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Comment Regarding Article “An Adolescent Found Unconscious”

Dear Dr Steele, This letter is written with regard to the clinical case report, “An Adolescent Found Unconscious.” Clin Pediatr. 2012;52(3):271-274. The authors report a clinical case in which a patient was discovered to have an epidural abscess and orbital cellulitis following a 3to 4-month period of headaches and rhinorrhea. The case is presented as a complication of chronic sinusitis and the discussion follows in a similar fashion. While a contemporary understanding of inciting bacteria and the pathophysiology of chronic sinusitis is detailed by the authors, the complications of chronic sinusitis discussed thereafter merit mention. The complications of sinusitis, including orbital and intracranial processes, occur almost exclusively as a result of acute sinusitis—either in isolation or superimposed on chronic sinusitis. While we agree with the authors that vigilance is justified in the identification and treatment of chronic sinusitis, we also feel that it is beyond a preference in nomenclature to suggest that the complications discussed are those of chronic disease. Instead, it is the acute infection that may occur with or without preexisting chronic disease that ultimately results in the aforementioned sequelae. Indeed, the patient discussed appears to have initially presented to the emergency department for an acute exacerbation of chronic sinusitis. Although directed cultures were not obtained from the sinus, the epidural abscess or the orbital abscesses after his second presentation, it is presumed that Fusobacterium was one of the (likely multiple) inciting organisms based on blood culture results. In the otolaryngology community, the management of chronic sinusitis is a familiar and important endeavor. However, our patients and physicians are counseled to have a high suspicion for acute infection superimposed on chronic disease when changes from baseline are appreciated. Fortunately, orbital and intracranial complications of sinusitis are almost always preceded by these changes, as appears to have been true for the patient presented here. 529019 CPJXXX10.1177/0009922814529019Clinical PediatricsSidell and Myer research-article2014