Sinusitis in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Template:Archana Y Vajjala

Synonyms and keywords: Sinusitis in kids, Sinusitis in children , Pediatric rhinosinusitis, Pediatric sinusitis

Overview

• Rhinosinusitis is an inflammation of the paranasal and nasal sinus mucosae which is a very common condition encountered in children.

Historical Perspective

• Rhinosinusitis was first coined by Task Force of Rhinology and Paranasal Sinus Committee, in 1997 as sinusitis is invariably accompanied by rhinitis.

Classification

• Anatomically paranasal sinuses are classified in to [four] paired sinuses, divided into subgroups that are named according to the bones within which the sinuses lie. The paranasal air sinuses are lined with respiratory epithelium (ciliated pseudostratified columnar epithelium).

• Maxillary Sinuses, the largest of the paranasal sinuses, are under the eyes, in the maxillary bones (open in the back of the semilunar hiatus of the nose). They are innervated by the trigeminal nerve (CN Vb)

• Frontal Sinuses, superior to the eyes, in the frontal bone, which forms the hard part of the forehead. They are also innervated by the trigeminal nerve (CN Va)

• Ethmoidal Sinuses, which are formed from several discrete air cells within the ethmoid bone between the nose and the eyes. They are innervated by the ethmoidal nerves, which branch from the nasociliary nerve of the trigeminal nerve (CN Va)

• Sphenoidal Sinus, in the sphenoid bone. They are innervated by the trigeminal nerve (CN Va & Vb)

• Sinusitis is classified into four subtypes/groups:

• Acute Rhinosinusitis Sudden onset, lasting less than 4 weeks with complete resolution.

• Subacute Rhinosinusitis A continuum of acute rhinosinusitis but less than 12 weeks.

• Recurrent Acute Rhinosinusitis Four or more episodes of acute, lasting at least 7 days each, in any 1-year period.

• Chronic Rhinosinusitis Signs of symptoms persist 12 weeks or longer.

Pathophysiology

• Most commonly a viral upper respiratory infection causes rhinosinusitis secondary to edema and inflammation of the nasal lining and production of thick mucus that obstructs the paranasal sinuses and allows a secondary bacterial overgrowth. Allergic rhinitis can lead to sinusitis also due to ostial obstruction. Ciliary immobility can lead to increased mucus viscosity, further blocking drainage. Bacteria are introduced into the sinuses by coughing and nose blowing. Bacterial sinusitis usually occurs after a viral upper respiratory infection and worsening symptoms after 5 days, or persistent symptoms after 10 days. A key concept in understanding the pathogenesis of acute bacterial sinusitis is that the nasal and nasopharyngeal mucosae are continuous with the paranasal sinus mucosa. Any process that affects the nasal mucosa may also affect the sinus mucosa; The mucosa consists of mucus secreting goblet cells and pseudo-stratified ciliated columnar epithelium. The role of the mucus covering the mucosa is to catch the dust, stimulating particles and microorganisms. The drainage of mucus is by active mucociliary transport, and not by gravity. Nasal secretions originate from goblet cells, epithelial cells, epithelial cell proteins, vascular transudation and lacrimal fluid. The essential protein parts of these secretions are mucin glycoproteins composed of oligosaccharide side chains and a peptide core structure. Those glycoproteins affect the composition of the mucus and facilitate the interaction between microorganisms and host. Mucin binds surface adhesins on microorganisms therefore inhibiting their ability to colonize the epithelium. Mucociliary movement transports mucus from the paranasal sinuses to the nasal cavity and pharynx where it is swallowed. The large nasal mucosal surface consists of a mucus layer that moistens the air flowing over it and filters the air particles. In the nasal submucosa, vascular plexi swell and produce nasal congestion after exposure to certain stimuli such as noxious or allergic triggers, and temperature changes.

Causes

[Rhinosinusitis] predisposed by a number of local and systemic factors. Any local condition that interferes with normal sinus drainage predisposes to the development of infection. Obstruction of the sinus outflow tract may be due to mucosal swelling (allergic rhinitis, viral URI) or mechanical obstruction (nasal polyp, foreign body, tumor, anatomic abnormality). Instrumentation (with nasotracheal, nasogastric, orotracheal, or orogastric tubes) is an essential risk factor for ABRS.

[Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3]. OR The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4]. OR The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Differentiating [disease name] from other Diseases

For further information about the differential diagnosis, click here.

Epidemiology and Demographics

There are higher rates of sinusitis in the South, Midwest, and among women.

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [sinusitis].
• [Sinusitis] is more commonly observed among children younger than 15 years of age and adults aged [25 to 64] years.

Gender

• Women are more commonly affected with sinusitis than men.

Race

• There is no racial predilection for [sinusitis].

Risk Factors

• Local predisposing factors

• Allergic rhinitis
• URI
• Anatomic abnormality
  • Deviated septum
  • Concha bullosa
  • Enlarged adenoid
• Nasal polyps
• Tumor
• Foreign body
• Trauma
• Barotrauma
• Diving, swimming
• Smoke
• Topical decongestant abuse
• Nasal intubation, Nasogastric tube

• Systemic predisposing factors

  Immune deficiency

  • IgA deficiency

    Panhypogammaglobulinemia

    IgG subclass deficiency

    HIV

  Cystic fibrosis

  Ciliary disorder

Natural History, Complications and Prognosis

• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].

• If left untreated, [many] of patients with [rhinosinusitis] may progress to develop [chronic rhinosinusitis].

• Common complications of [sinusitis] include

• Orbit (optic neuritis, orbital and periorbital cellulitis, Orbital and subperiostealabscess)
• Central nervous system (meningitis, subdural and epidural empyema, brain abscess andvenous sinus thrombosis)
• Bone (maxillaryosteitis, frontal osteitis (Pott puffy tumor))

Diagnosis

Diagnostic Criteria

The IDSA guidelines suggest that ABRS can be diagnosed with each of the following clinical scenarios:

• URI symptoms lasting more than 10 days without any improvement;

• Severe onset of signs and symptoms lasting more than 3-4 consecutive days, like high grade fever (>39°C),facial pain or purulent nasal discharge;

• Worsening of signs and symptoms following a typical viral URI that lasted 5-6 days and were initially improving, like new onset of fever, headache, or increase in nasal discharge “double-sickening”.

• The diagnosis of [Sinusitis] is made when at least [number] of the following [number] diagnostic criteria are met:

• [criterion 1]

• [criterion 2]

• [criterion 3]

• [criterion 4]

Symptoms

• [Disease name] is usually asymptomatic.

• Symptoms of [disease name] may include the following:

• [symptom 1]

• [symptom 2]

• [symptom 3]

• [symptom 4]

• [symptom 5]

• [symptom 6]

Physical Examination

• Patients with [disease name] usually appear [general appearance].

• Physical examination may be remarkable for:

• [finding 1]

• [finding 2]

• [finding 3]

• [finding 4]

• [finding 5]

• [finding 6]

Laboratory Findings

Diagnosis of rhinosinusitis in children is not easy. It should be suspected when cold does not improve beyond 10 days or nasal stuffiness is present with purulent discharge, facial pain, headache, fever, and diminution/loss of sense of smell. Dental, ear, or eye problems, allergies, or environmental pollutants can produce similar symptoms and cause confusion. Sneezing and nasal itching are common with allergic rhinitis. In these children with isolated allergic rhinitis, purulent nasal discharge is usually not seen. In those children of allergic rhinitis with superadded sinusitis, the picture is altered, and along with nasal itching and sneezing, purulent nasal secretions and loss of olfaction sense may also be associated. Allergic rhinitis is not uncommonly seen associated with sinusitis; hence a search for triggering allergies needs to be performed in children presenting with rhinosinusitis. Anterior rhinoscopy and fibreoptic nasal endoscopy may be useful for accurate assessment of the middle meatus pathologies and detection of associated adenoiditis, nasal polyps, or nasal masses. This can also be used to collect specimen for testing secretions or mucosa. Patient cooperation is of utmost importance for these procedures.

Transillumination of sinuses is useful in hands of experienced person. In this, a flashlight is placed against the patient's cheek and the doctor looks into the patient's open mouth. A lit-up reddened area is seen in the palatal area with normal sinuses. When sinuses are fluid-filled, this reddened area will not be visualized. Near-infrared light (750–1100 nm) can penetrate deeper and permit enhanced illumination of deeper structures. But since this light is invisible normally, a charge-coupled device camera is used to capture and record images. This technique has been found to be a safe, reliable, low-cost, and simple aid for diagnosis of sinusitis.

Plain radiography of paranasal sinuses can be performed, but it has a limited diagnostic role. Water and Caldwell-Luc's views are taken for sinusitis. Haziness, opacification, or fluid level is suggestive of sinusitis. CT scan of sinuses gives a better visualization and is a useful tool preoperatively. Limited axial and coronal cuts ordinarily suffice. Contrast is reserved for suspected suppuration. CT scan can pick up noninvasively ostiomeatal anomalies with great accuracy. Mucosal changes, intrasinus collections or growths, and adjacent bone changes can be visualized. Soft-tissue algorithms of CT scan reveal heterogeneity of signal intensity in AFS. Accumulations of heavy metals (iron, manganese, calcium) within the allergic mucin elicit enhanced signals. For orbital and intracranial extensions or in AFS, MRI is more informative. In AFS, allergic mucin is hyperdense on T1W1 images with signal void on T2 imaging. USG can be used for assessment of maxillary sinuses, but results are found to be inconsistent.

In acute cases, complete blood count, ESR, and blood cultures provide useful data. Tests for allergy, immunodeficiency, cystic fibrosis, and immotile cilia syndrome assist to detect associated conditions. In AFS, total serum IgE and skin or in vitro tests for fungi and common allergens are usually positive . For collection of specimen for culture from the maxillary sinus, a maxillary sinus puncture is the standard criterion. However, it is painful, needs patient cooperation, and can be done only under anaesthesia in children. Culture swabs obtained from middle meatus or anterior middle turbinate correlate well with cultures from maxillary or ethmoid sinuses. However, random nasal swab cultures bear no correlation with maxillary sinus cultures. Gram-staining, aerobic and anaerobic cultures, and fungal cultures can be performed on the collected swabs to guide appropriate antimicrobial therapy. Flexible endoscopes are also employed for such specimen collections. Biopsy taken during endoscopic sinus procedures shows submucosal inflammatory infiltrates in acute and chronic rhinosinusitis. In AFS, eosinophils and Charcot-Leyden crystals predominate. A positive fungal culture grown from infected sinuses is not confirmative of allergic fungal sinusitis. The isolated fungi may be a saprophyte, or the method of specimen collection and handling may also influence the yield. Presence of allergic mucin is a reliable pointer towards the disease.

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].

• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].

• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3]. OR There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].

• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• An acute attack of rhinosinusitis is usually self-limiting and recovers with symptomatic treatment and with minimal intervention. Steam inhalation, adequate hydration, instillation of topical decongestants, warm facial packs application, and saline nasal drops are useful. Nasal steroidal or cromolyn drops or sprays improve symptoms in children with concurrent nasal allergy. Environmental pollutants worsen the situation, and hence avoidance of them tends to improve rhinosinusitis. Antibiotics are usually not warranted. A “wait-and-watch” policy for 7–10 days is fruitful and cost-effective. About 90% recover without antibiotics in a week. Antibiotics are reserved for children with severe acute sinusitis, toxic features, suspected complications, or persistence of symptoms. Choice of antibiotics should be guided by local susceptibility studies, safety profile, and child's age. Usual preferred are amoxicillin, coamoxiclav, oral cephalosporins, and macrolide group of antibiotics. 2 weeks course is usually required. Associated conditions should be simultaneously and individually addressed as follows.

• Respiratory allergy. Allergen avoidance, environmental control, topical nasal steroids, second-generation antihistamine, leukotriene receptor antagonist, and immunotherapy are common measures to control allergic rhinitis. Anti-IgE therapy has been found to provide clinical benefit in patients with seasonal allergic rhinitis. Removal of trigger factors from the environment or diet also aid in minimizing asthmatic attacks. Active and/or passive smoking should be curtailed.
• Gastroesophageal reflux. Elevation of the head end of bed, small, frequent and thickened feeds, avoiding near-bedtime feeds, H2-blockers, prokinetic agents, and hydrogen ion pump inhibitors are used to control reflux.
• Cystic fibrosis. Nasal irrigations, nasal steroids, antibiotic courses, nebulized antibiotics, chest physiotherapy, and exercises aid to clear the copious secretions and thwart infections.
• Immunodeficiencies. Aggressive treatment of recurrent infections and regular immunoglobulin infusions could control secondary infections in such patients.
• Immotile cilia syndrome. This requires vigorous removal of secretions which in turn causes a decline in infection rate and associated complications.
• Removal or correction of nasal obstructions.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].

• [Medical therapy 1] acts by [mechanism of action 1].

• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• [Adenoidectomy] is usually the first surgical intervention considered for children with CRS. When appropriate, maximal medical therapy fails or with associated anatomic aberrations, surgical interventions are contemplated in rhinosinusitis.

Management of complications

Intra orbital and intracranial complications are common in chronic sinusitis, and fungal sinusitis with cystic fibrosis and immunodeficient states. Meningitis, abscess, and cavernous sinus thrombosis may occur. Sinusitis may extend to adjacent tissues and cause adenoiditis, serous or purulent otitis media, laryngitis, and dacryocystitis. Osteomyelitis and mucocele formation are also noted. Hospitalization and intravenous antibiotics may be required for treatment of these complications. Prolonged course of antibiotics for 4–6 weeks may be necessitated in some. Cerebral venous thrombosis needs anticoagulation. Nasal decongestants and steroids and nasal saline irrigation may be required for a longer time in such patients even after cessation of antimicrobial therapy. Pollutants, irritants, and allergens in the environment increase symptoms and avoidance of them is of benefit.

Prevention

• Effective measures for the primary prevention of [Sinusitis] include prevention of risk factors can help avoid development of rhinosinusitis. These include environmental pollutants including tobacco smoke, repeated colds and upper airway infections, daycare centre attendance, nasal allergies, and anatomical aberrations.

Acute attacks of rhinosinusitis should be optimally managed to prevent progress to chronicity. Influenza and pneumococcal vaccines could also lead to fall in upper airway infections and hence rhinosinusitis. Swimming in pools with high chlorine content may also worsen mucosal swelling and lining. Hence care should be taken at such places.

Conclusion

• Rhinosinusitis is an upper airway infection with chronic implications. Prompt management of acute cases would prevent cases slipping into chronicity with resistant polymicrobial infections. Management of chronic rhinosinusitis is an expensive, long-term affair with high likelihood of complications. Hence prevention and control of rhinosinusitis will assist in decreasing morbidity and lessen the burden on healthcare expenditure. Achieving sinonasal eutrophism and efficient mucociliary transport is the keystone to sinus health and reduction of recurrences.