Background


  • Acute rhinosinusitis is inflammation of mucosal lining of nasal passage and paranasal sinuses <4 weeks in duration

  • causes

    • viruses identified in <10% of childhood sinus infections

    • acute bacterial sinusitis is rhinosinusitis complicated by bacterial infection, such as 

      • Streptococcus pneumoniae

      • Nontypeable Haemophilus influenzae

      • Moraxella catarrhalis
    • uncommon bacterial agents in acute sinusitis include

      • Staphylococcus aureus (unless orbital or intracranial complication)

      • respiratory anaerobes (unless dental infections)

    • fungal sinusitis (such as Aspergillus species) if immunocompromised or diabetic

  • common, possibly affecting 6% to 7% of children attending medical care for respiratory symptoms

  • risk factors 

    • exposure to tobacco smoke or other irritants

    • underlying conditions such as 

      • anatomic abnormalities of nasal passages and sinuses

      • immunodeficiencies

      • cystic fibrosis

      • primary ciliary dyskinesia

  • pathogenesis

    • usually follows URIs or allergic rhinitis

    • mucosal edema, decreased mucus transport, and obstruction of ostiomeatal complex lead to stagnation of secretions

    • stagnation of secretions, decreased pH, and lowered oxygen tension within sinus promotes bacterial or viral overgrowth

    • age of pneumatization of paranasal sinuses based on MRI in 1,452 children with no history of sinus disease

      • at birth for maxillary and ethmoid sinuses

      • age 9 months for sphenoid sinus

      • age ≥5 years for frontal sinus


Evaluation


  • ISDA criteria for diagnosis of acute sinusitis includes presence of at least 2 major or 1 major plus ≥2 minor symptoms.

    • Major symptoms include
      • nasal congestion or obstruction

      • facial congestion or fullness

      • facial pain or pressure (may be unilateral, above 
or below eyes on leaning forward)

      • purulent anterior nasal discharge

      • purulent or discolored posterior nasal discharge

      • hyposmia or anosmia

      • fever

    • Minor symptoms include
      • Headache

      • ear pain, pressure, or fullness

      • halitosis

      • dental pain

      • cough

      • fatigue

    • percussion of sinuses may elicit tenderness but not useful to distinguish causes of rhinosinusitis

    • signs favoring acute bacterial sinusitis include
      • signs or symptoms lasting ≥10 days without clinical improvement

      • worsening signs or symptoms following initial improvement (“double sickening”)

      • severe symptoms including fever ≥39 degrees C (102 degrees F) and purulent nasal discharge lasting ≥3 consecutive days

    • symptoms suggestive of noninfectious rhinitis include
      • pruritis of eyes, nose, mouth, palate, ears

      • watery rhinorrhea

      • sneezing

      • nasal congestion

      • postnasal drip

  • differential diagnosis

    • viral URI (may be indicated by absence of either disturbed sleep or green nasal discharge)

    • allergic rhinitis 

    • migraine 

    • nasal foreign body

    • dental disease

  • testing

    • blood tests and imaging studies are not 
indicated to
      • confirm uncomplicated acute bacterial sinusitis 

      • distinguish bacterial from viral causes 

    • Contrast-enhanced CT preferred over MRI to identify suppurative complications (such as orbital or intracranial extension of infection) 

    • obtain cultures by direct sinus aspiration rather than by nasopharyngeal swab if no response to first- and second-line antibiotics