Further Outpatient Care
See the list below:
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Family support is essential in treating this disorder.
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Just giving medication to a child can be taxing on all involved, so the less frequent dosing the better.
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Management of chronic sinusitis or an associated condition may be very labor intensive.
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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.
Further Inpatient Care
See the list below:
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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.
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:
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Preseptal cellulitis - Eyelid edema, erythema, normal globe movement
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Orbital cellulitis - Proptosis, chemosis
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Periorbital abscess - Proptosis with globe displaced inferolaterally, decreased extraocular muscle movement
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Orbital abscess - Severe proptosis, impaired visual acuity, fixed globe, toxic patient
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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.
In a literature review of patients under age 18 years with subperiosteal abscess secondary to acute sinusitis, Adil et al reported that large abscess volume is the most significant predictor for surgical drainage. Looking at volumes above the threshold size specified in individual studies, the investigators found the likelihood of such intervention, as measured using a pooled risk ratio, to be more than three times that for patients with smaller-sized abscesses. Proptosis and gaze restriction were also significant risk factors for surgical drainage. [20]
A study by Miranda-Barrios et al of patients under age 16 years indicated that clinical characteristics and C-reactive protein (CRP) levels can be used to differentiate preseptal from orbital cellulitis. Pediatric study patients with preseptal cellulitis had a mean age of 3.9 years, versus 7.5 years in those with orbital cellulitis, while fever and preexisting sinusitis were present in, respectively, 51.5% and 2% of patients with preseptal sinusitis, versus, respectively, 82.2% and 77.8% of individuals with orbital cellulitis. Diplopia, ophthalmoplegia, and proptosis were found only in cases of orbital cellulitis, and the median CRP median levels were 17.85 and 136.35 mg/L in preseptal and orbital cellulitis, respectively. [21]
A study by Karakas et al of 16 pediatric patients with cavernous sinus thrombosis found that clinical variables, specifically age, gender, antibiotic use, anticoagulation, surgery, parenchymal abnormalities, the presence of additional cerebral venous thrombosis, and time at which anticoagulation commenced (early vs late), did not significantly affect whether there was full/partial resolution or no resolution of the thrombosis. [22]
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
See the list below:
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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.
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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.
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Preseptal cellulitis of the left eye. Courtesy of Dwight Jones, MD.
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Axial CT scan of subperiosteal abscess of the left eye.
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Coronal CT scan of subperiosteal abscess of the left eye.
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Coronal CT scan of superior subperiosteal abscess of the left eye.
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Axial CT scan of orbital cellulitis of the right eye.
