Download Sinusitis

Sinusitis
Laura Saldivar, M.D.
Duke Children’s Primary Care
HOCC Preclinic Conference
February 2008
Sinus Anatomy and Development
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Ethmoid and Maxillary -
formed in the 2nd trimester in
utero, present at birth.
(around nose and cheeks)
Sphenoid - formed and
pneumatized by age 5 years.
(around eyes)
Frontal - formed by age 7-8
years; not completely
developed until adolescence.
(forehead)
Definitions: What is sinusitis?
The sinuses are air-filled
cavities within the head
that communicate with
the nose, pharynx and
middle ear.
Sinusitis = Inflammation
within the paranasal
sinuses, causing
congestion and mucus
production, with URI
symptoms that worsen
and/or persist beyond 10
days.
Definitions:
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Acute Sinusitis: Infectious symptoms lasting for 10 - 30
days, with complete resolution of symptoms post-trtmt.
Subacute: Symptoms last between 30-90 days, and resolve
completely. Think of this as a prolonged acute infection
with eventual complete resolution.
Recurrent: Episodes of acute symptoms, each less than 30
days, with 10+ clear days in between and final resolution.
Chronic: Symptoms for more than 90 days, with persistent
residual symptoms (chronic cough, nasal obstruction,
rhinorrea). This is thought to be a different disease, not just
an extension of acute sinusitis, and is usually not infectious.
Etiology:
ACUTE SINUSITIS
Viral - Most common is Rhinovirus. Symptoms of a
viral rhinosinusitis usually resolve in 7-10 days.
Bacterial - Usually preceded by a viral URI, which
leads to sinus inflammation and congestion,
obstructing normal drainage processes, leading to
a bacterial sinusitis: The most common pathogens
cultured from sinus aspirates are Strep pneumo,
nontypeable H. Influenza, M. catarrhalis. If
symptoms persist or worsen beyond 10 days,
consider the dx of acute bacterial sinusitis.
Etiology:
CHRONIC SINUSITIS:
The current thinking is that chronic sinusitis is a
different disease from acute bacterial sinusitis. Most
chronic sinusitis is not due to infection, but is
more of a chronic inflammatory condition, similar
to asthma. The small subset of chronic infections
are w/different organisms, and are usually
associated with an underlying immunodeficiency or
anatomic abnormality.
Etiology:
CHRONIC SINUSITIS:
The most common causes of chronic sinus
inflammation are: Allergic rhinitis, environmental
pollutants/irritants, GERD, CF, primary ciliary
dyskinesias, immunodeficiency diseases and
anatomic abnormalities. Treatment needs to be
tailored to the particular underlying cause for the
inflammation. Antibiotics are typically not useful,
unless suspect an acute infection on top of chronic
underlying inflammation.
Acute Sinusitis: Epidemiology
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Acute bacterial sinusitis is preceded 80% of the time
by a viral URI.
Acute bacterial sinusitis is preceded up to 20% of
the time by allergic rhinitis.
Children in school and daycare have 6-8 URIs per
year, and it is estimated that 5-10% of these will
develop into sinusitis.
Between 5-15% of children in daycare are estimated
to have one case of sinusitis or otitis media by age 3
yrs.
Acute Sinusitis:
Clinical Manifestations
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Purulent Nasal and/or postnasal discharge
Cough, both day/night
Fever
Symptoms persisting/worsening after 7-10 days
Headache and/or facial pain (variable)
Eye pain and/or periorbital swelling
Tooth pain, halitosis
Frontal/Maxillary tenderness on palpation (variable)
General malaise, nausea
Acute Sinusitis: Diagnosis
Methods:
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Gold Standard - Sinus Aspiration.
Culture + growth of >100K cfu/mL bacteria.
Problems: invasive, time-consuming, painful,
requires specialist. Not recommended for
routine diagnosis.
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Imaging studies:
Sinus xrays: cannot visualize the ethmoids well,
difficult to interpret, abnormal findings not
specific for infection.
Acute Sinusitis: Diagnosis
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Imaging studies:
MRI: good for evaluating soft tissue complications
of sinusitis, intracranial or orbital, but not good for
uncomplicated sinus disease.
Ultrasound: very limited usefulness. Sometimes
used for maxillary and frontal sinus eval. if
concerned about radiation in a particular patient.
CT: The image of choice. The best eval of bones
and ethmoids, but poor specificity/sensitivity for
bacterial infection (high incidence of incidental
abnormal CT findings in asymptomatic patients).
Acute Sinusitis: Diagnosis
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Physical Exam: Maxillary/Frontal sinus
tenderness, max. tooth tenderness, nasal speculum
exam for purulent discharge, transillumination of
frontal/maxillary sinuses (not able to do in small
children, debatable if helpful in older pts.)
Clinical History: Given the limitations of sinus
aspiration and imaging, several national clinician
groups (ENT, Allergy/Immunol, Peds) have
developed recommendations for diagnosing acute
sinusitis by clinical criteria alone.
Acute Sinusitis:
Diagnosis and Management
Pediatrics 2001; 108; 798-808
“Clinical Practice Guideline (CPG): Sinusitis”
 Multispecialty pediatric subcommittee came up with
evidence-based recommendations for the diagnosis,
evaluation, and treatment of sinusitis in children
aged 1-21 years, based on an extensive medical
literature review and analysis.
Their recommendations for sinusitis management
are shown in the following slides. A published
algorithm for sinusitis evaluation is available.
Diagnosis:
Clinical Practice Guideline
Strong Recommendation #1:
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The diagnosis of pediatric acute sinusitis
should be based on clinical criteria alone, in
children who present with upper respiratory
symptoms that are either persistent or severe.
i.e., increasing severity and persistent symptoms beyond 10 days
was shown to be associated with a significantly higher rate
of bacterial infection, and these children had a consistently
high incidence of abnormal radiographs (at least 75%),
making imaging unnecessary for diagnosis.
Diagnosis:
Clinical Practice Guideline
Strong Recommendation #2:
 Imaging studies are not necessary to confirm a
diagnosis of clinical sinusitis in children aged 6
years or less, and imaging to confirm the
diagnosis is controversial above 6 years of age.
CT scans should be reserved for patients in
whom surgery is being considered (sinusitis
with complications).
The level of detailed anatomy with a CT can be used to guide
surgical treatment for complications of acute bacterial
sinusitis, but is not necessary for diagnosis.
Treatment:
Clinical Practice Guideline
Strong Recommendation #3:
 Antibiotics are recommended for the
management of acute bacterial sinusitis to
achieve a more rapid clinical cure.
The objective of abx treatment is to achieve a rapid recovery,
prevent complications, and minimize flare of reactive airways
disease.
Amoxicillin is first line therapy (90mg/kgd divided bid).
Augmentin is recommended if not responsive to Amox, also
consider if attendance at daycare, recent abx use, or more
severe illness sx at presentation.
Treatment:
Clinical Practice Guideline
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Alternative abx are cefdinir, cefuroxime,
cefpodoxime, clarithromycin, azithromycin.
Substantial resistance precludes using sulfa or
erythromycin abx as second-line.
The optimal duration is probably somewhere
between 10-28 days.
A newer literature recommendation is to Rx until
there are no symptoms, then 7 more days.
(this strategy will usually average 10-14 days, but
allows for adequate treatment of a prolonged
subacute infection).
Treatment:
Clinical Practice Guideline
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Adjuvant Therapies: No recommendations are
made based on lack of randomized controlled
studies in children.
Saline nasal irrigation - has not been studied in children, but
may help to liquefy secretions and prevent crust formation,
may also mildly vasoconstrict nasal passages. Often
recommended by allergy and ENT specialists.
Antihistamines, Decongestants, Mucolytics, Topical intranasal
and/or oral steroids are not recommended.
Home-based remedies such as soups, teas, herbal or nutritional
supplements, chiropractic, homeopathic, aromatherapy, etc.
are not recommended due to lack of controlled trials.
References:
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AAP: Clinical Practice Guideline: Management of Sinusitis, Pediatrics 2001;
108; 798-808.
Ioannidis, JPA and Lau, J: Electronic Article: A Systematic Overview :
Evidence for the Diagnosis and Treatment of Acute Sinusitis in Children,
Pediatrics 2001; 108 (3); e.57.
Novembre, E et al: Systemic treatment of rhinosinusitis in children,Pediatr
Allergy Immunol, 2007 (18):56-61.
Zacharisen, M et al: Sinusitis, Immunol Allergy Clin North Am, 2005, 25:313332.
Steele, RW: Rhinosinusitis in children, Curr Allergy Asthma Rep, 2006
6(6):508-12.
CPG
Algorithm:
Acute
Sinusitis