Chronic (and acute) sinusitis (& cystic fibrosis, hypogammaglobulinemia)
- chronic sinusitis is a common, difficult, and frequently missed diagnosis in pediatrics
- can have symptoms of chronic cough, fetid breath, sore throat, and
purulent nasal discharge for prolonged periods of time before the diagnosis is
made. Other signs and symptoms facial pain and headaches (rare), painless
morning eye swelling, sore throat, nausea, fetid breath, fatigue, and possibly
exacerbation of asthma.
- it can be difficult to distinguish between sinusitis and recurrent viral
- One clinical clue to the diagnosis of chronic sinusitis is a
cough that responds rapidly to
antibiotic therapy but recurs shortly (within 1 week) after discontinuation of the therapy.
- Definition of acute bacterial sinusitis (ABS): nasal and sinus sx present
at least 10 days and fewer than 30 days. A less common presentation of ABS is
a 'cold' that seems more severe than usual defined by: fever >39 and,
concurrently, purulent nasal
discharge 3-4 days.
- Subacute sinusitis: >4 wks and < 3 mos. Sore throat results from chronic
mouth breathing due to nasal obstruction. Nasal discharge and headache are
less common. Fever is rare.
- Chronic sinusitis: 3 mos or more
- Most uncomplicated episodes of viral rhinosinusitis last 5-7 days. Fever
is usually present at onset of illness, but disappears and respiratory
begin, and nasal secretions may start watery, become thick, colored,
opaque, purulent for several days, then clears back again to mucoid or watery
before resolving. By day 10 they may still be symptomatic, but should be
- Chronic sinusitis predominantly is associated with aerobic organisms,
- Streptococcus pneumoniae (most common, 30-40%) -resistance by altered
- nontypeable Haemophilus influenzae (20%) - may produce B-lactamase
therefore amox resistant
- Moraxella catarrhalis. (20%) - may produce B-lactamase therefore
- Other organisms causing chronic sinusitis include alpha-hemolytic
- Staphylococcus aureus and anaerobes are uncommon.
one study of children undergoing surgery for sinusitis, 76% had aerobes
isolated whereas only approximately 8% had anaerobic organisms.
- life-threatening complications can include
- osteomyelitis - Pott's
puffy tumor = area of edema surrounding regions of skull osteo -
involved bone has doughy consistency
- epidural, subdural, or brain abscess
- cavernous or sagittal sinus thrombosis.
- The proximity of the ethmoid
and maxillary sinuses can lead to
or involvement of the orbit,
which can progress to proptosis, chemosis, decreased vision, and impaired
- Infections of the ethmoid
or frontal sinuses can spread into the cranial cavity, causing
meningitis or epidural, subdural, or brain abscess.
- Infections of the maxillary sinus
anteroinferior walls can
lead to destruction of tooth buds
as well as sepsis, which can
spread by venous drainage of the face
to the cavernous sinus, resulting in cavernous sinus thrombosis and
- Indication for maxillary sinus aspiration by ENT: failure to
respond to multiple courses of ABX, severe facial pain, orbital or
intracranial complications, evaluation of immunocompromised host.
- Imaging is controversial; recent guidelines emphasize clinical diagnosis
- Plain films, indication: older children w/ recurrent acute
sinusitis, vague sx, poor response to abx, or hx of ABX hypersensitivity that
makes therapy risky. Get three views of the paranasal sinuses. The waters view
(head tilted up) is done to move the temporal bone/auditory canal down on the
film; in a direct AP view, they appear right behind the maxillary sinuses,
confusing the picture. also look at the adenoids behind the nose. Radiologic
findings c/w ABS include diffuse opacification, mucosal thickening of at least
4mm or air fluid level.
- CT, indication: complicated ABS or surgical candidates due to
recurrent or chronic sinusitis; any patient w/ proptosis, impaired vision,
notable swelling of forehead/face, deep seated headaches, or toxic appearance.
CT scan does not distinguish between mucosal abnormalities due to ABS or cold.
CT scans are normal in 1/3 of patients w/ sx of chronic sinusitis.
- Adenoidal hypertrophy can predispose to ABS, or when infected masquerade
as sinusitis. Note: Adenoids normally involute significantly during puberty.
- Panopacification of the
sinuses may be associated with an
immunologic disorder (eg,
or cystic fibrosis. Thus, such
findings on radiography warrant an evaluation of the child for these
- The child described in the vignette should have a
sweat chloride test because
this is the diagnostic test of choice for suspected cystic fibrosis.
- Quantitative measurement of serum
immune globulins would be indicated to evaluate for immune globulin
- A complete blood count with differential would be unhelpful in determining
the cause of this child's chronic sinusitis.
- A nasal smear also is not necessary because it would be expected to reveal
sheets of neutrophils.
- Rhinoscopy would be indicated if a nasal foreign body is suspected,
but this would be a very unlikely cause of panopacification.
- Serum immunoglobulin E measurement is unnecessary because allergic
rhinitis rarely causes panopacification of the sinuses.
- Rare systemic disorders:
- CDC, AAP suggest amoxicillin (regular dose) is a reasonable first choice
for ABS in children, especially if uncomplicated, mild-mod severity, and not
recently tx'ed (<1 month) w/ abx
- however, resistant S pneumoniae is more common. Indications for more than
just reg dose amox include:
- failure to improve with conventional dose amox
- recent tx w/ amox (<1 mo)
- day care
- frontal or sphenoidal sinusitis
- subacute sinusitis (>1 month sx)
- Alternatives include:
- high dose amox 80-90 mg/kg/d
- augmentin (80-90 mg/kg/d amox)
- amox 45 mg/kg/d PLUS augmentin (45 mg/kg/d amox)
- cefdinir (omnicef)
- appropriate duration of tx has not been studied systematically
- most can be tx'ed w/ 10-14 days.
longer courses have been used in those who have chronic sinusitis to avoid
- the use of antibiotic therapy for more than a few weeks is not supported
by clinical studies, exposing patients to developing allergic hypersensitivity
and inducing resistance
- Patients should improve in 48
hours. If not, clinical re-evaluation is approppriate
- adjuncts like antihistamines, decongestants, and antinflammatory agents
have received little evaluation.
- topical decongestant sprays
(phenylephrine (Neosynephrine), oxymetazoline(Afrin) 1-2 spray bid) can be
used for 3 days max, to avoid
rebound nasal congestion (rhinitis medicamentosa) - if this happens, dc spray
and start short course of topical steroid
- oral decongestants like
pseudoephedrine may be used up to one week.
- topical intranasal steroids:
very modest beneficial effect does not justify their use.
- saline nasal irrigation using hyper or isotonic solutions has been shown
to have a positive effect on some patients
The time to refer a patient
who has sinusitis is when he or she continues to have recurrence of disease
after adequate treatment. This
usually requires 3 weeks of antibiotic
therapy, sometimes also including topical nasal therapy. Referral to
either an allergist or ENT physician is appropriate, depending on whether
allergy is suspected. The allergist
would evaluate for possible triggers that are causing the nasal obstruction and
subsequently the recurrence of sinusitis. The
physician is better able to evaluate the structural features of the sinuses and
perform any necessary surgical interventions.
- maxillary and ethmoid sinuses are present at birth, but small
- ethmoid: multiple air cells, each draining through an ostium to middle
meatus; narrow caliber predisposes to obstruction
- frontal sinus develops from an
cell and moves above orbital ridge by 6th birthday
- sphenoid: behind ethmoids and in front of pituitary fossa. Isolated
involvement of sphenoid sinus is rare; usually infected as part of a sinusitis
- osteomeatal complex (OMC) = the confluence of drainage of the frontal,
ethmoid and maxillary sinuses (between the middle and inferior turbinates).
Here mucosal surfaces may touch and cilia may move in opposite directions,
creating the potential for infection even without physical destruction of the
- in cystic fibrosis, alterations in the mucus impairs ciliary activity
- Mild-to-severe asthma usually begins slowly and subtly; some children
present with an acute first exacerbation in conjunction with a viral upper
respiratory tract infection. However, even in these cases, symptoms appear
episodically and do not last for many months
- Bronchitis is rare in children, especially in the summer months, and it
responds at least to some extent to beta agonist therapy. The duration of the
symptoms rules out the possibility of acute sinusitis that, by definition, is
- Allergy could be a source of the child's symptomatology if a new pet or
allergen has been introduced recently
Slavin RG. Nasal polyps and sinusitis. In: Middleton E Jr, Reed CE,
Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy:
Principles and Practice. 5th ed. St Louis, Mo: Mosby-Year Book, Inc;
Slavin RG. Nasal polyps and sinusitis. JAMA. 1997;278:1849-1854
Sly M. Allergic rhinitis. In: Behrman RE, Kliegman RM, Jenson HB, eds.
Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders
Pediatrics in Review 22(4) april 2001