PAEDIATRIC SINUSITIS
Dr. (Major) K. Nagaraju*, Paediatric Allergist**
Kanchi Kamakoti Child's Trust Hospital, Chennai.*, Kanchi Kamakoti Child's Trust Hospital, Chennai.**
Introduction

Sinusitis

can be defined as an inflammation of the mucosal surface of the paranasal sinuses.

Classification:


Sinusitis may be classified in at least two ways, based on the time span of the problem (acute, subacute, or chronic) and the type of inflammation (either infectious or non-infectious).
Acute sinusitis is usually defined as being of less than thirty days duration; subacute sinusitis as being over one month but less than three months; chronic sinusitis as being greater than three months duration. Subacute and chronic forms of sinusitis usually are the result of incomplete treatment of an acute sinusitis.

Infected sinusitis is usually caused by uncomplicated virus infection. Far less frequently bacterial growth causes sinusitis. Non-infectious sinusitis can be caused by irritants and allergic conditions.

Anatomy:


The most important element in development of sinusitis is the ostiomeatal complex consisting of the outflow tracts of all of the sinuses into the nose, but most importantly the maxillary and ethmoid sinuses. Depending on the anatomy of the outflow tract (diameter, length, as well as configuration), obstruction may occur causing a sinusitis, both in the maxillary as well as ethmoid, frontal and sphenoid sinusitis.

The most common site of sinusitis is the ethmoid sinuses, which typically occurs as a result of obstruction of Mucociliary drainage, which then causes a secondary maxillary sinusitis.

Sinusitis involving the sphenoid sinus typically is unusual in children under age 5 yrs and frontal sinusitis typically does not occur until age 10, as a result of development of those sinuses in children at these ages.

Physiology:


The cilia move mucus toward the naturally occurring ostium. If the cilia are interfered with, stagnation of mucus typically will occur. Such can occur with exposure to noxious agents such as tobacco smoke. In situations where the ostia are obstructed, such as with inflammation, viruses, allergic rhinitis, foreign bodies, and polyps, Mucociliary clearance will be impaired. The reduction in patency of the ostium typically will cause a reduction in oxygen content within the sinuses, increasing the likelihood of bacterial overgrowth. In situations where nasal breathing is obstructed, a dramatic reduction in oxygen content within the sinuses will also occur.

A change in air pressure inside the sinuses will cause localized pain. This can occur both from obstruction of the ostia and increased mucus production, as well as a change in air pressure.
Points to remember
  1. Exposure to environmental exacerbating agents can be a problem in children.
  2. Exposure to tobacco smoke in the home can be a major problem.
  3. Day care can be a major factor in some younger children. Removal from day care for a period of time may be helpful.
  4. In older kids, exposure in school is often a problem, both from exposure to viruses, as well as due to problems with exposure to allergens.

Bacteriology:

The most common isolates in sinusitis are due to S. Pneumoniae, H. Influenzae, M. Catarrhalis, S. Pyogenes, and S. Aureus as well as anaerobes and Gram negative bacteria. The first three organisms are most commonly isolated, whereas the others more commonly occur in chronic sinusitis.

Fungal sinusitis may cause acute infection especially in immunocompromised patients.
Clinical manifestations
Symptoms of acute sinusitis are purulent or non-purulent nasal drainage (either rhinorrhea or post nasal drip), nasal blockage, the sensation of swelling in the nose or sinuses, ear symptoms, dizziness, difficulty concentrating, pain in the teeth, halitosis, pain on leaning over, fever, headache, cough, malaise, pharyngitis, etc. Gastrointestinal and even psychiatric symptoms are not unusual due to swallowing mucus.

Symptoms of a chronic sinusitis may vary, but typically will involve one or more of the symptoms of an acute sinusitis. Symptoms are typically less severe in chronic sinusitis. It is typical that chronic sinusitis symptoms may wax and wane and have a tend3ency to be relatively minimal.
Physical Examination

Evaluation of the respiratory tract

may in some cases be completely normal, however more commonly, patients will have one or more of the following symptoms: nasal turbinate swelling and erythema and injection, mucus, tenderness over the sinuses, allergic shiners, pharyngeal erythema or erythema of the lymphoid follicles in the pharynx, otitis, lymphoid hypertrophy, etc. Signs of asthma are not at all unusual.

Examination of nose by anterior rhinoscopy along with a nasal speculum is often inadequate in evaluating sinusitis. However with the newer, narrower endoscopes, it is often possible to visualize the mucosal surface inside the maxillary or sphenoid sinus in over 50% of patients. Because otitis commonly occurs in patients with sinusitis, ear examination is extremely important.

Nasal polyps also can obviously contribute to nasal congestion and predispose to sinusitis. It is common that these cannot be seen on anterior nasal examination and must be evaluated via nasal endoscopy and CT scan in order to provide adequate evaluation and treatment. Nasal polyps occurring in children should raise the suspicion of cystic fibrosis which should be evaluated. In patients who have chronic sinusitis, other evaluations are often necessary including immunodeficiency, allergies, dysmotile cilia and foreign bodies.

Endoscopic rhinoscopy

is used to evaluate the upper nasal airway down to the level of vocal chords. It gives information about polyps, septal deviation, adenoidal enlargement, bony spurs, turbinate hypertrophy, obstructed meatus, septal perforation, etc. can be helpful in evaluating the proper course of treatment.
Imaging
Plain films are now rarely done, although occasionally in patients with acute sinusitis they may be helpful. Because of the fact that in many institutions, CT scans may be obtained for approximately 50% more in cost than plain films, for the most part limited CT scans with coronal views are commonly done. Typically views may be primarily focused on the area of the ostiomeatal complex. Caution must be observed as viral URI's have been demonstrated to cause thickening of the mucosal lining on CT scan analogous to findings with sinusitis. MRI scans are generally less useful except in fungal disease.

Laboratory tests



Nasal cytology can be extremely helpful and is an extremely inexpensive diagnostic tool. Cytology can differentiate between allergic disease or fungal sinusitis with eosinophils versus neutrophils in the case of bacterial sinusitis. Evaluation for cystic fibrosis in children may need to be made under appropriate circumstances. Ciliary dysfunction may need to be considered in patients with recurrent sinusitis. The saccharine test, may be helpful in assessing Mucociliary dysfunction.

Immunodeficiency evaluation in patients with recurrent sinusitis, otitis or pneumonia is indicated including total immunoglobulin levels and possibly immunoglobulin subtypes. Antibody responses to Hemophilus. Tetanus/diphtheria and Pneumovax, may be useful. HIV assessment may also need to be made in appropriate patients.
Associated Diseases

Allergic rhinitis


Allergic rhinitis commonly occurs in association with sinusitis, and sinusitis may also cause worsening of associated allergic rhinitis. Patients with recurrent sinusitis should be evaluated for allergies to appropriate food and inhalant allergens and may necessitate treatment with environmental controls, antihistamines, and allergy immunotherapy in addition to medications commonly used in treatment of sinusitis.

Exacerbation of Asthma


Patients with sinusitis commonly may have worsening of symptoms at night which may cause exacerbation of nocturnal asthma. Sinusitis may cause worsening of asthma as a result of the sino-bronchial reflex, mouth breathing, post-nasal drip containing inflammatory chemicals from the sinuses, and infectious material dripping into the lungs.

G.O. Reflux


Reflux symptoms can exacerbate sinusitis and must be evaluated.
Treatment

Intranasal Steroids


Intranasal steroids form an important part of the treatment of most patients with acute and chronic sinusitis, although studies evaluating the efficacy have not been conclusive. Patients commonly note improvement in symptoms within several days and initially may need o.d. or b.i.d. dosing, but eventually treatment can be tapered down to several times per week. Systemic steroids are typically used in patients with more severe disease, but most of the times are not necessary. There are a large number of steroids available now, and the physician must develop familiarity with them to determine which ones work best.

Decongestants
Oral decongestants typically reduce mucosal edema and increase the patency of the ostia. Topical decongestants must be used with caution, may be used for 3-7 days. Longer use may cause rebound and rhinitis medicamentosa.

Mucolytics
Guaifenesin in high doses is often helpful in increasing clearance of secretions as well as thinning secretions. Efficacy has not clearly been proven, but most practitioners find that it is helpful.

Buffered saline lavage may help in clearing secretions. Hot steam is often helpful, especially at night.

Antihistamines


Antihistamines must be used cautiously as a result of drying of secretions which may then remain inside the sinuses. In patients with significant allergic symptoms, antihistamines do clearly have a place in treatment.

Adjunctive Treatment


A variety of non-medicinal agents have been used in order to treat sinusitis. Among the more popular ones are eucalyptus oil which when smelled may increase mucociliary clearance. Some patients have also claimed that garlic, vitamin C, multivitamins, Echinacea, quercetin, etc. but have not been proven scientifically.

Antibiotics


Antibiotics alone should not be relied upon to clear sinusitis. Antibiotic penetration into the sinuses is relatively poor, comparable to osteomyelitis. As a result, treatment generally must continue for at least two weeks in acute sinusitis and at least three weeks in chronic sinusitis. Generally, we treat patients for at least one week after symptoms have resolved. Medications must be based on the likelihood of resistant organisms, previous antibiotics used, duration of treatment, allergies, etc. Amoxicillin, sulfamethoxazole/trimethoprim, in children are reasonable to use and inexpensive for initial treatment. In patients with acute sinusitis, antibiotic coverage must include resistant S. Pneumonia, H. Influenza, M. Catarrhalis and S. Aureus. Appropriate antibiotics may also initially include amoxicillin/clavulanic acid, cefaclor, cefuroxime axetil and azithromycin. In patients with chronic sinusitis, consideration must also be given to anaerobic and gram-negative coverage. Patients who are suspected of having anaerobes may need to be treated with clindamycin or metronidazole. Treat patients on antibiotics for 4-5 days, and if they have not responded, after the regimen. Often patients will need multiple antibiotics, either sequentially or simultaneously. Prophylactic antibiotics remain controversial as resistant organisms and fungal sinusitis may occur despite treatment.
Recurrent Sinusitis
In patients who have recurrent infections, it is important to evaluate for immunodeficiency by an allergist/immunologist. Evaluation for cystic fibrosis may also need to be made, especially in situations where more unusual organisms occur or if the child has nasal polyps. Evaluation may also need to be made for allergy, gastroesophageal reflex and diseases of the cilia. Cultures from the middle meatus may be helpful in situations where there is no initial response to medications.

IVIG
Intravenous gammaglobulin is appropriate in patients who have recurrent sinusitis with appropriate immune deficiencies. Routine immunoglobulin treatment in patients without immunodeficiencies has not been found to be helpful, is expensive, and very difficult to terminate.

Surgery


Patients who have not responded adequately with optimal medical treatment including medications, allergy evaluation, and immunological evaluation, a surgical consultation is indicated. Surgery in children is done much less frequently than in adults, but in situations such as abscess, cellulites of the orbit, or intracranial abscess, surgery may be necessary. It is also done more frequently in patients with cystic fibrosis. Mini FESS is indicated in children; with minimal disturbance to the anatomy of growing bones. Surgery does not prevent future episodes of sinusitis. The ostium is enlarged, therefore providing adequate drainage. It is analogous to draining an abscess. A significant number of children with chronic sinusitis may also have adenoidal or tonsillar enlargement which may require surgery.

Antral Lavage
Antral lavage is generally considered an outdated technique because the lavage is only helpful for the maxillary and not the more frequently involved ethmoid sinuses. However in children, lavage with adenoidectomy is sometimes done to avoid sinus surgery. Antral puncture is done in order to more accurately determine the bacteria causing the infection.

Immunotherapy


In patients with allergies, it is important to manage the allergic problems, including immunotherapy as needed.
Conclusion
  1. Sinusitis is inflammation of the paranasal sinuses in the skull.
  2. Sinusitis can cause pain in the face, teeth or head.
  3. Sinusitis can be infectious or non-infectious.
  4. Infected sinusitis is usually caused by uncomplicated virus infection.
  5. Bacterial infection of the sinuses is suspected when facial pain, nasal discharge of pus and symptoms persisting for longer than a week and are not responding to over-the-counter nasal medications.
  6. Bacterial sinusitis is usually treated with antibiotic therapy.
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