Medical Treatment of Pediatric Sinusitis

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.

A prospective cohort study by Santee et al indicated that in children, a history of acute sinusitis is associated with a reduction in the relative abundance of certain taxa in the nasopharyngeal microbiota. In the study, of 47 healthy children aged 49-84 months, significantly depleted species in subjects with a history of acute sinusitis included Faecalibacterium prausnitzii and Akkermansia species, while the relative abundance of the bacterium Moraxella nonliquefaciens in these children was enriched. In addition, the investigators found that children who developed acute sinusitis over the 1-year study period were also characterized by enrichment of M nonliquefaciens.[1]

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.

A study by Gilani and Shin determined that in the United States between 2005 and 2012, in patients aged 0-20 years, there were 5.6 million ambulatory care visits per year for chronic rhinosinusitis. The condition was diagnosed in 2.1% of all pediatric ambulatory care visits, while acute rhinosinusitis was diagnosed in 0.6% of all such visits.[2]

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.[3]

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.

A study by Capra et al found a decrease between 2000 and 2009 in the estimated number of hospital admissions in the United States, from 5338 to 4511, for orbital complications of pediatric rhinosinusitis. The investigators suggested that the introduction of heptavalent pneumococcal vaccine was associated with the slight downward trend. The study also found that the mean patient age among children admitted for rhinosinusitis-related orbital complications rose from 4.77 years to 6.07 years and that the proportion of children who underwent surgery for these complications increased.[4]

A study by Al-Madani et al of 616 patients indicated that in children, acute sinusitis most commonly involves the ethmoid sinus and that orbital complications are more common than they are in adults. The investigators also found that most patients in the study responded well to medical treatment.[5]

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.

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.

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.

See the list below:

• CT scanning

  • CT scanning is the criterion standard for evaluation of both mucosal inflammation and anatomic 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.[10]

  • 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.

See the list below:

• 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.

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.

Antibiotics

Indications for antibiotic therapy for acute sinusitis are as follow:

• Persistent acute sinusitis

• Severe acute sinusitis

• Toxic child with suspected complications

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.

An update by Wald et al to the 2001 American Academy of Pediatrics clinical practice guidelines for the diagnosis and management of acute bacterial sinusitis in children and adolescents included the following changes: (1) a clinical presentation referred to as “worsening course," characterized by worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement; (2) an option in a child with persistent symptoms (ie, nasal discharge and/or daytime cough that last for more than 10 days without improvement) to either treat the patient immediately with antibiotics or observe him or her for 3 days before treating; and (3) a review of evidence that children with uncomplicated acute bacterial sinusitis do not require imaging studies. Amoxicillin with or without clavulanate remains the first-line treatment for acute bacterial sinusitis, according to the report.[11]

A study by Mahalingam et al of 98 patients with periorbital cellulitis secondary to upper respiratory tract infection/sinusitis indicated that treatment of such cellulitis with a combination of ceftriaxone and metronidazole from admission is more effective than therapy with co-amoxiclav or with ceftriaxone alone. The report, which included 72 children and 26 adults, found that patients treated with the ceftriaxone/metronidazole combination had an inpatient stay of 3.8 days, compared with 4.5 and 5.8 days with the other two treatments, respectively.[12]

A study by Fleming-Dutra et al found that, based on the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, sinusitis was responsible for 56 ambulatory antibiotic prescriptions per 1000 population in the United States, the highest rate of such prescriptions for a single diagnosis.[13]

A study by Bergmark and Sedaghat indicated that in the United States, antibiotics are prescribed to more than 50% of patients with acute rhinosinusitis presenting to primary care physicians (PCPs) and emergency departments (EDs). Using the 2005-2010 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys, the study looked at almost 38 million patient presentations to PCPs and EDs for uncomplicated acute rhinosinusitis. The investigators found that among pediatric patients with acute rhinosinusitis, 52.9% of presentations to PCPs and 51.4% of presentations to EDs resulted in antibiotic prescriptions, with the figures for adult patients being 57.0% and 59.1%, respectively.[14]

In a survey of chronic rhinosinusitis treatment in children by pediatric primary care, pediatric otolaryngology, and pediatric urgent care providers, Newton et al reported that 21% of the otolaryngology providers prescribed antibiotic therapy for 7 days past any symptom, compared with 6% and 5% of the primary care and urgent care providers, respectively.[15]

Irrigation

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.[16, 17]

Steroids

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. 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. Venekamp et al, in evaluating the efficacy of systemic steroids in the treatment of adults with acute sinusitis, found some, albeit limited, evidence that if used in combination with antibiotics, oral corticosteroids offer modest, short-term benefit in the relief of acute sinusitis symptoms. However, larger trials are probably needed to establish whether combined treatment with oral steroids and antibiotics is better than treatment with antibiotics alone in acute sinusitis.[18]

Decongestants and antihistamines

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

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.

See the list below:

• 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.

See the list below:

• 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

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.

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.

Antibiotic therapy is the mainstay of medical treatment for pediatric rhinosinusitis.[19] 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.

Class Summary

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.

See the list below:

• 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.

See the list below:

• 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.

See Medical Care and Medication.

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.

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.

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.

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 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.

See the list below:

• 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.