Management of pediatric rhinosinusitis
by Cecille Sulman, MD, and James Lustig, MD
Cecille Sulman, MD, is a pediatric otolaryngologist at Children's Hospital of Wisconsin. She also is an assistant professor of Pediatrics (Otolaryngology) at the Medical College and a member of Children's Specialty Group.
James Lustig, MD, is an asthma and allergy specialist at Children's Hospital of Wisconsin. He also is a professor of Pediatrics (Asthma/Allergy) at The Medical College of Wisconsin and a member of Children's Specialty Group.
Rhinosinusitis is a common disease. On average, children got 6-10 upper respiratory tract infections per year. Between 5 and 10 percent of upper respiratory tract infections are complicated by rhinosinusitis.
Acute rhinosinusitis most commonly presents as a upper respiratory tract infection. Symptoms persist beyond 10 days or symptoms become worse at 7-10 days. Primary symptoms include nasal discharge, cough and halitosis. Fever may be present. Otitis media is present in up to 50 percent of the children. The most common pathogens include Streptococcus pneumonia, Haemophilus influenza and Moraxella catarrhalis. Chronic rhinosinusitis is a more indolent infection that lasts more than three months, with symptoms including nasal congestion, cough, halitosis, behavioral problems, headache and nasal discharge. In addition to Streptococcus pneumonia, Haemophilus influenza and Moraxella catarrhalis, anaerobic bacteria (Peptococcus, Peptostreptococcus, Bacteroides) and Staphylococcus aureus may play a role in chronic rhinosinusitis. Recurrent acute rhinosinusitis is a recurrent infection lasting less than 30 days with relatively asymptomatic periods in between that last at least 10 days.
The presence of purulent secretions in the region of the middle meatus is highly suggestive of sinusitis. (See Figure 1.) This may be seen via anterior rhinoscopy, visualizing the middle meatus by positioning the speculum beyond the nasal vibrissae. A flexible nasopharygoscope also may be used to see the middle meatus and adenoid pad.
Imaging should be reserved for children who are refractory to therapy, being considered for surgery or if concern is present for complications of rhinosinusitis. The gold standard for sinus imaging is computed tomography with images in the coronal and axial plane. Plain film radiography is not a reliable screen for sinus disease. Obtaining plain films does not provide cost savings over a sinus CT. A lateral neck film is helpful in determining the presence of adenoid hypertrophy in a child with persistent rhinorrhea and nasal obstruction.
The ostiomeatal complex is located in the middle meatus under the middle turbinate and is the confluence of drainage points for the maxillary, anterior ethmoid and the frontal sinuses. (See Figure 2.) Inflammation or obstruction of the ostiomeatal complex is a contributing factor in the development of rhinosinusitis. Mucosal edema and disruption of ciliary motility also contribute to the pathophysiology of rhinosinusitis. (See Table 1.)
Most sinus infections in children develop following a viral upper respiratory tract infection. Inflammation of the sinus ostia causes stasis of secretions and poor ventilation of the affected sinus. This leads to absorption of oxygen and the development of a relatively negative pressure or vacuum within the sinus. Reflux of intranasal contents and nasopharyngeal bacteria into the sinus cavity incites rhinosinusitis. Viruses can have a direct inhibitory effect on ciliary function contributing to stasis of secretions.
More than 80 percent of children with rhinosinusitis have a family history of allergy, as opposed to a general population allergy frequency of 15 percent. Allergy may contribute by causing nasal congestion and ostial obstruction. Immunotherapy has been demonstrated to decrease the incidence of rhinosinusitis in children with known allergy and improve health-related quality of life.
The adenoid pad contributes to rhinosinusitis in children by blocking the outlet of secretions or acting as a bacterial reservoir. Cultures of the adenoid core have shown organisms similar to those seen in rhinosinusitis. Removal of the adenoids may improve rhinosinusitis in up to 80 percent of children.
Other diseases are associated with rhinosinusitis. These include primary immunodeficiency (especially B-cell defects), primary ciliary dyskinesia, cystic fibrosis and gastroesophageal reflux disease. Rhinosinusitis may be a major problem in cystic fibrosis. Patients who have nasal polyps should be evaluated for cystic fibrosis.
Many opinions exist about the relationship between GERD and rhinosinusitis in children. Double-lumen pH probe testing has shown that esophageal reflux can extend to the nasopharynx. A retrospective study suggested that GERD therapy could prevent sinus surgery in almost 90 percent of children with refractory chronic rhinosinusitis. However, controlled studies are lacking and children with chronic rhinosinusitis should be treated for GERD only if there are clear clinical indications.
Environmental pollutants can irritate the nasal and sinus mucosa. The most significant irritant in rhinosinusitis is environmental tobacco smoke. Less commonly, structural anomalies of the sinus and nasal cavities are implicated in rhinosinusitis. These include septal deviation, concha bullosa, hypoplastic maxilla, paradoxical middle turbinate and infraorbital (Haller) cells.
See Table 2 for an overview of therapy options for rhinosinusitis.
Antibiotic therapy: The mainstay of therapy for rhinosinusitis continues to be antibiotics. The ideal antibiotic should combine high susceptibility, clinical effectiveness, safety and tolerability.
There is an increased resistance to amoxicillin resulting from beta lactamase production in approximately 60 percent of Haemophilus influenza cases and 100 percent of Moraxella catarrhalis cases. An alteration in penicillin-binding proteins also occurs in about 50 percent of Streptococcus pneumonia cases.
Young children with mild to moderate acute rhinosinusitis should be treated with a high dosage of amoxicillin (75-90 mg/kg/day). Allergic patients may be treated with a macrolide such as clarithromycin or azithromycin. Children that do not respond to first-line therapy, children with more severe initial disease and children who are considered high-risk for resistant Streptococcus pneumonia (those who recently have used antibiotics or attend day care) should be treated with high-dose amoxicillin/clavulanate (90 mg/kg/day of amoxicillin component). The optimal duration of treatment has not been determined, but long courses of therapy typically are necessary.
For children with chronic rhinosinusitis, amoxicillin/clavulanate (90 mg/kg/day) or the second generation cephalosporins are recommended. Clindamycin may be used if Streptococcus pneumonia is the suspected organism or if there is no response to other antibiotics. Antibiotic therapy in chronic rhinosinusitis is extended for 3 to 6 weeks.
Adjuvant therapy: Other medical therapies have not been proved to be effective by randomized controlled trials, but may provide symptomatic relief. Saline irrigations twice a day help in clearing secretions. If significant nasal mucosal edema is present, oxymetazoline may be used for three days. Nasal steroids commonly are used to help decrease inflammation and should be used in children with allergies. Control of underlying causative factors, such as allergy, gastroesophageal reflux disease, day care exposure or environmental pollutants, should be addressed.
Surgical therapy: Adenoidectomy as a first-line surgical therapy if medical therapy has failed may provide improvement in up to 80 percent of children. The addition of maxillary sinus lavage allows for culture directed antibiotics. Functional endoscopic sinus surgery is considered if all other measures have failed. This surgery involves the removal of obstructive components, typically the uncinate process and anterior ethmoid air cells, and widening the maxillary ostia. In properly selected children, improvement should be expected in 80-90 percent of cases. If a child is being considered for functional endoscopic sinus surgery, causative factors should be considered, such as allergy, immunodeficiency, primary ciliary dyskinesia or cystic fibrosis.
A sick plan for respiratory infections is available at chw.org/provider. Select Medical Care Guidelines and look for the sinusitis section.
For outcomes from our Ear, Nose and Throat program, visit chw.org/quality.
For Sinus Clinic printable information sheet for your office staff, click here.
James Lustig, MD, and Cecille Sulman, MD, are part of the Sinus Clinic team at Children's Hospital of Wisconsin Clinics-New Berlin. The clinic provides a multidisciplinary approach for children with chronic rhinosinusitis. Physical exam and medical history review; allergy testing; exam of the nasal passages, upper airway, voice box and vocal cords; lung function tests; imaging studies, including X-ray, MRI or CT; and lab tests can be completed during the same visit.