Stat Consult: Acute sinusitis in children and adolescents

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


From the March 01, 2016 Issue of Clinical Advisor