eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Pediatric Sinusitis, Medical Treatment: Treatment & Medication

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

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.

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.

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.

Cefpodoxime (Vantin)

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

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.

Azithromycin (Zithromax)

Has better coverage against Haemophilus species than erythromycin.

Vancomycin (Vancocin, Lyphocin)

Provides good coverage for resistant S pneumoniae.

Clindamycin (Cleocin)

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

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