# Clinical features, treatment and outcomes of acute ethmoiditis: A case series of 20 hospitalized children

Sarah Salameh, Noémie Lachaume, Alexandra Bisca, Manon Beauvais, Adrien Chaud, Marie Cotillon, Laure Cohen, Romain Basmaci

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## To cite this version:

Sarah Salameh, Noémie Lachaume, Alexandra Bisca, Manon Beauvais, Adrien Chaud, et al. Clinical features, treatment and outcomes of acute ethmoiditis: A case series of 20 hospitalized children. Archives de Pédiatrie, 2025, 32 (5), pp.351 - 354. 10.1016/j.arcped.2025.04.002. hal-05503577

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Submitted on 10 Feb 2026

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Short communication

# Clinical features, treatment and outcomes of acute ethmoiditis: A case series of 20 hospitalized children

Sarah Salameh<sup>a, ID</sup>, Noémie Lachaume<sup>a</sup>, Alexandra Bisca<sup>b</sup>, Manon Beauvais<sup>a</sup>, Adrien Chaud<sup>c</sup>, Marie Cotillon<sup>a</sup>, Laure Cohen<sup>a, ID</sup>, Romain Basmaci<sup>a,d,* ID</sup>

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## ARTICLE INFO

**Keywords:**

Rhinosinusitis

Children

Antibiotic

Orbital infection

Ethmoidal sinus

## ABSTRACT

We described 20 children hospitalized with acute ethmoiditis between 2017 and 2022 in our center. Median age was 3.5 years, fifteen were Chandler's group II and three were group III. Despite adequate antibiotic therapy regarding national antibiotic treatment guidelines, six (30 %) patients experienced poor outcomes; five of them required surgical drainage, reinforcing the need of close surveillance of these children.

## 1. Introduction

The ethmoid sinus is a well-developed cavity separated from the orbital cavity by a thin bone called lamina papyracea. In contrast to other sinus cavities, the ethmoid is present at birth. Thus, ethmoiditis, which is the infection of the ethmoid sinus, can occur at a very young age [1]. Characterizing the infection into pre-septal or post-septal is essential in assessing the severity and in managing these children. A classification, based on local extension of the infection, was described by Chandler et al., and remains used in current practice [2]. Orbital infection is a frequent and severe complication of ethmoiditis requiring often surgery in addition to antibiotics [3,4].

Although a frequent condition, few studies describe the therapeutic management and evolution of ethmoiditis, and microbiological data are rare. In 2016, our national Pediatric Infectious Disease Group (“Groupe de Pathologie Infectieuse Pédiatrique”, GPIP) has published recommendations for probabilistic antibiotic therapy for ethmoiditis in children [5].

We aimed to describe the clinical characteristics, therapeutic management and evolution of patients treated in the pediatric department of our hospital between 2017 and 2022. The secondary objectives were to evaluate our antibiotic prescriptions against the GPIP recommendations published in 2016 and to identify the characteristics associated with a complicated form of ethmoiditis.

## 2. Patients and methods

### 2.1. Study design

We performed a retrospective observational cohort study of children hospitalized in our center from January, 1st 2017 to December, 31st 2022. Potential patients were identified by extracting all discharge diagnosis codes (International Statistical Classification of Diseases, Tenth Revision; ICD-10) related to acute ethmoiditis (i.e. J012 and J322). Inclusion criteria were: (i) patients aged 0-to-18 years old; (ii) with a diagnosis of acute ethmoiditis; and (iii) hospitalized in the general pediatric unit or the short stay hospitalization unit from the pediatric emergency department. Clinical, laboratory and imaging data, as well as antibiotic treatment (molecule, route, duration, and switch) and outcomes (length of stay, transfer to surgical department, and need of surgical drainage, and transfer to intensive care unit) were reported in a case report form.

Patients were considered as « non-complicated » or « complicated », based on the Chandler's classification (groups I and II versus groups III, IV, and V, respectively) [2].

### 2.2. Statistical analysis

Categorical data are presented in number (%); continuous variables

<footnote><sup>a</sup> Service de pédiatrie-urgences, AP-HP, Hôpital Louis-Mourier, F-92700 Colombes, France</footnote>

<footnote><sup>b</sup> Service de Radiologie, AP-HP, Hôpital Louis-Mourier, F-92700 Colombes, France</footnote>

<footnote><sup>c</sup> Service de chirurgie ORL, AP-HP, Hôpital Louis-Mourier, F-92700 Colombes, France</footnote>

<footnote><sup>d</sup> Université Paris Cité, Inserm, IAME, F-75018 Paris, France</footnote>

<footnote>* Corresponding author at: Service de Pédiatrie, Hôpital Louis-Mourier, 178 rue des Renouillers, F-92700 Colombes, France.
E-mail address: romain.basmaci@aphp.fr (R. Basmaci).</footnote>
are presented in medians [interquartile range]. Frequencies were compared by Fisher exact test and continuous variables were compared using Mann-Whitney U test and P values below 0.05 were considered to denote significant difference.

## 2.3. Ethics

The study protocol was approved by the Institutional Review Board of the Robert-Debré Hospital (CEER-RD, IRB 00006477) under the number 2024–731.

## 3. Results

Twenty children (12 males, 8 females) were hospitalized with a diagnosis of acute ethmoiditis during the study period and were included. The distribution of annual cases over the study period (i.e. from 2017 to 2022) was 8, 3, 5, 1, 0, and 3 cases, respectively.

Median age was 3.5 years [interquartile, IQR 2.5–5.6]. Five (25 %) patients had asthma, two (10 %) had recurrent tonsillitis; others had no significant comorbidities related to infectious, respiratory, ophthalmologic or nasopharyngeal diseases. Fifteen (75 %) patients were fully vaccinated with the pneumococcal conjugate vaccine 13. Four (20 %) patients had received antibiotics before the initial consultation at the emergency department (two oral amoxicillin and two oral amoxicillin-clavulanate). Of note, 2 (10 %) patients had received ibuprofen prior to their presentation.

The clinical and laboratory features of the 20 patients are shown in Table 1. Palpebral edema, pain, and fever were the most frequent signs and symptoms at initial presentation. A moderate biologic inflammatory syndrome was observed. All blood cultures were sterile. *Corynebacterium pseudodiphtheriticum* was further identified in a surgical sample in one patient.

After medical assessment at the emergency department, the diagnosis of acute ethmoiditis was suspected in 17 (85 %) cases. Finally, 19 (95 %) patients had a unilateral infection, while one (5 %) had bilateral ethmoiditis.

At initial presentation, a CT-scan was performed in 18 (90 %) patients, allowing the identification of 15 (75 %) patients in Group II and three (25 %) patients in Group III of the Chandler's classification (Fig. 1A and B). Among the 15 Group II patients, eight (53.3 %) were

<caption>**Table 1**</caption>

Clinical and laboratory features of 20 patients hospitalized with acute ethmoiditis.

<table><thead><tr><th>Features</th><th>Patients (n = 20)</th></tr></thead><tbody><tr><td>Symptoms motivating medical consultation</td><td></td></tr><tr><td>- Febrile palpebral edema</td><td>11 (55 %)</td></tr><tr><td>- Fever without source</td><td>4 (20 %)</td></tr><tr><td>- Headache</td><td>2 (10 %)</td></tr><tr><td>- Others*</td><td>3 (15 %)</td></tr><tr><td>Duration of fever at initial presentation (days)</td><td>2 [1–3.25] (0–10)</td></tr><tr><td>Initial temperature (°C)</td><td>37.8 [36.8–38] (36.1–40.4)</td></tr><tr><td>Signs at initial presentation</td><td></td></tr><tr><td>- Edema</td><td>18 (90 %)</td></tr><tr><td>- Pain</td><td>9 (45 %)</td></tr><tr><td>- Impossibility of eye opening</td><td>5 (25 %)</td></tr><tr><td>- Chemosis</td><td>3 (15 %)</td></tr><tr><td>- Conjunctivitis</td><td>2 (10 %)</td></tr><tr><td>- Exophthalmia</td><td>2 (10 %)</td></tr><tr><td>Laboratory data</td><td></td></tr><tr><td>- Leucocytes (G/L)</td><td>14.6 [12–18.6] (7.6–32.5)</td></tr><tr><td>- Neutrophils (G/L)</td><td>8.1 [5.8–12] (4.3–25.4)</td></tr><tr><td>- Platelets (G/L)</td><td>305.5 [273.5–362] (178–495)</td></tr><tr><td>- CRP (mg/L)</td><td>53.5 [38–103.5] (7–231)</td></tr><tr><td>- Procalcitonin (µg/L)</td><td>0.2 [0.15–0.21] (0.14–0.26)</td></tr></tbody></table>

Data are presented as number (%) or median [interquartile range] (minimum-maximum), as appropriate; *1 of each: ocular pain, vomiting, rash; CRP, C-reactive protein.

initially treated with cefotaxime and clindamycin, and seven (46.7 %) with IV amoxicillin-clavulanate at 150 mg/kg/d. Among the three Group III patients, two received cefotaxime and metronidazole and one received cefotaxime and clindamycin. Seventeen of these 18 patients received a final oral treatment with amoxicillin-clavulanate (80 mg/kg/d). One patient of the Group II received cefpodoxime (Supplementary Table S1).

CT-scan was not performed in two children. The first patient presented a clinically mild ethmoiditis with febrile palpebral edema with no complication. He was treated with intravenous amoxicillin-clavulanate (150 mg/kg/d) for 48 h, then orally (80 mg/kg/d) for a total of 10 days with favorable outcome. The second patient was a 36-day old newborn who was initially admitted for vomiting. Ethmoiditis was secondly suspected due to a poor clinical outcome, despite empirical treatment of enterocolitis with cefotaxime and metronidazole, with the appearance of a palpebral edema and erythema. A CT-scan was performed at day 3 that confirmed the ethmoiditis. This patient was transferred to a surgical unit for drainage and intravenous antibiotic treatment with cefotaxime and clindamycin for 2 days, followed by oral amoxicillin-clavulanate (80 mg/kg/d) for five additional days.

Overall, the median time to reach apyrexia was 1 [0.75–3] day and the median duration of antibiotics was 10 [10–13] days.

Fourteen (70 %) patients had favorable outcomes, whereas six (30 %) patients experienced a regional complication: three in Group II, two in Group III, and one with no initial CT-scan (see above and Supplementary Table S1). None required admission to an intensive care unit. Clinical signs of complication were the persistence of fever, the worsening of palpebral edema and the impossibility to open the eye. A CT-scan was performed allowing confirmation of the complication: among the three Group II patients, two evolved to a Group III, and one to Group IV (Fig. 1C and D); among the two Group III patients, one evolved to a Group IV; the patient without initial CT-scan evolved to a Group III (Supplementary Table S1). All of these six patients were transferred to a surgical unit for adequate treatment and surveillance. Five patients required surgical drainage. Four patients received a second-line antibiotic treatment: ceftriaxone and clindamycin instead of IV amoxicillin-clavulanate (150 mg/kg/d) in one case until the end of treatment, or cefotaxime-metronidazole in three cases (among these, one patient received a third-line treatment with vacomycin-rifampicin) before an oral treatment of amoxicillin-clavulanate 80 mg/kg/d) (Supplementary Table S1). Of note, the 2 patients having received ibuprofen (both were classified as Group II) developed complications: one required drainage, while the other one required a change in antibiotic therapy without surgical intervention.

None of the clinical (age, sex, temperature, eyelid edema, ocular pain, impossibility to eye opening) and laboratory (CRP, white blood cells, neutrophils) factors were significantly different between complicated and uncomplicated cases (data not shown). The median duration of fever at initial presentation was similar in patients with complication (2 days) and in their counterparts (2 days) ($p = 0.83$).

## 4. Discussion

In our series of 20 patients hospitalized for acute ethmoiditis (15 Group II and three Group III of the Chandler's classification), we observed that 14 (70 %) patients had a favorable outcome after initial treatment, while six (30 %) patients experienced a poor outcome requiring surgical drainage ($n = 5; 25 %$), and/or a modification of the first-line antibiotic treatment. Complications did not seem to be attributable to an inappropriate first-line antibiotic treatment, since three patients received cefotaxime-metronidazole (two from Group III and one with no initial CT-scan), two received cefotaxime-clindamycin (from Group II) and one received IV amoxicillin-clavulanate at 150 mg/kg/d (from Group II). Initial antibiotic treatment was concordant with the related national guidelines [5] for 7/15 (47 %) Group II patients and 2/3 (67 %) Group III patients. The eight patients from Group II who did not
<figure><img src="image_5.png" /><figcaption>**Fig. 1.** CT-scan imaging of patients presenting acute ethmoiditis included in our series

A, Axial contrast enhanced CT of the orbit showing left etmoiditis, preseptal edema (dashed arrows), postseptal medial extraconal edema (asterisk), without well-defined collection -Chandler II.

B, Axial contrast enhanced CT of the orbit demonstrating bilateral sinus disease and a right subperiosteal abscess (white arrow) - Chandler III

C and D, Axial (C) and sagital (D) contrast enhanced CT of the orbit demonstrating a right orbital abscess (black arrow) - Chandler IV.</figcaption></figure>

receive the first-line recommended treatment received a broader-spectrum antibiotic treatment (i.e. cefotaxime-clindamycin instead of IV amoxicillin-clavulanate at 150 mg/kg/d), mainly because these patients were diagnosed early after the guidelines implementation, in 2017 or 2018. The patient from Group III received cefotaxime-clindamycin instead of cefotaxime-metronidazole, which is quite similar in terms of antibacterial activity and site diffusion.

We described the initial features and evolution of children with acute ethmoiditis while most studies focused on periorbital abscesses [3,4,6]. We observed a high rate of local complication although initial treatment was concordant with the guidelines, reinforcing the need of hospitalization and surveillance of these children as well as the need for studies assessing which antibiotic treatment would be associated with a lower risk of complication. Unfortunately, a pathogen was identified in one case only, and the number of patients was too small to identify risk factors of complications. Other studies also failed to identify some risk factors [1,6]. Snidvongs et al. found in a population of acute rhinosinusitis that male sex and young age were associated with higher risk of orbital complications with univariable analysis but these factors did not remain statistically significant in multivariable analysis [7].

As only 20 cases over a 6-year period were retrieved in our study compared to a previous French study where 125 patients were described in 2007 over a 9-year period [8], we may hypothesize that the incidence of acute ethmoiditis has decreased in our setting. Indeed, some studies have shown a significant decrease in the overall incidence of orbital complications of pediatric acute rhinosinusitis since the implementation of pneumococcal conjugate vaccine, mainly in patients aged 0–4 years. Of interest, these studies have also observed an increase in the severity

of the cases [9,10].

Our study has several limitations. First, we performed a retrospective study, thus, our results have to be taken with caution due to some missing data. Second, we focused on hospitalized children only, which can increase the severity reported with no description of patients treated orally outside the hospital setting. In addition, some patients may have not been identified by the informatics system if the diagnosis code was incorrect. Lastly, as a monocentric study, our data may not be generalizable to other settings.

## 5. Conclusion

Ethmoiditis remains a common but infrequent disease in children with a high complication rate. Antibiotic guidelines published in 2016 were quite well followed in our center, and did not seem to be associated with the risk of complication. These guidelines have been updated in 2023, with no significant changes [11]. Further prospective studies would be useful to assess risk factors and to identify the best initial treatment in order to decrease the risk of orbital complication and surgery.

## Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
**Declaration of competing interest**

Authors have no conflict of interest to disclose.

**Supplementary materials**

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.arcped.2025.04.002.

**References**

[1] Ben Mabrouk A, Wannes S, Hasnaoui M, Werdani A, Ben Hamida N, Jerbi S, et al. Orbital complication of acute ethmoiditis: a Tunisian paediatric cross sectional study. Am J Otolaryngol 2020;41:102320.

[2] Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414–28.

[3] Coudert A, Ayari-Khalfallah S, Suy P, Truy E. Microbiology and antibiotic therapy of subperiosteal orbital abscess in children with acute ethmoiditis. Int J Pediatr Otorhinolaryngol 2018;106:91–5.

[4] Crosbie RA, Nairn J, Kubba H. Management of paediatric periorbital cellulitis: our experience of 243 children managed according to a standardised protocol 2012-2015. Int J Pediatr Otorhinolaryngol 2016;87:134–8.

[5] Cohen R, Haas H, Lorrot M, Biscardi S, Romain O, Vie Le Sage F, et al. Antimicrobial treatment of ENT infections. Arch Pediatr 2017;24(12S):S9–16.

[6] Martins M, Martins SP, Pinto-Moura C, Leal V, Spratley J. Management of post-septal complications of acute rhinosinusitis in children: a 14-year experience in a tertiary hospital. Int J Pediatr Otorhinolaryngol 2021;151:110925.

[7] Snidvongs K, Chitsuthipakorn W, Akarapas C, Aejmaturapat S, Chusakul S, Kanjanaumporn J, et al. Risk factors of orbital complications in outpatients presenting with severe rhinosinusitis: a case-control study. Clin Otolaryngol 2021; 46:587–93.

[8] Francois M, Mariani-Kurkdjian P, Dupont E, Bingen E. [Acute ethmoiditis in children, a series of 125 cases]. Arch Pediatr 2006;13:6–10.

[9] Dennison SH, Ask LS, Eriksson M, Granath A, Hertting O, Bennet R, et al. Serious complications due to acute rhinosinusitis in children up to five years old in Stockholm, Sweden - still a challenge in the pneumococcal conjugate vaccine era. Int J Pediatr Otorhinolaryngol 2019;121:50–4.

[10] Friedrich L, Sadeh R, Hazan I, Kordeluk S, Sabri ES, Tsumi E, et al. Orbital complications of pediatric acute rhinosinusitis in the pneumococcal conjugate vaccine era. Pediatr Neonatol 2025;66:116–21.

[11] Cohen R, Madhi F, Thollot F, Hau I, Vie le Sage F, Lemaitre C, et al. Antimicrobial treatment of ENT infections. Infect Dis Now 2023;53:104785.