eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Pediatric Sinusitis, Medical Treatment

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

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.

Preseptal cellulitis of the left eye. Courtesy of Dwight Jones, MD.

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.

Differential Diagnoses

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.

Treatment

Medical Care

• Antibiotic therapy for acute sinusitis
  • Indications are as follows:
    • Toxic child with suspected complications
    • Severe acute sinusitis
    • Persistent acute sinusitis
  • Because of the growing problem of bacterial resistance, do not administer antibiotics indiscriminately or without confirmation of history by physical examination.
  • Treat for 10-14 days or for 1 week beyond symptom resolution.
• Adjunctive medical therapy for acute sinusitis
  • Saline sinus irrigation has demonstrated efficacy in the treatment of acute and chronic sinusitis. It increases mucociliary flow rates and aids in vasoconstriction. It mechanically clears secretions, decreases bacterial counts, and clears allergens and environmental irritants from the nose.
  • Nasal steroids are essential for patients with concurrent allergic rhinitis. Of patients with allergic rhinitis, 90% report improvement in symptoms, including nasal congestion.
    • Absorption through the nasal mucosa to the systemic system is minimal with most steroid preparations.
    • Adverse effects, including suppression of the pituitary axis and glaucoma, have been reported in adults.
    • Severe varicella infections have been reported in the pediatric population.
    • Few nasal steroids have been studied for their safety in young patients.
    • Carefully consider all choices.
  • Short bursts of systemic steroids can be helpful for patients with allergies. Many otolaryngologists also give patients with nasal polyposis a short burst before surgical intervention to decrease intraoperative blood loss.
  • Nasal decongestants are variably effective. Topical decongestants may improve patients' level of comfort. Restricting use to the first 4-5 days of medical treatment is best in order to avoid rebound vasodilatation.
  • Mucolytics are variably effective. No controlled studies have demonstrated efficacy.
  • Antihistamines are most useful in patients with atopy.
  • Immunotherapy is effective for patients with known specific allergies who have symptoms not responsive to other forms of traditional medical therapy.
• Optimization of associated medical conditions
  • Allergic rhinitis: Measures include allergen avoidance, optimal environment, nasal steroids, a second-generation antihistamine, and possible immunotherapy.
  • Gastroesophageal reflux: Treat in consultation with a pediatrician or GI specialist. Conservative measures include elevating the head of the bed, not feeding immediately before bedtime, and thickening feeds. Medical therapy includes H-2 blockers, prokinetic agents, and hydrogen ion pump inhibitors.
  • Immune deficiency: Treat in consultation with an immunologist and possibly an infectious-disease specialist. Treatment involves aggressive routine medical therapy and possibly intravenous gamma-globulin injections. This is an expensive type of therapy with many possible associated complications.
  • Asthma: Measures include avoidance of exacerbating factors and use of bronchodilators and inhaled steroids.
  • Cystic fibrosis: Aggressive nasal toilet with saline irrigations, nasal steroids, and antibiotic irrigations for pseudomonad colonization may help optimize this condition, although antibiotic irrigations have never been prospectively studied effectively.
  • Immotile cilia syndromes: Mechanical clearance of secretions with daily irrigations is helpful in reducing the number of infections.
• Chronic sinusitis
  • For patients with chronic rhinosinusitis, administer at least 4 weeks of a broad-spectrum beta-lactamase–resistant second-line antibiotic therapy.
  • Consider changing antibiotics if no significant response has occurred within 1 week. A culture may be required at that point to more appropriately adjust antibiotic coverage.
  • All of the above medical adjuncts may play a role, especially nasal steroids and saline irrigations.
  • Excluding or maximally treating all associated conditions is essential.

Surgical Care

• Adenoidectomy
  • A significant symptom overlap exists between adenoiditis and chronic sinusitis. The adenoids are niduses for infection and sources of obstruction.With adenoidectomy alone, symptom improvement occurs for more than 50% of patients.
  • Functional endoscopic sinus surgery
  • Consider surgery as a last resort in the pediatric population. An atraumatic technique with mucosal preservation is essential
• Uncinate removal, anterior ethmoidectomy, and maxillary antrostomy are the most common forms of surgery. Second-look procedures to clean the cavity and remove crusts 2-3 weeks after surgery are not routinely needed. No data are currently available to support this as a necessary routine procedure.
  • Carefully consider risks of surgery and possible complications.
  • The overall success rate is approximately 80%. When combined with adenoidectomy at the same time, the rate can be higher.
  • Maxillary sinus wash and intravenous antibiotics have not been universally accepted.
  • Patients continue to require postoperative nasal toilet and treatment of associated conditions. This is especially true for patients with cystic fibrosis, in whom sinus surgery serves to open the sinuses more widely to aid in effective irrigation.
• Balloon sinuplasty
  • This new procedure should be considered prior to endoscopic sinus surgery.
  • It is helpful for children, especially those children with minimal findings on CT scan but with significant symptoms and a failure to respond to continued medical therapy.
  • The procedure consists of dilating the ostia of the sinuses with a balloon instead of with the use of a sharp instrument.
  • Experience with this technique is still limited.
  • No long-term data on the patency of the ostia are yet available in children.

Consultations

• Ophthalmologist for orbital complications
• Neurosurgeon for intracranial complications
• Allergist for allergic rhinitis
• Gastroenterologist for unmanageable GER
• Immunologist for immune deficiencies
• Pulmonologist for asthma or cystic fibrosis

Diet

Patients with GER should eliminate caffeine, chocolate, and acidic beverages from their diets. Also, patients should not lie supine after meals, and no food should be consumed for 2 hours before bedtime. With food allergies, which are common in the pediatric population, appropriate restrictions are necessary.

Activity

Tailor activity guidelines to the individual patient. Restrictions depend on the severity of illness and the patient's age. Patients with environmental allergies may require restrictions to avoid exposure to allergens. All patients with chronic sinusitis should be restricted from exposure to environmental irritants such as tobacco smoke.

Medication

Antibiotic therapy is the mainstay of medical treatment for pediatric rhinosinusitis. Because of increasing prevalence of beta-lactam–resistant bacteria in the community, administer antibiotics only for suspected infection as based on a careful history and physical examination. Direct the therapeutic regimen against the prevalent pathogens in the community and carefully consider suspicion for highly resistant bacteria. Typically, uncomplicated cases of acute sinusitis are responsive to amoxicillin. Most patients respond to this initial regimen. For children allergic to penicillin, a second- or third-generation cephalosporin can be used (only if the allergic reaction is not a type 1 hypersensitivity reaction). In cases of serious allergic reaction, a macrolide or clindamycin can be used.

Second-line antibiotics should account for bacterial resistance and should be safe in the pediatric population. For chronic sinusitis, a 4-week course of a broad-spectrum beta-lactam–stable antibiotic should be administered. This should allow treatment for more than a week beyond symptom resolution and ensure restoration of mucociliary function and resolution of mucosal edema. Antibiotic prophylaxis as a strategy to prevent infection in patients who experience recurrent episodes of acute bacterial rhinosinusitis has not been systemically evaluated and is controversial. There is little enthusiasm for this approach in light of the current concern with antibiotic resistance. Antibiotics for treatment of chronic sinusitis are best chosen based on culture results and sensitivities. Listed below are excellent choices for second-line antibiotics.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Amoxicillin (Trimox, Biomox)

First-line therapy; may be administered at mealtime; has a pleasant taste. Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Dosing

Adult

250-500 mg PO tid or 500-875 mg PO bid

Pediatric

45 mg/kg/d PO divided bid
Pediatric high dose: 90 mg/kg/d PO divided bid; consider in children in large day care settings

Interactions

Reduces efficacy of oral contraceptives

Contraindications

Documented hypersensitivity; infectious mononucleosis (eg, Epstein-Barr virus)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

More likely than other penicillins to produce a rash; adjust dose in renal impairment; may enhance chance of candidiasis

Amoxicillin-clavulanate (Augmentin)

First-line choice for chronic sinusitis; clavulanate gives beta-lactamase resistance (H influenzae, M catarrhalis, S aureus, anaerobes); may be administered at mealtime; IV form available.

Dosing

Adult

250-500 mg PO tid or 500-875 mg PO bid

Pediatric

<3 months: 125 mg/5mL PO susp based on amoxicillin; 30 mg/kg/d divided bid for 7-10 d
>3 months: If using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO divided q12h; if using 125 mg/5 mL or 250 mg/5 mL suspension, 40 mg/kg/d PO divided q8h for 7-10 d, or high dose 80-90 mg/kg/d PO divided bid
>40 kg: Administer as in adults

Interactions

Coadministration with warfarin or heparin increases risk of bleeding

Contraindications

Documented hypersensitivity; infectious mononucleosis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

GI adverse effects; still subject to pneumococcal resistance, but amoxicillin is active against intermediate-grade resistance; give for a minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci; adjust dose in renal impairment; cross allergy may occur with other beta-lactams and cephalosporins

Cefuroxime (Ceftin, Kefurox)

Highly active against all common sinusitis-causing pathogens; useful with resistance to amoxicillin; good coverage of Haemophilus and Moraxella species; IV form available; good CSF penetration makes it appropriate in cases of suspected orbital or intracranial extension.
Administer with meals; follow with yogurt.

Dosing

Adult

250-500 mg PO bid

Pediatric

20-30 mg/kg/d PO divided bid; not to exceed 250 mg PO bid

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer half dose if CrCl is 10-30 mL/min and one-quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy

Cefpodoxime (Vantin)

Highly active against all common sinusitis-causing pathogens; useful with resistance to amoxicillin.
Administer with meals; follow with yogurt.

Dosing

Adult

100-400 mg PO bid

Pediatric

10 mg/kg/d PO divided bid; not to exceed 800 mg/d

Interactions

May increase nephrotoxicity in patient receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases nephrotoxic potential; antacids and H2-receptor blockers may decrease absorption; probenecid may increase serum levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer half dose if CrCl is 10-30 mL/min and one-quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy

Cefdinir (Omnicef)

Used to treat acute maxillary sinusitis. Classified as a third-generation cephalosporin and inhibits mucopeptide synthesis in the bacterial cell wall. Typically bactericidal, depending on organism susceptibility, dose, and serum or tissue concentrations.

Dosing

Adult

600 mg PO qd or divided bid

Pediatric

14 mg/kg/d PO qd or bid; not to exceed 600 mg/d

Interactions

May increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer half dose if CrCl is 10-30 mL/min and one-quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy

Azithromycin (Zithromax)

Has better coverage against Haemophilus species than erythromycin.

Dosing

Adult

500 mg PO first day, 250 mg/d next 4 d
Alternatively, 500 mg/d IV

Pediatric

10 mg/kg PO first d, 5 mg/kg/d PO next 4 d; not to exceed adult dose

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Vancomycin (Vancocin, Lyphocin)

Provides good coverage for resistant S pneumoniae.

Dosing

Adult

1 g IV q12h

Pediatric

10 mg/kg IV q6h; not to exceed adult dose

Interactions

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure and neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given as 2-h administration or as PO or IP administration; red man syndrome is not an allergic reaction

Clindamycin (Cleocin)

Good for polymicrobial infections and in cases of S pneumoniae resistance shown to be sensitive by culture; poor activity against Haemophilus species.

Dosing

Adult

150-450 mg PO qid
600-900 mg IV q8h

Pediatric

8-20 mg/kg/d PO divided tid/qid
20-40 mg IV divided q6-8h

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

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.

Multimedia

Media file 1: Preseptal cellulitis of the left eye. Courtesy of Dwight Jones, MD.

Media file 2: Axial CT scan of subperiosteal abscess of the left eye.

Media file 3: Coronal CT scan of subperiosteal abscess of the left eye.

Media file 4: Coronal CT scan of superior subperiosteal abscess of the left eye.

Media file 5: Axial CT scan of orbital cellulitis of the right eye.

References

1. Kay DJ, Rosenfeld RM. Quality of life for children with persistent sinonasal symptoms. Otolaryngol Head Neck Surg. Jan 2003;128(1):17-26. [Medline].

2. Shin KS, Cho SH, Kim KR, et al. The role of adenoids in pediatric rhinosinusitis. Int J Pediatr Otorhinolaryngol. Nov 2008;72(11):1643-50. [Medline].

3. Sivasli E, Sirikci A, Bayazyt YA, et al. Anatomic variations of the paranasal sinus area in pediatric patients with chronic sinusitis. Surg Radiol Anat. Feb 2003;24(6):400-5. [Medline].

4. Bhattacharyya N, Jones DT, Hill M, Shapiro NL. The diagnostic accuracy of computed tomography in pediatric chronic rhinosinusitis. Arch Otolaryngol Head Neck Surg. Sep 2004;130(9):1029-32. [Medline].

5. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. Aug 2008;122(2 Suppl):S1-84. [Medline].

6. American Academy of Pediatrics, Subcommittee on Management of Sinusitis and Comm. Clinical practice guideline: management of sinusitis. Pediatrics. Sep 2001;108(3):798-808. [Medline].

7. Anon JB. Acute bacterial rhinosinusitis in pediatric medicine: current issues in diagnosis and management. Paediatr Drugs. 2003;5 Suppl 1:25-33. [Medline].

8. Barbero GJ. Gastroesophageal reflux and upper airway disease. Otolaryngol Clin North Am. Feb 1996;29(1):27-38. [Medline].

9. Bothwell MR, Parsons DS, Talbot A, Barbero GJ, Wilder B. Outcome of reflux therapy on pediatric chronic sinusitis. Otolaryngol Head Neck Surg. Sep 1999;121(3):255-62. [Medline].

10. Buchman CA, Yellon RF, Bluestone CD. Alternative to endoscopic sinus surgery in the management of pediatric chronic rhinosinusitis refractory to oral antimicrobial therapy. Otolaryngol Head Neck Surg. Feb 1999;120(2):219-24. [Medline].

11. Clement PA, Bluestone CD, Gordts F, et al. Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996. Arch Otolaryngol Head Neck Surg. Jan 1998;124(1):31-4. [Medline].

12. Dohlman AW, Hemstreet MP, Odrezin GT, Bartolucci AA. Subacute sinusitis: are antimicrobials necessary?. J Allergy Clin Immunol. May 1993;91(5):1015-23. [Medline].

13. Garbe E, LeLorier J, Boivin JF, Suissa S. Inhaled and nasal glucocorticoids and the risks of ocular hypertension or open-angle glaucoma. JAMA. Mar 5 1997;277(9):722-7. [Medline].

14. Gilger MA. Pediatric otolaryngologic manifestations of gastroesophageal reflux disease. Curr Gastroenterol Rep. Jun 2003;5(3):247-52. [Medline].

15. Goldsmith AJ, Rosenfeld RM. Treatment of pediatric sinusitis. Pediatr Clin North Am. Apr 2003;50(2):413-26. [Medline].

16. Gross CW, Gurucharri MJ, Lazar RH, Long TE. Functional endonasal sinus surgery (FESS) in the pediatric age group. Laryngoscope. Mar 1989;99(3):272-5. [Medline].

17. Gungor A, Corey JP. Pediatric sinusitis: a literature review with emphasis on the role of allergy. Otolaryngol Head Neck Surg. Jan 1997;116(1):4-15. [Medline].

18. Gwaltney JM Jr. Combined antiviral and antimediator treatment of rhinovirus colds. J Infect Dis. Oct 1992;166(4):776-82. [Medline].

19. Herrmann BW, Forsen JW Jr. Simultaneous intracranial and orbital complications of acute rhinosinusitis in children. Int J Pediatr Otorhinolaryngol. May 2004;68(5):619-25. [Medline].

20. Kaliner MA, Osguthorpe JD, Fireman P, et al. Sinusitis: bench to bedside. Current findings, future directions. J Allergy Clin Immunol. Jun 1997;99(6 Pt 3):S829-48. [Medline].

21. Knutsson U, Stierna P, Marcus C, Carlstedt-Duke J, Carlstrom K, Bronnegard M. Effects of intranasal glucocorticoids on endogenous glucocorticoid peripheral and central function. J Endocrinol. Feb 1995;144(2):301-10. [Medline].

22. Lesserson JA, Kieserman SP, Finn DG. The radiographic incidence of chronic sinus disease in the pediatric population. Laryngoscope. Feb 1994;104(2):159-66. [Medline].

23. Mabry RL, Marple BF, Mabry CS. Outcomes after discontinuing immunotherapy for allergic fungal sinusitis. Otolaryngol Head Neck Surg. Jan 2000;122(1):104-6. [Medline].

24. Mair EA, Bolger WE, Breisch EA. Sinus and facial growth after pediatric endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg. May 1995;121(5):547-52. [Medline].

25. Manning S. Surgical intervention for sinusitis in children. Curr Allergy Asthma Rep. May 2001;1(3):289-96. [Medline].

26. Manning SC. Chronic sinusitis as a manifestation of primary immunodeficiency in adults. Am J Rhinol. 1994;8:29-34.

27. Manning SC. Medical management of infectious and inflammatory disease. In: Cummings CW, et al, eds. Otolaryngology: Head and Neck Surgery. Vol 2. 3^rd ed. St. Louis: Mosby; 1998:1135-1144.

28. Manning SC. Paranasal sinus disease in children. Otolaryngol Head Neck Surg. 1993;171-176:1.

29. McAlister WH, Lusk R, Muntz HR. Comparison of plain radiographs and coronal CT scans in infants and children with recurrent sinusitis. AJR Am J Roentgenol. Dec 1989;153(6):1259-64. [Medline].

30. McCormick DP, John SD, Swischuk LE, Uchida T. A double-blind, placebo-controlled trial of decongestant-antihistamine for the treatment of sinusitis in children. Clin Pediatr (Phila). Sep 1996;35(9):457-60. [Medline].

31. Meltzer EO. To use or not to use antihistamines in patients with asthma. Ann Allergy. Feb 1990;64(2 Pt 2):183-6. [Medline].

32. Milczuk HA, Dalley RW, Wessbacher FW, Richardson MA. Nasal and paranasal sinus anomalies in children with chronic sinusitis. Laryngoscope. Mar 1993;103(3):247-52. [Medline].

33. Muntz HR. Allergic fungal sinusitis in children. Otolaryngol Clin North Am. Feb 1996;29(1):185-22. [Medline].

34. Parsons DS. Chronic sinusitis: a medical or surgical disease?. Otolaryngol Clin North Am. Feb 1996;29(1):1-9. [Medline].

35. Pipkorn U, Proud D, Lichtenstein LM, Kagey-Sobotka A, Norman PS, Naclerio RM. Inhibition of mediator release in allergic rhinitis by pretreatment with topical glucocorticosteroids. N Engl J Med. Jun 11 1987;316(24):1506-10. [Medline].

36. Rosenfeld RM. Pilot study of outcomes in pediatric rhinosinusitis. Arch Otolaryngol Head Neck Surg. Jul 1995;121(7):729-36. [Medline].

37. Sanclement JA, Webster P, Thomas J, Ramadan HH. Bacterial biofilms in surgical specimens of patients with chronic rhinosinusitis. Laryngoscope. Apr 2005;115(4):578-82. [Medline].

38. Shapiro GG, Virant FS, Furukawa CT, Pierson WE, Bierman CW. Immunologic defects in patients with refractory sinusitis. Pediatrics. Mar 1991;87(3):311-6. [Medline].

39. Tanner SB, Fowler KC. Intravenous antibiotics for chronic rhinosinusitis: are they effective?. Curr Opin Otolaryngol Head Neck Surg. Feb 2004;12(1):3-8. [Medline].

40. Ungkanont K, Damrongsak S. Effect of adenoidectomy in children with complex problems of rhinosinusitis and associated diseases. Int J Pediatr Otorhinolaryngol. Apr 2004;68(4):447-51. [Medline].

41. Vandenberg SJ, Heatley DG. Efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg. Jul 1997;123(7):675-8. [Medline].

42. Vazquez E, Creixell S, Carreno JC, et al. Complicated acute pediatric bacterial sinusitis: Imaging updated approach. Curr Probl Diagn Radiol. May-Jun 2004;33(3):127-45. [Medline].

43. Wolf G, Anderhuber W, Kuhn F. Development of the paranasal sinuses in children: implications for paranasal sinus surgery. Ann Otol Rhinol Laryngol. Sep 1993;102(9):705-11. [Medline].

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

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

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.

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

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)