eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Pediatric Sinusitis, Medical Treatment

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

Introduction

Background

Pediatric sinusitis is a common problem treated by primary care physicians and otolaryngologists. Although this disorder has been addressed for many centuries, full appreciation for its scope, pathophysiology, diagnosis, treatment, and complications has been realized only relatively recently. Children with occasional episodes of acute sinusitis following a routine cold are treated with short courses of antibiotic therapy with good results. However, treatment of chronic and recurrent sinusitis can be more challenging for physicians and frustrating for families. In these cases, the physician must not only treat with an appropriate antibiotic but must also address the associated conditions contributing to the problem.

The goal in treating these children is to combine antibiotic therapy with treatment of associated conditions for a time sufficient to allow resolution of symptoms with return of normal sinus physiology and mucociliary clearance. This article addresses the medical management of pediatric sinusitis.

Pathophysiology

The ostiomeatal complex (OMC) is believed to be the critical anatomic structure in sinusitis and is entirely present, although not at full size, in newborns. Present within the middle meatus, the OMC is composed of the uncinate process, infundibulum ethmoidalis, hiatus semilunaris, ethmoid bulla, and frontal recess. Although obstruction of the OMC has not been proven to be the primary source for pediatric sinusitis, changes occurring in the anterior ethmoids are known to impair drainage through the OMC, resulting in chronic maxillary sinusitis and, occasionally, frontal sinusitis.

The normal metachronous movement of mucous toward the natural ostia of the sinuses and eventually to the nasopharynx can be disrupted by mucosal inflammation. This most commonly occurs secondary to routine viral upper respiratory tract infections (URTIs) or nasal allergies and the host response to these insults. In addition, many other predisposing factors to chronic disease exist, including allergic rhinitis, anatomical abnormalities, gastroesophageal reflux (GER), immune deficiency, and disorders of ciliary function.

Frequency

United States

Although the exact incidence of sinusitis in the pediatric population is unclear, it is diagnosed commonly, most often following a viral URTI. The number of URTIs that an individual has per year may be as high as 25 (children will have on average 6-8 per year); the number depends on a several factors, including age, day care attendance, and number of siblings. Approximately 5-13% of URTIs are complicated by bacterial sinusitis. Many viral URTIs are mislabeled early in their course as acute sinusitis and are inappropriately treated with antibiotics.

International

International incidence is similar to that in the United States.

Mortality/Morbidity

Recent health-related quality of life measures showed a poor result in children with chronic rhinosinusitis. Because quantifying the morbidity caused by pediatric conditions is difficult, it must also be viewed in other terms. A child with an acute episode of sinusitis may lead the caregiver to experience emotional distress and lack of sleep and miss days from work. Chronic illness may have a negative impact on a child's quality of life in many ways, including complications of chronic antibiotic therapy, school absences, poor sleep patterns, impaired school performance, and irritability.¹

Children are also susceptible to more serious sequelae from a complication of sinusitis such as orbital cellulites (in about 9.3% of the cases) and intracranial complications (in 3.7-11% of patients). With close follow-up care, counseling of the family, and proper medical treatment, morbidity from this disease should be very low.

Race

No race predilection exists.

Sex

No sex predilection exists.

Age

The ethmoid and maxillary sinuses are present at birth. The sphenoid sinuses are pneumatized by age 5 years, and the frontal sinuses appear by age 7 years but are not completely developed until adolescence. Thus, children are predisposed to sinus infection at an early age. In young children, the most common sinuses involved are the ethmoid and maxillary sinuses. Acute sinusitis is much less common in young children than routine URTI or adenoiditis.

In an older child, the sphenoid and frontal sinuses are more likely to be involved with disease. Allergic rhinitis is also more common in older children. It affects only 1% of infants and 5% of children aged 5-9 years, while 15% of the adolescent population is affected. Allergic rhinitis is one of the most common predisposing factors for sinusitis, second only to viral URTIs.

Clinical

History

Any condition that alters mucociliary clearance, decreases ventilation through a patent sinus ostium, or interferes with local or systemic defense mechanisms can lead to a cycle of sinus infection that can be very difficult to clear without concurrently addressing the associated condition.

• Acute sinusitis
  • Signs and symptoms normally clear within 30 days.
  • URTI symptoms persisting longer than 7-10 days suggest acute sinusitis.
  • Daytime cough and rhinorrhea are the 2 most common symptoms.
  • Other common signs and symptoms include the following:
    • Nasal congestion
    • Infrequent low-grade fever
    • Otitis media (50-60% of patients)
    • Irritability
    • Headache
  • Signs and symptoms of severe infection include the following:
    • Purulent rhinorrhea
    • High fever (ie, >39°C)
    • Periorbital edema
  • Uncomplicated sinusitis spontaneously resolves in 40% of patients.
• Recurrent acute sinusitis: This condition is defined as episodes each lasting fewer than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic.
• Subacute sinusitis: This condition is defined as signs and symptoms lasting between 30-90 days.
• Chronic sinusitis
  • Chronic sinusitis is defined as low-grade persistence of signs and/or symptoms lasting longer than 90 days without improvement.
  • The patient may have 6 or more recurrent episodes per year.
  • The patient may have a history of acute exacerbations without ever being completely well between episodes.
  • Nighttime cough is more prevalent.

Physical

Perform a thorough head and neck examination on patients with sinusitis, with emphasis on otoscopy, anterior rhinoscopy, and nasal endoscopy to examine the middle meatus, nasopharynx, and adenoids.²

• Anterior rhinoscopy
  • This study can be difficult to perform in young children.
  • Examine the middle turbinate and middle meatus for evidence of purulence or sinus discharge.
  • Using a nasal spray mixture of a vasoconstrictive agent, such as oxymetazoline and lidocaine, is helpful.
  • Polyps, if present, should prompt an evaluation for cystic fibrosis.
• Nasal endoscopy
  • This study provides an excellent look at the middle meatus and provides the most accurate examination results outside the operating room.
  • Nasal endoscopy can be difficult to perform in young and uncooperative children.
• Transillumination of the sinuses: This study is not usually helpful.

Causes

Causes of rhinosinusitis are best organized according to microbiological agents and associated conditions.

• Acute and subacute pathogens
  • Streptococcus pneumoniae - 20-30%
  • Nontypeable Haemophilus influenzae - 15-20%
  • Moraxella catarrhalis - 15-20% (not as common in adults)
  • Streptococcus pyogenes (beta-hemolytic) - 5%
• Chronic pathogens
  • No well-defined bacterial pathogen population
  • Chronic sinusitis more commonly a polymicrobial infection
  • Commonly cultured bacteria
    • Alpha-hemolytic streptococci
    • Staphylococcus aureus
    • Coagulase-negative staphylococci
    • Nontypeable H influenzae – More common than acute sinusitis
    • Moraxella catarrhalis
    • Anaerobic bacteria, including Peptostreptococcus, Prevotella, Bacteroides, and Fusobacterium species
    • Pseudomonads - More common after multiple courses of antibiotics; consider immunodeficiency
• Viral URTI
  • This is the most significant predisposing factor for sinusitis.
  • Day care attendance is associated with a 3-fold increase in overall incidence of URTIs. Hand-to-hand contact is the primary method of spread. Hand washing and decreased numbers of children in day care have been demonstrated to aid in prevention of URTI transmission. To break the cycle of chronic infection, removing the child from day care for a time may be required.
  • No criterion standard treatment exists for viral URTIs, despite multiple trials. Antiviral agents currently under investigation are promising. A vaccine is difficult to develop because of the multiple viruses responsible for URTIs.
• Allergic rhinitis
  • This is the second most common predisposing factor for sinusitis after viral URTIs.
  • Viral URTI affects 10-15% of the pediatric population older than 9 years.
  • Eosinophilia with resultant increase in major basic protein is toxic to mucosa and disrupts mucociliary clearance.
  • In a 1991 study by Shapiro et al, 60% of patients with refractory sinusitis had increased total immunoglobulin E (IgE) or marked skin reactivity.
  • IgE testing is not as reliable in children younger than 4 years.
  • Physicians must aim therapy at decreasing allergic mucosal edema to stop recurrent sinusitis symptoms.
  • Allergy testing is recommended in all patients with unresponsive symptoms, particularly in children with a strong family history and in children showing other signs of atopy such as skin manifestations.
• Anatomical abnormalities: Several anatomical abnormalities of the lateral nasal wall can predispose to sinusitis.
  • Concha bullosa, an aerated middle turbinate, can cause blockage of the OMC.
  • Haller cells, infra-orbital cells that cause narrowing of the maxillary sinus ostium, predispose to maxillary sinusitis.
  • Deviated septum in the area of the middle turbinate can cause lateralization of the middle turbinate with blockage of the OMC.
  • Other variations include an agger nasi, hypoplastic maxillary sinus, and a large ethmoidal bulla.³
• Immune deficiency
  • Immune deficiencies are present in 0.5% of the population.
  • Humoral immune response matures to a level near that of adults by approximately age 7 years, and the prevalence of chronic sinusitis decreases accordingly by this age.
  • As many as one third of cases of refractory rhinosinusitis may involve immune deficiencies, especially if the patient has a history of frequent bacterial infections or becomes ill soon after antibiotics are stopped.
  • Immune deficiencies are more common in the general population than cystic fibrosis or ciliary disorders. In order of decreasing prevalence, the most common types are common variable, immunoglobulin G (IgG) subclass, and selective antibody.
  • Symptoms may be more severe in patients with immune deficiency.
  • Recurrent URTIs are the most common manifestations of an immune disorder.
  • Always consider immune deficiency in cases refractory to proper courses of aggressive medical therapy.
  • Initial evaluation includes total immunoglobulin levels and IgG subclasses, as well as response to pneumococcal, tetanus toxoid, and diphtheria vaccines.
• Asthma
  • Impaired nasal function increases postnasal drip and irritant burden on the lower airways, which can exacerbate asthma symptoms.
  • Chronic rhinitis is present in 80% of individuals with asthma, and viral URTIs are implicated in exacerbation of reactive airway disease.
  • Treatment of chronic sinusitis can aid in normalization of pulmonary function tests and ability to decrease long-term use of bronchodilators.
• Gastroesophageal reflux disease
  • Clinicians are becoming more aware of GER as an etiologic agent in patients with asthma symptoms, chronic cough, and hoarseness.
  • GER may lead to inflammation of the eustachian tube orifices or sinus ostia secondary to mucosal irritation.
  • Silent GER has respiratory manifestations in as many as 60% of patients.
  • GER is especially likely in children with a history of poor weight gain, chronic reactive airway disease, or reflux as infants.
  • An empiric trial of antireflux medications in children with chronic sinusitis symptoms not responsive to medical management has been proposed but has not gained widespread acceptance.
• Allergic fungal sinusitis
• Polypoid mass or mucosal changes associated with allergic fungal sinusitis are commonly unilateral.
• Nasal and sinus secretions of allergic mucin the consistency of peanut butter are present.
  • Histologic examination of sinus secretions shows the presence of abundant eosinophils and Charcot-Leyden crystals.
  • The most common causative organisms are in the Aspergillus genus.
  • Treatment is surgical.
  • Immunotherapy has also been demonstrated to be helpful as an adjuvant treatment. Limited trials of immunotherapy with a 3-year follow-up period have shown no recurrence of disease after surgery for allergic fungal sinusitis.
• Biofilms
  • Biofilms have recently been associated with 80% of patients with chronic rhinosinusitis compared with none in control subjects.
  • Work is still in progress to define the exact role of biofilms and how to treat those patients.

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