SINUSITISIn Pediatric Age Group

Anatomy

MAXILLARY ANT ETHMOID FRONTAL

POST ETHMOID SPHENOID

LACRIMAL DUCTS

MIDDLE MEATUS

SUPERIOR MEATUS

INFERIOR MEATUS

Development

MAXILLARY AND ETHMOID SINUSES DEVELOPS DURING 3RD & 4TH GESTATIONAL MONTH AND GROW IN SIZE UNTIL LATE ADOLESCENCE

SPHENOID SINUS PRESENTS BY 2 YEARS OF AGE

FRONTAL SINUS DEVELOPS DURING 5 AND 6 YRS.

Physiology

THREE KEY ELEMENTS– PATENCY OF THE OSTIA– FUNCTION OF THE CILIARY APPARATUS– QUALITY OF SECRETIONS

Factors Predisposing To Obstruction Of Sinus Drainage.

A. MUCOSAL SWELLING

Systemic disorderViral URIAllergic inflammationCystic fibrosisImmune disorderImmotile cilia

Local insultFacial traumaSwimming, divingRhinitis medicamentosa

B. MECHANICALOBSTRUCTION

Choanal atresiaDeviated septumNasal polypForeign bodyTumorEthmoid bullae

C. MUCUS ABNORMALITIES

Viral URIAllergic inflammationCystic fibrosis

Epidemiology

Occurs during viral respiratory season Attendance at Day Care Center School-age siblings in the household

Symptoms And Signs

PERSISTENT >10 DAYS No appreciable improvement Nasal discharge of any

quality Cough(must be present

during day) Malodorous breath Facial Pain and headache are

rare If fever then low grade May not appear very ill

SEVERE High fever > 39 C And Purulent nasal discharge Present for atleast 3-4 days Headaches may be present Periorbital swelling

occasionally

Subacute Sinusitis

30 days to 4 months Mild to moderate and often intermittent

symptoms Nasal discharge of any quality Cough often worse at night Low-grade fever may be periodic usually

not prominent

Chronic Sinusitis

Extremely protracted nasal symptoms Discharge or congestion or Cough or both Some cases rhinorhhea minimal or absent Nasal congestion-mouth breathing-sore

throat

Chronic Sinusitis

Chronic headache usually on awakening Intermittent fever Malodorous breath Secondary affects

– fatigue, impaired sleep– decreased appetite– irritability

Physical Findings

Mucopurulent discharge in nose or posterior pharynx

Nasal mucosa- erythematous Throat- moderate injection Ears- acute otitis or otitis with effusion Paranasal sinus tenderness- occasionally Periorbital edema-occasionally Malodorous breath

Differential Diagnosis-Purulent Nasal Discharge

Uncomplicated viral URI Group A Strep infection Adenoiditis Nasal foreign body

Differential Diagnosis- Nasal Symptoms Persistent clear nasal discharge or nasal

congestion– Allergic rhinitis- nasal discharge, congestion,

sneezing, itchiness of eyes, nose, other mucous membranes, pale boggy mucosa, Dennies lines, allergic shiners, transverse crease on bridge of nose, headaches

Differential Diagnosis-Nasal Symptoms Nonallergic rhinitis

-resemble allergic rhinitis children -specific allergens cannot be demonstrated, IgE levels normal, radioallergosorbent test negative

Rhinitis Medicamentosa Vasomotor Rhinitis

Differential Diagnosis-Cough

Reactive airway disease GER CF pertussis Mycoplasma bronchitis TB

Diagnosis- Sinus Aspiration

Indications– failure to respond to multiple antibiotics

– severe facial pain

– orbital or intracranial complications

– evaluation of an immunoincompetent host

Material should be sent for quantitative aerobic and anaerobic cultures

Density of atleast 104 colony-forming units/ml represents true infection

Diagnosis-Imaging Standard views

– Anterioposterior– Lateral – Occipitomental

When children older than 1 have neither respiratory signs nor symptoms, their sinus radiographs are almost normal

Findings– acute-diffuse opacification,mucosal thickening of atleast 4 mm, or

an air-fluid level

Significantly abnormal in 88% of children younger than 6

Diagnosis- CT Scans

Frequent abnormalities are found in patients with a “fresh common cold”

Indications– complicated sinus disease(either orbital or CNS

complications)– numerous recurrences– protracted or nonresponsive symptoms(surgery

is being contemplated)

Microbiology

Streptococcus pneumoniae 30-40% Haemophilus influenzae 20% Moraxella catarrhalis 20% Strep pyogenes 4%

Respiratory viral isolates 10% – adenovirus– parainfluenzae– influenzae– rhinovirus

Other rarer isolates- group A strep, group C strep, viridians strep, peptostrep, Moraxella species, Eikenella corrodens

Complications of Acute Bacterial Sinusitis Preseptal cellulitis Orbital cellulitis Osteomyelitis Subperiosteal orbital abscess Subdural or Epidural Empyema Meningitis Brain abscess Cortical thrombophlebitis Cavernous or sagittal sinus thrombophlebitis

Treatment

Amoxicillin Amoxicillin-potassium

clavunate Erythromycin/

sulfisoxazole Sulfamethoxazole/

trimethorphim Cefaclor

Cefuroxime axetil Cefprozil Cefixime Cefpodoxime proxetil Ceftibuten Loracarbef Clarithromycin Erythromycin

Treatment-Antimicrobials

Amoxicillin preferred in most cases Situations when broader treatment appropriate

– failure to improve on amoxicillin

– residence in an area with high prevalence of beta-lactamase producing H.influenzae

– occurrence of frontal or sphenoidal sinusitis

– occurrence of complicated ethmoidal sinusitis

– presentation of very protracted symptoms >30days

Treatment-Most Comprehensive Coverage Amoxicillin/potassium clavunate Erythromycin-sulfisoxazole Cefuroxime axetil Cefpodoxime Proxetil Azithromycin

Treatment

In patients with acute sinusitis 40-50% have spontaneous clinical cure rate

Penicillin-resistant pneumococci serious emerging problem- most susceptible to clindamycin and rifampin

Hospitalization- systemic toxicity or unable to take oral antimicrobials

– cefuroxime

– ampicillin/sulbactam

– cefotaxime and vanc if suspecting penicillin-resistant strep pneumoniae

Treatment

Clinical improvement is prompt If no reduction of nasal discharge or cough

in 48 hours reevaluate Patients with brisk response- 10 days of

treatment If respond more slowly- treat until patient is

symptom free plus 7 more days

Surgery

Rarely required Consider if orbital or central nervous system complications or Failure of maximal medical therapy Functional endoscopic sinus surgery (FESS) 1st stage- removal of uncinate process, ethmoid bulla, and variable

number of anterior ethmoidal cells, maxillary sinus ostium enlarged and frontal recess diseased tissue is removed if present, occasionally a stent is placed

2nd stage- several weeks later- crusting, granulation tissue, adhesions, and stents are removed

Approximately 20-30% of those with extensive mucosal disease do not benefit

Absolute Indications for Surgery

Causing brain abscess or meningitis, subperiosteal/orbital abscess, cavernous sinus thrombosis, another contiguous infection, or an impending complication (Pott’s tumor)

Sinus mucocele or pyocele Fungal sinusitis Nasal polyps (massive ) Neoplasm or suspected neoplasm

Other Medications

Antihistamines, decongestants, and anti-inflammatory agents have not systematically been studied in children

May try these above agents

Recurrent Sinusitis

Most common cause is recurrent viral URIs– day care attendance

– presence of other school age siblings in house

Other predisposing conditions– allergic and nonallergic rhinitis

– CF

– immunodeficiency disorder

– ciliary dyskinesia

– anatomical problem