Medical Treatment of Pediatric Sinusitis

Medical Treatment of Pediatric Sinusitis

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Pediatric sinusitis is a common problem treated by primary care physicians and otolaryngologists. Although this disorder has been addressed for many centuries, full appreciation for its scope, pathophysiology, diagnosis, treatment, and complications has been realized only relatively recently. Children with occasional episodes of acute sinusitis following a routine cold are treated with short courses of antibiotic therapy with good results. However, treatment of chronic and recurrent sinusitis can be more challenging for physicians and frustrating for families. In these cases, the physician must not only treat with an appropriate antibiotic but must also address the associated conditions contributing to the problem.

The goal in treating these children is to combine antibiotic therapy with treatment of associated conditions for a time sufficient to allow resolution of symptoms with return of normal sinus physiology and mucociliary clearance. This article addresses the medical management of pediatric sinusitis.

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Laboratory tests are normally not particularly helpful in making the diagnosis of sinusitis. However, they can be essential in determining whether associated conditions such as allergic rhinitis, cystic fibrosis, or immunodeficiency are present. In addition, in patients with suppurative complications or in a very toxic-appearing child, some blood work and cultures may be helpful for determining treatment.

Computed tomography (CT) scanning is the criterion standard for evaluation of both mucosal inflammation and anatomic abnormalities in the paranasal sinuses. CT scanning provides a reliable picture of the ostiomeatal complex (OMC) in a noninvasive fashion.

Various procedures in patients workup include the following:

Indications for antibiotic therapy for acute sinusitis are as follow:

Surgical approaches include the following:

The ostiomeatal complex (OMC) is believed to be the critical anatomic structure in sinusitis and is entirely present, although not at full size, in newborns. Present within the middle meatus, the OMC is composed of the uncinate process, infundibulum ethmoidalis, hiatus semilunaris, ethmoid bulla, and frontal recess. Although obstruction of the OMC has not been proven to be the primary source for pediatric sinusitis, changes occurring in the anterior ethmoids are known to impair drainage through the OMC, resulting in chronic maxillary sinusitis and, occasionally, frontal sinusitis.

The normal metachronous movement of mucous toward the natural ostia of the sinuses and eventually to the nasopharynx can be disrupted by mucosal inflammation. This most commonly occurs secondary to routine viral upper respiratory tract infections (URTIs) or nasal allergies and the host response to these insults. In addition, many other predisposing factors to chronic disease exist, including allergic rhinitis, anatomical abnormalities, gastroesophageal reflux (GER), immune deficiency, and disorders of ciliary function.

A prospective cohort study by Santee et al indicated that in children, a history of acute sinusitis is associated with a reduction in the relative abundance of certain taxa in the nasopharyngeal microbiota. In the study, of 47 healthy children aged 49-84 months, significantly depleted species in subjects with a history of acute sinusitis included Faecalibacterium prausnitzii and Akkermansia species, while the relative abundance of the bacterium Moraxella nonliquefaciens in these children was enriched. In addition, the investigators found that children who developed acute sinusitis over the 1-year study period were also characterized by enrichment of M nonliquefaciens. [1]

United States

Although the exact incidence of sinusitis in the pediatric population is unclear, it is diagnosed commonly, most often following a viral URTI. The number of URTIs that an individual has per year may be as high as 25 (children will have on average 6-8 per year); the number depends on a several factors, including age, day care attendance, and number of siblings. Approximately 5-13% of URTIs are complicated by bacterial sinusitis. Many viral URTIs are mislabeled early in their course as acute sinusitis and are inappropriately treated with antibiotics.

A study by Gilani and Shin determined that in the United States between 2005 and 2012, in patients aged 0-20 years, there were 5.6 million ambulatory care visits per year for chronic rhinosinusitis. The condition was diagnosed in 2.1% of all pediatric ambulatory care visits, while acute rhinosinusitis was diagnosed in 0.6% of all such visits. [2]

International

International incidence is similar to that in the United States.

Recent health-related quality of life measures showed a poor result in children with chronic rhinosinusitis. Because quantifying the morbidity caused by pediatric conditions is difficult, it must also be viewed in other terms. A child with an acute episode of sinusitis may lead the caregiver to experience emotional distress and lack of sleep and miss days from work. Chronic illness may have a negative impact on a child’s quality of life in many ways, including complications of chronic antibiotic therapy, school absences, poor sleep patterns, impaired school performance, and irritability. [3]

Children are also susceptible to more serious sequelae from a complication of sinusitis such as orbital cellulites (in about 9.3% of the cases) and intracranial complications (in 3.7-11% of patients). With close follow-up care, counseling of the family, and proper medical treatment, morbidity from this disease should be very low.

A study by Capra et al found a decrease between 2000 and 2009 in the estimated number of hospital admissions in the United States, from 5338 to 4511, for orbital complications of pediatric rhinosinusitis. The investigators suggested that the introduction of heptavalent pneumococcal vaccine was associated with the slight downward trend. The study also found that the mean patient age among children admitted for rhinosinusitis-related orbital complications rose from 4.77 years to 6.07 years and that the proportion of children who underwent surgery for these complications increased. [4]

A study by Al-Madani et al of 616 patients indicated that in children, acute sinusitis most commonly involves the ethmoid sinus and that orbital complications are more common than they are in adults. The investigators also found that most patients in the study responded well to medical treatment. [5]

No race predilection exists.

No sex predilection exists.

The ethmoid and maxillary sinuses are present at birth. The sphenoid sinuses are pneumatized by age 5 years, and the frontal sinuses appear by age 7 years but are not completely developed until adolescence. Thus, children are predisposed to sinus infection at an early age. In young children, the most common sinuses involved are the ethmoid and maxillary sinuses. Acute sinusitis is much less common in young children than routine URTI or adenoiditis.

In an older child, the sphenoid and frontal sinuses are more likely to be involved with disease. Allergic rhinitis is also more common in older children. It affects only 1% of infants and 5% of children aged 5-9 years, while 15% of the adolescent population is affected. Allergic rhinitis is one of the most common predisposing factors for sinusitis, second only to viral URTIs.

Santee CA, Nagalingam NA, Faruqi AA, et al. Nasopharyngeal microbiota composition of children is related to the frequency of upper respiratory infection and acute sinusitis. Microbiome. 2016 Jul 1. 4 (1):34. [Medline]. [Full Text].

Gilani S, Shin JJ. The Burden and Visit Prevalence of Pediatric Chronic Rhinosinusitis. Otolaryngol Head Neck Surg. 2017 Dec. 157 (6):1048-52. [Medline].

Kay DJ, Rosenfeld RM. Quality of life for children with persistent sinonasal symptoms. Otolaryngol Head Neck Surg. 2003 Jan. 128(1):17-26. [Medline].

Capra G, Liming B, Boseley ME, et al. Trends in orbital complications of pediatric rhinosinusitis in the United States. JAMA Otolaryngol Head Neck Surg. 2015 Jan 1. 141(1):12-7. [Medline].

Al-Madani MV, Khatatbeh AE, Rawashdeh RZ, et al. The prevalence of orbital complications among children and adults with acute rhinosinusitis. Braz J Otorhinolaryngol. 2013 Nov-Dec. 79(6):716-9. [Medline].

Shin KS, Cho SH, Kim KR, et al. The role of adenoids in pediatric rhinosinusitis. Int J Pediatr Otorhinolaryngol. 2008 Nov. 72(11):1643-50. [Medline].

Min HJ, Chung HJ, Seong SY, et al. Differential characteristics of pediatric sinusitis who underwent endoscopic sinus surgery: children vs. adolescents. Clin Otolaryngol. 2015 Oct 17. [Medline].

Sivasli E, Sirikci A, Bayazyt YA, et al. Anatomic variations of the paranasal sinus area in pediatric patients with chronic sinusitis. Surg Radiol Anat. 2003 Feb. 24(6):400-5. [Medline].

Anfuso A, Ramadan H, Terrell A, et al. Sinus and adenoid inflammation in children with chronic rhinosinusitis and asthma. Ann Allergy Asthma Immunol. 2015 Feb. 114(2):103-10. [Medline]. [Full Text].

Bhattacharyya N, Jones DT, Hill M, Shapiro NL. The diagnostic accuracy of computed tomography in pediatric chronic rhinosinusitis. Arch Otolaryngol Head Neck Surg. 2004 Sep. 130(9):1029-32. [Medline].

Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013 Jul. 132(1):e262-80. [Medline].

Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016 May 3. 315 (17):1864-73. [Medline].

Bergmark RW, Sedaghat AR. Antibiotic prescription for acute rhinosinusitis: Emergency departments versus primary care providers. Laryngoscope. 2016 Nov. 126 (11):2439-2444. [Medline].

Newton L, Kotowski A, Grinker M, Chun R. Diagnosis and management of pediatric sinusitis: A survey of primary care, otolaryngology and urgent care providers. Int J Pediatr Otorhinolaryngol. 2018 May. 108:163-7. [Medline].

Jeffe JS, Bhushan B, Schroeder JW Jr. Nasal saline irrigation in children: a study of compliance and tolerance. Int J Pediatr Otorhinolaryngol. 2012 Mar. 76(3):409-13. [Medline].

Wei JL, Sykes KJ, Johnson P, He J, Mayo MS. Safety and efficacy of once-daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis. Laryngoscope. 2011 Sep. 121(9):1989-2000. [Medline].

Venekamp RP, Thompson MJ, Hayward G, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev. 2014 Mar 25. 3:CD008115. [Medline].

Brook I. The role of antibiotics in pediatric chronic rhinosinusitis. Laryngoscope Investig Otolaryngol. 2017 Jun. 2 (3):104-8. [Medline]. [Full Text].

Hassan H Ramadan, MD, MSc Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine

Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children’s Hospital, Montreal General Hospital, and Royal Victoria Hospital

Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children’s Hospital, Montreal General Hospital, and Royal Victoria Hospital

Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Karla R Brown, MD, and Lincoln Lippincott, MD, to the development and writing of this article.

Medical Treatment of Pediatric Sinusitis

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