The epidemiology of sinusitis parallels that of the common cold (Mandell, Bennett, & Dolin, 2010). Upper respiratory illnesses occur in children on the average of six to eight times per year with 5–13% of these progressing into a secondary bacterial infection of the paranasal sinus (American Academy of Pediatrics Subcommittee on Management of Sinusitis and Committee on Quality Improvement, 2001). This makes sinusitis a frequent pediatric illness and a cause for many office visits. Due to the anatomical contiguity of the paranasal sinus with the nose, the term rhinosinusitis is often used to describe a sinus infection.
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The definition of sinusitis has been subdivided by the American Academy of Pediatrics’ “Clinical Practice Guideline: Management of Sinusitis.” This guideline specifies the diagnosis, evaluation, and treatment of children between the ages of 1 and 21 years. The definitions are described below:
•
Acute Bacterial Sinusitis. Bacterial infection of the paranasal sinuses lasts less than 30 days, in which symptoms resolve completely.•
Subacute Bacterial Sinusitis. Bacterial infection of the paranasal sinuses lasts between 30 and 90 days, in which symptoms resolve completely.•
Recurrent Acute Bacterial Sinusitis. Episodes of bacterial infection of the paranasal sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic.•
Chronic Sinusitis. Episodes of inflammation of the paranasal sinuses lasting more than 90 days. Patients have persistent residual respiratory symptoms, such as cough, rhinorrhea, or nasal obstruction.•
Acute Bacterial Sinusitis Superimposed on Chronic Sinusitis. Presence of residual respiratory symptoms with the development of new respira- tory symptoms. When treated with antimicrobials, these new symp- toms resolve, but the underlying residual symptoms do not.Pathophysiology
When presented with a child with a suspected sinusitis, consider the patho- physiological factor that may be contributing or causing the illness.
Infections within the sinus develops because of either a blockage of the
“main river” that drains the sinus, specifically the osteomeatal complex, impaired function of the cilia that “sweeps” the sinus to prevent bacterial invasion, or changes in the quality of the secretions, which can “plug up”
the sinus and hamper the function of the cilia.
Ostial obstruction can be related to mucosal swelling or mechanical obstruction. Mucosal swelling can be related to viral upper respiratory illnesses, allergic inflammation, inflammation from gastroesophageal reflux disease, cystic fibrosis, immune disorders, immotile cilia, facial trauma, exposure to cigarette smoke, or rhinitis. Mechanical obstruction includes choanal atresia, deviated septum, nasal polyps, foreign body, turbinate hypertophy, adenoid hypertrophy, and tumors.
Most cases of acute bacterial sinusitis are frequently considered to be bacterial complications of viral upper respiratory infections (Wald, 2008).
Viral infections affect ciliary function and cause obstruction of the sinus ostia. This is due to the resulting inflammation and changes in the secre- tions, which interrupt drainage from the osteomeatal complex predispos- ing the child to the development of sinusitis (Lusk, 2010). The principle bacterial pathogens for acute sinusitis include Streptococcus pneumoniae,
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affecting 30% of children, and nontypeable Haemophilus influenzae and Moraxella catarrhalis, each accounting for 20% of cases in children (American Academy of Pediatrics Subcommittee on Management of Sinusitis and Committee on Quality Improvement, 2001). Other less common bacterial species include group A streptococcus, group C streptococcus, viridans streptococci, Peptostreptococcus spp., other Moraxella spp., and Eikenella cor- rodens (Wald, 2008). Staphylococcus aureus and anaerobic bacteria are seen more often in chronic sinusitis (Wald, 2008).
Gastroesophageal reflux disease is common in children suffering from recurrent or chronic sinusitis. Most children who demonstrate evidence of gastroesophageal reflux disease in addition to their symptoms of sinusitis have shown an improvement in their sinus symptoms once their gastro- esophageal reflux disease was adequately treated (Phipps, Wood, Gibson,
& Cochran, 2000). The exact cause and effect of gastroesophageal reflux disease and sinusitis is unclear. Research suggests that it is due to naso- pharyngeal reflux affecting the sinus mucosa directly causing inflamma- tion and edema and impaired mucociliary clearance. This leads to obstruction of the osteomeatal complex and to subsequent infection.
Allergic rhinitis has also been implicated in the etiology of sinusitis in children. Because of this association, it has been suggested that any child with recurrent acute or chronic sinusitis undergo an allergy evaluation with testing for perennial and seasonal allergies, especially dust mite, mold, animal dander, and pollen, which tend to be responsible for many symptoms of allergic rhinitis.
Otontogenic sinusitis can occur due to a periapical abscess or periodon- titis of the upper teeth that can extend into the sinus cavity and cause a maxillary sinusitis (Wald, 2003). This is more typical in the adolescent population and can cause symptoms of acute sinusitis in addition to com- plaints of halitosis or purulent oral drainage from a potential oroantral fistula. Treatment would include drainage of the abscess and operative closure of the oroantral fistula. The child would also require antibiotic therapy.
Signs and symptoms
Uncomplicated viral upper respiratory infections are collaboratively agreed to last 5–7 days in duration. Symptoms usually resolve by the 10th day or are exhibiting significant improvement by that time. When respiratory symptoms persist beyond that point without evidence of improvement, a secondary bacterial infection is felt to have developed. Symptoms of bacte- rial sinusitis in children are different from those in adults and are difficult at times to distinguish from those of the common cold or rhinitis. They tend to be more nonspecific.
Fever can be present in association with purulent nasal discharge for at least 3–4 days. Headache may be identified in a child with a significant sinusitis, either above or behind the eye. Complaints of a headache should
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be explored in great detail as it is not uncommon for children’s complaints of headaches to be frequently misdiagnosed as a “sinus headache,” which results in inappropriate sinus treatment (Senbil, Yavuz Gurer, Uner, &
Barut, 2008). Facial pain and facial tenderness is an unusual complaint of children. In highly symptomatic children, they may actually complain of a feeling that their face feels “funny” or “heavy” or like “there is someone sitting on their face.”
A cough is frequently described in a child with acute or chronic sinusitis.
Cough receptors are present in the pharynx, paranasal sinuses, stomach, and external auditory canals. Because of this, the source of the cough should be viewed holistically (Boat & Green, 2007). Lower respiratory stimuli include excessive secretions and an inflammatory response to upper respiratory infections or allergic processes. Chronic sinusitis, in par- ticular, is responsible for complaints of a chronic cough, especially at night.
The cough may or may not be productive and may not present with obvious signs of acute sinusitis (Pratter, 2006).
Additional signs and symptoms that can be seen and reported includes nasal congestion; malodorous breath; hyposmia/anosmia; ear pressure or fullness; fatigue; irritablitiy; snoring; hyponasal speech; mouth breathing;
nasal discharge; purulent anterior or posterior nasal discharge that can also be evident in the orophayrnx; decreased appetite; erythematous, pale, and/or boggy nasal mucosa; and, rarely, maxillary dental pain.
On nasal examination, mucopurulent discharge emanating from the middle meatus may be appreciated.
Diagnosis
The diagnosis of acute sinusitis is often difficult and is based on a careful, thorough history and physical examination. Although a sinus aspiration and culture is considered to be the “gold standard” of diagnosis, this pro- cedure is very painful and unreasonable in the pediatric population.
Intranasal cultures are not indicative of the bacterial origin of acute sinus- itis and are therefore not recommended (Brook et al., 2000).
The American Academy of Pediatrics Subcommittee on Management of Sinusitis and Committee on Quality Improvement Panel (2001) noted that diagnostic imaging is not necessary to confirm a diagnosis of clinical sinus- itis in children less than or equal to 6 years of age. Plain sinus radiographs are not felt to be highly diagnostic as they are felt to be technically difficult to perform, especially in young children, making the accuracy of the images not definitive as they can be abnormal in children with mild upper respiratory illnesses. Their diagnostic value is further limited by their poor sensitivity and specificity (Brook et al., 2000). On the other hand, CT scans of the paranasal sinuses are advised for children with persistent and chronic symptoms, particularly if surgical intervention is being considered.
A CT scan of the head may be indicated when signs and symptoms of sinusitis are accompanied by increased intracranial pressure, meningeal
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irritation, proptosis, toxic appearance, limited extraocular movements, or focal neurological deficits.
Anterior rhinoscopy is critical and can be performed with a nasal specu- lum or otoscope. The examination should encompass notation of the nasal turbinates, septum, quality of the mucus, and for obvious nasal polyps or bleeding. Transillumination is a diagnostic technique that has limited diag- nostic use and requires unique expertise. A nasal endoscopy should be completed to investigate the presence of nasal polyps, hypertrophy of the inferior turbinates, septal deviations or spurs, and adenoid hypertrophy.
Allergy testing using either in vivo skin testing or in vitro blood tests should be considered in children with recurrent or chronic sinusitis to explore allergic contributing factors. Quantitative immunoglobulins including IgG subclasses should be completed as well to evaluate immu- nologic deficiencies. Evaluating for cystic fibrosis with a sweat chloride test is also advisable, particularly if nasal polyps are identified.
Due to the association of gastroesophageal reflux disease, a diagnostic laryngoscopy should be completed to investigate for evidence of reflux disease in the supraglottic region with the presence of cobblestoning, ery- thema, and inflammation. If debilitating symptoms of gastroesophageal reflux are reported and clinical evidence of gastroesohageal reflux disease is appreciated, referral to a gastroenterologist may be considered for a more in-depth evaluation with endoscopy.
A nasal mucosal biopsy can be completed to investigate ciliary function and structure. As this procedure requires sedation, it is often completed simultaneously with another surgical procedure in the operating room.
Management of acute sinusitis
Treatment of acute sinusitis is almost always medical. The goal of therapy is to restore normal mucociliary function, to eradicate the infection, and to improve the child’s symptoms and quality of life. The American Academy of Pediatrics’ “Clinical Practice Guideline: Management of Sinusitis”
developed an algorithm for the care of children between the ages of 1 and 21 years of age with acute sinusitis, which is summarized subsequently.
Amoxicillin is recommended for children who have mild–moderate sinusitis who do not attend day care or have recently been treated with an antibiotic. This can either be dosed at 45 or 90 mg/kg/day divided in twice-a-day dosing. For children who are allergic to penicillin, other appro- priate antibiotic choices include cefuroxime (30/mg/kg/day) in two divided doses or cefpodoxime (10 mg/kg/day) once a day. First-generation cephalosporins, such as cephalexin and cefadroxil do not provide adequate coverage against H. influenzae and should not be prescribed. Trimethoprim–
sulfamethoxazole and erythromycin sulfisoxazole is not recommended due to pneumococcal resistance. While azithromycin is a frequently pre- scribed antibiotic, the Food and Drug Administration (FDA) has not included this medication for sinusitis (American Academy of Pediatrics
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Subcommittee on Management of Sinusitis and Committee on Quality Improvement, 2001). The American Academy of Pediatrics Guidelines con- tinues to endorse the use of azithromycin (10 mg/kg/day on day 1 and 5 mg/kg/day for the following 4 days once a day) and clarithromycin (10 mg/kg/day divided twice a day) for children with severe drug allergies.
Children being treated for acute sinusitis should demonstrate signs of clinical improvement within 48–72 hours. If a child fails to improve or actually worsens, the treatment plan should be reevaluated as the antibi- otic selected may be ineffective or the child’s initial diagnosis may have not been accurate. Children who do not improve on the initial treatment regime should have their therapy changed to high-dose augmentin. Dosing includes 80–90 mg/kg/day of amoxicillin and 6.4 mg/kg/day of clavula- nate in twice-a-day dosing. For those children allergic to amoxicillin, cef- dinir, cefuroxime, or cefpodoxime should be used. Ceftriaxone is frequently used either intravenously or intramuscularly with a single dose of 50 mg/
kg/day if the child is very ill and unable to tolerate the oral medication.
There is no standardized treatment course regarding the duration of therapy once an appropriate antibiotic is started. Empiric recommenda- tions are for 10, 14, 21, or 28 days depending on the clinician’s judgment (Wald, 2003).
Additional management strategies
Supplemental therapies are frequently advised in addition to appropriate antibiotics. While there has been no generalized acceptance of any of these treatments, many are recommended for children to address the debilitating and annoying symptoms accompanying the acute infection.
Nasal decongestants (afrin/neosynephrine)
These nasal decongestants are frequently used to provide temporary relief of nasal discharge and congestion. They can be highly efficacious. They are also addictive because of their immediate benefit. Therefore, their usage is limited to 3–5 days to avoid the complication of rhinitis medicamentosa.
This is a rebound congestion that is progressive with continued use and actually worsens the congestion and sinus pressure.
Mucolytic agents
These medications aid in decreasing the viscosity of nasal secretions to expedite clearance from the nasal cavities. This helps to lessen the conges- tion and pressure the child is experiencing.
Nasal saline spray or saline irrigations
The use of nasal saline spray or saline irrigations can be adjusted to either a normal saline concentration or a hypertonic saline concentration for more
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aggressive irrigation. These are tremendously advantageous for the child with acute sinusitis. They are successful in mechanically clearing secre- tions, loosening crusted debris and mucus, and liquefying secretions. They can specifically address occlusions of the osteomeatal complexes, which are critical to reopen and to allow normal ventilation and drainage of the sinus cavities. They also promote vasoconstriction of nasal blood flow to reduce inflammation. At times, various additives into the sinus irrigations may be recommended, such as Pulmicort, Bactroban, baby shampoo, and various antibiotics or antifungal agents.
Antihistamines
Antihistamines are generally not advised for the child with acute sinusitis.
They can actually worsen symptoms of sinusitis as they can dry nasal and sinus secretions preventing mucous clearance and aggravating sinus pres- sure and congestion. At times, a child may already be on an antihistamine for baseline allergic rhinitis. In such cases, the antihistamine can he held temporarily during the sinusitis treatment.
Topical nasal steroids
While nasal steroids clearly benefit a patient with allergic rhinitis by decreasing nasal mucosal inflammation, they are not recommended for use in a child with acute sinusitis as there is limited support for its use in the literature.
Oral decongestants (Pseudoephedrine/Phenylpropanloamine hydrochloride)
These decongestants constrict blood vessels in the nares to reduce nasal congestion. Presently, these medications are not advised in children due to their potentially toxic side effects, including cardiac stimulation, hyperten- sion, and neurological complications (Brook et al., 2000).
Herbal and complementary therapies
Many families practice the use of herbal and complementary remedies;
thus, the nurse or the nurse practitioner should always inquire about their use. Herbal and complementary therapies include a wide variety of treat- ments, including various soups, teas, as well as herbal and nutritional supplements, such as vitamin C preparations, zinc lozenges, echinacea, garlic, and eucalyptus oil. Families may seek additional holistic care from acupuncturists, chiropractors, homeopathics, naturopathics, and thera- peutic touch therapists. While nurses and nurse practitioners are not able to specifically endorse these therapies as little research has been done regarding their benefits and there is no specific FDA approvals, it can oftentimes be comforting to families to supplement the prescribed medical therapies.
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Management of chronic sinusitis/recurrent sinusitis
Antibiotics are used for children with chronic or recurrent sinusitis that is due to the occurrence of an acute exacerbation. Prophylactic antibiotics were considered in the past in the prevention of these exacerbations, but due to recent concerns of antibiotic resistance, their use is highly contro- versial. Systemic steroids have a place in the treatment of chronic and recurrent sinusitis, particularly in providing relief of the persistent com- plaints of sinus pressure and congestion. Intravenous antibiotics are some- times used as an alternative to sinus surgical treatment. A study by Don, Yellon, Casselbrant, and Bluestone (2001) found that intravenous antibiotic therapy for the management of chronic sinusitis was an effective alterna- tive to an endoscopic sinus surgical procedure. Nebulized intranasal anti- biotics have also been used in the treatment of chronic sinusitis, but mostly in the adult population, with inconsistent results.
For children with associated allergic rhinitis that is precipitating their chronic or recurrent sinusitis, various oral or intranasal antihistamines, intranasal steroids, leukotriene receptor antagonists, or anticholinergic sprays may be used to supplement their care. These medication therapies should always be accompanied by environmental strategies for allergen avoidance and at times, if found appropriate, by immunotherapy. When children have gastroesophageal reflux disease as an etiologic factor to their sinusitis, appropriate medication therapy should be combined with an antireflux diet. Potential medications include proton pump inhibitors and H2 blockers. Food avoidance includes caffeine-containing foods and bever- ages, fatty foods, spicy foods, chocolate, citrus foods and beverages, and tomatoes. Children should not be allowed to eat right before bed and should make their final meal of the day at least 2–3 hours before bed. When these therapies are unable to control the allergic rhinitis or gastroesopha- geal reflux disease effectively, then a referral to a gastroenterologist or an allergist may be appropriate.
Surgical treatment
Children with chronic sinusitis who fail medical therapy may be candi- dates for surgical intervention. This includes the possibility of an adenoid- ectomy and/or a functional endoscopic sinus surgery (FESS). The adenoids can act as a reservoir for bacteria and can result in recurrent or chronic sinus infections due to the proximity of the adenoids to the sinus ostia (Ramadan, 1999). They have also been implicated as a source of biofilms acting as a repository for bacterial seeding (Lusk, 2010). A study by Ramadan (1999) found that endoscopic sinus surgery was better than an adenoidectomy for the treatment of refractory sinusitis in a select group of children.
Endoscopic sinus surgery has become a primary method of surgical therapy for chronic sinusitis following an adenoidectomy for those patients
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whose symptoms persist, although at times they may be completed simul- taneously. Absolute indications for endoscopic sinus surgery include (1) complete nasal airway obstruction in children with cystic fibrosis due to massive polyps, (2) antrochoanal polyps, (3) intracranial complications, (4) mucoceles, (5) orbital abscesses, (6) traumatic injury to the optic canal, (7) dacrocystorhinitis due to sinusitis and resistance to medical treatment, (8) fungal sinusitis, (9) some meningoencephaloceles, and (10) some neo- plasms (Lusk, 2010). There was a long-standing concern of altered facial growth in children undergoing endoscopic sinus surgery, but a study by Bothwell, Piccirillo, Lusk, and Ridenour (2002) found no evidence that endoscopic sinus surgery affected facial growth.
Complications
Complications of sinusitis occur more frequently in children than in the general adult population (Hengerer & Klotz, 2003). These complications are related to the anatomical relationship of the sinus to the other structures of the head, neck, and chest.
Orbital complications
A medial subperiosteal abscess of the orbit is the most common serious complication of sinusitis in children (Pereira, Mitchell, Younis, & Lazar, 1997). The presence of ethmoid sinusitis is largely responsible for the development of orbital complications, particularly a medial subperiosteal abscess. This is due to a direct and hematogenous spread of the infection from the ethmoid sinus to the orbit through the paper-thin bony plates separating the ethmoid from the orbit. Further classification of periorbital and orbital complications include preseptal inflammation, which is limited to the eyelid, and postseptal inflammation, which involves the structures of the orbit (American Academy of Pediatrics Subcommittee on Management of Sinusitis and Committee on Quality Improvement, 2001).
CT scanning is the preferred method of diagnosis of this complication.
Symptoms can be limited to the tissues of the eyelid, causing periorbital edema and erythema. Progression of symptoms indicative of extension into the orbital structures can include fever, tenderness, proptosis, chemo- sis of the conjunctiva, diplopia, impaired visual acuity, and/or impaired ocular mobility.
Treatment of mild periorbital cellulitis requires treatment with antibiot- ics and nasal decongestants. If symptoms fail to improve after 24–48 hours, the child requires an admission for intravenous antibiotics and topical nasal decongestants. An opthamological evaluation should be included in the treatment plan. If a subperiosteal abscess is diagnosed, surgical drain- age is indicated. Many times, children may only present with symptoms over a course of 2–4 days before being diagnosed with a subperiosteal abscess, making prevention of this serious complication a challenge (Sinclair & Berkowitz, 2007).