (36.8%) showed improvement. There was no serious side effect of doxycycline. CONCLUSION: The data suggest that doxycycline may be an effective alternate regimen for otosyphilis.

Port-wine stains are more than skin-deep! Expanding the spectrum of extracutaneous manifestations of nevi flammei of the head and neck.

UNLABELLED: It is well known that port-wine stains of the upper part of the face may herald abnormalities of the brain or eye in the form of Sturge-Weber syndrome. This study focuses on other extracutaneous anomalies in patients with nevi flammei of the head and neck, giving rise to functional complications. PATIENTS AND METHODS: A retrospective study was performed on patients with port-wine stains involving the head and neck area. Records were reviewed for demographic parameters, extent of the lesion, clinical complications, diagnostic measures, previous treatments, ultimate therapeutic approach, and outcome. RESULTS: Nine patients, mean age 50.4 years, with port-wine stains and clinical symptoms due to extracutaneous involvement, were admitted and treated from 2006 to 2009. Major clinical features included macrocheilia in three cases, gingival bleeding in two, dysphonia with globus sensation, painful parotideal swelling with recurrent otitis, painful lingual swelling, recurrent epistaxis, and nasal obstruction in one case each. Cases with lower lip hypertrophy were treated by conventional surgical approaches. Recurrent epistaxis and nasal obstruction due to affected inferior turbinate were treated by Nd:YAG laser therapy, and globus sensation and dysphonia by speech therapy. Patients with gingival affection and recurrent otitis were treated by local ear care. CONCLUSION: Port-wine stains in the head and neck may develop extracutaneous manifestations causing severe problems. A multimodal and interdisciplinary approach is mandatory for an appropriate treatment.

Community-acquired bacterial meningitis in patients of 80 years and older.

BACKGROUND: Advanced age is a risk factor for unfavorable outcome in community-acquired bacterial meningitis, but clinical characteristics and outcome in meningitis patients of 80 years or older have not been defined. METHODS: We compared clinical characteristics and outcome of community-acquired bacterial meningitis patients aged 80 years or older and adults under 80 years old within a prospective nationwide cohort study. RESULTS: Out of 2140 episodes identified between March 2006 and July 2018, 149 occurred in patients aged 80 years or older (7%). Common predisposing factors other than age were diabetes mellitus (25 of 148 [17%]), otitis or sinusitis (30 of 136 [22%]), and pneumonia (23 of 141 [16%]). The triad of fever, neck stiffness and altered consciousness was present in 60 of 139 (43%). The most common causative pathogen was Streptococcus pneumoniae (99 of 149 [66%]). Atypical causative pathogens, such as Listeria monocytogenes, Staphylococcus aureus, and Escherichia coli, occurred more often compared to younger patients (49 of 149 [33%] vs 362 of 1991 [18%]; p < 0.001). Patients of 80 years and older had high case fatality rate (75 of 149 [50%]), but 45 of 149 (30%) had a favorable outcome. Characteristics associated with an unfavorable outcome were absence of otitis or sinusitis, presence of aphasia, mono- or hemiparesis, a lower score on the Glasgow Coma Scale, a higher heart rate, a higher blood C-reactive protein concentration and CSF leukocytes <100 per mm3 . CONCLUSIONS: Bacterial meningitis in patients of 80 years of older is associated with high rates of unfavorable outcome and death. Atypical causative pathogens such as L. monocytogenes, S. aureus, and E. coli occur commonly and should be considered when starting empirical antimicrobial therapy in this age group.

Hearing impairment in children living with HIV in Haiti.

OBJECTIVE: To identify the prevalence of hearing impairment and associated risk factors in children living with human immunodeficiency virus (HIV) in Haiti. METHODS: A validated smartphone-based platform with pure-tone audiometry was used to screen 341 HIV-infected children for hearing impairment in Port-au-Prince, Haiti from March 2019 to September 2020. If screening was failed, a more comprehensive pure-tone audiometric evaluation was administered. Demographic, otologic, and HIV-related data were obtained through caregiver surveys and medical charts. Statistical analysis included univariate and multivariate logistic regression. RESULTS: Sixty (18%) of 341 HIV-infected children (ages 7-18 years) had hearing impairment. Of those failing their hearing assessment, 17 (28%) had moderate and 5 (8%) had severe or profound hearing loss. Hearing impairment was associated with frequent ear infections (OR 3.37; 95% CI 1.76-6.46; p < 0.001) and family history of hearing loss (OR 5.12; 95% CI 2.14-12.23; p = 0.001) but not viral load (OR 1.00; 95% CI 0.73-1.02; p = 0.28) or antiretroviral therapy duration (OR 0.96; 95% CI 0.79-1.17; p = 0.66). Only 35% of caregivers correctly perceived their child's hearing loss. CONCLUSIONS: Hearing impairment occurs at a higher prevalence in HIV-infected children in Haiti than what is expected for those living without HIV. Frequent ear infections were significantly associated with hearing loss while antiretroviral therapy duration was not. Despite their potential ototoxicity, antiretroviral therapies should be continued and may decrease incidence of otitis media. Low caregiver perception of hearing loss emphasizes the need for routine hearing screening for HIV-infected children.

Multidisciplinary management and outcome in subdural empyema--a case report.

Cranial subdural empyema (SDE), a localized septic intracranial collection, occurs mostly as a complication of sinusitis, otitis or mastoiditis. Although relatively rare, SDE requires an increased attention for early recognition, cerebral imagery being mandatory in any suspected case. Any delay in treatment can lead to coma with a fatal outcome. The authors report the case of a young boy, who developed a severe, important cerebral edema, thin subdural collection with minimal displacement of the median line. Repeated cerebral MRI showed an enlarged subdural collection with higher median line shift and imposed rapid surgical intervention. The collection proved to be empyema. Other findings on MRI are pansinusitis, mild mastoiditis and transverse sinus thromboflebitis. The recovery was accompanied by the need for long course of antibiotherapy, secondary epilepsy treatment and kinetotherapy for hemiparesis. The patient also developed intracerebral cysts expanding the brain through the postoperative cranial defect which later needed surgical intervention, for both neurological and esthetic improvement. The management of the case implied strong interdisciplinary collaboration between infectionist, neurologist, neurosurgeon, microbiologist and imagist.