Sinusitis in children

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Sinusitis in children

• Presented by
• Theera Rojanapremsuk

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References

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• Clinical practice guideline management of
  sinusitis AMERICAN ACADEMY OF PEDIATRICS
  Volume 108, Number 3 September 2001
• SINUSITIS IN CHILDREN Dept. of Otolaryngology,
  UTMB, Grand Rounds ,Kyle L. Kennedy, M.D.
  November 1, 1995
• Up to date 13.1

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Sinuses

• Sinuses are moist air spaces within the bones of
  the face around the nose
• Human have 4 pairs of sinuses
• The ethmoid and the maxillary sinuses form in the
  third to fourth gestational month
• 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.

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Sinuses
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Sinusitis
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Sinusitis

• Sinusitis is the inflammation/infection of 1 or
  more paranasal sinuses
• It is traditionally subdivided into
• - acute (symptoms lasting lt3 wk)
• - subacute (symptoms lasting 3 wk to 3 mo)
• - chronic (symptoms lasting gt3 mo).

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Anatomy and physiology

• The maxillary, ethmoid, frontal and sphenoid are
  air-containing spaces that are lined by
  pseudostratified, columna epithelium bearing
  cilia
• The sinus mucosa contain goblet cells, which
  secrete that aids in trapping inhales particle
  and debris

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Mucociliary pathways in the maxillary and frontal
sinuses
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Osteomeatal complex
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• Pattern of the mucociliary clearance is essential
  for the proper health of the function of the
  paranasal sinuses (PNS)
• The middle meatus is functional importance , as
  it serves as a drainage pathway for the
  maxillary, ethmoid and frontal sinuses

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Epidemiology

• An estimated more than 30 million patients in US
  have sinus disease.
• Although the exact incidence of sinusitis in the
  pediatric population is unclear
• Upper respiratory infections (URIs) are one of
  the most common presentations
• A viral infection associated with the common cold
  is the most frequent etiology of acute sinusitis
• Approximately 5-13 of URTIs are complicated by
  bacterial sinusitis

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Pathogenesis
Secretion stagnate
Secretion thicken pH change
Mucosal gas metabolism change
Mucosal congestion or anatomical obstruction
blocks air flow drainage
Cilia epithelium are damaged
Sinusitis cycle
Change in host milieu creates culture medium for
bacterial growth in closed cavity
Ostium closed
Mucosal thickening creates further blokage
Bacterial infection develops in the sinus cavity
Retained secretion causes tissue inflammation
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Predisposing factors

• 1. Local factor
• - cold or rhinitis - allergy
• - nasal polyp - foreign body
• - deviated of nasal septum
• 2. Systemic factor
• - cystic fibrosis
• - defective ciliary function
• - immuno- compromised host

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Microbial etiology

• Viruses are the most frequent cause of
  rhinosinusitis
• viruses are known to predispose to subsequent
  bacterial infection via such mechanisms as
  viral-induced impairment of the mucociliary
  apparatus.

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Microbial etiology
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Diagnosis

• Sign and symptom
• Physical examination
• Radiologic tests

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sign and symptom of sinusitis

• Nasal congestion
• Purulent discharge
• Maxillary tooth discomfort
• Hyposmia
• Facial pain or pressure that is worse when
  bending forward

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Sites of refered pain from individual sinuses
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Sign and symptoms

• In pediatric patients, most URIs last 5-7 days.
• By 10 days, the URI almost always improves.
• Most rhinoviral infections improve within 7-10
  days so the complaint of persistent or worsening
  symptoms may indicate a developing bacterial
  sinusitis.
• Pediatric patients may complain of a daytime
  cough and persistent nasal discharge.
• Complaints of facial pain and headache are rare
  in children.

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• Younger kids typically have cold-like symptoms,
  including a stuffy or runny nose and slight fever
• if child develops a fever after the third
  or fourth day after cold symptom begin, it could
  sinusitis
• In older children and teens, the most frequent
  symptoms of sinusitis are a daytime dry cough
  that doesn't improve after the first 7 days of
  cold symptoms, fever, worsening congestion,
  dental pain, ear pain, or tenderness in the face.

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Physical examination

• - Facial tenderness to palpation is present
• - Nasal mucosa is inflammation, redness and
  swelling
• - Purulent secretions in the middle meatus
  (highly predictive of maxillary sinusitis)
• - Complete opacification of sinus on
  transillumination is present.

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Transillumination of the Maxillary Sinus. A light
source is placed along the infraorbital rim, and
the hard palate is inspected.
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Radiologic tests

• Plain film
• CT scan
• MRI

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Plain film

• - caldwell for frontal and ethmoid
• - Waters for maxillary and sphenoid
• - submentovertex and lateral for
• sphenoid

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Caldwell
Waters
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Lateral
Submentovertex
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Plain film
The right maxillary sinus shows mucosal thickening
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CT scan

• - CT scanning is the criterion standard for
  evaluation
• - Indications for obtaining a CT of the
  sinuses include
• 1. evidence of severe, persistent sinus
  disease following maximal medical therapy
• 2. sinus disease in the immunocompromised
  patient
• 3. suspicion of a suppurative complication of
  sinus disease.

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CT scan
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Therapy

• Non-medical treatment
• Medical theray
• Surgical therapy

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Supportive treatment

• Avoid cigarette smoking
• Drink plenty of liquids
• Steam (e.g. showers or baths) to loosen
  secretions
• Warm facial packs for 5-10 minutes 3-4 times a
  day to promote drainage
• Saline nasal spray or drops may provide some
  relieve
• Adequate rest
• Elevate head of bed to promote sinus drainage

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Medical therapy

• Acetaminophen or ibuprofen
• Decongestants
• Antihistamine
• Mucoevacuants
• Antibiotics

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Antibiotics

• Amoxicillin remains as efficacious as newer drugs
  80-90 MKD divided bid for 10-14 days (maximum
  dose 2-3 g/day)
• If not improvement in 48-72 hrs ceftriaxone or
  amoxicillin-clavulanate 80-90 MKD divided bid for
  7-10 days
• Other treatment alternatives cefdinir,
  cefpodoxime, cefuroxime
• For severe allergies azithromycin or
  clarithromycin

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• For the treatment of recurrent or chronic
  sinusitis, a more lengthy course of therapy,
  usually with a beta lactamase- resistant
  antibiotic, is desirable
• 3-4 week course of an appropriate antibiotic
• In the immunocompromised patient, prophylactic
  antibiotic regimens are often utilized in
  addition to aggressive general management.

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Surgical therapy

• Indirect sinus procedure
• - septoplasty
• - adenoidectomy
• Direct sinus procedure
• - antral lavage sinus aspiration
• - Nasal antral windows
• - Middle meatal antrostomy

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Complication

• Orbital involvement
• - Preseptal cellulitis - Eyelid edema,
  erythema, normal globe movement
• - Orbital cellulitis - Proptosis, chemosis
• - Periorbital abscess - Proptosis with globe
  displaced inferolaterally, decreased extraocular
  muscle movement
• - Orbital abscess - Severe proptosis,
  impaired visual acuity, fixed globe, toxic
  patient
• - Cavernous sinus thrombosis - High fever,
  bilateral symptoms

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• Intracranial involvement
• - Intracranial involvement usually occurs
  subsequent to direct spread from sphenoid or
  frontal sinus disease.
• - Subdural and frontal lobe abscesses are
  most common.
• -Meningitis may occur

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