A 7 year old previously healthy female presents to her primary care physician with a 12 day history of persistent thick nasal discharge, nasal congestion, cough, and intermittent low grade fever. On further questioning, her parents reveal that the cough is worse at night but there is no wheezing, currently or in the past. She also seems to have one temperature spike daily to about 38.2 degrees (100.8 degrees F). She is not taking any medications. They deny the possibility of a nasal foreign body. She denies any vomiting, headache, earache, or rashes.
Her past medical history is negative for hospitalizations, asthma, allergic rhinitis, or cystic fibrosis.
Exam: VS T 37.2, P 90, R 15, BP 88/50. She is an alert, interactive female breathing comfortably. She has no eye abnormalities. Her tympanic membranes are clear. She has nasal congestion with thick yellow purulent mucus in the posterior nasal pharynx. Her nasal turbinates are red and swollen. Transillumination of her sinuses is equivocal. She has mild tenderness to palpation of her maxillary sinuses. Her oral pharynx is non erythematous. Her breath is malodorous. She has no obvious dental caries or pain on tapping of her teeth. Her lungs are clear. The rest of her exam is normal.
A diagnosis of acute bacterial sinusitis is made on the basis of history and physical exam. She is started on amoxicillin at 50mg/kg/day for 10 days. Her symptoms quickly resolve, and by day 3 of treatment she is asymptomatic.
Sinusitis is a common childhood disease which involves inflammation of the paranasal sinuses (frontal, maxillary, ethmoid, and/or sphenoid). There are many etiologies and forms of sinusitis, including the simple self limited viral rhinosinusitis, the acute bacterial, subacute, and chronic sinusitis. The differences between these designations lie largely in the duration of symptoms.
In acute bacterial sinusitis, nasal and sinus symptoms have been present for at least 10 days, but fewer than 30 days. Subacute sinusitis involves nasal and sinus symptoms lasting longer than 4 weeks but fewer than 12 weeks, and chronic sinusitis involve symptoms lasting at least 12 weeks (1).
Anatomically, the maxillary and ethmoid sinuses form during the third and fourth gestational month, but at birth are still very small. The frontal sinuses develops by one to two years of age and assume their final position above the orbital ridge by the fifth or sixth birthday. However, the frontal sinuses are not completely developed until late adolescence. The frontal, ethmoid, and maxillary sinuses all drain through the ostiomeatal complex located between the middle and inferior turbinates. This makes normal mucociliary motility imperative to preventing sinus infections. In the absence of effective clearing of secretions by the cilia, the sinuses become a medium for bacterial growth. Thus, anything that impairs normal ciliary function such as cigarette smoke exposure, viral infections, allergic rhinitis, cystic fibrosis, immunodeficiency, gastroesophageal reflux, and ciliary dyskinesia, can predispose patients to developing sinusitis. Nasal obstructions caused by foreign bodies, polyps, large adenoids, cleft palate, and trauma are also risk factors for sinusitis. However, viral infections represent the inciting event in about 80% of cases of acute sinusitis with allergic inflammation accounting for about 20% of acute sinusitis. It is estimated that the typical child has 6-8 viral URIs per year and approximately 10% of these may be complicated by secondary bacterial sinusitis.
The principle bacterial pathogens implicated in bacterial sinusitis are Streptococcus pneumonia (30%), non-typable Haemophilus influenzae (20%), and Moraxella catarrhalis (20%) (2). Viral isolates include adenovirus, parainfluenza virus, influenza, and rhinovirus, which account for 10% of sinusitis cases. In chronic sinusitis, results have been variable with alpha hemolytic streptococci, Staphylococcus aureus, anaerobes, and mixed colonies frequently recovered.
The most common presenting patient complaint is persistent nasal discharge which can be of any quality from thin, thick, clear, or purulent. Other common complaints include persistent cough which is worse at night, malodorous breath, low grade fever, dental pain, and sore throat. Older children, teens, and adults will have more specific complaints such as facial pain and pressure, and headaches.
On physical exam it is often difficult to differentiate between uncomplicated viral rhinosinusitis and acute bacterial sinusitis. Both conditions will have mild erythema and swelling of the nasal turbinates with mucopurulent nasal discharge. Sinus tenderness can be useful in the older child and adolescent, but is unreliable in younger children. Transillumination of the sinuses may be useful to assess the presence of fluid in the maxillary and frontal sinuses. However, this technique is difficult to perform correctly and has been shown to be unreliable in children less than 10 years old due to asymmetrical sinus development or lack of sinus development.
Sinus aspiration remains the gold standard for the diagnosis of acute bacterial sinusitis. However, it is invasive and requires a skilled ENT surgeon. Subsequently less invasive tests such as sinus x-rays, sinus CT scans, and MRI's have been used to help confirm the diagnosis of sinusitis. Radiographic findings of sinusitis are complete opacification, mucosal thickening of at least 4mm, or an air fluid level. However, even in the presence of these x-ray findings it will not help differentiate between viral rhinosinusitis, acute or chronic sinusitis.
In September 2001, the American Academy of Pediatrics published a clinical practice guideline for the management of sinusitis. Part of their recommendations include appropriate diagnosis and use of imaging studies to confirm sinusitis. In short, they recommend that for children <6 years of age, the diagnosis of acute bacterial sinusitis be based on clinical criteria rather than radiographic criteria. In this age group, there was an 88% correlation between history (persistent cough and nasal symptoms) and abnormal sinus radiographs, thus reducing the benefit of x-rays. Furthermore, the guidelines recommend reserving sinus CT scans for those patients requiring evaluation for surgery (2).
The treatment for acute bacterial sinusitis is antibiotics. In uncomplicated sinusitis the treatment is standard dose amoxicillin of 45-50 mg/kg/day. However, alternate dosing or medication should be considered if a patient fails to improve on conventional doses of amoxicillin, recent treatment with amoxicillin (<1 month ago) or attendance at day care. Alternate drug regimens recommended in these cases are high dose amoxicillin of 80-90 mg/kg/day and amoxicillin with clavulanate (1,2). Appropriately treated sinusitis patients will have a marked improvement in nasal discharge and cough within 48-72 hours.
The duration of antibiotic therapy has been controversial, between 10-28 days. Recent recommendations suggest continuing antibiotics until the patient is symptom free, plus an additional 7 days, but for a minimum of 10 days.
Surgical treatment is seldom indicated in acute sinusitis. However, in cases where patients fail to respond to aggressive antimicrobial therapy, or suffer from refractory chronic sinusitis, sinus aspiration may be indicated. Sinus aspiration is useful to both ventilate the sinuses and obtain cultures. Surgical intervention for chronic sinusitis involves endoscopic enlargement of the ostiomeatal complex and anterior ethmoidectomy. However, the actual outcome and benefit of sinus surgery is not well established.
The vast majority of acute bacterial sinusitis resolves without problems. The few reported complications associated with sinusitis involve contiguous spread of infection to the orbit, bone, or central nervous system. Orbital involvement is the most likely, and can lead to periorbital and orbital cellulitis, orbital abscess, and subperiosteal abscess. Other documented complications include frontal osteomyelitis (Pott's puffy tumor), epidural abscess, subdural empyema, cavernous sinus thrombosis, and meningitis.
1. What is the dose and drug of choice for uncomplicated sinusitis?
2. What percentage of viral URI's will progress to acute bacterial sinusitis?
3. Name some risk factors in the development of sinusitis.
4. What are some radiographic finding of sinusitis?
5. What is the most common complication of sinusitis?
1. Nash D, Wald E. Sinusitis. Pediatr Rev 2001;22(4):111-116.
2. Wald E, et al. Clinical Practice Guideline: Management of Sinusitis. Pediatrics 2001:108(3):798-806.
3. Cherry JD, Newman A. Chapter 17-Sinusitis. In: Feign RD, Cherry JD (eds). Textbook of Pediatric Infectious Diseases, 4th edition. 1998, Philadelphia: WB Saunders Co, pp. 183-190.
4. Kenna M. Part XVII, Section II- Upper Respiratory Tract. In: Behrman RE, Kliegman RM, Jenson HB (eds). Nelson Textbook of Pediatrics, 16th edition. 2000, Philadelphia: WB Saunders Co, pp. 11258-1264.
Answers to questions
1. Amoxicillin 45-50 mg/kg/day.
2. Up to 10% will progress.
3. Allergic rhinitis, viral infections, cystic fibrosis, foreign body.
4. Mucosal thickening of at least 4mm, air fluid levels, opacification.
5. Periorbital cellulitis.