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Download Sinusitis in the Pediatric Age Group
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RHINO SINUSITIS M.Mohammadi Ardehali,MD. Associate Professor of TUMS AMIRALAM HOSPITAL Anatomy Development MAXILLARY AND ETHMOID SINUSES DEVELOPS DURING 3RD & 4TH GESTATIONAL MONTH AND GROW IN SIZE UNTIL LATE ADOLESCENCE SPHENOID SINUS PRESENTS BY 2 YEARS OF AGE FRONTAL SINUS DEVELOPS DURING 5 AND 6 YRS. Factors Predisposing To Obstruction Of Sinus Drainage. A. MUCOSAL SWELLING Systemic disorder Viral URI Allergic inflammation Cystic fibrosis Immune disorder Immotile cilia Local insult Facial trauma Swimming, diving Rhinitis medicamentosa B. MECHANICAL OBSTRUCTION Choanal atresia Deviated septum Nasal polyp Foreign body Tumor Ethmoid bullae C. MUCUS ABNORMALITIES Viral URI Allergic inflammation Cystic fibrosis Pathophysiology Key Factors: The patency of the ostia Normal ciliary function The quality and quantity of secretion The patency of the ostia Obstruction of the sinus ostium Negative pressure Intruduction of bacteria sinusitis Normal ciliary function ciliary Dysfunction Impaired secretion clearance Sinusitis The quality and quantity of secretion Loss of: Antioxidan activiy Humidification of URT Entrapping microorganisms Immunologic antimicrobial functions Sinusitis Epidemiology Incidence Lifetime Incidence: 25% United States clinic office visits: 1% Attendance at Day Care Center Occurs during viral respiratory season School-age siblings in the household Definitions: Acute Rhinosinusitis Transition from Viral to Bacterial Infection Up to 2% of VRS complicated by bacterial infection Day 1-10: Can be difficult to distinguish VRS from ABRS. “Double Sickening” Pattern Pt initially gets better then gets worse Consistent with ABRS Symptoms And Signs PERSISTENT >10 DAYS No appreciable improvement Nasal discharge of any quality Cough(must be present during day) Malodorous breath Facial Pain and headache are rare If fever then low grade May not appear very ill SEVERE High fever > 39 C Purulent nasal discharge And Present for at least 3-4 days Headaches may be present Periorbital swelling occasionally Subacute Sinusitis 30 days to 4 months Mild to moderate and often intermittent symptoms Nasal discharge of any quality Cough often worse at night Low-grade fever may be periodic usually not prominent Chronic Sinusitis Extremely protracted nasal symptoms Discharge or Congestion or Cough or both Some cases rhinorhhea minimal or absent Nasal congestion-mouth breathing-sore throat Chronic Sinusitis Chronic headache usually on awakening Intermittent fever Malodorous breath Secondary affects – fatigue, impaired sleep – decreased appetite – irritability Physical Findings Mucopurulent discharge in nose or posterior pharynx Nasal mucosa- erythematous Throat- moderate injection Ears- acute otitis or otitis with effusion Paranasal sinus tenderness- occasionally Periorbital edema-occasionally Malodorous breath Differential Diagnosis-Purulent Nasal Discharge Uncomplicated viral URI Group A Strep infection Adenoiditis Nasal foreign body Differential Diagnosis- Nasal Symptoms Persistent clear nasal discharge or nasal congestion – Allergic rhinitis: nasal discharge, congestion, sneezing, itchiness of eyes, nose, other mucous membranes, pale boggy mucosa, Dennies lines, allergic shiners, transverse crease on bridge of nose, headaches Differential Diagnosis-Nasal Symptoms No allergic rhinitis -resemble allergic rhinitis children -specific allergens cannot be demonstrated, IgE levels normal, radioallergosorbent test negative Rhinitis Medicamentosa Vasomotor Rhinitis Differential Diagnosis-Cough Reactive airway disease GER CF pertussis Mycoplasma bronchitis TB Diagnosis Diagnosis-Imaging Standard views – Anterioposterior – Lateral – Occipitomental Sinus XRay (Rarely indicated) Complicated Acute Sinusitis Suspected Chronic Sinusitis Significantly abnormal in 88% of children younger than 6 Imaging Imaging Imaging Diagnosis- CT Scans Frequent abnormalities are found in patients with a “fresh common cold” Indications complicated sinus disease(either orbital or CNS complications) numerous recurrences protracted or nonresponsive symptoms(surgery is being contemplated) Axial CTScan Diagnosis- CT Scans Limitations of CT: – Radiation may be 10x that of plain films – lack of specificity for bacterial infection DIAGNOSIS The diagnosis is based largely on symptoms with confirmation by nasendoscopy Are endoscopically-directed cultures of the middle meatus an acceptable means of documenting microbiological diagnosis of acute sinusitis? Talbot et al. (1995) – 47 evaluable patients with acute maxillary sinusitis – overall sensitivity = 65%, specificity =40% – better performance with Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis – increased isolation of staphylococcal species with endoscopic cultures ABRS Microbiology Streptococcus pneumoniae 30-40% Haemophilus influenzae 20% Moraxella catarrhalis 20% Strep pyogenes 4% Respiratory viral isolates 10% – – – – adenovirus parainfluenzae influenzae rhinovirus Other rarer isolates- group A strep, group C strep, viridians strep, peptostrep, Moraxella species, Eikenella corrodens CRS Microbiology: Anaerobes gm+ cocci, bacteroides, corynebacteria Staphylococcus aureus Streptococcus H. Influenzae M. catarrhalis Complications Complications of Acute Bacterial Sinusitis Preseptal cellulitis Orbital cellulitis Osteomyelitis Subperiosteal orbital abscess Subdural or Epidural Empyema Meningitis Brain abscess Cortical thrombophlebitis Cavernous or sagittal sinus thrombophlebitis 6 weeks post op. Treatment Choice of Antibiotic for ABRS Wright & Frankel Symptomatic Relief of Acute Bacterial Rhinosinusitis Adjunctive treatments for rhinosinusitis that may aid in symptomatic relief include – decongestants (-adrenergic) – corticosteroids (topical?) – saline irrigation – Mucolytics – **None of these products have been specifically approved by the FDA for use in acute rhinosinusitis (as of February 2007), and few have data from controlled clinical studies supporting this use. Treatment: cont, In patients with acute sinusitis 40-50% have spontaneous clinical cure rate Hospitalization- systemic toxicity or unable to take oral antimicrobials – cefuroxime – ampicillin/sulbactam – cefotaxime and vanco. if suspecting penicillinresistant strep pneumoniae Treatment: cont, Clinical improvement is prompt If no reduction of nasal discharge or cough in 48 hours reevaluate Patients with brisk response- 10 days of treatment If respond more slowly- treat until patient is symptom free plus 7 more days Recurrent Sinusitis Most common cause is recurrent viral URIs – day care attendance – presence of other school age siblings in house Other predisposing conditions – – – – – allergic and nonallergic rhinitis CF immunodeficiency disorder ciliary dyskinesia anatomical problem Absolute Indications for Surgery Failure of maximal medical therapy Causing brain abscess or meningitis, subperiosteal/orbital abscess, cavernous sinus thrombosis, another contiguous infection, or an impending complication (Pott’s tumor) Sinus mucocele or pyocele Fungal sinusitis (all types( Nasal polyps (massive ) Neoplasm or suspected neoplasm Surgery Functional endoscopic sinus surgery (FESS) Rarely required in children Consider if anatomical variations causing local obstruction, Thank you
