eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Pediatric Sinusitis, Medical Treatment: Differential Diagnoses & Workup

Author: Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Contributor Information and Disclosures

Updated: Apr 22, 2009

Differential Diagnoses

Allergic Fungal Sinusitis
Sinusitis, Ethmoid, Acute, Surgical Treatment
Cystic Fibrosis
Sinusitis, Frontal, Acute, Surgical Treatment
Malignant Tumors of the Nasal Cavity
Sinusitis, Fungal
Malignant Tumors of the Sinuses
Sinusitis, Maxillary, Acute, Surgical Treatment
Sinonasal Papillomas, Treatment
Sinusitis, Maxillary, Chronic, Surgical Treatment
Sinusitis, Acute, Medical Treatment
Sinusitis, Sphenoid, Acute, Surgical Treatment
Sinusitis, Chronic, Medical Treatment

Other Problems to Be Considered

Adenoid hypertrophy
Adenoiditis
Benign tumors of the nasal cavity
Benign tumors of the sinuses
Ciliary dyskinesia
Congenital malformations of the sinuses
Immune deficiency
Upper respiratory infection

Workup

Laboratory Studies

Laboratory tests are normally not particularly helpful in making the diagnosis of sinusitis. However, they can be essential in determining whether associated conditions such as allergic rhinitis, cystic fibrosis, or immunodeficiency are present. In addition, in patients with suppurative complications or in a very toxic-appearing child, some blood work and cultures may be helpful for determining treatment.

Imaging Studies

  • CT scanning
    • CT scanning is the criterion standard for evaluation of both mucosal inflammation and anatomical abnormalities in the paranasal sinuses. CT scanning provides a reliable picture of the ostiomeatal complex in a noninvasive fashion.
    • CT scanning demonstrates exceptional diagnostic accuracy for the diagnosis of pediatric sinusitis with excellent sensitivity and specificity. However, its predictive value depends on prevalence of chronic rhinosinusitis in the population being evaluated.4
    • CT scanning is mandatory before endoscopic sinus surgery and very valuable when an impending complication of sinusitis such as periorbital or intracranial involvement exists.
    • Thin-cut axial and coronal images of the paranasal sinuses are optimal. A limited number of coronal images alone are used by some as a screening method.
    • Contrast is not necessary for routine sinus evaluation, but it is necessary when a complication such as orbital or intracranial abscess is suspected.
    • The best images for chronic sinusitis are taken at the point of maximal wellness, usually during the last week of a 4-week course of maximal medical therapy. Maximal medical therapy includes appropriate antibiotics and possibly nasal saline irrigations, topical nasal steroids, or decongestants.
    • A 45% occurrence of incidental sinusitis/opacification has been found on pediatric facial CT scans taken for other reasons. In an asymptomatic patient, no treatment or further workup is necessary. In children younger than 12 years, mucosal thickening or sinus opacification are associated with only a 50% chance of actual sinusitis. During an acute viral URTI, the sinuses are routinely opacified on CT scan. In the early stages, URTIs do not require treatment with antibiotics.
    • Note anatomic abnormalities, hypoplastic maxillary sinuses, concha bullosa, and changes consistent with cystic fibrosis (eg, medial displacement of the lateral nasal wall) on review of CT scans.
    • A thinning of the surrounding bone with wispy areas of calcium density may be observed in patients with allergic fungal sinusitis.
  • Plain radiography/sinus series
    • These studies have a poor correlation with CT scanning; as many as 75% of them either underestimate or overestimate disease.
    • Plain radiography is a fairly inaccurate screening method even for maxillary sinus disease.
    • Inaccuracies are compounded by mucosal tears, asymmetric facial or sinus development, overlying soft tissue, multiple septal walls, sinus overlap, improper exposure, and head rotation.
  • MRI: MRI is useful when intracranial complications are suggested or when allergic fungal sinusitis (nonenhancing on T1, bright on T2, central signal void) is suggested.
  • Ultrasonography
    • Ultrasonography can be used to evaluate the maxillary sinuses, but results have been somewhat inconsistent.
    • It has not yet gained widespread acceptance in the United States.

Procedures

  • Rigid or flexible nasal endoscopy
    • Nasal endoscopy provides an excellent view of the OMC.
    • It is helpful for evaluation of the adenoid pad.
    • This procedure requires patient cooperation.
  • Maxillary sinus puncture
    • This test is the criterion standard for obtaining maxillary sinus cultures.
    • Aerobic and anaerobic culture and sensitivity and Gram staining may enable pathogen-directed antibiotic therapy.
    • Indications for maxillary sinus puncture include the following:
      • Severe toxic illness
      • Acute illness unresponsive to antibiotics within 72 hours
      • Immunocompromised patients
      • Suppurative complications
      • Workup for fever of unknown origin
    • Contents of the maxillary sinus may be aspirated safely through the canine fossa or inferior meatus, but in the pediatric population this often requires a brief general anesthetic. In this instance, the physician may also consider obtaining a culture via the natural maxillary sinus ostia.
  • Middle meatal swab
    • Cultures taken from the middle meatus or anterior middle turbinate have good (>80%) correlation with cultures taken from ipsilateral maxillary or ethmoid sinuses.
    • Having a carefully guided endoscopic sample of purulence from the middle meatus is important. Random nasal swabs show little correlation with maxillary cultures.
    • This procedure requires a cooperative child but is definitely less invasive than sinus puncture.

Histologic Findings

A submucosal inflammatory infiltrate is observed in acute and chronic sinusitis. Only allergic fungal sinusitis has a characteristic finding on histopathologic examination, with Charcot-Leyden crystals and eosinophilia. An abundance of eosinophils may also be seen in the submucosa of any patient with allergic rhinitis.

More on Pediatric Sinusitis, Medical Treatment

Overview: Pediatric Sinusitis, Medical Treatment
Differential Diagnoses & Workup: Pediatric Sinusitis, Medical Treatment
Treatment & Medication: Pediatric Sinusitis, Medical Treatment
Follow-up: Pediatric Sinusitis, Medical Treatment
Multimedia: Pediatric Sinusitis, Medical Treatment
References
Further Reading
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Further Reading

In 2008, the practice parameter guidelines for the diagnosis and management of rhinitis was updated. 5

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Keywords

sinusitis, rhinosinusitis, sinus infection, sinus infections, sinus, sinuses, chronic sinusitis, sinusitis treatment, sinusitis medical treatment, sinusitis symptoms, ostiomeatal complex, OMC, uncinate process, infundibulum ethmoidalis, hiatus semilunaris, ethmoid bulla, frontal recess, chronic maxillary sinusitis, frontal sinusitis, mucosal inflammation, upper respiratory tract infection, URTI, nasal allergy, allergic rhinitis, chronic rhinosinusitis, recurrent sinusitis, adenoiditis, immune deficiency

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Contributor Information and Disclosures

Author

Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Rhinologic Society
Disclosure: Nothing to disclose.

Medical Editor

Ted L Tewfik, MD, FRCS(C), Professor, Department of Otolaryngology, Director of Continuing Medical Education of Otolaryngology, McGill University Medical School; Director, Director of Professional Affairs of Otolaryngology, Department of Otolaryngology, Montreal Children's Hospital; Senior Staff, Montreal General Hospital and Royal Victoria Hospital
Ted L Tewfik, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society of Pediatric Otolaryngology, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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