Kelli A. Petronis
Acute sinusitis is defined as inflammation of the mucosal lining of the nasal passage and paranasal sinuses lasting less than 4 weeks. Predisposing factors include allergens, environmental irritants, and infection. The most frequent cause of sinusitis is an upper respiratory infection (URI) (1). It is estimated that children between the ages of 6 and 35 months of age have six episodes of URI per year, and acute bacterial sinusitis (ABS) complicates viral URI in 8% (2). Children in day care have a higher risk of developing sinusitis than those in home care (3). The second most common predisposing factor in the development of childhood acute sinusitis is allergic inflammation (4). Other predisposing conditions include cystic fibrosis, immune disorders, abnormal ciliary function, nasal polyps, nasal foreign bodies (including indwelling nasal tubes), cleft palate, adenoidal hypertrophy, septal deviation, and gastroesophageal reflux disease (5).
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common etiologic agents in ABS. Visit rates for acute sinusitis in children have not decreased after the introduction of the pneumococcal vaccine (6). Although some recent studies have suggested that Staphylococcus aureus is a major pathogen in ABS, they should be interpreted with caution. The majority of isolates in the pediatric studies were taken from cultures of the middle meatus, which has not been established as a reliable surrogate for maxillary sinus aspirates in children (7).
CLINICAL PRESENTATION
Children with ABS present with upper respiratory symptoms that are either persistent or severe. Most viral URIs last approximately 5 to 7 days, and almost all are resolved or improving by 10 days (2). Children who have symptoms beyond 10 days without improvement should be considered to have ABS. The most common symptoms include cough and nasal discharge. The cough may be either “wet” or “dry” and is usually present in the daytime but may worsen at night. Fever or history of fever is present in about half of patients (5). The nasal discharge may be of any quality, ranging from clear to purulent, thin to thick. Malodorous breath is commonly reported by parents of preschool-aged children (8). Headache and facial pain or swelling, common symptoms of sinusitis in adults, are uncommon in children younger than 5 years of age but may be present in older children and adolescents (9).
Children who present with severe upper respiratory symptoms and high fever should also be suspected of having ABS. In the usual course of a viral URI, fever may be present during the first 48 hours but usually disappears, and purulent nasal discharge does not usually develop until later in the illness. In contrast, children with the severe onset of ABS are ill appearing and present with concurrent high fever (>39°C/102°F) and purulent nasal discharge for 3 to 4 consecutive days. In addition, they may complain of intense headache above or behind the eye or present with periorbital swelling (8).
In children, the most common manifestations of bacterial sinusitis are cough (80%), nasal discharge (76%), and fever (63%). Some children also have malodorous breath. Symptoms of headache, facial pain, and swelling are uncommon (1).
Any of the following clinical presentations are recommended for identifying patients with ABS (1):
• Persistent symptoms
• Nasal congestion/discharge and/or daytime cough (may be worse at night) (4)
• Lasts ≤10 days without any evidence of clinical improvement (1)
• Presence of fever, headache, or facial pain is variable (1)
• Severe symptoms (1,4)
• High fever (≤39°C/102°F)
• AND purulent nasal discharge or facial pain
• AND lasting at least 3 to 4 consecutive days at the BEGINNING of illness
• Worsening symptoms (1)
• New onset of fever, headache, or increase in nasal discharge following typical viral URI that lasted 5 to 6 days and was initially improving
• If nuchal rigidity is present, the patient should be evaluated for meningitis.
Complications of acute sinusitis include bony, orbital, and central nervous system extension (10). Osteomyelitis of the frontal bone is called Pott’s puffy tumor. Orbital complications include subperiosteal abscess, orbital cellulitis, and orbital abscess. Central nervous system complications include cavernous or sinus venous thrombosis, meningitis, subdural empyema, and subdural, epidural, or brain abscesses.
DIFFERENTIAL DIAGNOSIS
• Viral URI (1,4)
• If fever is present, it typically occurs in the first 24 to 48 hours and then resolves
• Purulent nasal discharge is not generally present until the fourth or fifth day of illness
• Sequential viral URI
• Allergic rhinitis
• Nasal foreign body (often presents with unilateral nasal discharge)
ED EVALUATION
There are no physical examination findings that are specific for sinusitis. There may be mild erythema and edema of the nasal turbinates with mucopurulent discharge, but patients with uncomplicated viral URIs may have similar findings. Facial tenderness is rare, although reproducible unilateral pain to percussion or direct pressure over the frontal or maxillary sinus may indicate sinusitis. In addition, periorbital swelling suggests ethmoid sinusitis (2), although one must be careful to rule out true orbital complications in these patients. Findings that suggest an orbital or intracranial complication include proptosis, abnormal extraocular movements, focal neurologic deficits, or signs of intracranial pressure. If nuchal rigidity is present, the patient should be evaluated for meningitis. Transillumination is unreliable in children younger than 10 years (2).
The most important part of the emergency department (ED) evaluation is the history, since the diagnosis is usually made clinically. The physical examination is most important for ruling out complications, rather than diagnosing sinusitis. No physical examination findings are specific for sinusitis; mild erythema and edema of the nasal turbinates with mucopurulent discharge may be present, but also occur with URI (4).
Facial tenderness is rare, but reproducible unilateral pain to percussion or direct pressure over maxillary or frontal sinus may indicate sinusitis (4). Periorbital swelling suggests ethmoid sinusitis, although one must be careful to rule out true orbital complications in patients with this finding (4).
Findings suggestive of orbital or intracranial complications (5) include proptosis, abnormal extraocular movements, focal neurologic deficits, signs of increased intracranial pressure, altered mental status, or nuchal rigidity.
Sinus aspiration is the gold standard for the diagnosis of bacterial sinusitis but should only be performed by specialists. Sinus aspiration is not recommended for the routine diagnosis of ABS in children (2). Cultures of the throat and nasopharynx have poor correlation with those of maxillary sinus aspirates and are not recommended (11).
Laboratory Studies
Sinus aspiration (4) is the gold standard, but should only be performed by specialists and is not recommended for routine diagnosis of ABS in children. Nasal/nasopharyngeal cultures are not useful in predicting the results of culture of the paranasal sinuses themselves (8).
Imaging
Plain films are not recommended for the diagnosis of acute uncomplicated bacterial sinusitis in children by the American Academy of Pediatrics, the American College of Radiology, and the Sinus and Allergy Health Partnership. It should be reserved for children who do not improve or worsen with therapy (4).
Computed tomography (CT) scanning is recommended for patients with suspected suppurative complications such as orbital or intracranial extension (1,12). It is also indicated in patients who do not respond to therapy (12).
Magnetic resonance imaging (MRI) should be considered in those with suspected intracranial complications (13). Obstacles include limited availability, length of test, and need sedation often required in children.
There are limited studies of ultrasound, but there may be a role in evaluating fluid collections in the maxillary sinus in pediatric patients (12).
Findings on plain film that may help confirm a diagnosis of sinusitis include air–fluid levels, complete sinus opacification, and mucosal thickening (≤4 mm). Studies have shown strong correlation (80% to 92.5%) between persistent symptoms and abnormal radiographs (10,12). In studies in which sinus aspirates were taken from children with persistent or severe symptoms and abnormal radiographs, bacteria were recovered in 70% to 75% of cases (2). Because there is such a high correlation among persistent symptoms, abnormal radiographs, and positive sinus aspirates, the American Academy of Pediatrics, the American College of Radiology, and the Sinus and Allergy Health Partnership do not recommend the routine use of radiography in the diagnosis of acute uncomplicated sinusitis in children (2). Instead, radiography should be reserved for children who do not improve with therapy or who worsen during therapy.
CT scans are indicated for patients with suspected complications, with persistent or recurrent infections, who fail to respond to therapy, and who are being considered for surgical treatment (2). MRI is also recommended for patients with suspected intracranial complications, but MRI often has limited availability.
KEY TESTING
• History and physical examination are the most important elements of the evaluation.
• CT scan is reserved for selected patients who are at risk for infectious complications, including abscess or orbital cellulitis.
ED MANAGEMENT
The most current recommendations for the management of ABS in both adults and children were published in 2012 by the Infectious Disease Society of America (IDSA) using a multidisciplinary panel. Recent randomized controlled trials of antimicrobial therapy versus placebo for treatment of ABS show a modest benefit favoring the use of antimicrobials. Therefore, the IDSA guidelines do recommend antimicrobial therapy be initiated as soon as the clinical diagnosis of ABS is made (1).
Antibiotics are the mainstay of treatment for ABS (Table 257.1). Many children will improve spontaneously without the use of antibiotics, but improvement is more rapid when antibiotics are used. In a study comparing antimicrobial treatment to placebo, 83% of children receiving antimicrobials were cured or improved by day 3, in comparison to only 51% of those in the placebo group (12). The antibiotic chosen should have adequate coverage for the most common causative organisms of ABS (see introduction). Resistance of S. pneumoniae to penicillins has been increasing, and attention should be paid not only to local resistance patterns but also to factors that increase the risk that a child harbors a resistant strain. These factors include day care attendance, age younger than 2 years, and antibiotic use within 90 days (2).
TABLE 257.1
Antibiotic Recommendations
Amoxicillin in a usual dose (45 mg/kg/d divided bid) or high dose (90 mg/kg/d divided bid) can be used as first-line therapy in children who have mild to moderate uncomplicated ABS, do not attend day care, and have not been on antibiotics in the past 90 days. Although amoxicillin does not adequately cover β-lactamase producing organisms, approximately 80% of children without risk factors for resistance can be expected to respond to amoxicillin. This is because S. pneumoniae is the most common causative organism, and 50% to 75% of sinusitis caused by H. influenzae and M. catarrhalis will resolve spontaneously. In children who attend day care, have received antibiotics in the past 90 days, have moderate to severe illness, or do not improve on usual dose amoxicillin, therapy should be initiated with high-dose amoxicillin–clavulanate (80 to 90 mg/kg/d of amoxicillin component in two divided doses). In children who are allergic to penicillin, there are the following options: cefdinir (14 mg/kg/d in one or two doses), cefuroxime (30 mg/kg/d divided bid), or cefpodoxime (10 mg/kg/d once daily). In children who have had anaphylactic reactions to penicillins, many prefer instead to use clarithromycin (15 mg/kg/d divided bid) or azithromycin (10 mg/kg/d on day 1 and 5 mg/kg/d × 4 more days, given once daily). A final option in the allergic patient is clindamycin (30 to 40 mg/kg/d in three divided doses). A single dose of intramuscular (IM) or intravenous (IV) ceftriaxone (50 mg/kg) may be used for children who are vomiting, followed by completion of a treatment course with an oral antibiotic starting 24 hours later. Recent studies have shown significant resistance of S. pneumoniae to trimethoprim–sulfamethoxazole and erythromycin–sulfisoxazole; therefore, these antibiotics should not be used (2).
Current recommendations for length of treatment vary from 10 to 28 days. In most cases, treatment for 7 days beyond the time when the patient becomes symptom-free results in adequate treatment (2,8). Most patients become symptom-free by 3 days of treatment, so 10 days of treatment usually suffices. A good recommendation for ED treatment is treat for 10 days and have patients with longer symptomatic periods follow-up with their primary care physician for continuation of antibiotics.
Saline nasal irrigation, antihistamines, topical or systemic decongestants, mucolytic agents, and topical intranasal steroids have all been suggested as ancillary treatments, but few data exist on their efficacy, especially in children (2). In one study, intranasal budesonide spray was added to antibiotics, and a significant improvement in symptoms of cough and nasal discharge was noted in the treatment group compared to the placebo group, but only at the end of the second week of treatment (3). Another study compared the addition of topical decongestant and oral decongestant–antihistamine to placebo (in addition to amoxicillin in both groups) and found similar treatment response in both groups (6).
Any child suspected of having an orbital or central nervous system complication should be treated aggressively. This includes imaging, IV antibiotics, and emergent consultation with appropriate subspecialists. Antibiotic treatment for orbital complications should be with either ceftriaxone (100 mg/kg/d IV divided bid) or ampicillin–sulbactam (200 mg/kg/d IV in four divided doses) or an antibiotic with equivalent antimicrobial spectrum. Antibiotic treatment for intracranial complications should be with ceftriaxone (see previous dose) or cefotaxime (200 mg/kg/d divided q6h). Vancomycin (60 mg/kg/d in four divided doses) should be added if S. pneumoniae resistance is suspected (2).
CRITICAL INTERVENTIONS
• The diagnosis of sinusitis in children can be made based on clinical criteria: persistent upper respiratory symptoms without improvement (>10 days), severe upper respiratory symptoms (high fever AND purulent nasal discharge for 3 to 4 days), or worsening symptoms (new onset of fever, headache, or increased nasal discharge following URI that lasted 5 to 6 days and was initially improving).
• Careful examination to rule out potential orbital and central nervous system complications.
• Imaging should be reserved for toxic-appearing patients, those suspected of having complications, or those who have failed treatment.
• Antibiotic therapy should be initiated with amoxicillin–clavulanate (standard-dose or high-dose depending on risk factors) for 10 to 14 days. Options for penicillin-allergic children include levofloxacin for type I hypersensitivity reactions, and clindamycin PLUS cefixime or cefpodoxime for non-type I hypersensitivity reactions.
• Patients suspected of having orbital or central nervous system complications need aggressive treatment, including IV antibiotics, imaging, emergent consultation with the appropriate subspecialist, and hospital admission.
DISPOSITION
Uncomplicated ABS:
• Discharge from ED with appropriate antimicrobial treatment
• Follow-up with primary care physician if worsening, or if no improvement after 3 to 5 days
• Follow-up immediately if any signs or symptoms of a complication develop
Toxic-appearing, immunocompromised, or suspected orbital or intracranial complications:
• Admit
• Appropriate antimicrobials (typically parenteral)
• Appropriate imaging (typically CT)
• Subspecialty consultation (consider ENT, Ophthalmology, Neurosurgery)
Common Pitfalls
• Not performing a thorough neurologic examination and missing signs of an associated intracranial or suppurative complication of sinusitis.
• Relying on laboratories and/or imaging to make the diagnosis of sinusitis in children.
• Prescribing inappropriate antibiotics.
REFERENCES
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3. Celedon JC, Litonjua AA, Weiss ST, et al. Day care attendance in the first year of life and illnesses of the upper and lower respiratory tract in children with a familial history of atopy. Pediatrics.1999;104:495–500.
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