SINUSITIS In Pediatric Age Group

Anatomy MAXILLARY ANT ETHMOID FRONTAL POST ETHMOID SPHENOID LACRIMAL DUCTS MIDDLE MEATUS SUPERIOR MEATUS INFERIOR MEATUS

Sinusitis 03-21-2000 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. Tabassum Z Imam, MD

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

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

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

Symptoms And Signs PERSISTENT >10 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 > 39 C And Purulent nasal discharge Present for atleast 3-4 days Headaches may be present Periorbital swelling occasionally

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

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

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

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

Differential Diagnosis-Purulent Nasal Discharge Uncomplicated viral URI Group A Strep infection Adenoiditis Nasal foreign body

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

Differential Diagnosis-Nasal Symptoms Sinusitis 03-21-2000 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 Tabassum Z Imam, MD

Differential Diagnosis-Cough Reactive airway disease GER CF pertussis Mycoplasma bronchitis TB

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

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

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)

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

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

Treatment Amoxicillin Amoxicillin-potassium clavunate Erythromycin/sulfisoxazole Sulfamethoxazole/ trimethorphim Cefaclor Cefuroxime axetil Cefprozil Cefixime Cefpodoxime proxetil Ceftibuten Loracarbef Clarithromycin Erythromycin

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 >30days

Treatment-Most Comprehensive Coverage Amoxicillin/potassium clavunate Erythromycin-sulfisoxazole Cefuroxime axetil Cefpodoxime Proxetil Azithromycin

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

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

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

Absolute Indications for Surgery Causing brain abscess or meningitis, subperiosteal/orbital abscess, cavernous sinus thrombosis, another contiguous infection, or an impending complication (Pott’s tumor) Sinus mucocele or pyocele Fungal sinusitis Nasal polyps (massive ) Neoplasm or suspected neoplasm

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

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