Download Chronic Sinusitis

SINUSITIS
In Pediatric Age Group
Anatomy
 MAXILLARY
 ANT ETHMOID
MIDDLE
MEATUS
 FRONTAL
 POST ETHMOID
SUPERIOR
MEATUS
 SPHENOID
 LACRIMAL DUCTS
INFERIOR
MEATUS
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.
Physiology
THREE KEY ELEMENTS
– PATENCY OF THE OSTIA
– FUNCTION OF THE CILIARY APPARATUS
– QUALITY OF SECRETIONS
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. MECHANICALOBSTRUCTION
Choanal atresia
Deviated septum
Nasal polyp
Foreign body
Tumor
Ethmoid bullae
C. MUCUS ABNORMALITIES
Viral URI
Allergic inflammation
Cystic fibrosis
Epidemiology
 Occurs during viral respiratory season
 Attendance at Day Care Center
 School-age siblings in the household
Symptoms And Signs
 PERSISTENT
 SEVERE
 >10 DAYS
 High fever > 39 C
 No appreciable improvement
 And
 Nasal discharge of any quality
 Purulent nasal discharge
 Cough(must be present
 Present for atleast 3-4 days




during day)
Malodorous breath
Facial Pain and headache are
rare
If fever then low grade
May not appear very ill
 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
 Nonallergic 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- Sinus Aspiration
 Indications
–
–
–
–
failure to respond to multiple antibiotics
severe facial pain
orbital or intracranial complications
evaluation of an immunoincompetent host
 Material should be sent for quantitative
aerobic and anaerobic cultures
 Density of atleast 104 colony-forming
units/ml represents true infection
Diagnosis-Imaging
 Standard views
– Anterioposterior
– Lateral
– Occipitomental
 When children older than 1 have neither respiratory
signs nor symptoms, their sinus radiographs are almost
normal
 Findings
– acute-diffuse opacification,mucosal thickening of atleast 4 mm,
or an air-fluid level
 Significantly abnormal in 88% of children younger
than 6
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)
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
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
Treatment
 Amoxicillin
 Cefuroxime axetil
 Amoxicillin-potassium
 Cefprozil
clavunate
 Erythromycin/sulfisox
azole
 Sulfamethoxazole/
trimethorphim
 Cefaclor
 Cefixime
 Cefpodoxime proxetil
 Ceftibuten
 Loracarbef
 Clarithromycin
 Erythromycin
Treatment-Antimicrobials
 Amoxicillin preferred in most cases
 Situations when broader treatment appropriate
– failure to improve on amoxicillin
– residence in an area with high prevalence of betalactamase producing H.influenzae
– occurrence of frontal or sphenoidal sinusitis
– occurrence of complicated ethmoidal sinusitis
– presentation of very protracted symptoms >30days
Treatment-Most Comprehensive
Coverage
 Amoxicillin/potassium clavunate
 Erythromycin-sulfisoxazole
 Cefuroxime axetil
 Cefpodoxime
 Proxetil
 Azithromycin
Treatment
 In patients with acute sinusitis 40-50% have
spontaneous clinical cure rate
 Penicillin-resistant pneumococci serious emerging
problem- most susceptible to clindamycin and rifampin
 Hospitalization- systemic toxicity or unable to take oral
antimicrobials
– cefuroxime
– ampicillin/sulbactam
– cefotaxime and vanc if suspecting penicillin-resistant
strep pneumoniae
Treatment
 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
Surgery
 Rarely required
 Consider if orbital or central nervous system complications or
 Failure of maximal medical therapy
 Functional endoscopic sinus surgery (FESS)
 1st stage- removal of uncinate process, ethmoid bulla, and variable
number of anterior ethmoidal cells, maxillary sinus ostium
enlarged and frontal recess diseased tissue is removed if present,
occasionally a stent is placed
 2nd stage- several weeks later- crusting, granulation tissue,
adhesions, and stents are removed
 Approximately 20-30% of those with extensive mucosal disease do
not benefit
Absolute Indications for Surgery
 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
 Nasal polyps (massive )
 Neoplasm or suspected neoplasm
Other Medications
 Antihistamines, decongestants, and anti-
inflammatory agents have not
systematically been studied in children
 May try these above agents
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