Pediatric Rhinosinusitis

Anatomy
 Maxillary Sinus
 first to develop at day 65 of gestation
 seen on plain films at 4-5 months
 slow expansion until 18 years
 Ethmoid Sinus
 develop in third month of gestation
 ethmoids seen on radiographs at one year
 enlarges to reach adult size at age 12
 Sphenoid Sinus
 originates in fourth gestational month from posterior part of nasal cavity
 pneumatization begins at age 3
 rapid growth to reach sella by age 7 and adult size at age 18
 Frontal Sinus
 begins in fourth month of gestation from superior ethmoid cells
 seen on radiographs at age 5-6
 grows slowly to adult size by adolescence
 Definitions
 Acute: symptoms often inseparable from URI and include
rhinorrhea, daytime cough, nasal congestion, infrequent low-grade
fever, otitis media, irritability and headache. Key in diagnosis of
sinusitis is persistence beyond 7-10 days or worsening of symptoms
at around 7 days
 Severe Acute Sinusitis: purulent rhinorrhea, high fever, periorbital
edema

 Recurrent: complete resolution between episodes and 3 or more

episodes in six months or more than 4 episodes in one year

 Subacute: signs and symptoms lasting three weeks to three months

 Chronic: signs and symptoms lasting longer than three months

 Pathogenesis
 Ostia obstruction creates
increasingly hypoxic
environment within sinus
 Retention of secretion
results in inflammation
and bacterial infection
 Secretion stagnate,
obstruction increases,
cilia and epithelial
damage become more
pronounced
 Most common inciting
event is viral URI
 Diagnosis
 Physical Examination
 Anterior rhinoscopy with otoscope in younger
children
 Tenderness over sinuses
 Periorbital edema and discoloration
 Flexible and rigid endoscopy in older child
 Most specific-- mucopurulence, periorbital
swelling, facial tenderness
 Adjunctive Tests
 Imaging usually not indicated for uncomplicated patients. CT scan may
be indicated if suppurative complications suspected, patient fails to
improve after treatment or as pre-operative study
 Ideally should be obtained after several weeks of medical therapy
 Major bony anatomic abnormalities unusual in children
 Mucosal inflammation common incidental finding in children and strongly
related to viral URI
 Incidence of sinus mucosal inflammation drops off after age 7 to 8
 Sinus aspirate is indicated in severe toxic illness, acute illness not
responsive to antibiotics within 72 hours, immunocompromised patients,
suppurative complications and workup for fever of unknown origin
 Oropharyngeal/Nasopharyngeal swabs do not correlate with sinus aspirate
 Endoscopically guided middle meatus swab correlates fairly well with sinus
aspirate
 Microbiology
 Similar to adults: Streptococcus pneumoniae, Moraxella catarralis,
nontypeable Hemophilus influenzae

 ICU patients/cystic fibrosis: Pseudomonas aeruginosa, Staphyloccus aureus

 Resistant organisms more common in patients already treated with multiple

rounds of antibiotics, children in day care, children who have received
antibiotic therapy in the last 30 days

 Chronic pathogens may include

 Alpha-hemolytic streptococci
 S. aureus
 Nontypeable H. inflluenzae
 M. catarrhalis
 Anaerobic bacteria
 Pseudomonads
 Medical Treatment
 Acute Sinusitis:
 Young children with mild to moderate ARS, amoxicillin
at normal or high dose
 Amoxil-allergic patients, treat with a cephalosporin—
severe allergy, treat with macrolide
 Nonresponders, more severe initial disease, those at
high-risk for resistant strep, treat with high dose
amoxil/clavulanate
 Parenteral ceftriaxone for children not tolerating oral
meds
 Duration of therapy is usually 10-21 days or until
symptoms resolve plus 10 days
 Medical Treatment
 Chronic Rhinosinusitis
 4 to 6 week course of beta lactam stable
antibiotic
 Adjuvant therapy with nasal steroids
commonly employed
 Antihistamines especially if underlying allergic
condition suspected
 Mucolytics may thin secretions
 Refractory Rhinosinusitis
 Consider associated conditions
 Allergy
 Immune deficiency
 Asthma
 Gastroesophageal reflux disease
 Cystic Fibrosis
 Primary Ciliary Dyskinesia (Immotile Cilia Syndrome)
 Allergic Fungal Sinusitis
 Allergy

 Major contributing factor in rhinosinusitis

 Similar pathogenesis as viral etiology with obstruction -- mucostasis
--hypoxia – colonization
 Itching mucous membranes, clear rhinorrhea, eczema, food
intolerance, nasal congestion, stuffiness, fluctuating rhinorrhea,
sneezing, cough, behavioral changes, headaches, facial pressure
 Avoidance
 clean, allergy proof house, filter, no pets, air conditioning
 Pharmacotherapy
 antihistamines, nasal steroids, mast cell stabilizers
 Immunotherapy
 Immune Deficiency
 History of frequent otitis media, pneumonia and sinusitis may
suggest a primary or secondary immunodeficiency state
 Serum immunoglobulins and IgG subclasses should be checked as
well as ability to respond to capsular antigens of S. pneumoniae and
H. influenzae
 Must have laboratory with age-appropriate norms

 Chronic pediatric sinusitis associated with IgG2 deficiency

 Consistent low total immunoglobulin defines common variable

hypoglobulinemia
 Treatment in primarily medical
 Patients may benefit from IVIG therapy
 Genetic counseling for patient and family may be appropriate
 Asthma
 Sinusitis and asthma frequently
associated: same underlying disease
process or causal relationship?
 Sinonasal/bronchial reflex
 Aspiration
 Treatment of sinusitis whether medical or
surgical reduces use of bronchodilators,
improves pulmonary symptoms
 Gastroesophageal Reflux Disease
 Many pediatric patients experience improvement in their
chronic sinonasal symptoms after a trial of antireflux
medicine
 GERD theorized to have direct effect on nasal mucosa,
initiating inflammatory response with edema and
impaired mucociliary clearance
 Phipps in 2000 reported a prospective trial in which 63%
CRS patients were found to have esophageal reflux by
pH probe; 32% demonstrated nasopharyngeal reflux
 Bothwell in 1999 reported 89% of pediatric candidates
for FESS avoided surgery with treatment for GERD
 Cystic Fibrosis
 Autosomal recessive disease
 Mutation of CFTR protein
 Patients develop chronic pulmonary disease in
childhood; also affected with sinusitis and nasal
polyposis, pancreatic insufficiency and biliary cirrhosis
 If surgery contemplated, check coags
 Recent studies suggest heterozygous mutations in the
CFTR gene are associated with chronic rhinosinusitis
 Raman found that 12.1% of CRS patients harbored CFTR
mutations compared with the expected rate of 3-4%
 Wang found a 7% incidence of CFTR mutation in 123 CRS
patients compared to 2% in a control group
 Primary Ciliary Dyskinesia
 History of chronic otitis media, chronic
sinusitis and chronic bronchitis or
bronchiectasis
 Kartagener’s syndrome: sinusitis, situs
inversus, bronchiectasis and male
infertility)
 Diagnosis established with inferior or
middle turbinate or tracheal biopsy
 Allergic Fungal Sinusitis
 Allergic reaction to aerosolized
fungi, usually of the
dematiceous species
 Treatment is surgical with
perioperative oral steroid and
post-operative topical steroids
 High recurrence rate, requires
close follow up
 Findings in children different
than adult findings
 Children more frequently have
abnormalities of their facial
skeleton
 More likely to have unilateral
disease
 Complications
 Orbital:
 Orbital complications more common in
children than adults
 Most common is medial subperiosteal abscess
 Intracranial:
 More common in adolescents/adults
 Include meningitis (most common), epidural
abscess, subdural abscess, intracerebral
abscess, cavernous sinus thrombosis
 Orbital Complications
 Classified by Chandler:
 I. Preseptal cellulitis

 II. Orbital cellulitis

 III. Periorbital abscess

 IV. Orbital abscess

 V. Cavernous sinus thrombosis

 Spread by direct extension via osseous structures or

indirectly via valveless venous plexuses
 Obtain CT scan with contrast if orbital involvement
suspected
 Stage I—Preseptal Cellulitis
 Eyelid edema,
erythema and normal
globe movement
 Stage I in children
more likely due to
cutaneous lesions or
hematogenous
seeding rather than
sinusitis
 Stage II—Orbital Cellulitis
 Proptosis, Chemosis,
Edema, Pain
 Dilated pupil
 Visual loss
 Ophthalmoplegia
 Afferent pupillary
defect
 Stage III—Periorbital Abscess
 Proptosis with globe
displacement
inferolaterally,
decreased EOM,
vision decreased
 IVAbx with external or
endoscopic drainage
of abscess and
involved sinus
 Stage IV—Orbital Abscess
 orbital abscess
 severe proptosis and
chemosis
 usually no globe
displacement
 opthalmoplegia
present
 Impaired visual acuity
 Stage V—Cavernous Sinus
Thrombosis
 Progressive symptoms
 Proptosis and fixation
 CN II, IV, VI
 Meningitis
 High mortality
 High fever, bilateral
symptoms
Intracranial Complications
 Meningitis, Epidural Abscess, Intracerebral
Abscess, Pott’s Puffy Tumor
 Neurosurgical Consultation, high-dose
antimicrobial therapy, drainage of
intracranial abscess planned in concert
with drainage of affected sinus
 Frontal sinus is most implicated sinus:
venous drainage of the frontal sinus via
small diploic veins extending through
sinus wall; these communicate with
venous plexi of dura, periorbita and
cranial periostuem
 Surgical Management
 Adenoidectomy
 FESS
 Only after maximal medical therapy has failed and patient has
been screened and treated for any underlying conditions
 Concern for developing nasal and sinus anatomy in children and
possibility of altering facial growth