Orbital and intracranial complications of acute bacterial rhinosinusitis are relatively common, but a delay in diagnosis and appropriate treatment may result in serious complications or life-threatening events. This article describes the etiology, microbiology, symptoms, examinations and treatments of these complications. Early diagnosis and appropriate medical and surgical therapy are crucial to ensure recovery.

Purpose

A 7-valent pneumococcal conjugate vaccine (PCV7) was placed on the market in 2010. We conducted a survey comparing changes in the clinical status of pediatric acute otitis media diagnosed in our hospital by dividing the period into a pre-PCV era and post-PCV era.

Subjects

Survey 1: The subjects were the 0–6-year-old pediatric otitis media patients examined in our hospital between 2008 and 2016.

Period: The 9-year period was divided into 3 eras: a pre-vaccine era (pre-PCV era: 2008–2009), a Prevenar 7 era (PCV7 era: 2010–2013), and a Prevenar 13 era (PCV13 era: 2014–2016).

Survey 2: In the same period we investigated the course of changes in bacterial strains isolated from the nasopharynx and middle ear effusions of pediatric acute otitis media patients (0–15 years of age) and their pneumococcal capsular serotypes.

Results

Survey 1: In the age range of the subjects of this survey we observed effusions in the middle ears of 1746 children (32.2%). The acute otitis media prevalence rate was significantly lower in the PCV7 era than in the pre-PCV era (P<0.01), and in the PCV13 era than in the pre-PCV era (P<0.05). The bilateral acute otitis media prevalence rate was significantly lower in the PCV7 era than in the pre-PCV era (P<0.01), and in the PCV13 era than in the pre-PCV era (P<0.01).

Survey 2: A total of 4250 strains of bacteria were isolated by bacterial culture tests. The proportion of pneumococci was 37.7% in 2008, but subsequently declined, and was 21.7% in 2016. There was a statistically significant trend for detection of pneumococci to decrease over the 3 eras. The proportion of drug-resistant pneumococci decreased from 2012 onward. Serotype replacement occurred among the capsular serotypes, but type 3, which was a vaccine type, was detected. The frequency of β-lactamase-positive Haemophilus influenzae isolation increased.

Conclusions

Significant decreases in the prevalence of acute otitis media and bilateral otitis media were seen between the pre-PCV era and post-PCV era. A decrease in the number of drug-resistant pneumococci was also seen.

Infection and inflammation enhance hyper-sensitivity of the airway mucosa, and promote the onset and severity of allergic diseases. In this study, commercial non-inflammatory cultured nasal epithelial cells were set up to elucidate the inflammatory reaction based on analyzing cytokine production by stimulation of S. aureus enterotoxin and/or house dust mite antigen directly on the nasal epithelium without effects from the network of infiltrating leukocytes or subepithelial matrix.

A culture experiment using human nasal epithelial cells was performed. Single or co-stimulation was carried out with S. aureus enterotoxin B (0, 5, 10 μg/ml) and mite antigen (Der f 1) (0, 5, 10 μg/ml), and cytokines in the culture supernatant were quantified by ELISA. Although IL-4, 13, 17, 25, 33, and TNF-α were not detected, IL-5 and 8 were detected after the stimulation with Der f 1 and enterotoxin B. However, dose dependency between the stimulation and cytokine products was not observed. IL-6 production tended to increase in a dose-dependent manner 24 hours after stimulation with Der f1 and enterotoxin B. Synergistic effects from the two types of stimulation were not observed. Although VEGF production tended to increase in a dose-dependent manner after stimulation with Der f1, it conversely decreased by stimulation with a higher dose of enterotoxin B within 24 hours. After stimulation with 5 or 10 μg/ml of enterotoxin B, VEGF production tended to increase in a dose-dependent manner.

It has been reported that some cytokines affect other cytokine production in epithelial cells. Taking this into account, IL-6 and VEGF production may indirectly affect other cytokines, as well as each other, via cytokine receptors on epithelial cells.

Skull base osteomyelitis typically results from spillover of malignant otitis externa in elderly diabetes patients following temporal bone destruction. Atypical cases do not present with such features and have been reported in recent years; most cases occur in immunocompromised patients. Here, we present a case of skull base osteomyelitis in an otherwise healthy elderly patient.

A 79-year-old man without underlying disease presented to his local clinic complaining of persistent left temporal headache and left-sided hearing loss. He was treated for about 6 months conservatively with no improvement. Imaging revealed findings suggestive of nasopharyngeal malignancy. He was then referred to our hospital for further management.

He underwent epipharyngeal biopsy twice under general anesthesia by transnasal endoscopic surgery. Histopathological examination showed only nonspecific inflammation. Pseudomonas aeruginosa was identified from a purulent discharge from the skull base during the second operation.

Integrating the clinical picture, imaging, histopathology, and bacteriology findings, we made a diagnosis of atypical skull base osteomyelitis.

He was subsequently treated with intravenous doripenem for 1 week then oral garenoxacin for 6 months. His symptoms promptly improved on treatment, with no recurrence of clinical features during an 8-month follow-up period. Also, post-recovery CT images showed new bone formation at the skull base.

It is commonly presumed that advanced age and immunosuppression are both necessary concomitant risk factors for skull base osteomyelitis, in typical and atypical cases. This patient was of advanced age, but was otherwise healthy and yet he developed atypical skull base osteomyelitis as the diagnosis could not be made during the initial examination. Accurate diagnosis requires biopsy obtained intraoperatively as well as imaging. Early treatment improves prognosis, and thus this case highlights the fact that skull base osteomyelitis could occur in healthy individuals. In this case, surgery to obtain biopsy and culture specimens was necessary for definitive diagnosis.

Acute rhinosinusitis is major disease for otorhinolaryngologists. The medical treatment is often the use of antibiotics and most of patients are improvement. However, only slightly patients are not only improvement but also severe. Rhinogenic intracranial infection has been still one of the most serious complication, although advances in antibiotic therapy have reduced its incidence.

We experienced that a healthy 15-year-old boy with headache was diagnosed with right sphenoiditis by CT and with clival bone marrow edema by MRI. The antibiotic therapy made his condition better and CRP and white blood cells improving. But otherwise, rhinosinusitis was getting worse by CT. We performed endoscopic sinus surgery and continued antibiotic therapy for three weeks, so that disease progression resolved and he completely cured. MRI after four postoperative months showed the normal clival bone marrow without sinusitis.

“Bone marrow edema” is a term of a characteristic signal pattern on MRI. It describes an altered signal pattern (decreased T1 signal and increased T2 signal) of a specific part of bone marrow. Clival bone marrow edema with rhinosinusitis (especially sphenoiditis) is may be important sign like before clival osteomyelitis and intracranial infection. In general, MRI sagittal view provides a method for evaluating clivus. When a patient might have rhinogenic intracranial infection, MRI sagittal view of clivus may be useful for diagnosis and treatment.

Soft palate perforation in an adult is a challenge for differential diagnosis. The differential diagnosis includes a wide variety of diseases, such as granulomatosis with polyangiitis (GPA), malignancy such as NK/T cell malignant lymphoma, tuberculosis, and syphilis. A rare manifestation of actinomycosis, a perforation in the left soft palate, is presented. Typically, actinomycosis presents as a slowly progressive, painless, indurated mass, evolving into multiple abscesses with draining sinus tracts on the skin surface or oral mucosa. Therefore, it often misdiagnosed as malignancy or tuberculosis due to their similar appearances. The case of a 75-year-old man with long-term tobacco abuse and recurrent tonsillitis who presented with soft palate perforation is described. Imaging findings were noncontributory to the diagnosis. Cultures from the oral smear were unremarkable and did not reveal actinomycosis, probably due to its anaerobic nature. Histopathological examination of actinomycotic granules was useful in the diagnosis. First, surgery was performed, similar to tonsillectomy, to excise a recalcitrant fibrotic lesion. The patient received intravenous benzylpenicillin potassium (PCG, 400 MU/day) for 6 weeks, followed by oral therapy with ampicillin sodium (ABPC, 1000 mg/day) for 4 months. During the 4-month follow-up period, no recurrence was observed. The traditional prolonged, high-dose penicillin treatment can likely be shortened and the dose reduced if sufficient surgical resection of the infected tissues is performed in the absence of bone involvement.

The present case highlights the importance of actinomycosis in the differential diagnosis of soft palate perforation.

Actinomycosis is a chronic suppurative disease primarily caused by Actinomyces israelii. Extra time may be necessary for diagnosis before the initiation of treatment, as some cases exhibit a tumor-like clinical presentation and others require differential diagnosis of unusual bacterial infections. Although biopsy is the most useful method to confirm the diagnosis, it is too invasive, particularly for young patients. Therefore, it is important to perform diagnostic imaging such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), and we should know the specific findings of actinomycosis on each type of image.

We saw a case of actinomycosis with a hard, board-like mass in the temporal lesion and mastoiditis-like image findings. Actinomycosis is rare, so we should determine the specific infectious route and the image findings of actinomycosis on US and MRI.

Guidelines for the treatment of sinusitis in our country, recommended washing catheters. Paranasal sinus washing therapy with the YAMIK catheter began in 1991 in Japan. This therapy was an epoch-making method as a paranasal sinus washing therapy to assume Proetz substituted principle. Unfortunately, in Japan, the availability of the YAMIK catheter became difficult in 2005.

However, the ENT-DIB sinusitis therapeutic catheter released in Japan In 2014. This new method is expected to show a similar treatment effect to YAMIK catheter that is considered to be useful as a choice of conservative medical treatment for rhinosinusitis. Briefly, we would like to present the washing method with the ENT-DIB sinusitis therapeutic catheter. First, insert the catheter into the nasal cavity after intranasal gauze anesthesia. Secondly, fix by inflating the balloons around both the nostril and choana. This procedure may change both nasal cavity and sinuses into a closed cavity. Finally, wash rhinosinuses with a supine position down to affected side by adding pressurization and depressurization from another channel to rhinosinuses.

In our study, there were a high improvements in acute sinusitis and paranasal mycosis cases. Chronic sinusitis and eosinophilic chronic rhinosinusitis also showed moderate improvements in several cases. This therapy, as an intermediate treatment between surgical therapy and conservative therapy, is considered to be capable of becoming a proactive choice for selected cases.

This method has the complexity of the maneuver. However, as an otorhinolaryngology specialist, it is considered as one of the procedures to be learned.