The editors and current author would like to thank and acknowledge the significant contribution of the previous author of this chapter from the 2004 first edition, Dr. Kathleen Morimoto, MD. This current third edition chapter is a revision and update of the original author’s work.
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: T99.0 degrees F, P 90, R 15, BP 88/50mm Hg. She is an alert, interactive female breathing comfortably. She has no eye abnormalities. Her tympanic membranes are dull, but not red. 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 involving inflammation of the paranasal sinuses (frontal, maxillary, ethmoid, and/or sphenoid). Sinusitis can be broadly divided based on etiology into viral rhinosinusitis, bacterial, and fungal sinusitis which is rare in immunocompetent patients (1).
In acute bacterial sinusitis, symptoms are typically present for at least 10 days, but fewer than 30 days. In subacute sinusitis, symptoms last longer than 4 weeks but fewer than 12 weeks, and chronic sinusitis involve symptoms persisting for longer than 12 weeks (1). However, the sinuses are difficult to see or assess on examination, thus the true duration of the actual sinusitis is often not precisely known.
Anatomically, the maxillary and ethmoid sinuses form during the third and fourth gestational month. At birth only the ethmoidal sinuses are pneumatized. The frontal sinuses start developing at 7 to 8 years of age, and are completely developed by adolescence. Sphenoidal sinuses are developed by 5 years of age (1). 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. Viral URI often precedes acute bacterial sinusitis. In the absence of effective clearing of secretions by the cilia, in addition to paranasal inflammation and edema, the fluid within the sinuses becomes a medium for bacterial growth.
Anything that impairs normal ciliary function such as cigarette smoke exposure, viral infections, allergic rhinitis, cystic fibrosis, immunodeficiencies (IgG and IgA), gastroesophageal reflux, and ciliary dyskinesia, can predispose patients to developing sinusitis. Nasal obstructions caused by foreign bodies, prolonged use of nasogastric tubes or nasotracheal intubation, nasal polyps, large adenoids, anatomical abnormalities such as cleft palate, trauma, and cocaine abuse are also risk factors for sinusitis. Fungal sinusitis can be seen in patients with profound neutropenia and lymphopenia secondary to malignancy or chronic immunosuppression for organ/bone marrow transplant. 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 to 8 viral URIs per year and approximately 0.5% to 2% of these may be complicated by secondary bacterial sinusitis (1).
The causative bacterial pathogens implicated in bacterial sinusitis are Streptococcus pneumonia (30%), non-typable Haemophilus influenzae (30%), and Moraxella catarrhalis (10%) (1,2). Note that these are the same bacterial organisms that typically cause acute otitis media. Viral isolates include adenovirus, parainfluenza virus, influenza, and rhinovirus, which account for 20% of sinusitis cases. There is in increasing prevalence of MRSA which remains of significant concern. In chronic sinusitis, results have been variable with alpha hemolytic streptococci, staphylococcal species, M. catarrhalis, anaerobes, and mixed colonies which are frequently recovered. Fungi such as Aspergillus and Mucor can cause sinusitis in immunocompromised patients (1).
The most common presenting patient complaint is persistent nasal discharge (unilateral or bilateral) which can be of any quality from thin, thick, clear, or purulent, fever, and persistent cough. Other less common complaints include, malodorous breath (halitosis), maxillary tooth discomfort/pain, decreased sense of smell (hyposmia), periorbital edema, and sore throat. Older children, teens, and adults will have more specific complaints such as facial pain and pressure which is exacerbated by forward bending, 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. It is performed by using a bright light in a darkened room. Apply the light over the sinuses externally and examine the mouth, nasal cavity, or adjacent structures to assess the amount of light that is being transmitted. The reverse can also be done where the light is applied below or adjacent to the sinus (e.g., under the medial supraorbital ridge to transilluminate the frontal sinus above it), to see the transillumination through the sinuses. A light can be covered and placed in the patient’s mouth to view the symmetry of how the sinuses glow. The mouth light can be applied to the mucosal surface adjacent to the maxillary sinuses to view light transmission externally. A positive finding reveals an opaque sinus with poor transmission of light (1). However, this technique is relatively insensitive, 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.
Acute bacterial sinusitis is presumptively diagnosed when a child with an acute upper respiratory infection presents with the following: Persistent illness with cough/rhinorrhea lasting for >10 days without improvement; or worsening course after initial improvement; or severe onset of illness with fever >102.2 degrees F and purulent rhinorrhea for 3 or more consecutive days (3). Per the Infectious Disease Society of America guidelines, conventional criteria for the diagnosis of sinusitis includes presence of at least 2 major criteria or 1 major and at least 2 minor symptoms (2).
Sinus aspiration remains the gold standard for the diagnosis of acute bacterial sinusitis; however, it is invasive and requires a skilled ENT surgeon. Aspiration and culture studies may be of high utility for immunosuppressed patients. Radiographic findings of sinusitis on sinus x-rays, CT scans, and MRI scans are seen as complete opacification, mucosal thickening of at least 4mm, or an air fluid level; however, these findings will not help differentiate between viral rhinosinusitis, acute or chronic bacterial sinusitis, and therefore are not completely diagnostic and are not routinely recommended in otherwise healthy children (1).
In 2013, the American Academy of Pediatrics updated their previously published clinical practice guideline for the management of sinusitis. Updates from this revision included the addition of another clinical presentation as a "worsening course" with an option to observe children with persistent symptoms for 3 days before treating or immediately treating with antibiotics (3). This is in contrast to 2001 guidelines, which recommended antibiotic treatment for all children diagnosed with acute bacterial sinusitis. Limiting use of antibiotics reduces risk of antibiotic resistance and antibiotic related side effects. Additionally, further review of evidence continued to show that imaging studies are not mandatory in the diagnosis of uncomplicated bacterial sinusitis (3).
In uncomplicated sinusitis, the treatment is the standard dose amoxicillin of 45 to 50 mg/kg/day, unless the patient is in an area with high rates of Streptococcus pneumoniae resistance, where high dose amoxicillin of 80 to 90 mg/kg/day should be used. Additionally, alternate dosing or medication should be considered if a patient fails to improve on conventional doses of amoxicillin within 72 hours, recent treatment with amoxicillin (less than 1 month ago), age less than 2 years, or attendance at day care. Alternate drug regimens recommended in these cases are high dose amoxicillin/clavulanate 80 to 90 mg/kg/day (1,2,3). In children with poor oral tolerance to medications or at risk of medication non-adherence, ceftriaxone 50 mg/kg IM or IV dose can be given, followed by oral antibiotics for the remainder duration provided there is significant clinical improvement (1). In patients who have a penicillin allergy, alternative treatment includes cefdinir, cefpodoxime, cefixime (2). Appropriately treated patients with sinusitis will have a marked improvement in nasal discharge and cough within 48 to 72 hours. The duration of antibiotic therapy has been controversial, between 10 to 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.
Indications for referral to a specialist include severe persistent infection with orbital/CNS signs, failed response to prolonged course of antibiotics, resistant/unusual pathogens, fungal sinusitis, granulomatous disease, anatomical defects causing obstruction, immunocompromised patient, and multiple recurrent episodes of acute bacterial sinusitis (3 to 4 episodes/year) (2). 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.
Adjunctive therapies with intranasal corticosteroids, saline nasal irrigation, topical/oral decongestants, mucolytic and topical/oral antihistamines are controversial, with insufficient study data (3).
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; periorbital cellulitis is the most common of these. Other documented complications include frontal osteomyelitis (Pott's puffy tumor), epidural abscess, subdural empyema, cavernous sinus thrombosis, cerebritis, and meningitis. Evaluation for these complications should include a CT scan or an MRI with contrast and consultation with ophthalmology, otolaryngology, and neurosurgery.
Questions
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 findings of sinusitis?
5. What is the most common complication of sinusitis?
References
1. Pappas DE, Hendley JO. Chapter 408. Sinusitis. n: Kliegman RM, St. Geme JW, Blum NJ, et al (eds). Nelson Textbook of Pediatrics, 21st edition. 2020, Elsevier, Philadelphia, PA. pp: 2188-2192.
2. Chow AW, Benninger MS, Brook I, et al, Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72–e112. doi: 10.1093/cid/cir1043
3. Wald ER, Applegate KE, Bordley C, et al, American Academy of Pediatrics. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics 2013;132(1): e262-e280. doi:10.1542/peds.2013-1071
Answers to questions
1. Amoxicillin 45 to 50 mg/kg/day, unless the patient is in an area with high rates of Streptococcus pneumoniae resistance, in which case 80 to 90 mg/kg/day should be used. Pneumococcal resistance is becoming more common which is shifting clinicians toward prescribing the higher dose in most instances.
2. Up to 0.5% to 2% will progress. It is difficult to be certain about this number. Most studies that have attempted to answer this question might be underestimating the denominator (the number of URIs) since most of them do not seek medical attention.
3. Allergic rhinitis, viral infections, cystic fibrosis, nasal foreign body.
4. Mucosal thickening of at least 4mm, air fluid levels, opacification.
5. Periorbital cellulitis.