Medical Treatment of Pediatric Sinusitis Clinical Presentation

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.

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. ^[6]

• 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.

A study by Min et al indicated that the clinical features of pediatric chronic sinusitis differ between adolescent and preadolescent patients. The investigators found, for example, that adolescents more often experienced cough, nasal obstruction, and septal deviation, while preadolescents more commonly suffered sleep disturbances and exhibited larger tonsils. Moreover, preadolescents had higher total computed tomography (CT) scan scores and serum total immunoglobulin E levels. The study included 195 patients. ^[7]

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. ^[8]

• 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.

  • A prospective, nonrandomized study by Anfuso et al indicated that in children with a combination of chronic rhinosinusitis and asthma, the inflammatory response in the upper airway mucosa is more severe than it is in pediatric chronic rhinosinusitis patients without asthma, suggesting that sinus disease treatment is essential to addressing chronic asthma in pediatric patients. The study involved 28 children with chronic rhinosinusitis, some of whom also had asthma, as well as 10 controls. ^[9]

• 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.