Rhonda Lesniak Primary Care II SINUSITIS Rhonda Lesniak Primary Care II

Anatomy Paranasal Sinuses

Anatomy Lateral View of Sinuses

Where are the sinuses? Four pairs of paranasal sinuses Frontal-above eyes in forehead bone Maxillary-in cheekbones, under eyes Ethmoid-between eyes and nose Sphenoid-in center of skull, behind nose and eyes

What are the sinuses? The sinuses are hollow air-filled sacs lined by mucous membrane. The ethmoid and maxillary sinuses are present at birth. The frontal sinus develops during the 2nd year and the sphenoid sinus develops during the 3rd year.

What are the sinuses? (cont’d) Sinuses have small orifices (ostia) which open into recesses (meati) of the nasal cavities. Meati are covered by turbinates (conchae). Turbinates consist of bony shelves surrounded by erectile soft tissue. There are 3 turbinates and 3 meati in each nasal cavity (superior, middle, and inferior).

Considerations for Pediatrics At birth, the ethmoid, sphenoid and maxillary sinuses are tiny and cause problems in infants and toddlers. Frontal sinuses develop between 4-7 years of age, causing problems in school aged children and adolescents.

Sinusitis Inflammation of paranasal sinuses

What is sinusitis? An acute inflammatory process involving one or more of the paranasal sinuses. A complication of 5%-10% of URIs in children. Persistence of URI symptoms >10 days without improvement. Maxillary and ethmoid sinuses are most frequently involved.

How Does Sinusitis Develop? Usually follows rhinitis, which may be viral or allergic. May also result from abrupt pressure changes (air planes, diving) or dental extractions or infections. Inflammation and edema of mucous membranes lining the sinuses cause obstruction. This provides for an opportunistic bacterial invasion.

Development (cont’d) With inflammation, the mucosal lining of the sinuses produce mucoid drainage. Bacteria invade and pus accumulates inside the sinus cavities. Postnasal drainage causes obstruction of nasal passages and an inflamed throat. If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities.

Predisposing Factors Allergies, nasal deformities, cystic fibrosis, nasal polyps, and HIV infection. Cold weather High pollen counts Day care attendance Smoking in the home Reinfection from siblings

Acute or Chronic Sinusitis? Acute Sinusitis – respiratory symptoms last longer than 10 days but less than 30 days. Subacute sinusitis – respiratory symptoms persist longer than 30 days without improvement. Chronic sinusitis – respiratory symptoms last longer than 120 days.

Etiology of Sinusitis 70% of bacterial sinusitis is caused by: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Other causative organisms are: Staphylococcus aureus Streptococcus pyogenes, Gram-negative bacilli Respiratory viruses

Complications of Sinusitis Orbital cellulitis or abscess Meningitis Brain abscess Intractable wheezing in children with asthma Cavernous sinus thrombosis Subdural empyema

Subjective Symptoms of Sinusitis History of URI or allergic rhinitis History of pressure change Pressure, pain, or tenderness over sinuses Increased pain in the morning, subsiding in the afternoon Malaise Low-grade temperature Persistent nasal discharge, often purulent Postnasal drip Cough, worsens at night Mouthing breathing, snoring History of previous episodes of sinusitis Sore throat, bad breath Headache

Clinical Presentations of Sinusitis Periorbital edema Cellulitis Nasal mucosa is reddened or swollen Percussion or palpation tenderness over a sinus Nasal discharge, thick, sometimes yellow or green Postnasal discharge in posterior pharynx Difficult transillumination Swelling of turbinates Boggy pale turbinates

Pale, Boggy Turbinates

Diagnostic Tests Imaging studies, such as sinus radiographs, ultrasonograms, or CT scanning – indicated if child is unresponsive to 48 hours of antibiotics and if the child has a toxic appearance, chronic or recurrent sinusitis, and chronic asthma. Laboratory studies, such as culture of sinus puncture aspirates.

Differential Diagnoses Allergic rhinitis Non-allergic rhinitis Infectious rhinitis Drug-induced rhinitis Nasal polyps Dental abscess Carcinoma of sinus Cluster headache Structural defects (septum deviation) Nasal foreign body

Pharmacological Plan of Care Antimicrobials-treat for 10-14 days, depending upon severity, with one of the following: Amoxicillin:20-40mg/kg/d in 3 divided doses(>20kg, 250mg tid) Augmentin:25-45mg/kg/d in 2 divided doses(>20kg, 400mg q12) Use chewable or suspension if child is less than 40kg.

Pharmacological Plan of Care Biaxin:15mg/kg/d in 2 divided doses(>30kg, 250mg q12) Cefzil:15mg/kg/d in 2 divided doses (>35kg, 250mg bid) Lorabid: 30mg/kg/d in 2 divided doses (>26kg, 400mg bid)

Other Relief Medications Codeine – for severe pain Rhinocort nasal spray – 2 sprays in each nostril every 12 hours for children over 6 years of age.

OTC Medications Acetaminophen or ibuprofen to relieve pain Decongestants Antihistamines Nasal saline

Non-pharmacological treatment Humidifier to relieve the drying of mucous membrances associated with mouth breathing Increase oral fluid intake Saline irrigation of the nostrils Moist heat over affected sinus Prolonged shower to help promote drainage

Patient Education Child should not dive. Child should not travel by airplane. Urge parent to eliminate triggers in the home (dust, smoking) Have all members of the family treated, if indicated.

Follow Up Guidelines Instruct parent to call in 48 hours if condition of child has not improved. Instruct parent to bring child in for a recheck in 2 weeks.

Guidelines for Referral Child with complications or signs of invasive infection. Child needing control of allergic rhinitis. Child with chills and fever. Child with persistent headache. Child with edema of forehead, eyelids. Child with orbital cellulitis

Case Study Austin, 9 years old, was seen in the clinic ten days ago, was diagnosed with rhinitis and sent home with instructions for increased fluids, decongestants, and rest. Austin presents today with worsened symptoms of malaise, low-grade temperature, nasal discharge, night time coughing, mouth breathing, early morning pain over sinuses, and congestion.

Case Study (cont’d) Physical findings for Austin: Thick, yellow nasal discharge Edematous, reddened nasal mucosa Postnasal discharge visible in posterior pharynx Periorbital swelling Tenderness of sinuses upon palpation

Case Study (cont’d) Treatment: Austin weighs 90 lbs, or 40.8 kg Amoxicillin – 250 mg tid po Comfort measures – acetaminophen for pain relief Moist heat applied to sinuses Increased oral fluids Rest

References Boynton, R., Dunn, E., Stephens, G., & Pulcini, J. (2003) Manual of ambulatory pediatrics (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Burns, C., Dunn, A., Brady, M., Starr, N., & Blosser, C. (2004). Pediatric primary care: A handbook for nurse practitioners (3rd ed.). St. Louis, Missouri: Saunders.

References (cont’d) Colyar, M. (2003). Well-child assessment for primary care providers. Philadelphia: F. A. Davis Company. Tierney, L., Saint, S., & Whooley, M. (2005). Current essentials of medicine (3rd ed.). New York: Lange Medical Books/McGraw-Hill.