Sinusitis

Development of the paranasal sinuses

  1. Ethmoid are present at birth and developed at 3 years of age
  2. Maxillary are present at birth and developed by 3 years of age
  3. Sphenoid are present at 3 years of age and developed by 12 year of age
  4. Frontal are present at 8 years of age and developed by 12 years of age

Developmental Time Line For Paranasal Sinuses Pediatric Emergency Medicine Practice_0_0.jpg
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Normal physiology of the paranasal sinuses dependent on

  1. Patency of the ostia
  2. Normal functioning of the cilia
  3. Normal viscosity of the secretions

 

Pathogenesis of sinus infection

  1. Ostial obstruction leads to negative pressure in the sinus and when obstruction is released, bacteria enter the sinus cavity. Sneezing and blowing of the nose may also allow bacteria to enter the sinuses. Obstruction most often associated with URI and allergies.
  2. Decreased number of cilia, dysfunction, and changes in morphology may allow for entry of bacteria into the sinuses
  3. Thickened secretions may affect cilia function and also lead to obstruction. This occurs in asthma and CF

 

Presentation of Acute Sinusitis

  1. Prolonged URI symptoms without clinical improvement. Sinusitis may complicate 0.5% to 10% of URIs
  2. The nasal discharge may be clear, mucousy, or purulent. 
  3. Cough is present in the daytime although worse at night. 
  4. Headache and facial pain are uncommon. 
  5. Periorbital swelling (greatest earlier in the day) and low grade fever

 

Physical findings (may differ from URI)

  1. Erythema of nasal mucosa
  2. Red pharynx
  3. Otitis media
  4. Swelling of the eyelids that aren't tender
  5. Tenderness over the paranasal sinuses
  6. Bad breath 
  7. Differential Diagnosis- mucopurulent rhinitis, allergic rhinitis, foreign body, pharyngitis, adenoiditis

 

Diagnosis

  1. Transillumination-difficult to perform
  2. Presence of opacification, air fluid levels, and mucosal thickening on a plain radiograph are non-specific findings but may help in making the diagnosis
  3. CT- During a common URI, CT will demonstrate fluid in the sinus cavities. Most useful in complicated or chronic cases and able to find intracranial and intraorbitial abnormalities. Also useful when the patient isn't improving or the host is immunocompromised.
  4. "10 day rule". Most URIs are better in 10 days. Therefore entertaining the diagnosis of sinusitis before 10 days may be premature.

 

Common Bacterial Etiologies

  1. Streptococcus pneumoniae-30%
  2. Non-typable H. Flu-20%
  3. Moraxella catarrhalis-20%
  4. Streptococcus pyogenes-4%

 

Treatment

  1. Antibiotics- treatf or 7 days after the patient is symptom-free. Antibioic choice dependent on severity of symptoms and whether the patient was recently on antibiotics.
    1. Amoxicillin- should be the initial drug of choice
    2. Augmentin
    3. Pediazole
    4. Cefaclor ,Cefuroxime and other second and third generation Cephalosporins
    5. Clindamycin- good for anaerobes and penicillin resistant pneumocoocal infections
  2. Antihistamines and decongestants not proven to be effective
  3. Topical anti-inflammatory drugs may also help

 

Complications

  1. Periorbital and orbital cellulitis
  2. Orbital abscess
  3. Optic neuritis
  4. Osteomyelitis
  5. Intracranial complications- meningitis and abscess

 

References

  1. Bussey MF and Moon RY. Acute Sinusitis. Pediatrics in Review. 1999; 20:142.
  2. Newton DA. Sinusitis in Children and Adolescents. Primary Care; Clinics in Office Practice. 1996; 23(4):701-717.
  3. O'Brien KL et al. Acute Sinusitis - Principles of Judicious Use of Antimicrobial Agents. Pediatrics. 1998 101(1 Suppl.):174-177.
  4. Ueda D and Yuko Y. The ten-day mark as a practical diagnositc approach for acute paranasal sinusitis in children. Pediatric Infectious Disease. Vol 15, no1. July, 1996.
  5. Wald ER. Sinusitis. Pediatrics in Review. September 1993.
  6. Nash David, and Wald Ellen SinusitisPediatrics in Review April 2001
  7. Clinical Practice Guidleines: Management of Sinusitis Pediatrics September 2001
  8. Garbutt et al.  A Randomized, Placebo Controlled Trial of Antimicrobial Treatment for Children with Clinically Diagnosed Sinusitis  Pediatrics 2001 107 619-25
  9. The Diagnosis and Management of Sinusitis: A Practice Parameter Update.  Journal of Allergy and Clinical Immunology Dec. 2005
  10. Demuri G, Wald E.  Complications of Acute Vacterial Sinusitis  Pediatric Infectious Disease Journal August 21011
  11. DeMuri DJ, Wald E. Acute Bactertial Sinusitis in Children.  New England Journal of Medicine.  Sept 20, 2012

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