Practice Essentials
Pediatric sinusitis is a common problem treated by primary care physicians and otolaryngologists. Although this disorder has been addressed for many centuries, full appreciation for its scope, pathophysiology, diagnosis, treatment, and complications has been realized only relatively recently. Children with occasional episodes of acute sinusitis following a routine cold are treated with short courses of antibiotic therapy with good results. However, treatment of chronic and recurrent sinusitis can be more challenging for physicians and frustrating for families. In these cases, the physician must not only treat with an appropriate antibiotic but must also address the associated conditions contributing to the problem.
The goal in treating these children is to combine antibiotic therapy with treatment of associated conditions for a time sufficient to allow resolution of symptoms with return of normal sinus physiology and mucociliary clearance. This article addresses the medical management of pediatric sinusitis.
See the image below.
Signs and symptoms of acute sinusitis
The signs and symptoms of acute sinusitis include, most commonly, daytime cough and rhinorrhea. Other common signs and symptoms include the following:
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Nasal congestion
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Infrequent low-grade fever
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Otitis media (50-60% of patients)
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Irritability
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Headache
Signs of severe infection include the following:
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Purulent rhinorrhea
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High fever (ie, >39°C)
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Periorbital edema
Diagnosis and management of sinusitis
Laboratory tests are normally not 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 a very toxic-appearing child, some blood work and cultures may be helpful for determining treatment.
Computed tomography (CT) scanning is the criterion standard for evaluation of both mucosal inflammation and anatomic abnormalities in the paranasal sinuses. CT scanning provides a reliable picture of the ostiomeatal complex (OMC) in a noninvasive fashion.
Various procedures in patients workup include the following:
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Rigid or flexible nasal endoscopy - Provides an excellent view of OMC
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Maxillary sinus puncture - The criterion standard for obtaining maxillary sinus cultures
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Middle meatal swab
Indications for antibiotic therapy for acute sinusitis are as follow:
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Persistent acute sinusitis
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Severe acute sinusitis
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Toxic child with suspected complications
Surgical approaches include the following:
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Adenoidectomy
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Functional endoscopic sinus surgery
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Uncinate removal, anterior ethmoidectomy, and maxillary antrostomy - The most common forms of surgery
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Balloon sinuplasty
Pathophysiology
The ostiomeatal complex (OMC) is believed to be the critical anatomic structure in sinusitis and is entirely present, although not at full size, in newborns. Present within the middle meatus, the OMC is composed of the uncinate process, infundibulum ethmoidalis, hiatus semilunaris, ethmoid bulla, and frontal recess. Although obstruction of the OMC has not been proven to be the primary source for pediatric sinusitis, changes occurring in the anterior ethmoids are known to impair drainage through the OMC, resulting in chronic maxillary sinusitis and, occasionally, frontal sinusitis.
The normal metachronous movement of mucous toward the natural ostia of the sinuses and eventually to the nasopharynx can be disrupted by mucosal inflammation. This most commonly occurs secondary to routine viral upper respiratory tract infections (URTIs) or nasal allergies and the host response to these insults. In addition, many other predisposing factors to chronic disease exist, including allergic rhinitis, anatomical abnormalities, gastroesophageal reflux (GER), immune deficiency, and disorders of ciliary function.
A prospective cohort study by Santee et al indicated that in children, a history of acute sinusitis is associated with a reduction in the relative abundance of certain taxa in the nasopharyngeal microbiota. In the study, of 47 healthy children aged 49-84 months, significantly depleted species in subjects with a history of acute sinusitis included Faecalibacterium prausnitzii and Akkermansia species, while the relative abundance of the bacterium Moraxella nonliquefaciens in these children was enriched. In addition, the investigators found that children who developed acute sinusitis over the 1-year study period were also characterized by enrichment of M nonliquefaciens. [1]
Epidemiology
Frequency
United States
Although the exact incidence of sinusitis in the pediatric population is unclear, it is diagnosed commonly, most often following a viral URTI. The number of URTIs that an individual has per year may be as high as 25 (children will have on average 6-8 per year); the number depends on a several factors, including age, day care attendance, and number of siblings. Approximately 5-13% of URTIs are complicated by bacterial sinusitis. Many viral URTIs are mislabeled early in their course as acute sinusitis and are inappropriately treated with antibiotics.
A study by Gilani and Shin determined that in the United States between 2005 and 2012, in patients aged 0-20 years, there were 5.6 million ambulatory care visits per year for chronic rhinosinusitis. The condition was diagnosed in 2.1% of all pediatric ambulatory care visits, while acute rhinosinusitis was diagnosed in 0.6% of all such visits. [2]
International
International incidence is similar to that in the United States.
Mortality/Morbidity
Recent health-related quality of life measures showed a poor result in children with chronic rhinosinusitis. Because quantifying the morbidity caused by pediatric conditions is difficult, it must also be viewed in other terms. A child with an acute episode of sinusitis may lead the caregiver to experience emotional distress and lack of sleep and miss days from work. Chronic illness may have a negative impact on a child's quality of life in many ways, including complications of chronic antibiotic therapy, school absences, poor sleep patterns, impaired school performance, and irritability. [3]
Children are also susceptible to more serious sequelae from a complication of sinusitis such as orbital cellulites (in about 9.3% of the cases) and intracranial complications (in 3.7-11% of patients). With close follow-up care, counseling of the family, and proper medical treatment, morbidity from this disease should be very low.
A study by Capra et al found a decrease between 2000 and 2009 in the estimated number of hospital admissions in the United States, from 5338 to 4511, for orbital complications of pediatric rhinosinusitis. The investigators suggested that the introduction of heptavalent pneumococcal vaccine was associated with the slight downward trend. The study also found that the mean patient age among children admitted for rhinosinusitis-related orbital complications rose from 4.77 years to 6.07 years and that the proportion of children who underwent surgery for these complications increased. [4]
A study by Al-Madani et al of 616 patients indicated that in children, acute sinusitis most commonly involves the ethmoid sinus and that orbital complications are more common than they are in adults. The investigators also found that most patients in the study responded well to medical treatment. [5]
Race
No race predilection exists.
Sex
No sex predilection exists.
Age
The ethmoid and maxillary sinuses are present at birth. The sphenoid sinuses are pneumatized by age 5 years, and the frontal sinuses appear by age 7 years but are not completely developed until adolescence. Thus, children are predisposed to sinus infection at an early age. In young children, the most common sinuses involved are the ethmoid and maxillary sinuses. Acute sinusitis is much less common in young children than routine URTI or adenoiditis.
In an older child, the sphenoid and frontal sinuses are more likely to be involved with disease. Allergic rhinitis is also more common in older children. It affects only 1% of infants and 5% of children aged 5-9 years, while 15% of the adolescent population is affected. Allergic rhinitis is one of the most common predisposing factors for sinusitis, second only to viral URTIs.
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Preseptal cellulitis of the left eye. Courtesy of Dwight Jones, MD.
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Axial CT scan of subperiosteal abscess of the left eye.
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Coronal CT scan of subperiosteal abscess of the left eye.
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Coronal CT scan of superior subperiosteal abscess of the left eye.
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Axial CT scan of orbital cellulitis of the right eye.
