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Pediatrics: Surgery > Otolaryngology
Sinusitis
Article Last Updated: Jul 17, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Girish D Sharma, MD, Associate Professor, Department of Pediatrics, Rush University Medical Center, Rush Children's Hospital; Director of Pediatric Pulmonary Section and Rush Cystic Fibrosis Center
Girish D Sharma is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians of Ireland
Editors: Orval Brown, MD, Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; John E McClay, MD, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's Medical Center, University of Texas Southwestern Medical School; Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine; Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
sinusitis, paranasal sinuses, acute sinusitis, chronic sinusitis, recurrent sinusitis, upper respiratory tract infection, URTI, asthma, allergies, functional endoscopic sinus surgery, FESS
Background
Sinusitis, the inflammation of one or more paranasal sinuses, is a common pediatric problem. Sinusitis can be acute, chronic, or recurrent. Upper respiratory tract infection (URTI) is a common pediatric problem, and as many as 10% of URTIs can be complicated by acute sinusitis. Untreated chronic sinusitis can lead to life-threatening complications. A recent study suggested a higher incidence of complications associated with fungal sinusitis.
Pathophysiology
A brief review of the anatomy, physiology, and development of the sinuses enhances understanding of the pathophysiology of sinusitis. A normally sterile environment, paranasal sinuses are spaces in the facial bones. The sinuses open into the nose via small openings called ostia. The maxillary and ethmoid sinuses form during the third to fourth months of gestation. Thus, an infant is born with 3-4 ethmoid cells and tiny teardrop-shaped maxillary sinuses. By the teenage years, each maxillary sinus enlarges progressively to an adult capacity of 15 mL. In healthy individuals, the ethmoid sinuses increase in number to 18-20, and each drains by an individual ostium that is 1-2 mm in diameter. The frontal sinus develops from an anterior ethmoid cell and moves to its supraorbital position when the individual is aged 6-7 years. Frontal sinuses may begin to develop at this age but usually do not appear radiologically until the individual is aged approximately 12 years. The maxillary, anterior ethmoid, and frontal sinuses drain into the middle meatus; the posterior ethmoid and sphenoid sinuses drain into the superior meatus (see Image 1). Secretions produced in the sinuses flow by ciliary action through the ostia and drain into the nasal cavity. In the healthy individual, flow of sinus secretions is always unidirectional (ie, toward the ostia), which prevents back contamination of the sinuses. In most individuals, the maxillary sinus has a single ostium (2.5 mm in diameter, 5 mm2 in cross-sectional area) serving as the only outflow tract for drainage. This slender conduit sits high on the medial wall of the sinus cavity in a nondependent position. Most likely, the edema of the mucosa at these 1-3 mm openings becomes congested by some means (eg, allergy, viruses, chemical irritation) that causes obstruction of the outflow tract stasis of secretions with negative pressure, leading to infection by bacteria. Anterior and posterior ethmoid sinuses are composed of multiple air cells separated by thin bony partitions. Each cell is drained by an independent ostium that measures only 1-2 mm in diameter. These small openings are readily clogged by secretions or are occluded by swelling of the nasal mucosa. The sphenoid sinuses sit immediately anterior to the pituitary fossa and just behind the posterior ethmoid. All sinus ostia drain into the nares at locations beneath the middle and superior turbinates (see Image 1). The posterior ethmoid and sphenoid sinuses drain into the superior meatus below the superior turbinate. The ostia of the maxillary, anterior ethmoid, and frontal sinuses share a common site of drainage within the middle meatus. The common drainage pathway of the frontal, maxillary, and anterior ethmoid sinuses within the middle meatus allows relatively localized mucosal infection processes to promote infection in all these sinuses. This region is called the osteomeatal complex and can be visualized by coronal CT scan. The sinus cavities are lined with pseudostratified, ciliated, columnar epithelium. Goblet cells in the epithelium and submucosal seromucous glands contribute to the mucus layer that covers the epithelium. The mucus layer is 1.0-1.5 mm thick and is moved continuously by the cilia at a speed of 6 mm/min. The successful maintenance of sinus drainage represents a complicated interaction between ciliary action, mucus viscosity, size of sinus ostia, and orientation of body structures. The ciliary action can be affected due to local factors, such as infection and local hypoxia that is associated with complete occlusion of sinus ostia. Ciliary action can also be affected by genetic factors (eg, dyskinetic cilia syndrome) or factors such as long-standing dehydration, anticholinergic medications and antihistamines, cigarette smoke, or chemical toxins. Additionally, ciliary action can be affected after certain viral infections. The 2 layers of normal mucus produced in healthy states are (1) an inner serous layer (ie, sol phase) in which cilia recover from their active beat and (2) an outer, more viscous layer (ie, gel phase), which is transported by the ciliary beat. Proper balance between the inner sol phase and outer gel phase is of critical importance for normal mucociliary clearance. If the composition of mucus is changed, so that the mucus produced is more viscous (eg, as in cystic fibrosis), transport toward the ostia slows considerably, and the gel layer becomes demonstrably thicker. This results in a collection of thick mucus that is retained in the sinus for varying periods. In the presence of a lack of secretions or a loss of humidity at the surface that cannot be compensated for by mucous glands or goblet cells, the mucus becomes increasingly viscous, and the sol phase may become extremely thin, thus allowing the gel phase to have intense contact with the cilia and impede their action. The ostia can be blocked by mucosal swelling, inflammation-associated systemic disorders (eg, cystic fibrosis, respiratory allergies, ciliary dyskinesia), immune disorders, or local causes (eg, trauma, rhinitis). Mechanical obstruction because of nasal polyps, foreign bodies, deviated septa, or tumors can also lead to ostial blockage. One recent study suggested histopathological differences in children with chronic rhinosinusitis compared with adults. The sinus mucosa of young children with chronic sinusitis has less eosinophilic inflammation, basement membrane thickening, and mucus glad hyperplasia that is characteristic of adults with chronic rhinosinusitis.
Frequency
United States
Approximately 35 million people endure acute, chronic, or recurrent sinusitis. Chronic sinusitis is estimated to affect 15% of the population. An average child is likely to have 6-8 colds (ie, URTIs) per year, and approximately 5-10% of such episodes are estimated to be complicated by acute sinusitis.
Race
No racial predilection is described.
Sex
No sex predilection is described.
Age
Prevalence of sinusitis is highest in adults aged 18-75 years, followed by people living in the Midwest and the South (associated with higher prevalence of allergies), and then children younger than 15 years. In children aged 5-10 years, URTI episodes can be associated with acute sinusitis.
History
- Acute sinusitis symptoms
- Suspect acute sinusitis in any patient with a URTI that persists beyond 7-10 days, particularly if the infection is severe and is accompanied by high fever, purulent nasal discharge, or periorbital edema.
- Coughing at night is the second most common symptom or sign of sinusitis following purulent rhinitis.
- Headache, facial pain, tenderness, or edema is uncommon.
- Chronic sinusitis symptoms
- Symptoms of chronic sinusitis are more subtle and variable.
- Fever, when present, may be low grade.
- Malaise, easy fatigability, and anorexia may be present.
- Nasal discharge may be of any character from thin to thick and from clear to purulent.
- Halitosis is reported more commonly by parents of younger children.
- Nasal obstruction with mouth breathing and associated sore throat may be present.
- In some individuals with chronic sinusitis, parents may note occasional and painless morning eye swelling.
- Older children may complain of loss of taste due to associated nasal obstruction and anosmia.
- Nocturnal symptoms may include snoring and coughing due to associated postnasal drip.
Physical
Presence of pus in the middle meatus suggests involvement of maxillary, frontal, or ethmoid sinuses; pus in the superior meatus suggests involvement of sphenoid or posterior ethmoid cells.
- In children younger than 6 years, the nasal examination usually consists of evaluating the anterior nasal cavity and middle meatus with anterior rhinoscopy using an otoscope and ear speculum.
- The superior meatus can never be observed with this technique and is difficult to observe with nasal endoscopy and/or rigid rhinoscopy.
- Purulence running into the posterior nasal cavity and nasopharynx, observed only by rigid rhinoscopy, can indicate probable drainage from the sphenoethmoid recess, which drains the posterior ethmoids and sphenoid sinuses.
- In persons with acute ethmoiditis, especially in infants and younger children, periorbital cellulitis with edema of the soft tissues and erythema of the overlying skin is not uncommon.
- In individuals with chronic sinusitis, middle turbinates may be swollen and may cause substantial nasal obstruction.
- Hypertrophy and congestion of nasal mucosa may occur. Occasionally, nasal mucosa may be pale and boggy because of associated allergic rhinitis.
- Other signs of allergies, such as ocular shiners and a transverse crease on the nose due to constant rubbing, may manifest.
- Evidence of posterior nasal drip may be observed on the posterior oropharyngeal wall as it drips down from the nasal cavity.
- Local tenderness of sinuses on palpation or percussion may be elicited in some patients; however, this is a rare finding in children.
Causes
- Organisms usually recovered in children are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Streptococcus species (groups A or B).
- Commonly recovered anaerobes are anaerobic gram-positive cocci (eg, Peptococcus species, Peptostreptococcus species) and Bacteroides species.
- Cultures obtained from patients with cystic fibrosis tend to reflect pulmonary flora (eg, Pseudomonas aeruginosa).
- Reports exist of fungal sinusitis (eg, allergic fungal sinusitis) similar to lower airway disorder and allergic bronchopulmonary aspergillosis.
- Fungal agents associated with this condition include Aspergillus and Alternaria species.
- Bipolaris and Curvularia species are the most common fungi recovered in allergic fungal sinusitis, accounting for 60% and 20%, respectively, in most studies.
- Curvularia species is occasionally reported as the most common causative organism in the Deep South of the United States.
Allergic Rhinitis
Gastroesophageal Reflux
IgA and IgG Subclass Deficiencies
Other Problems to be Considered
Upper respiratory tract infection
Cystic fibrosis
Primary ciliary dyskinesia
Unilateral choanal atresia
Adenoidal hypertrophy
Foreign body
Immune deficiency (IgA, IgG subclass)
Lab Studies
- Cultures
- Order nasopharyngeal cultures for microbiology.
- However, if attainable, cultures directed at the middle meatus more accurately reflect the contents of the sinuses themselves, according to most studies.
Imaging Studies
- Paranasal sinus radiography
- Basic radiographic examination includes 3 projections as follows:
- Waters view (occipitofrontal) - Primarily useful for evaluation of maxillary and frontal sinuses
- Caldwell view (angled posteroanterior) - Only view that visualizes the ethmoid air cells
- Lateral view - Primarily for adenoid and/or nasopharyngeal size and sphenoid disease
- Radiographic findings
- Radiographic findings in patients with acute sinusitis include diffuse opacification, mucosal thickening (>4 mm), or an air fluid level. These findings, in conjunction with clinical features of acute sinusitis, are helpful to confirm the diagnosis.
- However, when plain film radiographs are compared with the criterion standard (CT scans), a 75-80% disagreement occurs. This means that 40% of the time the plain-film radiograph demonstrates disease while no disease is demonstrated on CT scan, and 35-40% of the time the plain-film radiograph looks clear while disease is found on the CT scan.
- Radiographic findings in individuals with chronic sinusitis may demonstrate osteoblastic response in the affected sinus walls, mucoperiosteal thickening, opacification of sinus cavity, and even reduction of cavity size. Younger children with persistent respiratory symptoms probably have significant abnormalities that are observable on sinus radiographs. These radiographs provide noninvasive and rapid evaluation of the lower third of the nasal cavity and of the maxillary, frontal, sphenoid, and posterior ethmoid sinuses. Unfortunately, these views provide only limited information about anterior ethmoid anatomy and may be misleading in soft-tissue inflammatory disease; hence, more physicians are using CT for preoperative evaluation and MRI for excluding orbital and intracranial extension.
- CT scan
- CT scan is the procedure of choice for evaluation of regional anatomy of the nasal cavity and paranasal sinuses and for determining the true extent of disease for that moment in time.
- A proposed classification of CT scan findings in pediatric chronic sinusitis is as follows:
- Stage 0: Normal (<2 mm mucosal thickening on any sinus wall)
- Stage I: Unilateral disease or anatomic abnormality
- Stage IIA: Bilateral disease limited to ethmoid or maxillary sinuses; normal sinus development
- Stage IIB: Bilateral disease limited to ethmoid or maxillary sinuses; absence of frontal and/or sphenoid sinus development
- Stage III: Bilateral disease with involvement of at least one sphenoid or frontal sinus
- Stage IV: Pansinusitis
- These scans are especially useful for examination of the anterior ethmoid cells, the upper two thirds of the nasal cavity, and the frontal recess.
- Delay CT until antibiotics control acute exacerbation; this practice allows correct diagnosis of chronic inflammation, mucoperiosteal thickening, soft tissue swelling, and ethmoid osteitis.
- Take coronal projections for evaluating the osteomeatal complex.
- Axial projections are useful for evaluating anterior and posterior walls of the maxillary, frontal, and sphenoid sinuses.
- CT is also useful for guiding endoscopic surgery and for detecting bone erosion.
- Because of concerns of radiation exposure, use of limited sinus CT (see Image 2) is gaining wide acceptance as an alternative to single Waters view for evaluation of pediatric chronic sinusitis.
- CT scanning is characteristic in allergic fungal sinusitis and is one of the major criteria for diagnosis.
- Magnetic resonance imaging
- This type of imaging may be too sensitive to define soft tissue structures.
- MRI is not useful for detecting bone pathology.
- MRI is used mainly to evaluate intracranial extension and can be used as an adjunct to CT scanning in defining allergic fungal sinusitis.
- Ultrasonography
- A-mode ultrasonography may be useful to screen for fluid in the maxillary sinus.
- B-mode (gray scale) ultrasonography may be useful to detect fluid in the cavity, mucosal thickening, or soft tissue mass in the maxillary sinus.
Procedures
- Sinus aspiration
- Maxillary sinus aspiration can be considered if medical treatment produces no response, complications are suspected, and severe facial pain exists.
- However, consider a maxillary antrotomy in these situations.
Medical Care
Antimicrobial therapy is the mainstay of medical treatment. Choice of antibiotic depends upon whether the sinusitis is acute, chronic, or recurrent (see Medication section).
Surgical Care
Unless complications exist, patients with acute sinusitis rarely require surgery. Recurrent or persistent sinusitis and presence of complications may require surgical therapy. Failure to respond to appropriate antibiotic therapy, especially in chronic and persistent sinusitis (eg, cystic fibrosis), is an indication for surgical intervention.
- In such cases, functional endoscopic sinus surgery (FESS) is gaining acceptance for clearance of obstructed areas to facilitate ventilation of secondarily involved sinuses and to restore mucociliary function.
- A previous approach to create a nasoantral window within the maxillary sinus (to facilitate gravitational drainage) is ineffective, because the normal mucociliary clearance is unidirectional and against the pull of gravity; therefore, this pattern persists despite creation of a window.
- In patients who have cystic fibrosis with chronic persistent sinusitis, a more aggressive approach, endoscopic sinus surgery and serial antimicrobial lavage (ESSAL), has been introduced.
- ESSAL uses an indwelling catheter through a window in the nasal sinus wall for serial antimicrobial instillation.
- This technique is reported to be useful to clear any nidus of P aeruginosa from the respiratory tract before a patient undergoes lung transplant for end-stage lung disease.
Consultations
Surgical consultation is advised when chronic sinusitis is refractory to maximal medical therapy or a complication such as formation of mucopyocele with orbital or intracranial extension is suspected.
Drug Category: Antibiotic agents
Antimicrobial therapy is the mainstay of medical treatment. Choice of antibiotic depends on whether the sinusitis is acute, chronic, or recurrent.
| Drug Name | Amoxicillin (Amoxil, Biomox, Polymox, Trimox, Wymox) |
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| Description | Antimicrobial DOC. First line for simple uncomplicated acute sinusitis. |
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| Adult Dose | 250-500 mg PO q8h; not to exceed 3 g/d |
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| Pediatric Dose | 40 mg/kg/d PO divided q8h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; reduces efficacy of oral contraceptives |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction; some patients may develop diarrhea |
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| Drug Name | Amoxicillin and clavulanic acid (Augmentin) |
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| Description | Treatment of otitis media, sinusitis, and infections caused by susceptible organisms involving lower respiratory tract, skin and skin structure, and urinary tract.
In children > 3 mo, base dosage protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg. |
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| Adult Dose | 250-500 mg PO q8h or 875 mg q12h; not to exceed 2 g/d |
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| Pediatric Dose | <40 kg: 20-40 mg/kg/d PO divided q8h or 45 mg/kg divided q12h
>40 kg: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with warfarin or heparin increases risk of bleeding |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Some patients may develop rash and diarrhea |
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| Drug Name | Erythromycin and sulfisoxazole (Eryzole, Pediazole) |
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| Description | Treatment of susceptible bacterial infections of upper and lower respiratory tract: in children, otitis media caused by susceptible strains of H influenzae, as well as many other infections in patients allergic to penicillin. |
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| Adult Dose | <45 kg: 50 mg (based on erythromycin component)/kg/d PO divided q6h for 10 d; not to exceed 2 g erythromycin/d or 6 g sulfisoxazole/d
>45 kg: 400 mg erythromycin and 1200 mg sulfisoxazole PO q6h |
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| Pediatric Dose | <2 months: Contraindicated
>2 months: Administer as in adults |
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| Contraindications | Documented hypersensitivity; age <2 mo |
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| Interactions | Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Avoid near term in pregnancy because of risk of sulfonamide component causing kernicterus in the newborn; caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs |
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| Drug Name | Sulfamethoxazole and trimethoprim (Bactrim, Cotrim, Septra) |
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| Description | Treatment of acute otitis media and URTIs in children. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. |
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| Adult Dose | 160 mg (trimethoprim)/800 mg (sulfamethoxazole) PO q12h (ie, 1 double-strength tab [DS] q12h) |
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| Pediatric Dose | <2 months: Contraindicated
>2 months: 5-10 mg/kg/d (based on trimethoprim component) PO divided bid |
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| Contraindications | Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo |
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| Interactions | May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases prevalence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Avoid in pregnancy near term because of risk of kernicterus in the newborn; discontinue at first appearance of rash or sign of adverse reaction; frequently obtain CBCs; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; caution in folate deficiency (eg, individuals with chronic alcoholism, elderly patients, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation |
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| Drug Name | Cefaclor (Ceclor, Ceclor CD) |
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| Description | Infections caused by susceptible organisms including H influenzae; treatment of otitis media, sinusitis, and infections involving the respiratory tract. |
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| Adult Dose | 250-500 mg PO q8h |
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| Pediatric Dose | Children > 1 month: 20-40 mg/kg/d PO divided q8-12h; not to exceed 2 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Alcoholic beverages consumed <72 h after taking cefaclor may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Reduce dosage by half if CrCl is 10-30 mL/min and by three fourths if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy |
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Deterrence/Prevention
- In patients with allergic rhinitis, aggressive treatment of nasal symptoms and signs of mucosal edema, which can cause obstruction of the sinus outflow tracts, may decrease secondary sinusitis. If the adenoids are chronically infected, removing them eliminates a nidus of infection and can decrease sinus infection.
- In a recent study, severity of radiographic sinus disease on pre–bone marrow transplant CT scans was noted to correlate with clinical and radiographic sinusitis later in the post–bone marrow transplant course and was associated with a trend toward decreased survival. Thus, pre–bone marrow transplant CT scans may be useful in determining which children need early and more aggressive intervention for clinical sinusitis after bone marrow transplantation.
- A correlation has been noted between in vitro biofilm-producing capacity by Pseudomonas aeruginosa and Staphylococcus aureus and unfavorable evolution after endoscopic sinus surgery, suggesting a role for biofilm production in chronic sinusitis.
Complications
- Local, orbital, and/or intracranial complications can occur.
- Orbital complications include cellulitis, subperiosteal abscess, orbital abscess, and optic neuritis.
- Osteomyelitis of local bone may occur.
- Intracranial complications can be in the form of epidural abscess, subdural abscess, cavernous or sagittal sinus thrombosis, meningitis, or brain abscess. Unless obvious symptoms occur, intracranial extension of mucocele can be diagnosed only after examining CT scan or MRI findings.
- Pyocele and mucocele are chronic lesions of the nasal sinuses (usually frontal) and can be associated with bone erosion.
- Mucocele with intraorbital extension can manifest as strabismus, diplopia, or blurred vision.
- Ethmoid sinus involvement can result in orbital periostitis, subperiosteal abscess, or orbital abscess. The infection can spread directly through lamina papyracea between the ethmoid sinus and the orbit.
- In incidents of mucopyocele with erosion of bone, osteoplastic flaps and obliteration of the sinus cavity with adipose tissue may be indicated.
Prognosis
- Patients with acute sinusitis, when treated with appropriate antibiotics, usually shoe prompt improvement. In the absence of response within 48 hours or worsening of symptoms, reevaluate the patient.
- In individuals with recurrent or persistent sinusitis, suspect other predisposing conditions such as cystic fibrosis, ciliary dyskinesia, allergic inflammation, immunodeficiency, or an anatomic problem.
Medical/Legal Pitfalls
- Failure to diagnose chronic sinusitis can lead to complications that may be very serious and, sometimes, life threatening (eg, patients with cystic fibrosis having chronic sinusitis).
- Perform prompt evaluation to exclude complications of chronic sinusitis when a patient presents with ocular or central nervous system signs and symptoms.
| Media file 1:
Sagittal section of the lateral nasal wall demonstrating openings of paranasal sinuses. Conchae have been cut to depict details of meatal structures. |
 |  View Full Size Image | |
Media type: Photo
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Sinusitis excerpt Article Last Updated: Jul 17, 2006
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