Sinusitis in children
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Archana Vajjala, M.B.B.S
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
The most common causes of [sinusitis] include conditions 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)
- Mechanical obstruction (nasal polyp, foreign body, tumor, anatomic abnormality).
- Instrumentation (with nasotracheal, nasogastric, orotracheal, or orogastric tubes) is an essential risk factor for ABRS.
Differentiating [Sinusitis] from other Diseases
Differential diagnosis include
- Adenoid hypertrophy
- Adenoiditis
- Benign tumors of the nasal cavity
- Benign tumors of the sinuses
- Ciliary dyskinesia
- Congenital malformations of the sinuses
- Immune deficiency
- Upper respiratory infection
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.
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”.
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
- There are no specific laboratory findings associated with [sinusitis] 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 very sick children, some blood work and cultures may be helpful for determining treatment.
Electrocardiogram
There are no ECG findings associated with [sinusitis].
X-ray
An x-ray may not be helpful in the diagnosis of [sinusitis] as 75% of them are either underestimate or overestimate the 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.
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with [Sinusitis]. However, an echocardiography/ultrasound may be helpful in the diagnosis of of [maxillary sinusitis], but results have been somewhat inconsistent.
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.