Key Points
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Sinusitis is diagnostically challenging because symptoms (i.e. nasal discharge, congestion and cough), signs and radiographic findings are similar to those in common upper respiratory tract infections. Coronal sinus CT scans may be helpful in chronic, recurrent or complicated sinusitis.
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Respiratory infections (viruses, bacteria), bacterial biofilms and microbiome disruption have pathogenic roles. The most common causes of bacterial sinusitis are Streptococcus pneumoniae (20–30%), Haemophilus influenzae (20–30%) and Moraxella catarrhalis (10–20%); 30–35% are sterile.
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Antibiotic resistance is common: Streptococcus pneumoniae (15–50% penicillin resistant), Haemophilus influenzae (25–80% β-lactamase positive), and Moraxella catarrhalis (90–100% β-lactamase positive). Antral irrigation can provide sinus specimens for bacterial culture and targeted antimicrobial therapy in patients with chronic, refractory and complicated disease.
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Children with chronic sinusitis have mucosal pathology and inflammation that typically differs from adults. In adults, chronic sinusitis is characterized by mucosal thickening, goblet cell hyperplasia, subepithelial fibrosis and persistent Th2-type eosinophilic inflammation. In children, pan-immune inflammation (CD8 + T lymphocytes, B lymphocytes, neutrophils) with reduced basement membrane thickness, fewer mucous glands, and less epithelial injury is common.
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Management of uncomplicated, acute sinusitis consists of antimicrobial treatment aiming for symptom relief and prevention of complications and recurrence. Severe intraorbital and intracranial complications are uncommon today.
This chapter on sinusitis in children will provide an overview of the pathogenesis and management of acute and chronic sinus disease. Although acute sinusitis has been substantially investigated, relatively little is known about chronic sinusitis in children.
Sinus Development in Childhood
There are four pairs of paranasal sinuses in humans: maxillary, ethmoid, frontal, and sphenoid. The maxillary and ethmoid sinuses are present at birth and invaginate to become radiographically visible in the first 1 to 2 years of life ( Figure 26-1 ). In comparison, frontal and sphenoid sinuses begin to develop in the first few years of life and gradually become pneumatized and radiographically visible between 7 and 15 years of age. The maxillary, anterior ethmoid and frontal sinus ostia enter the nasal cavity through the middle meatus, under the middle turbinate (i.e. osteomeatal complex; see Figure 26-1 ). The sphenoid and posterior ethmoid ostia join the nasal cavity through the superior meatus, above the middle turbinate.
Clinical Definitions of Sinusitis
Several descriptive modifiers for sinusitis are commonly used. In terms of sinusitis duration, (1) acute sinusitis refers to sinus symptoms of 10 to 30 days, with complete resolution of symptoms, (2) subacute sinusitis refers to symptoms that last 30 to 90–120 days, and (3) chronic sinusitis is used for symptoms that last more than 90–120 days. Recurrent sinusitis occurs in patients who improve with sinus therapy but experience multiple episodes. Refractory sinusitis refers to patients who do not respond to conventional therapy for sinusitis.
The uses of the term sinusitis and rhinosinusitis have been debated; sinusitis implies that the disease is the manifestation of an infectious process of the sinuses. In comparison, the term rhinosinusitis implies that the nasal and sinus mucosae are involved in similar and concurrent pathogenic (e.g. inflammatory) processes. In this chapter the two terms will be used interchangeably.
Epidemiology
Sinusitis is a common problem in childhood. In a study of 1- to 5-year-old children seen in pediatric practices, 9.3% met the clinical criteria of sinusitis (i.e. ≥ 10 days of symptoms). In a large birth cohort study primarily intended to study the natural history of childhood asthma (Children’s Respiratory Study, Tucson, Arizona), 13% of 8-year-old children reported physician-diagnosed sinusitis within the past year. Of children with sinusitis, 50%, 18% and 11% had sinusitis diagnosed for the first time at ages 6 years, 3 years and 2 years, respectively. The main risk factors for sinusitis were current allergic rhinitis and grass pollen hypersensitivity.
The US National Center for Health Statistics reported that, from 1980 to 1992, sinusitis was the fifth leading diagnosis for which antibiotics was prescribed. The annual outpatient visit rates for sinusitis increased about 3-fold over this period and the use of amoxicillin and cephalosporin antibiotics for sinusitis also increased significantly. Antibiotic resistance of bacterial pathogens from the sinuses of children with acute and chronic sinusitis is common. Severe alterations in quality of life can result from chronic recurrent sinusitis in children. Using a standardized child health questionnaire, children with chronic sinusitis and their parents reported more bodily pain and greater limitation in their physical activity than were typically reported by children with asthma or juvenile rheumatoid arthritis. Complications of sinusitis, such as intracranial or intraorbital extension of bacterial infection from the sinuses, are medical emergencies that are life-threatening.
Etiology
A combination of anatomic, mucosal, microbial and immune pathogenic processes is believed to underlie sinusitis in children. Children with congenital mucosal diseases (e.g. cystic fibrosis, ciliary dyskinesias) and lymphocyte immune deficiencies (congenital and acquired) typically have chronic recurrent sinus disease. Also, allergic airway diseases in children have both epidemiologic and pathogenic links to sinusitis.
Anatomic Pathogenesis
Anatomic obstructions of the sinus ostia in the nasopharynx have long been suspected causes of sinusitis. The pathophysiology of osteomeatal obstruction leading to sinusitis is believed to be similar to that of otitis media. For the middle ear space, animal model studies reveal that a lack of ventilation (i.e. oxygenation) of the middle ear results in negative pressure in the closed space, leading to mucosal vascular leakage, edema, inflammation and middle ear fluid accumulation. Both anatomic obstructive lesions and mucosal disorders such as mucosal injury from viral upper respiratory tract infections (URTIs), inhalant allergies, cystic fibrosis and ciliary dyskinesias may begin this cascade of pathogenic events. Anatomic variations associated with sinusitis in children in uncontrolled studies include concha bullosa (10%), paradoxical turbinates (4–8%), lateralized uncinate process with hypoplastic maxillary sinus (7–17%), Haller cell (5–10%) and septal deviation (10%). Recent studies have failed to establish a relationship between anatomic variations and the severity and extent of chronic sinusitis in children. Adenoid hypertrophy has also been implicated as a possible predisposing factor to sinusitis in children by serving as a mechanical obstruction to nasal drainage; however, an etiologic role has not been established. Therefore, it is not prudent to base surgical intervention on anatomic variations alone.
Microbial Pathogenesis
Both viral and bacterial infections have integral roles in the pathogenesis of sinusitis. Viral URTIs commonly cause sinus mucosal injury and swelling, resulting in osteomeatal obstruction, loss of ciliary activity and mucous hypersecretion. Indeed, radiologic sinus imaging studies of adults and children with common colds revealed that sinus mucosal abnormalities are the norm, and even air-fluid levels in the maxillary sinuses and opacification of the maxillary sinuses are common. Specifically, coronal sinus computed tomography (CT) scans of adults with URTIs revealed that 87% had abnormalities of one or both maxillary sinuses, 77% had obstruction of the ethmoid infundibulum, 65% had abnormal ethmoid sinuses, 32% had abnormal frontal sinuses and 39% had abnormal sphenoid sinuses.
Sneezing and nose blowing are thought to introduce nasal flora into the sinuses. Chronically infected adenoids, which may be colonized by bacterial biofilms, and intracellular bacteria (in particular, Staphylococcus aureus ) in the nasopharynx have been proposed as nasopharyngeal reservoirs of pathogens that may be introduced into the sinuses. Normal nasopharyngeal flora such as alpha streptococci and anaerobes may elaborate bacteriocins and other inhibitory compounds that interfere with colonization and infection by pathogenic bacteria. Bacterial growth conditions are favorable in obstructed sinuses, reflected by bacterial concentrations of up to 10 7 bacterial colony-forming units (cfu)/mL in sinus aspirates. Additionally, bacterial biofilms have been demonstrated in sinus mucosal specimens obtained from 45% to 80% of children and adults with chronic sinusitis. White blood cell counts in excess of 10,000 cells/mL in sinus aspirates are evidence of a robust inflammatory response to infection. The combination of infection, biofilm formation and inflammation can result in intense epithelial damage and transmucosal injury.
Microbiology of Acute and Subacute Sinusitis
The gold standard for microbiologic diagnosis of bacterial sinusitis has been the recovery of ≥ 10 4 cfu/mL of pathogenic bacteria from a sinus aspirate. Studies employing sinus aspirates indicate that the pathogens responsible for acute and subacute sinusitis are similar to each other and mirror those responsible for acute otitis media ( Table 26-1 ). Streptococcus pneumoniae is recovered in approximately 20% to 30% of cases, nontypable Haemophilus influenzae in approximately 20% to 30%, and Moraxella catarrhalis in approximately 10% to 20%. Similar to observations for acute otitis media, a modest reduction in the proportion due to S. pneumoniae and a corresponding increase in the proportion due to H. influenzae is suggested in populations with routine pneumococcal conjugate vaccination of young children. A significant proportion of S. pneumoniae isolates have intermediate or high-level resistance to penicillin due to alterations in penicillin-binding proteins (up to 15–50%). H. influenzae and M. catarrhalis isolates are frequently β-lactamase positive (25–80% and 90–100%, respectively), and a minority of H. influenzae are ampicillin resistant due to altered penicillin-binding proteins and/or an efflux pump. Actual resistance rates vary with time period, geographic region and the prevalence of risk factors for resistance (e.g. age < 2 years, daycare attendance, recent antibiotic exposure). Streptococcus pyogenes and other streptococcal species are generally recovered in only a small number of cases, although several series have highlighted a frequent association between recovery of Streptococcus anginosus group with acute sinusitis leading to intraorbital and/or intracranial complications in children and adults. Staphylococcus aureus and anaerobes are uncommon causes of acute and subacute pediatric sinusitis; however, they are more frequently identified in severe, complicated disease, or, in the case of anaerobes, associated with dental disease. Less commonly recovered bacteria include Gram-negative organisms such as Eikenella corrodens and other Moraxella and Neisseria species. Fungi are uncommonly recovered in acute sinusitis except in immunocompromised patients. The protozoan Acanthamoeba has also been identified as a rare cause of sinusitis in severely immunosuppressed hosts. Sinus aspirates are sterile in approximately 30% to 35% of children with clinically and/or radiographically diagnosed sinusitis. Acute sinusitis in children has been associated with rhinovirus URTIs. Chronic rhinosinusitis (CRS) has also been associated with nasal respiratory viruses. Comparing nasal lavage from CRS participants with non-CRS controls: nasal respiratory virus detection (50% vs 26%), especially rhinovirus (26% vs 10%), parainfluenza virus (23% vs 8%), influenza virus (13% vs 4%), RSV (11% vs 2%), and multiple respiratory viruses (24% vs 4%, respectively). Respiratory viruses have been recovered from ~10% of sinus aspirates, although sinus aspirates and biopsy investigations with more sensitive modern viral detection methods may provide additional insights. Whether or not respiratory viruses have a direct pathogenic role in sinusitis is poorly understood, but it is clear that viral rhinosinusitis and bacterial sinusitis may have overlapping clinical and radiographic features that make clinical diagnosis of the latter entity challenging.
| Microorganism | FREQUENCY | ||
|---|---|---|---|
| Common | Occasional | Uncommon | |
| Streptococcus pneumoniae | A, C | ||
| Haemophilus influenzae, nontypable | A, C | ||
| Moraxella catarrhalis | A, C | ||
| Streptococcus pyogenes | A, C | ||
| Other streptococcal species (including Streptococcus milleri ) | A, C | ||
| Staphylococcus aureus (including methicillin-resistant S. aureus ) | C | A | |
| Diphtheroids | C | ||
| Coagulase-negative staphylococci | C | ||
| Other Gram-negatives, Moraxella , Neisseria | C | A | |
| Anaerobes | C | A | |
| Respiratory viruses | A, C | ||
| Fungi ( Aspergillus , Alternaria , other dematiaceous fungi, zygomycetes) * | C | A | |
| Acanthamoeba † | A | ||
* Primarily in immunocompromised hosts or associated with allergic fungal sinusitis.
Microbiology of Chronic Sinusitis
Infection is a key component in pediatric chronic sinusitis, although concomitant factors may be an important contributor to the chronic inflammatory process. In numerous studies, 65% to 100% of children with chronic sinusitis have positive cultures of sinus aspirates. Rates of recovery of specific organisms vary among studies; this variability is likely to be explained by differences in patient populations, sinuses evaluated, specimen collection methods and microbiologic culture techniques. Despite these differences, certain general observations can be made. S. pneumoniae, H. influenzae and M. catarrhalis are frequently isolated from children with chronic sinusitis, mirroring acute and subacute sinusitis (see Table 26-1 ). With increasing chronicity, other organisms may also be recovered, including S. aureus, S. pyogenes, alpha streptococci (including Streptococcus anginosus group), group D streptococci, diphtheroids, coagulase-negative staphylococci, Neisseria species, Gram-negative aerobic rods (including Pseudomonas aeruginosa ), and anaerobes; infection is frequently polymicrobial. S. aureus and anaerobes tend to be disproportionately associated with protracted, severe or complicated disease. In concert with the overall increase in community-acquired methicillin-resistant S. aureus (MRSA) infections, an increased frequency of MRSA-associated sinus infections has been observed. Recovery of anaerobes (e.g. Peptococcus , Peptostreptococcus , Propionibacterium acnes, Prevotella , Veillonella , Fusobacterium , Bacteroides and Actinomyces ) has varied widely from less than 5% to more than 90%, depending on the populations and sinuses evaluated and microbiologic methods employed. Many anaerobic isolates are β-lactamase producing.
In a study using modern profiling techniques to determine the sinus microbiome in chronic rhinosinusitis, an abundance of a single fastidious species, Corynebacterium tuberculostearicum , and depletion of Lactobacillus sakei was identified compared with healthy controls. In a mouse model, C. tuberculostearicum was demonstrated to be a sinus pathogen following pretreatment with amoxicillin-clavulanic acid, and protection against this organism was conferred by pretreatment with L. sakei .
Fungi, including Aspergillus , Alternaria and other dematiaceous species (e.g. Bipolaris and Curvularia ), and zygomycetes are occasionally isolated, although invasive disease is uncommon except in immunocompromised children. Respiratory viruses are occasionally identified in sinus mucosal or lavage specimens. Interestingly, bilateral cultures of the sinuses are often discordant.
Antibiotic resistance has emerged as an important factor in the microbiology of chronic sinusitis. For example, in a 4-year retrospective review of maxillary sinus aspirates from children with sinusitis for more than 8 weeks, rates of nonsusceptibility of S. pneumoniae (recovered in 19% of cultures) were 64% for penicillin, 40% for cefotaxime and 18% for clindamycin. Of H. influenzae isolates (recovered in 24%), 44% were nonsusceptible to ampicillin, and all M. catarrhalis isolates (recovered in 17%) were β-lactamase positive.
Immune Pathogenesis
There are few studies in the literature on the immunopathology of sinusitis in children. Most of our knowledge is derived from studies conducted on adults with chronic hyperplastic sinusitis and nasal polyposis (CHS/NP). In adults, chronic sinusitis is characterized by mucosal thickening, goblet cell hyperplasia, subepithelial fibrosis and persistent inflammation ( Figure 26-2 ). These fibrotic changes are thought to be driven by activated eosinophils and their products, including the profibrotic transforming growth factor-β, GM-CSF and interleukin (IL)-11. Tissue fibroblasts are stimulated to increase the synthesis and deposition of collagen and matrix products, resulting in thickening of the sub-basement membrane layer.
Current views associate sensitivity to aeroallergens as a primary pathologic mechanism in the development of chronic sinusitis in both adults and children. Many studies have shown that the composition of the inflammatory substrate in chronic sinusitis is similar to that seen in allergic rhinitis and the late-phase response to antigen challenge.
Th2-Mediated Eosinophilic Inflammation
Although many immune cell types are involved in the pathogenesis of chronic sinusitis, a specific subclass of T lymphocytes (i.e. T helper cell type 2 [Th2] lymphocytes) and eosinophils appear to have a central role. The orchestration of cellular recruitment and activation of the inflammatory infiltrate in CHS/NP has been largely attributed to the Th2 cells and their cytokines (i.e. IL-3, IL-4, IL-5, IL-9, IL-13, GM-CSF). Among immune cell types, eosinophils are the most characteristic and are found in 80% to 90% of nasal polyps. A histopathologic study has investigated the inflammatory cells in pediatric chronic sinusitis and reported similar findings: the numbers of eosinophils, and to a much lesser extent mast cells and T lymphocytes, are significantly increased in children with chronic sinusitis compared to control subjects (see Figure 26-2 ). The degree of tissue eosinophilia was not affected by the allergic status of patients. This is in agreement with published studies on chronic sinusitis in the adult population where the level of eosinophilic infiltration was found to be similar between allergic and nonallergic patients with either chronic sinusitis without nasal polyps or CHS/NP. Levels of neutrophils are also increased in the sinus lavage fluid of adults with chronic sinusitis, particularly in nonallergic patients.
Allergic fungal sinusitis (AFS), an uncommon condition due to an intense and chronic allergic reaction to fungi growing in allergic mucin within the sinus cavities, is believed to be pathogenically similar to allergic bronchopulmonary mycoses. Aspergillus and dematiaceous fungi (e.g. Alternaria, Curvularia, Bipolaris ) have been cultured from affected sinuses. Nasal polyposis, facial deformity, bony erosion of the sinuses, proptosis and fungal hyphae in allergic mucin filling the sinuses are common in children with AFS. Because of its destructive nature, AFS is managed aggressively, with topical and oral corticosteroids after surgical debridement. Antifungal therapy (e.g. itraconazole) has been associated with clinical improvement, oral steroid reduction and resolution of disease in some series.
Chronic rhinosinusitis in young children differs from the common pathology in older children and adults. Sinus mucosal biopsies from younger children (median age 3.9 years; range 1.4–8.2) with chronic rhinosinusitis (i.e. despite at least two courses of antibiotics, one with a second-line agent), when compared with adult sinusitis controls, had significantly fewer eosinophils, less basement membrane thickness, fewer submucosal mucous glands and less epithelial injury. These young children had more CD8 + (cytotoxic T lymphocytes), CD20 + (B lymphocytes), myeloperoxidase-positive (neutrophils) and CD68 + (monocytes, macrophages) cells in sinus epithelium and/or submucosal tissues. Those whose sinus cultures grew a bacterial pathogen (55%) had significantly more submucosal neutrophils. This pan-immune histopathology might indicate inadequate and/or dysregulated immune responses to bacterial biofilms, pathogenic microbiomes and/or common respiratory viruses.
Asthma and Allergy Risk Factors
Along with histologic evidence that the immune pathologic processes of chronic sinusitis and asthma can be similar, epidemiologic, radiographic and clinical studies also link sinusitis with asthma. In a large European survey study, a strong association of asthma with chronic rhinosinusitis (adjusted odds ratio 3.47) was observed at all ages, and was stronger in those also reporting allergic rhinitis (aOR 11.85). Using plain radiography of the sinuses, the prevalence of radiographic sinus abnormalities was significantly higher in asthmatic children (31%) than nonasthmatic controls (0%). In asthmatic children who were hospitalized for an acute exacerbation, significant radiographic abnormalities of the sinuses were revealed in 87%. A study of patients undergoing surgery for chronic sinusitis found that sinus CT evidence of extensive disease was associated with asthma, allergen sensitization and peripheral blood eosinophilia. Of those with eosinophilia, 87% had extensive sinus disease.
Allergic rhinitis and inhalant allergen sensitization have also been associated with sinusitis in children. In a large birth cohort study, both allergic rhinitis and grass pollen sensitization were significant and independent risk factors for sinusitis in childhood (i.e. age 8 years). Experimentally, in allergic rhinitis subjects, nasal provocation with allergen induced sinus radiographic changes (i.e. mucosal thickening, sinus opacification) and symptoms of headache and pressure in the maxillary sinuses.
Genetic Risk Factors
Association studies between chronic sinusitis and a few candidate gene markers have been reported. Chronic rhinosinusitis, and sometimes nasal polyposis, are hallmark features of cystic fibrosis (CF) and primary ciliary dyskinesia, two autosomal recessive inherited disorders. A small proportion of chronic sinusitis patients without CF are carriers of mutations in the cystic fibrosis transmembrane regulator ( CFTR ) gene, especially in association with the M470V polymorphism; however, siblings of CF patients, who are all CFTR mutation carriers, do not have an increased prevalence of rhinosinusitis. Modest linkages of single-nucleotide polymorphisms (SNPs) in other CRS candidate genes include TNF-α (CHS/NP), LTC4 synthase, TGF-β1, TNF-β2 (chronic sinusitis), and the major histocompatibility B54 haplotype. A replication study of 53 CRS-associated SNPs replicated significance for SNPs in seven good gene candidates, especially prolyl-tRNA synthetase 2 (odds ratio 0.77), transforming growth factor B1 (OR 0.81) and nitric oxide synthase 1 (OR 0.84).
Other Risk Factors
Medical conditions that render children susceptible to acute and chronic sinus disease include immune deficiencies (especially patients with T and B lymphocyte defects, AIDS and those receiving immunosuppressive medications) and primary ciliary dyskinesias. The association of gastroesophageal reflux disease (GERD) with chronic sinusitis has also received attention. GERD, diagnosed by pH-monitored nasopharyngeal acid reflux or esophageal biopsy, was associated with rhinosinusitis in children. Phipps and colleagues also reported significantly increased nasopharyngeal reflux in children with chronic sinusitis when compared with a historical control group. Antireflux treatment of their GERD-positive cohort resulted in a 79% improvement in chronic sinusitis symptoms.
Sinusitis Management
Overview
Medical histories and physical examinations can help to distinguish sinusitis in children from URTIs and other masqueraders and to identify complications from sinusitis and underlying risk factors for chronic recurrent disease. Radiographic imaging studies are particularly helpful in evaluating children with chronic, recurrent or complicated sinusitis. Sinus washings for bacterial culture and targeted antimicrobial therapy, while ideal, are surgical procedures (e.g. antral irrigation) that require general anesthesia in children. Therefore, their use is generally reserved for (1) children with chronic sinusitis that does not adequately improve with multiple courses of antibiotics, (2) children with sinusitis with complications, and (3) sinusitis in immunocompromised hosts. Differential diagnostic considerations are provided in Box 26-1 .
Acute Sinusitis
Prolonged viral upper respiratory tract infection
Foreign body in the nose
Acute exacerbation of inhalant allergies
Acute adenoiditis or adenotonsillitis
Chronic Sinusitis
Rhinitis, allergic and nonallergic
Anatomic causes of nasopharyngeal obstruction
Turbinate hypertrophy
Adenoid hypertrophy
Nasal polyps
Severe septal deviation
Choanal atresia
Asthma
Neoplasms of the nose and nasopharynx
Juvenile angiofibroma
Rhabdomyosarcoma
Lymphoma
Dermoid cyst
Cystic fibrosis
Lymphocyte immune deficiencies
B lymphocytes – antibody deficiencies
T lymphocyte deficiencies – congenital and acquired
Primary ciliary dyskinesias
Wegener’s granulomatosis
Churg-Strauss vasculitis
Dental caries/abscess
Gastroesophageal reflux disease with nasopharyngeal reflux
Consensus-based guidelines on the management of sinusitis in children have been published, from the American Academy of Pediatrics (AAP), the Infectious Diseases Society of America (IDSA), the American Academy of Allergy, Asthma and Immunology and the American Academy of Otolaryngology–Head and Neck Surgery. These consensus guidelines, along with randomized controlled trials, systematic reviews and meta-analyses of specific management topics, have been considered in the following discussion.
History and Physical Examination
Acute Sinusitis
Persisting, non-improving symptoms, such as nasal discharge (76%) and cough (80%), lasting longer than 10 to 14 days are the most common presentation of acute sinusitis in children. Nasal discharge can be of any quality, and cough can be daytime, nighttime or both. Fever may accompany the illness. Less common presentations include severe symptoms such as high fever, purulent nasal discharge or facial pain for 3 to 4 days or longer at the start of illness, or worsening symptoms after 5 to 6 days of a viral URTI that had been improving.
Although headaches and sinus tenderness are generally believed to be the hallmarks of sinusitis, a study of 200 sinusitis patients did not find a significant correlation of facial pain or headache with abnormal findings on sinus CT. Additionally, the reported regions of facial pain did not correlate with radiographically identified sinus abnormalities. The nasal cavity is usually filled with discharge and the nasal mucosa and turbinates are generally edematous. Following decongestion of the nasal cavity, purulent drainage coming from the middle meatus can sometimes be observed in older children. Tenderness over the frontal sinus in older children may indicate frontal sinus disease, but tenderness, in general, is uncommon in children with acute disease. Transillumination, considered by some to be a useful tool in adults, is unreliable in children.
Chronic Sinusitis
The most common symptoms associated with chronic sinusitis in children are nasal discharge (59%), facial pain/discomfort (33%), nasal congestion (30%), cough (19%) and wheezing (19%). Nasal discharge can be of any quality, but purulent discharge is the most common. Daytime mouth-breathing and snoring are common complaints. Examination of the nasal cavity may or may not reveal nasal discharge. The nasal turbinates are generally enlarged and can be edematous or erythematous. Although facial pain or discomfort may be a common complaint, tenderness over the sinuses is an uncommon finding in children.
Radiographic Imaging
A consensus report provided by the American College of Radiology provided appropriateness criteria of different radiographic imaging modalities in assessing pediatric sinus disease. Currently, coronal CT is the recommended examination for imaging persistent or chronic sinusitis in patients of any age. Plain sinus radiographs (Waters and Caldwell projections), although widely available, can both underdiagnose and overdiagnose sinus soft tissue changes. Magnetic resonance imaging provides superior soft tissue delineation; however, it is expensive, has limited availability and does not provide bony details of the osteomeatal complex. Conventional tomography, nuclear medicine studies and ultrasound have significant limitations for imaging the sinuses.
It is tempting to consider sinus mucosal abnormalities and associated anatomic variations seen in imaging studies in symptomatic patients as clear indications for sinusitis therapy (e.g. antimicrobial therapy and sinus surgery). However, the clinical importance of such findings is challenged by studies that have revealed a high prevalence of such soft tissue findings in people without sinusitis symptoms or with URTIs. In these studies, URTI symptoms and associated radiographic sinus abnormalities have improved without specific sinusitis therapy (i.e. no antibiotics or surgery for sinusitis).
The American College of Radiology consensus report has the following recommendations: (1) the diagnoses of acute and chronic sinusitis should be made clinically and not on the basis of imaging findings alone; (2) no imaging studies are indicated for acute sinusitis except for cases where complications are suspected or cases that are not responding to therapy; and (3) if imaging information in patients with chronic sinusitis is desired, coronal sinus CT is recommended. The use of plain radiographs of the sinuses (i.e. Waters and Caldwell views) is generally discouraged in this report, except in children younger than 4 years of age. The use of Waters view radiographs in children is supported by a study in which the sensitivity and specificity of a Waters view radiograph to diagnose chronic sinusitis in children were 76% and 81%, respectively. In the same study, limited coronal CT scans were better than sinus x-rays and nearly as good as full sinus CT evaluations.
Sinusitis Complications
Complications of sinusitis ( Table 26-2 ) are generally believed to be acute events that result from a combination of outflow obstruction and pathogenic bacteria in the sinuses. Intracranial extension of infection is by direct erosion, thrombophlebitis or extension through preformed pathways (e.g. fracture lines). The incidence of intracranial complications in children hospitalized for sinusitis was 3%.
| Complication | Maxillary Sinus | Ethmoid Sinus | Frontal Sinus | Sphenoid Sinus |
|---|---|---|---|---|
| Osteomyelitis | + | + + | ||
| Mucocele | + + | + + | + + | + |
| Preseptal cellulitis | + + + | |||
| Orbital cellulitis | + + + | + | ||
| Subperiosteal abscess | + + + | |||
| Orbital abscess | + | |||
| Meningitis | + + | |||
| Epidural abscess | + + | |||
| Subdural abscess | + | |||
| Brain abscess | + |
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