Download Sinusitis in the Pediatric Age Group

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