Medical Treatment of Pediatric Sinusitis Treatment & Management

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.