PEDIATRIC ACUTE SINUSITIS

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Acute Sinusitis in Pediatrics
Dr. Mutaz Sulatan / Pediatrician / Department
of Pediatrics June 2004
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Acute Sinusitis in Pediatrics

• Dr. Mutaz Sultan
• Pediatrician
• Department of Pediatrics
• Makassed Hospital
• June 2005

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Background

• The ethmoid the maxillary sinuses form in the
  3rd to 4th gestational mo and, accordingly,are
  present at birth.
• The sphenoid sinuses are generally pneumatized
  by 5 years of age .
• The frontal sinuses appear at age 7 to 8 years
  but are not completely developed until late
  adolescence..

Maxillary sinus
Sphenoid sinus
Frontal sinus
Ethmoid sinus
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SINUSITIS

• In 1996, 13 million patients had diagnosed as
  sinusitis in USA .
• Viruses caused the vast majority of acute sinus
  inflammation .
• 87 with rhinovirus cold had abnormal sinus CTS
  .
• Estimated 5-13 of URIs in children complicated
  by bacterial sinusitis (Ped 2001).
• Even when clinician have high degree of suspicion
  for acute bact sinisitis only correct in lt50
  .

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Definitions

• Acute bacterial sinusitis Bacterial infection of
  the paranasal sinuses lasting less than 30 days .
• Subacute bacterial sinusitis infection lasting
  between 30 and 90 days .
• Chronic sinusitis Episodes of inflammation of
  the paranasal sinuses lasting more than 90 days .
• Recurrent acute bact sinusitis 3 episodes of
  acute bacterial sinusitis in 6 months or 4
  episodes in 12 months.

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Pathophysiology of acute bacterial sinusitis

• Obstruction of the sinus ostis, inspissated mucus
  and paralysis of celia all caused by colds
  viruses.
• Inflammation caused by allergies lead to
  obstruction of the ostia .
• Nasal flora trapped in closed space ,inflammatory
  response with influx of PMNs and cytokines with
  eventual mucosal damage .

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Etiology

• Acute and subacute pathogens
• Streptococcus pneumoniae - 20-30
• Nontypeable Haemophilus influenzae - 15-20
• Moraxella catarrhalis - 15-20 (not as common in
  adults)
• Streptococcus pyogenes (beta-hemolytic) - 5

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Etiology

• Chronic sinusitis
• The role of infection is controversial .
• Noninfectious conditions
• allergy .
• cystic fibrosis .
• gastroesophageal reflux .
• Cilliary dysfunction .

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AAP Recommendations for the Management of
Sinusitis in Children

• clinical practice guideline developed by the
  American Academy of Pediatrics (AAP) provides
  evidence-based recommendations for physicians to
  diagnose, evaluate, and treat patients between
  one and 21 years of age who present with
  uncomplicated acute, subacute, and recurrent
  acute bacterial sinusitis .

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RecommendationsMethods for diagnosis

• The gold standard for the diagnosis of acute
  bacterial sinusitis is the recovery of bacteria
  in high density from the cavity of paranasal
  sinuses .
• But not recommended for the routine diagnosis
  (not feasible) .

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Recommendation 1

• The diagnosis of acute bacterial sinusitis is
  based on the clinical criteria in children who
  present with upper respiratory symptoms that
  either persistent or severe .

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Sinusitisclinical diagnosis

• Persistent symptoms greater than 10 days with
  no improvement that include
• nasal or postnasal discharge of any quality .
• day time cough (may be worse at night ) .
• Less common complains include low grade fever
  fatigue malodorous breath or periorbital edema .

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Sinusitisclinical diagnosis

• Severe symptoms include a temp of at least 39C
  and purulent nasal discharge present for at least
  3-4 consecutive days in a child who seems ill .

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Sinusitisclinical diagnosis

• Physical examination does not contribute
  substantially to the diagnosis of acute bacterial
  sinusitis .
• Facial pain is unusual and facial tenderness is
  rare and unreliable finding .
• Periorbital swelling is suggestive of ethmoid
  sinusitis .
• The value of transillumination of the sinuses is
  controversial and found to be unreliable in
  children younger than 10 years .

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Sinusitis Laboratory

• Laboratory assessment
• Routine laboratory testing is not recommended in
  the initial evaluation.
• Organisms recovered from the nasopharyngeal
  washing do not reflect the organism found in
  sinus aspirate (Wald et al 1998).

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Sinusitis Laboratory

• Sinus aspiration and culture may need to be
  considered in
• Sever illness and toxic looking child .
• Immunocomproised child .
• Suppurative or intracranial complications

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Recurrent sinusitis

• Recurrent acute bacterial sinusitis
  3 episodes of acute bacterial sinusitis in
  6 months or 4 episodes in 12 months.
• The most common cause is recurrent viral upper
  respiratory infections .
• Other predisposing conditions
• allergic rhinitis 60 of patients with
  refractory sinusitis had increased total
  immunoglobulin E (IgE) or marked skin reactivity
  .

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Recurrent sinusitis

• Other predisposing conditions
• Anatomical abnormalities ,( deviated septum ) .
• Immune deficiencies .
• cystic fibrosis .
• ciliary disorders .

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Recommendation2

• Imaging studies are not necessary to confirm a
  diagnosis of clinical sinusitis in children below
  6 years of age .

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SinusitisImaging

• In children with persistent or protracted
  symptoms predicted significantly abnormal
  radiographs
• Complete opacifications.
• Mucosal thickening .
• Air fluid level in 88
  of children below 6 years and 70 after 6 years .

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Abnormal Imaging in Children with Upper
Respiratory Symptoms
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SinusitisImaging

• Radiographs can be safely omitted before 6 years
  but still controversial after 6 years.
• Paranasal sinus abnormalities are nonspecific
  ,often present without sinusitis and may last
  longer than clinical symptoms .

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Recommendation 3

• CT scans for the paranasal sinuses should be
  reserved for patients in whom surgery is
  considered as a management strategy.

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Sinusitis CT Scan

• CTS of the paranasal sinuses indicated in
• Suspected subperiosteal or orbital abscess
  ,otolaryngology consultation is recommended .
• Suspected intracranial complications .
• Persistent or recurrent infections not responding
  to medical treatment .

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Recommendation 4

• Antibiotics are recommended for the management of
  acute bacterial sinusitis to achieve a more
  rapid clinical cure .

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Sinusitistreatment

• Children receiving antimicrobial therapy
  recovered more quickly and more often than those
  receiving placebo (Wald et al).
• A recent study has challenged the notion that
  children identified as acute sinusitis on
  clinical ground will benefit from antimicrobial
  therapy (Garbutt et al Ped 2001).

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Calculation of the Likelihood that a Child With
Acute Bacterial Sinusitis Will Fail Treatment
With Standard Doses of Amoxicillin
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Sinusitistreatment

• Amoxicillin is still the first line therapy .
• Approximately 80 of children with acute
  bacterial sinusitis will respond to treatment
  with amoxicillin in the absence of any risk
  factors which are
• Attendance at day care .
• Recent recipient (lt90 days) of antimicrobial .
• Age less than 2 years .

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Sinusitistreatment

• Patients with risk factors for resistant strains
  , not improving on usual dose of amoxicillin or
  with moderate or more severe illness should be
  initiated with high dose amoxicillin-clavulanate
  .
• Alternative therapies include cefuroxime ,
  cefdinir ,cefporoxim .
• If the patient is allergic to amoxicillin
  clarithromycin or azithromycin can be used .

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Sinusitis

• Neither trimethoprim-sulfamthoxazole nor
  erythromycin-sulfisoxazole are appropriate
  choices .
• Two options for patients not improving on second
  coarse of AB or who are acutely ill
• Ceftriaxone IV.
• Consult an otolaryngologist for consideration of
  sinus aspiration.
• Suggestion has been made to continue antibiotics
  for 7 days after clinical improvement.

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Dosages

• High dosage amoxicillin 90mg/kg/day in 2
  divided doses. High dose amox/clav 90mg/kg/day
  amox 6.4 mg/kg/day clav in 2 divided doses
• Usual dose amox 45 mg/kg/day in 2 divided doses
• Most patients with penicillin allergy will
  tolerate Cephalosporins. If allergy manifests as
  anaphylaxis macrolides should be given instead of
  Cephalosporins
• Cefuroxime 30mg/kg/day in 2 divided doses
• Cefpodoxime 10mg/kg/day once daily
• Cefdinir 14 mg/kg/day once daily
• Azithromycin 10 mg/kg on day 1 5mg/kg x 4 days
  once daily.
• Clarithromycin 15mg/kg/day in 2 divided doses

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Recommendation 5

• For adjuvant therapy no recommendations are made
  based on controversial or limited data .Available
  agents include
• Nasal saline irrigation .
• Antihistamine and decongestants .
• Topical intranasal steroid .
• Mucolytic agents .

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Recommendation 6

• No recommendations are made for antibiotic
  prophylaxis based on limited and controversial
  data .
• Concerns regarding the increasing prevalence of
  antibiotic-resistant organism .
• More appropriate to initiate evaluation for
  predisposing factors for recurrent sinusitis .

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Recommendation 7

• No recommendations are made for complementary /
  alternative medicine for prevention or treatment
  of rhinosinusitis based on limited and
  controversial data .

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Recommendation 8

• Children with complications or suspected
  complications of acute bacterial sinusitis should
  be treated promptly and aggressively .
• This should include referral to otolarungiologist
  with consultation of ophthalmologist and
  neurosurgeon strong recommendation based on
  strong consensus .

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Complications of sinusitis

• Orbital and periorbital inflamation are the most
  common complications of acute sinusitis
• Periorbital cellulitis .
• Subperiosteal abscess .
• Orbital abscess .
• Orbital cellulitis .
• Suppurative complications generally require
  surgical drainage .

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Complications of sinusitis

• Patients with altered mental status ,signs of
  increased intracranial pressure or nuchal
  rigidity require CT scanning of the brain , orbit
  and sinuses to exclude intracranial complications
  .

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Preseptal cellulitis
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Orbital cellulitis
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Subperiosteal abscess
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Sphenoid sinusitis
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Brain abscess
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Cavernous sinus thrombosis
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• The diagnosis of acute bacterial sinusitis is
  based on clinical criteria.
• antibiotic therapy should be reserved for
  patients who have clear and severe symptoms of
  bacterial disease (not a pill for every ill).
• Imaging studies has limited role in diagnosis.
• Use of amoxicillin as first-line therapy .
• Suspected complications of acute bacterial
  sinusitis should be treated immediately and
  aggressively.

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Thanks for listening