Summary

Rhinosinusitis (RS) in children can present a diagnostic dilemma for practitioners. Viral upper respiratory infection (URI) is the most common entity seen by primary care doctors, and recent data states that 5% to 10% of URIs in children are complicated by RS.[1] Proper diagnosis of bacterial RS is important in establishing the need for treatment. Viral URI and allergic inflammation need to be differentiated from a sinus infection to avoid unnecessary antibiotics and continued increases in community-wide bacterial resistance.

Educational objectives

At the conclusion of this activity, participants will be able to:

• Describe the pathophysiology of bacterial sinusitis in children
• Name the predominant organisms responsible for sinusitis and the antibiotics recommended for treatment
• List the orbital and intracranial complications of bacterial sinusitis in children

CME credit

This is an article from The Child's Doctor, Fall 2005 issue. You may take the quiz for learning purposes, but credits are no longer valid.

Author disclosures

Dr. Seligman has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

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The peak incidence of bacterial RS occurs between the ages of 3 and 6 years, similar to the peak years for URIs.[2] Children average 6 to 8 colds a year (more in day care and with multiple siblings), and unless complicated by bacterial RS, these self-limited infections should resolve within 7 to 10 days.[3]

Allergic rhinitis is an inflammation of the mucous membranes of the nose, whereas RS is an inflammation of the mucous membranes of the nasal passages and sinuses. Nasal allergies cause itching and sneezing, clear rhinorrhea, stuffiness, and postnasal drainage. These symptoms are similar to those of RS and a common cold. Complete history and physical exam, and often accompanying imaging help make the correct diagnosis. Allergies also can contribute to swelling in the sinus and nasal mucous membranes. The swelling can lead to blockage of the natural openings, trapping bacteria and leading to infection.

There is controversy surrounding treatment, despite the fact that RS has a significant adverse effect on health related quality of life. Many practitioners feel that the disease process is self-limited, rarely needs antibiotic therapy and almost never requires surgical treatment. Others believe that these infections require aggressive medical therapy and surgical treatment when medical therapy fails. The answer is somewhere between these viewpoints, and it is essential to consider each case individually to avoid serious complications.

Definitions

Sinusitis is an infection of the mucosa of the paranasal sinuses. Rhinosinusitis is a better term than sinusitis alone, since inflammation and infection of the sinuses involves changes in the nasal epithelium with concurrent nasal airway inflammation. RS is generally divided into 3 varieties: acute, chronic, and recurrent.

Acute RS commonly presents as a URI that persists beyond 10 days with some combination of the following signs and symptoms: purulent rhinorrhea, persistent cough that is often worse at night, bad breath, fever, headache, and facial pain. Since most viral URIs resolve within 10 days, a worsening or persistence of these symptoms beyond this time has been empirically viewed as RS by practitioners for the purpose of prescribing antibiotics. Acute bacterial RS that is severe may present with the same symptoms, but is accompanied by greater toxicity, fever greater than 102.2° F, and the duration of symptoms observed may be less than 10 days. This is a less common presentation and can only be objectively differentiated from an acute viral URI with a CT scan or plain films.

Chronic RS is an infection of greater than 3 months duration, usually with a more benign course. Symptoms include nasal congestion, cough, bad breath, malaise, decreased energy, headache, behavioral problems, and nasal discharge. Exacerbation to acute RS is common in children with chronic RS.

Recurrent acute RS occurs when a child has complete resolution of an acute infection, but has repeated incidents. Some element of chronic RS is likely to be present between acute infections, but this cannot be determined without imaging.

Pathophysiology

Human beings have ethmoid sinuses on either side of the upper nose, bilateral maxillary sinuses in the face between the orbital rim and the upper teeth, and frontal sinuses above the eyes. The sphenoid sinus is in the back of the nose, at the base of the skull, and is divided by a septum. Because of its relative isolation, the sphenoid sinus is the least likely sinus to become infected.

The mucus membrane of each sinus has cilia that move the mucus to the sinus ostia for clearance through the nose. Maxillary drainage involves a cilia-dependent upward movement that joins the drainage of the anterior ethmoid air cells in a functional unit called the ostiomeatal complex. This area is believed to be the focus of edema during a viral illness, resulting in obstruction of the maxillary, frontal and anterior ethmoid drainage.

The failure of normal mucus transport (mucociliary transport) and decreased sinus ventilation are the major factors contributing to the development of RS. Obstruction of the sinus ostia occurs with mucosal edema or anatomic blockage, such as polyps, interfering with sinus drainage. Polyps are a common product of chronic allergic RS (Figures 1, 2). Noninfectious inflammation, such as allergic rhinitis can also block the ostia and lead to RS.

FIGURE 1: Typical nasal polyp seen through a nasal telescope.

FIGURE 2: Sphenochoanal polyp in the nasopharynx visualized with a mirror in the oral cavity. This is an unusual presentation that can occur with chronic RS.

Cilia can beat only in a fluid medium. Alteration of cilia number, morphology and function may facilitate secondary bacterial invasion of the nose and sinuses. In addition to viral URI and allergic inflammation, factors predisposing the formation of bacterial RS include, adenoid hypertrophy and infection, cystic fibrosis, immune disorders (especially IgG subclass deficiency), primary ciliary dyskinesia, trauma, swimming and diving, rhinitis medicamentosa, choanal atresia, deviated septum, nasal polyps, foreign body, tumor, dental infections, inhalation of irritants, mechanical ventilation, nasal dryness, nasotracheal and nasogastric tubes, and gastroesophageal reflux disease (GERD).

Diagnosis

On physical exam, the patient with acute bacterial RS may have mucopurulent discharge in the nose or posterior pharynx, with an erythematous nasal mucosa, but this can occur with acute viral rhinitis as well. Transillumination may be helpful in adolescents and adults, but does not tell much in children under 10 years of age, since frontal sinuses are not yet fully developed. In young children, the physical exam is generally not very helpful for making a specific diagnosis of acute bacterial RS. Although otolaryngologists may decongest the nose and use a telescope to view pus coming directly from the middle meatus, this is not practical for pediatricians.

One sign that does not predict acute bacterial RS is rhinorrhea that changes color from clear to cloudy or colored. This event coincides with migration of polymorphonuclear leukocytes into nasal secretions and occurs during the natural course of viral URIs.

All children with persistent RS should be evaluated for allergies to assess the role they play in the etiology. Therapy then can be directed towards decreasing the allergic response.

Getting culture from nasal discharge, the throat, or the sinus is not necessary for diagnosis of bacterial RS. Culture of nasal discharge or the nasopharynx lacks predictive reliability, both for establishing the diagnosis and for identifying the infective pathogen when acute bacterial RS is actually present. Organisms recovered from nasopharyngeal washing and throat culture do not reflect the organisms found in sinus aspirate.

Needle puncture of the maxillary sinus to get a culture is impractical and unnecessary in immunocompetent children with uncomplicated disease, and should be reserved for special circumstances. It is reasonable to get a culture of the sinus under controlled conditions in the operating room when a patient is not responding to antibiotics, is immune suppressed, or beginning to show signs of complications.

The radiographic finding most diagnostic of bacterial RS is an air-fluid level in, or complete opacification of the sinus cavities. Standard radiographic projections include anteroposterior, lateral and occipitomental (Waters projection) views. Complete opacification in a plain radiograph in a symptomatic patient has a specificity of 85%, and an air-fluid level has a specificity of 80% in establishing the diagnosis. When clinical signs and symptoms suggesting acute RS are accompanied by abnormal maxillary sinus films, bacteria in a sinus aspirate will be present 70% to 75% of the time.[4]

Computed tomography (CT) scans (Figures 3, 4) are the best way to view the extent of disease and are reserved for children with chronic RS, acute RS unresponsive to therapy or for evaluation of complications. Limited coronal views without contrast will provide information and use the least amount of radiation, however these studies may not be as sensitive in identifying the osteomeatal complex.

FIGURE 3: Moderate bilateral maxillary sinus mucosal thickening with blockage of both osteomeatal complexes in a coronal CT scan.

FIGURE 4: Complete opacification of the right maxillary sinus in a caronal CT scan.

However, CT scans can overdiagnose RS. In a study of infants and children, 97% of patients who had a cold during the 2 weeks preceding cranial CT performed for other purposes had mucosal abnormalities suggesting bacterial RS.[5] Abnormalities of the sinuses also are found frequently on conventional radiographs and CT scans in children without clinical evidence of sinusitis. MRI is not the best imaging modality for evaluation the bone/mucus membrane interface of the sinuses.

The American College of Radiology has taken the position that the diagnosis of acute uncomplicated RS in children, especially if they are less than 6 years of age, should be made on clinical grounds alone, since the films are technically difficult on young children, and images should be reserved for worsening clinical circumstance.[6] Similarly, the Subcommittee on Management of Sinusitis and Committee on Quality Improvement of the American Academy of Pediatrics stated that imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children less than 6 years of age.[7] They did not make a recommendation for older children, leaving open the possibility that imaging may be necessary in this age group.

Microbiology

Children and adults have similar RS bacteriology. The predominant organisms include Streptococcus pneumoniae, Moraxella catarrhalis, and Hemophilus influenzae, found in approximately 75% of maxillary sinus aspirates. Both H influenzae and M catarrhalis may produce beta-lactamase and are amoxicillin resistant.

The role of bacteria in chronic RS is controversial, since there may be disease in the absence of bacterial growth, as described below. Group A streptococci, Staphylococcus aureus, and enteric bacilli have been cultured in children with chronic RS, but 20% to 35% of sinus aspirates are sterile. Treatment with antibiotics in such cases most likely will not be effective. These patients are candidates for surgery to create better drainage, if medicines fail.

Fungi are normal flora of the upper airway, but can cause acute RS in immunocompromised and diabetic patients, with invasion that leads to life threatening disease. The noninvasive forms of fungal RS, mycetoma (fungus ball) and allergic fungal sinusitis, are likely caused by an IgE-mediated hypersensitivity to a fungus, and are not life threatening. Aspergillus is the most common organism cultured, but several other fungal species have been identified. Bacterial RS and noninvasive fungal infection can look alike and are difficult to distinguish radiographically, except when there is a distinct fungal ball or mycetoma. Noninvasive disease has an indolent, often asymptomatic and benign course. Invasive disease is accompanied by severe toxicity, and inflammation and necrosis in the nose, sinuses, and surrounding tissues.

Treatment

The treatment of acute RS is directed at the predominant organisms. Physicians should consider use of the most narrow spectrum antibiotic for the initial treatment. Risk factors to consider for penicillin-resistant S pneumoniae include day care, recent antimicrobial therapy (less than 30 days), age less than 2 years, and exposure to environmental tobacco smoke. In a child without these risk factors, standard dose amoxicillin or amoxicillin/ clavulanate may be considered as initial therapy. In children with the above risk factors, high dosage amoxicillin (80-90mg/kg/day) or amoxicillin/clavulanate with a high dosage amoxicillin component may be used as first-line therapy.

Cefprozil, cefdinir, cefuroxime, and cefpodoxime are reasonable choices as secondline agents. Third-line agents with failure of above include clindamycin and cefixime. In penicillin allergic patients, second- or third-line agents, in addition to the macrolides and azilides may be considered. The efficacy of macrolides (erythromycin, clarithromycin), azilides (azithromycin) and sulfa containing agents has not been established.

The duration of therapy should be a minimum of 10 to 14 days and is often continued for several weeks depending on the clinical response. If no improvement occurs or there is worsening after 72 hours, a change in antibiotics should be considered. Optimum duration of therapy in acute disease has never been proven in scientific trials, although recommendations typically include 10 to 21 days, or until symptoms resolve, plus an additional 7 days.[8] In patients with persistent or recurrent RS, it is important to consider an otolaryngology consultation after antibiotic therapy of at least 6 weeks duration or 3 separate courses of unsuccessful treatment.

Patients with severe acute RS who cannot take oral therapy may require initial parenteral therapy. Therapy by intravenous injection has not been shown to be superior to oral therapy for acute RS in the absence of complications.

Successful treatment of chronic RS with antibiotics is critical because failure will usually lead to surgical therapy. There are many conflicting studies regarding adjuvant therapy, and the efficacy of nasal steroids, saline spray, oxymetazolone, mucolytics, and antihistamines has not been established. Saline spray may help clear nasal secretions, and antihistamines may be beneficial in children with RS where allergy is suspected as a causative factor. Control of causative factors, including allergy and GERD, is important in the prevention and treatment of recurrent or chronic infections.

Surgical therapy is indicated for children with chronic RS or recurrent acute RS who have failed maximum medical therapy, including treatment of any underlying disease. Occasionally, it is necessary to drain an acute infection unresponsive to antibiotic therapy for relief of severe symptoms.

Adenoid tissue serves as a reservoir of bacterial pathogens. Adenoidectomy for enlarged adenoids is almost always the first-line intervention for preschoolers, with a 70% to 80% expected rate of improvement. The procedure is safe, has minimal morbidity, and no effect on long-term immune function.

For treatment of chronic disease, functional endoscopic sinus surgery (FESS) has replaced the creation of nasal antral windows in children. The technique is designed to alleviate the cause of RS, which is mechanical obstruction to drainage at the ostiomeatal complex, with a net effect of widening the outflow tract. The natural ostia are enlarged while preserving most or all of the sinus mucosa. Surgical outcome is dependent on the degree of mucosal disease present before the operation. With careful patient selection, the published results indicate 80% to 100% improvement with surgery.[9] FESS should only be performed in children by an otolaryngologist experienced in pediatric sinus surgery. The incidence of major complications in experienced surgeons is less than 1%.[10]

Complications

In the era of antibiotic therapy and adequate access to primary care, major complications are uncommon. Complications of RS can be divided into orbital, intracranial, and local.

Orbital complications are the most common category, and include orbital cellulitis, orbital abscess, optic neuritis or retrobulbar neuritis, superior orbital fissure syndrome, and cavernous sinus thrombosis. Seventy five percent of orbital infections are a direct result of RS.

Intracranial complications are the second most common category, and include intracranial mucocoele, meningitis, epidural abscess, and subdural abscess. Finally, brain abscess, which has a high mortality rate, also is a possible complication of RS.

Local complications include the formation of mucocoeles and pyoceles, which may enlarge and cause bone erosion, pain, and swelling over the sinus. Other local manifestations include osteitis, especially of the maxillary sinus, with swelling and erythema of the cheek and osteomyelitis of the frontal or maxillary sinus, and rarely, the sphenoid bone.

What's new?

RS is complex and we are far from completely understanding all aspects of this disease. Clinical trials that target its various causes will help clinicians understand better how to prevent and treat RS.[11] Some of the more promising research directions are listed below:

• Aerosolized antimicrobials and steroids are widely prescribed now, but evidence of their effectiveness has not been established and is being evaluated.

• No studies have established the role of vaccines in prevention of acute RS and chronic RS, but it is reasonable to expect that severely affected children would benefit from the conjugated pneumococcal vaccine.

• Biofilms can develop in patients with chronic disease. A film of glycocalyx may protect bacteria from contact with antimicrobials, explaining the poor response to medical therapy in some patients.

Summary

RS is a common pediatric infection that usually responds well to medical therapy. The goal for clinicians is to prevent complications and improve quality of life for children with this disease. Treatment depends on accurate diagnosis, identification and correction of underlying contributing factors, as well as adequate antimicrobial therapy. Surgery, including adenoidectomy and functional endoscopic sinus surgery, is effective in selected patients who are refractory to more conservative measures, and in patients with complications of RS.

REFERENCE S

[1.] Wald ER. Rhinitis and acute and chronic sinusitis. In: Bluestone CD, Stool SE, Kenna MA, eds. Pediatric Otolaryngology. 4th ed. Philadelphia, PA: WB Saunders Co; 2003.

[2.] Conrad DA, Jenson HB. Management of acute bacterial rhinosinusitis. Current Opinion in Pediatrics 2002;14:86-90.

[3.] Aitken M, Taylor JA. Prevalence of clinical sinusitis in young children followed up by primary care practitioners. Archives of Pediatric and Adolescent Medicine 1998;152(3):244-248.

[4.] Wald ER, Milmoe GJ. Bowen A, et al. Acute maxillary sinusitis in children. N Engl J Med l981;304(13):749-754.

[5.] Glasier CM, Ascher DP, Williams KD. Incidental paranasal sinus abnormalities on CT of children: Clinical correlation. Am J Neurorad 1986;7:861-864.

[6.] AAP Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guideline: Management of sinusitis. Pediatrics 2001;108:798-808.

[7.] American College of Radiology Expert Panel on Pediatric Imaging. Sinusitis in the pediatric population. ACR Appropriateness Criteria,TM 1999. Available at: http://www.acr.org/ac_pda. Accessed July 21, 2005.

[8.] Morris P, Leach A. Antibiotics for persistent nasal discharge (rhinosinusitis) in children. Cochrane Database of Systematic Reviews 2; 2005.

[9.] Goldsmith AJ, Rosenfeld RM. Treatment of pediatric sinusitis. Pediatric Clin N Am 2003;50:413-426.

[10.] Hebert RL, Bent JP. Meta-analysis of outcomes of pediatric functional endoscopic sinus surgery. Laryngoscope 1998;108:796-799.

[11.] Meltzer EO, et al. Rhinosinusitis: Establishing definitions for clinical research and patient care. Otolaryngology-Head and Neck Surgery 2004 Dec;131(6 Suppl):S1-62.