Pediatrics

Sinusitis

OVERVIEW: What every practitioner needs to know

Are you sure your patient has sinusitis? What are the typical findings for this disease?

  1. Cough

  2. Nasal obstruction/drainage

  3. Post-nasal drip

  4. Fever

What other disease/condition shares some of these symptoms?

Asthma

Chronic adenotonsillitis

Foreign body in the nose (unilateral purulent discharge)

What caused this disease to develop at this time?

  • Recent upper respiratory infection

  • Non-infectious inflammation and swelling: allergy, tobacco smoke exposure

  • Adenoid hypertrophy, nasal polyposis

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

  • CBC can help confirm clinical diagnosis and follow response to treatment

Would imaging studies be helpful? If so, which ones?

  • Acute sinusitis is a clinical diagnosis. Imaging should be reserved for children suspected of orbital or intracranial complications of acute sinusitis. CT must include contrast to identify and delineate subperiosteal collections of the orbit, and help to characterize extradural empyema.

  • CT without contrast is used for pre-operative planning and intraoperative stereotactic navigation for the patient whose clinical course dictates surgical intervention.

  • MRI with contrast can be helpful for characterizing extradural empyema and identifying sinonasal neoplasia.

Confirming the diagnosis

Sinusitis should be suspected when patients present with a combination of the following:

  • Recent or current upper respiratory infection and persistence of upper respiratory symptoms, with or without worsening

  • Development of fever

  • Transition from clear to purulent rhinorrhea

  • Pre-septal orbital involvement with palpebral edema or erythema, or orbital involvement with orbital cellulitis

If you are able to confirm that the patient has sinusitis, what treatment should be initiated?

Treatment includes the following:

Nasal hygiene with normal saline nasal spray. Appropriate antibiotic therapy can include amoxicillin (high dose of 90 mg/kg/day), or amoxicillin-clavulanate (same amoxicillin dose), or other agents.

Nasal corticosteroids may decrease sinonasal inflammation.

Oral antihistamine: to mediate allergic inflammation

Oral pulse corticosteroids are commonly used in adults and may be considered in children.

Anti-reflux therapy for patients with symptomatic gastroesophageal reflux disease (GERD), history of GERD, chronic respiratory problems, or as empirical therapy for asymptomatic laryngopharyngeal reflux.

What are the adverse effects associated with each treatment option?

  • Normal saline nasal spray: requires cooperation.

  • Antibiotic therapy: possible allergic reaction, GI complications including diarrhea, antimicrobial resistance.

  • Nasal corticosteroids: nasal drying, limited evidence of benefit, mometasone furoate is approved for children over age 2, reported decrease in height growth rate in asthmatic children.

  • Oral antihistamines: may thicken or dry secretions.

  • Oral pulse corticosteroids, commonly used in adults, may be considered in children to relieve severe symptoms.

What are the possible outcomes of sinusitis?

Potential for progression to complications of sinusitis, including orbital cellulitis, orbital abscess, intracranial complications including meningitis, extradural and intradural abscess, and intraparenchymal abscess

What causes this disease and how frequent is it?

Sinusitis is a common complication of upper respiratory infection (URI). The annual incidence of URI in children is 5-10 episodes per child per year. Possible development of bacterial superinfection in even 5% of upper respiratory infections leads to a high incidence of sinusitis in children. Upper respiratory infections follow seasonal patterns, with year-round infections and highest infection rates during fall and winter months.

How do these pathogens/genes/exposures cause the disease?

Exposures that inhibit mucociliary clearance can transition viral upper respiratory infection to bacterial sinusitis, including exposure to tobacco smoke, allergens, and possible changes in barometric pressure associated with air travel.

Other clinical manifestations that might help with diagnosis and management

Other less common causes of nasal disease should be considered, especially in refractory or repeated episodes: asthma, gastroesophageal reflux disease (GERD), immunodeficiency, ciliary dyskinesia, and cystic fibrosis.

What complications might you expect from the disease or treatment of the disease?

Are additional laboratory studies available; even some that are not widely available?

If gastroesophageal reflux is suspected to have led to sinusitis, esophageal pH probe or referral to a gastroenterologist may be indicated.

If immunodeficiency is suspected, testing should include immunoglobulin and lymphocyte testing. Ciliary dyskinesia can be diagnosed by mucosal biopsy, and sweat chloride testing or genetic tests should be performed to diagnose cystic fibrosis.

How can sinusitis be prevented?

Mediation of contributing factors above, including second hand smoke, can reduce the likelihood of developing bacterial sinusitis.

Regular vaccination may reduce incidence of bacterial infection after viral upper respiratory infection.

What is the evidence?

"Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guideline: management of sinusitis". Pediatrics. vol. 108. 2001. pp. 798-808.

Shaikh, N, Wald, ER, Pi, M. "Decongestants, antihistamines and nasal irrigation for acute sinusitis in children". Cochrane Database Syst Rev. vol. 8. 2010.

Lusk, R. "Chronic rhinosinusitis: contrasts between children and adult patients". Clin Allergy Immunol. vol. 20. 2007. pp. 287-98.

Lusk, R. "Pediatric chronic rhinosinusitis". Curr Opin Otolaryngol Head Neck Surg. vol. 14. 2006. pp. 393-6.

Lai, L, Hopp, RJ, Lusk, RP. "Pediatric chronic sinusitis and asthma: a review". J Asthma. vol. 43. 2006. pp. 719-25.

Mullol, J, Obando, A, Pujols, L, Alobid, I. "Corticosteroid treatment in chronic rhinosinusitis: the possibilities and the limits". Immunol Allergy Clin North Am. vol. 29. 2009. pp. 657-8.

Felisati, G, Ramadan, H. "Rhinosinusitis in children: the role of surgery". Pediatr Allergy Immunol. vol. 18. 2007. pp. 68-70.

Lusk, RP, Bothwell, MR, Piccinillo, J. "Long-term follow-up for children treated with surgical intervention for chronic rhinosinusitis". Laryngoscope. vol. 116. 2006. pp. 2099-107.

Ongoing controversies regarding etiology, diagnosis, treatment

Surgical treatment of sinusitis in children should be reserved for rare cases of anatomic obstruction, or repeated, severe refractory episodes. Functional endoscopic sinus surgery is a controversial topic and should be considered a technique of last resort in a multifactorial disorder. There is excellent evidence that adenoidectomy improves outcomes for children who fail medical therapy.

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