eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Pediatric Sinusitis, Medical Treatment: Follow-up

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

Follow-up

Further Inpatient Care

  • In general, sinusitis can be managed on an outpatient basis. In cases of resistant organisms or for patients with orbital or intracranial complications, inpatient treatment with intravenous antibiotics may be necessary.

Further Outpatient Care

  • Family support is essential in treating this disorder.
  • Just giving medication to a child can be taxing on all involved, so the less frequent dosing the better.
  • Management of chronic sinusitis or an associated condition may be very labor intensive.
  • Children in day care settings are often sent home when they have URTI symptoms. This results in missed days of work for family members and additional financial stressors. Still, most patients with sinusitis are treated as outpatients.

Inpatient & Outpatient Medications

See Medical Care and Medication.

Transfer

If a pediatric intensive care unit or skill in dealing with acutely ill children is unavailable, transfer children with sinusitis complications to the nearest appropriate facility.

Deterrence/Prevention

Good nasal hygiene and use of saline irrigations may be critical for the prevention of exacerbations of acute or chronic sinusitis. Maximize control of associated conditions and warn patients to avoid exposure to environmental irritants such as cigarette smoke.

Complications

  • Orbital involvement
    • Orbital involvement usually occurs subsequent to direct spread from disease in the ethmoid sinuses.
    • Obtain a CT scan with contrast study to determine the full extent of orbital involvement and to identify ring-enhancing fluid collections typical of a subperiosteal abscess.
    • Chandler classification is as follows:
      • Preseptal cellulitis - Eyelid edema, erythema, normal globe movement
      • Orbital cellulitis - Proptosis, chemosis
      • Periorbital abscess - Proptosis with globe displaced inferolaterally, decreased extraocular muscle movement
      • Orbital abscess - Severe proptosis, impaired visual acuity, fixed globe, toxic patient
      • Cavernous sinus thrombosis - High fever, bilateral symptoms
    • Sinusitis involving the orbit is potentially life threatening and has a high risk of rapid visual loss. Manage orbital involvement closely, even in early cases, because visual changes may be permanent.
    • Orbital involvement requires intravenous antibiotics and possible endoscopic or open surgical management by physicians with expertise in treating these patients.
    • Strongly consider consulting an ophthalmologist early in the course of sinusitis to document and monitor the visual examination.
  • Intracranial involvement
    • Intracranial involvement usually occurs subsequent to direct spread from sphenoid or frontal sinus disease.
    • Subdural and frontal lobe abscesses are most common.
    • Meningitis may occur.
    • Administer intravenous antibiotics with good cerebrospinal fluid (CSF) penetration, such as third-generation cephalosporins. Obtain empiric broad-spectrum intravenous antibiotic coverage while awaiting more specific culture and sensitivity results.
    • Obtain a CT scan with contrast to detect ring-enhancing fluid collections.
    • Consulting a neurosurgeon is necessary.

Prognosis

Prognosis is excellent for acute rhinosinusitis. Chronic sinusitis can be much more difficult to manage, but with optimal treatment of associated conditions and full medical treatment, high cure rates are probable. Only rarely is surgery required.

Patient Education

  • Patient and family education is important. Understanding the mechanism underlying development of rhinosinusitis gives the caregiver much more incentive for the often-arduous task of compliance with medical treatment for a child.
  • With the rising rate of resistant pathogens, educating the public about the proper uses of antibiotics is mandatory. Dispensing antibiotics over the phone or prophylactically is strongly discouraged. Long courses of antibiotics should be based on culture results.

Miscellaneous

Medicolegal Pitfalls

The only likely pitfall is a failure to recognize a life- or vision-threatening complication in its early stages. Physicians should have a low threshold for starting intravenous antibiotics and ordering a CT scan if orbital or intracranial spread is suspected.

Special Concerns

One current concern in the United States is the rising number of children in day care. In addition to the potential social and psychological effects, a well-documented increase in the number of illnesses exists. Groups of more than 5 children have dramatically higher rates of URTIs because of the easy spread of viruses. Not only is the number of URTIs increased, but these viral infections are much more likely to progress to bacterial rhinosinusitis. In addition, this population of children is much more likely to be infected with resistant strains of bacteria. Inquire about day care attendance in every pediatric interview, and treat children who attend day care more aggressively than other patients.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Karla R Brown, MD, and Lincoln Lippincott, MD, to the development and writing of this article.



More on Pediatric Sinusitis, Medical Treatment

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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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