SINUSITIS In Pediatric Age Group

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SINUSITISIn Pediatric Age Group

• TABASSUM Z. IMAM, MD
• SENIOR RESIDENT IN PEDIATRICS
• LUTHERAN GENERAL HOSPITAL

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Anatomy

• MAXILLARY
• ANT ETHMOID
• FRONTAL
• POST ETHMOID
• SPHENOID
• LACRIMAL DUCTS

MIDDLE MEATUS
SUPERIOR MEATUS
INFERIOR MEATUS
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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.

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Physiology

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

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Factors Predisposing To Obstruction Of Sinus
Drainage.
A. MUCOSAL SWELLING Systemic disorder Viral
URI Allergic inflammation Cystic
fibrosis Immune disorder Immotile cilia Local
insult Facial trauma Swimming, diving Rhinitis
medicamentosa
B. MECHANICALOBSTRUCTION Choanal
atresia Deviated septum Nasal polyp Foreign
body Tumor Ethmoid bullae C. MUCUS
ABNORMALITIES Viral URI Allergic
inflammation Cystic fibrosis
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Epidemiology

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

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Symptoms And Signs

• PERSISTENT
• gt10 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 gt 39 C
• And
• Purulent nasal discharge
• Present for atleast 3-4 days
• Headaches may be present
• Periorbital swelling occasionally

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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

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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

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Chronic Sinusitis

• Chronic headache usually on awakening
• Intermittent fever
• Malodorous breath
• Secondary affects
• fatigue, impaired sleep
• decreased appetite
• irritability

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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

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Differential Diagnosis-Purulent Nasal Discharge

• Uncomplicated viral URI
• Group A Strep infection
• Adenoiditis
• Nasal foreign body

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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

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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

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Differential Diagnosis-Cough

• Reactive airway disease
• GER
• CF
• pertussis
• Mycoplasma bronchitis
• TB

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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

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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

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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)

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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

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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

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Treatment

• Amoxicillin
• Amoxicillin-potassium clavunate
• Erythromycin/sulfisoxazole
• Sulfamethoxazole/ trimethorphim
• Cefaclor

• Cefuroxime axetil
• Cefprozil
• Cefixime
• Cefpodoxime proxetil
• Ceftibuten
• Loracarbef
• Clarithromycin
• Erythromycin

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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 gt30days

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Treatment-Most Comprehensive Coverage

• Amoxicillin/potassium clavunate
• Erythromycin-sulfisoxazole
• Cefuroxime axetil
• Cefpodoxime
• Proxetil
• Azithromycin

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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

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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

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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

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Absolute Indications for Surgery

• Causing brain abscess or meningitis,
  subperiosteal/orbital abscess, cavernous sinus
  thrombosis, another contiguous infection, or an
  impending complication (Potts tumor)
• Sinus mucocele or pyocele
• Fungal sinusitis
• Nasal polyps (massive )
• Neoplasm or suspected neoplasm

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Other Medications

• Antihistamines, decongestants, and
  anti-inflammatory agents have not systematically
  been studied in children
• May try these above agents

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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

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References

• Wald, Diagnosis and Management of sinusitis in
  children. Advances in Pediatric Infectious
  Diseases 1996 121-20
• Hopp, Medical Management of Sinusitis in
  Pediatric Patients. Current Problems in
  Pediatrics May/June 1997
• Newton, Sinusitis in Children and Adolescents.
  Primary Care Clinics in Office Practice Dec
  1996 23701-17