1. Sinusitis Laura Saldivar, M.D. Duke Children’s Primary Care HOCC Preclinic Conference February 2008

2. Sinus Anatomy and Development Ethmoid and Maxillary - formed in the 2nd trimester in utero, present at birth. (around nose and cheeks) Sphenoid - formed and pneumatized by age 5 years. (around eyes) Frontal - formed by age 7-8 years; not completely developed until adolescence. (forehead)

3. Definitions: What is sinusitis? The sinuses are air-filled cavities within the head that communicate with the nose, pharynx and middle ear. Sinusitis = Inflammation within the paranasal sinuses, causing congestion and mucus production, with URI symptoms that worsen and/or persist beyond 10 days.

4. Definitions: Acute Sinusitis: Infectious symptoms lasting for 10 - 30 days, with complete resolution of symptoms post-trtmt. Subacute: Symptoms last between 30-90 days, and resolve completely. Think of this as a prolonged acute infection with eventual complete resolution. Recurrent: Episodes of acute symptoms, each less than 30 days, with 10+ clear days in between and final resolution. Chronic: Symptoms for more than 90 days, with persistent residual symptoms (chronic cough, nasal obstruction, rhinorrea). This is thought to be a different disease, not just an extension of acute sinusitis, and is usually not infectious.

5. Etiology: ACUTE SINUSITIS Viral - Most common is Rhinovirus. Symptoms of a viral rhinosinusitis usually resolve in 7-10 days. Bacterial - Usually preceded by a viral URI, which leads to sinus inflammation and congestion, obstructing normal drainage processes, leading to a bacterial sinusitis: The most common pathogens cultured from sinus aspirates are Strep pneumo, nontypeable H. Influenza, M. catarrhalis. If symptoms persist or worsen beyond 10 days, consider the dx of acute bacterial sinusitis.

6. Etiology: CHRONIC SINUSITIS: The current thinking is that chronic sinusitis is a different disease from acute bacterial sinusitis. Most chronic sinusitis is not due to infection, but is more of a chronic inflammatory condition, similar to asthma. The small subset of chronic infections are w/different organisms, and are usually associated with an underlying immunodeficiency or anatomic abnormality.

7. Etiology: CHRONIC SINUSITIS: The most common causes of chronic sinus inflammation are: Allergic rhinitis, environmental pollutants/irritants, GERD, CF, primary ciliary dyskinesias, immunodeficiency diseases and anatomic abnormalities. Treatment needs to be tailored to the particular underlying cause for the inflammation. Antibiotics are typically not useful, unless suspect an acute infection on top of chronic underlying inflammation.

8. Acute Sinusitis: Epidemiology Acute bacterial sinusitis is preceded 80% of the time by a viral URI. Acute bacterial sinusitis is preceded up to 20% of the time by allergic rhinitis. Children in school and daycare have 6-8 URIs per year, and it is estimated that 5-10% of these will develop into sinusitis. Between 5-15% of children in daycare are estimated to have one case of sinusitis or otitis media by age 3 yrs.

9. Acute Sinusitis: Clinical Manifestations Purulent Nasal and/or postnasal discharge Cough, both day/night Fever Symptoms persisting/worsening after 7-10 days Headache and/or facial pain (variable) Eye pain and/or periorbital swelling Tooth pain, halitosis Frontal/Maxillary tenderness on palpation (variable) General malaise, nausea

10. Acute Sinusitis: Diagnosis Methods: Gold Standard - Sinus Aspiration. Culture + growth of >100K cfu/mL bacteria. Problems: invasive, time-consuming, painful, requires specialist. Not recommended for routine diagnosis. Imaging studies: Sinus xrays: cannot visualize the ethmoids well, difficult to interpret, abnormal findings not specific for infection.

11. Acute Sinusitis: Diagnosis Imaging studies: MRI: good for evaluating soft tissue complications of sinusitis, intracranial or orbital, but not good for uncomplicated sinus disease. Ultrasound: very limited usefulness. Sometimes used for maxillary and frontal sinus eval. if concerned about radiation in a particular patient. CT: The image of choice. The best eval of bones and ethmoids, but poor specificity/sensitivity for bacterial infection (high incidence of incidental abnormal CT findings in asymptomatic patients).

12. Acute Sinusitis: Diagnosis Physical Exam: Maxillary/Frontal sinus tenderness, max. tooth tenderness, nasal speculum exam for purulent discharge, transillumination of frontal/maxillary sinuses (not able to do in small children, debatable if helpful in older pts.) Clinical History: Given the limitations of sinus aspiration and imaging, several national clinician groups (ENT, Allergy/Immunol, Peds) have developed recommendations for diagnosing acute sinusitis by clinical criteria alone.

13. Acute Sinusitis: Diagnosis and Management Pediatrics 2001; 108; 798-808 “Clinical Practice Guideline (CPG): Sinusitis” Multispecialty pediatric subcommittee came up with evidence-based recommendations for the diagnosis, evaluation, and treatment of sinusitis in children aged 1-21 years, based on an extensive medical literature review and analysis. Their recommendations for sinusitis management are shown in the following slides. A published algorithm for sinusitis evaluation is available.

14. Diagnosis: Clinical Practice Guideline Strong Recommendation #1: The diagnosis of pediatric acute sinusitis should be based on clinical criteria alone, in children who present with upper respiratory symptoms that are either persistent or severe. i.e., increasing severity and persistent symptoms beyond 10 days was shown to be associated with a significantly higher rate of bacterial infection, and these children had a consistently high incidence of abnormal radiographs (at least 75%), making imaging unnecessary for diagnosis.

15. Diagnosis: Clinical Practice Guideline Strong Recommendation #2: Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children aged 6 years or less, and imaging to confirm the diagnosis is controversial above 6 years of age. CT scans should be reserved for patients in whom surgery is being considered (sinusitis with complications). The level of detailed anatomy with a CT can be used to guide surgical treatment for complications of acute bacterial sinusitis, but is not necessary for diagnosis.

16. Treatment: Clinical Practice Guideline Strong Recommendation #3: Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical cure. The objective of abx treatment is to achieve a rapid recovery, prevent complications, and minimize flare of reactive airways disease. Amoxicillin is first line therapy (90mg/kgd divided bid). Augmentin is recommended if not responsive to Amox, also consider if attendance at daycare, recent abx use, or more severe illness sx at presentation.

17. Treatment: Clinical Practice Guideline Alternative abx are cefdinir, cefuroxime, cefpodoxime, clarithromycin, azithromycin. Substantial resistance precludes using sulfa or erythromycin abx as second-line. The optimal duration is probably somewhere between 10-28 days. A newer literature recommendation is to Rx until there are no symptoms, then 7 more days. (this strategy will usually average 10-14 days, but allows for adequate treatment of a prolonged subacute infection).

18. Treatment: Clinical Practice Guideline Adjuvant Therapies: No recommendations are made based on lack of randomized controlled studies in children. Saline nasal irrigation - has not been studied in children, but may help to liquefy secretions and prevent crust formation, may also mildly vasoconstrict nasal passages. Often recommended by allergy and ENT specialists. Antihistamines, Decongestants, Mucolytics, Topical intranasal and/or oral steroids are not recommended. Home-based remedies such as soups, teas, herbal or nutritional supplements, chiropractic, homeopathic, aromatherapy, etc. are not recommended due to lack of controlled trials.

19. References: AAP: Clinical Practice Guideline: Management of Sinusitis, Pediatrics 2001; 108; 798-808. Ioannidis, JPA and Lau, J: Electronic Article: A Systematic Overview : Evidence for the Diagnosis and Treatment of Acute Sinusitis in Children, Pediatrics 2001; 108 (3); e.57. Novembre, E et al: Systemic treatment of rhinosinusitis in children,Pediatr Allergy Immunol, 2007 (18):56-61. Zacharisen, M et al: Sinusitis, Immunol Allergy Clin North Am, 2005, 25:313- 332. Steele, RW: Rhinosinusitis in children, Curr Allergy Asthma Rep, 2006 6(6):508-12.

20. CPG Algorithm: Acute Sinusitis