1. Chronic Rhinosinusitis in Children
Clinical Presentation
Hector Stone-Aguilar, M.D.
Pediatric Allergy & Immunology
Hospital San Jose de Hermosillo
Universidad del Valle de Mexico

2. Clinical presentation of CRS in Children
The problem:
To fully define chronic sinusitis has been difficult
There is a wide variation in clinical expression of the disease
Discordance between patient symptoms and objective findings
No one set of diagnostic criteria has been agreed on by all specialty groups

3. Clinical presentation of CRS in Children
The problem:
Clinical criteria to diagnose CRS, as well as the predictive value of these criteria, are not well defined, specially in children
Historically, the diagnosis of CRS was based on several clinical symptoms, similar to acute RS, but usually less severe
However, none of these symptoms are specific to sinusitis

4. Definition of Sinusitis
Inflammation of 1 or more of the paranasal sinuses
Acute Sinusitis: less than 4 weeks/duration
Subacute Sinusitis: 4 to 12 weeks/duration
Chronic Sinusitis: longer than 12 weeks Some guidelines also requiring :
Failure to respond to treatment
One positive imaging study
Dykewicz M, JACI Feb 03

5. Definition of Rhinosinusitis
Inflammation of the nose and paranasal sinuses characterized by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip)
± facial pain/pressure
± reduction or lost of smell
EPOS Guidelines, Rhinology 2007

6. Rhinosinusitis
OHNS , 1997

7. Definition of Chronic Rhinosinusitis
More than 12 weeks of symptoms without complete resolution
Can be subdivided in:
Chronic Rhinosinusitis with Nasal Polyps
Chronic Rhinosinusitis without Nasal Polyps
CRS also may be susceptible to exacerbations
EPOS Guidelines, Rhinology 2007

8. CRS: Symptom-based Diagnosis
73.15% of the nonallergic patients with symptom based diagnosed CRS
65.34% of the allergic patients with symptom-based diagnosed CRS
Had No CT and endoscopic pathology (Endoscopic score 0 + CT score 0)
Tahamiler R, Allergy 2007

9. Chronic Rhinosinusitis in Children
In general : The main symptoms associated with rhinosinusitis in children are rhinorrhea, nasal obstruction, mouth breathing, hyponasal speech, and snoring but…

10. Diagnosing CRS in Children: Special issues
Infants and Pre-school children
Signs/symptoms difficult to evaluate:
Congestion (very subjective/indirect/parent’s biass)
Only anterior rhinorrhea is reported
Symptoms impossible to evaluate:
Posterior discharge
Sense of smell
Headache / toothache / facial pain
Symptoms very unspecific :
Cough, irritability, fever, fatigue/decreased activity, etc.

11. Diagnosing CRS in Children: Special issues
Infants and Pre-school children
Anterior Rhinoscopy : Limited data
Anterior third of nasal cavity
Osteomeatal zone difficult to reach, even w/use of topical decongestant
Nasal Endoscopy: Ideal but impossible to perform without sedation or anesthesia
CT scan: Also requieres sedation or anesthesia
Sedation/anesthesia: increases costs and risks
Increased value of plain X-Rays at this age ??

12. Severity of Sinusitis Disease severity can be divided into:
Mild (0-3 points)
Moderate (4-7 points)
Severe (8-10 points)
Using a 10-point scoring system or
Visual Analogue Scale (VAS)
EPOS Guidelines, Rhinology 2007

13. Clinical presentation of CRS in Children
Diagnosis must be based in a combination of:
Clinical symptoms and evolution
Age-group related
Previous treatments (type and duration)
Likelihood of allergy involvement: Family history, allergy stigmata, personal history of other allergic diseases (AD or Asthma)
Clinical Signs
Anterior rhinoscopy and/or Nasal endoscopy
Imaging support
Plain X-Rays
CT scans
MRI

14. Chronic Rhinosinusitis in Children
By definition, needs to be at least 12 weeks old (3 m.o.)
Ethmoid and maxillary sinuses present at birth
Clinical presentation strongly related to the specific pediatric age group:
Infants: Persistent or recurrent rhinorrhea after an acute febrile URIs ( ± AOM, Rhinopharyngitis, Bronchitis)
Pre-schoolars: Persistent rhinorrhea and nasal congestion w/adenoid and tonsil hypertrophy, serous OM, allergies and asthma.
Scholars and adolescents : Nasal obstruction, headaches, sore throath, hyposmia, irritability, sleep disturbances, etc. (PAR or PNAR)

15. Clinical presentation of CRS in Children
In infants and preschool childrens, most cases of CRS are a chronologic extension of acute infectious sinusitis (viral bacterial)
In contrast, in older children or adolescents most CRS cases are not an infectious disease but an inflammatory disease, much akin to asthma.
Jones NS, Curr Opinion Pulm Med, 2000

16. Clinical evolution of Viral URI’s

17. When to suspect CRS in INFANTS
Continuous or intermittent RHINORRHEA
Anterior, posterior or both
Usually clear initially (days or weeks)
Colored (greenish or yellowish) more dense secretions
It can alternate clear and colored secretions
Nasal CONGESTION
Mild at the beginning
Worsening in an intermittent pattern in absence of appropriate treatment
Not as bad as other age groups
Objective findings: mouth breathing, snoring

18. When to suspect CRS in INFANTS
COUGH :
A prominent feature of sinusitis at this age
Starts as “Dry” cough usually for several days
Can continue with “wet” cough all the way
Intermittent along the day, not very intense
Can start or worse at night or bedtime
Usually associated with posterior rhinorrhea
Also associated with coarse and audible ronchi
Maybe a better predictor than rhinorrhea about the outcome

19. When to suspect CRS in INFANTS
FEVER:
Usually present at the beginning of the clinical picture
Low or mid grade
Fades away after few days (with or without treatment)
Can not be present at all
Can relapse in the course of the disease (worsening)
Its absence doesn’t rule out the possibility of chronic infection

20. When to suspect CRS in INFANTS
Other possible symptoms:
Irritability
Bad appetite
Sleep disturbances:
Trouble to got sleep
Restless sleeping
Nocturnal awakenings
Halitosis
Reduced general activity

21. When to suspect CRS in INFANTS
Physical signs, NASAL :
Rhinorrhea (anterior)
Pale and enlarged turbinates
Mucosal edema
Hyperemic mucosa
Middle meatus colored discharge

22. Rhinoscopy

23. Muco-purulent discharge in the Sinus Ostium zone
Middle turbinate
Lateral nasal wall
Purulent mucus
Septum

24. When to suspect CRS in INFANTS
Physical signs, GENERAL :
Posterior rhinorrhea
Mouth breathing
Pallor
Dark infra-orbital shiners
Halitosis
Tympanic opacity, retraction or hyperemia
Enlarged tonsils
Granular (cobblestone) adenoid tissue in the pharynx
“rude” breathing
Coarse rhonchi on chest examination

25. Serous Otitis Media

26. Enlarged Adenoids: Cause or consequence ?

27. Chronic Rhinosinusitis in PRE-SCHOLARS
Not necessarily associated to respiratory infection
Mostly related to allergies and asthma
Difficult to distinguish from PAR. Same sort of signs and symptoms
Usually considered a “complication” of allergic rhinitis
Nasal or sinusal polyps not frequent at this age

28. Chronic Rhinosinusitis in PRE-SCHOLARS
Differences with CRS in Infants
Congestion more prominent than rhinorrhea
Cough frequently related to asthma or BHR
Headaches, frequently mild or intermittent
Hyposmia rarely reported
Halitosis
Clear or thick mucoid rhinorrhea
Paler and more enlarged turbinates
Intense edema of nasal mucosa

29. Chronic Rhinosinusitis in School children and adolescents
Moderate to severe nasal congestion/obstruction:
Snoring
Sleeping problems
Dry mouth and sore throat at mornings
Headaches:
Mild to severe
Frequent or intermittent
Frontal, maxillary or occipital
Rhinorrhea:
Posterior > anterior
Halitosis

30. Chronic Rhinosinusitis in School children and adolescents
Daytime somnolence
Tiredness
Poor concentration: altered school performance
Hyposmia
Dysgeusia
Middle ear:
Hypoacusia, Popping, Buzzing
Polyps: More frequent than the other pediatric groups

31. Consequences of chronic nasal congestion
Snoring
Oral breathing
Hyponasal speech
Sleep disturbances
Obstructive Sleep Apneas (OSA)
Dry mouth
Sore throath
Headaches
Daytime somnolence
Poor concentration
Tiredness
Facial and dental changes

32. CRS Diagnosis: Plain X Rays: Useful?

33. Plain X-rays vs. CT scan in Sinusitis
 The sensitivity of Plain X-Ray compared to CT was:
77% (30/39)
The specificity of the radiograph to CT was 81% (25/31). 
The positive likelihood ratio is 4.05 and
The negative likelihood ratio is 0.28.
Conclusions - The difference between radiographs and CT for diagnosing sinus disease in this population is relatively small but favors CT exam.
Garcia, DP Radiographic imaging studies in pediatric chronic sinusitis
 J Allergy Clin Immunol, 94: , 1994.

34. CRS Diagnosis: CT scan: Gold standard ?

35. ‘Limited’ CT Scan
Garcia D, JACI sept 1994

36. Sinusitis severity Index (grading): (Glicklich)
Grade 0: mucosal thickening of ≤ 2 mm in any sinusal wall
Grade 1: Any unilateral disease or abnormality
Grade 2: Bilateral disease limited to ethmoid or maxillary sinuses
Grade 3: Bilateral disease with frontal or sphenoidal involvement (any)
Grade 4: Pansinusitis.
Emmanuel IA, Otolaryngology Head Neck Surg 2000

38. CRS Diagnosis: CT scan: Gold standard ?
HWANG et al, OHNS april, 2003

39. CRS Diagnosis: CT scan: Gold standard ?
Unilateral involvement of the right maxillary sinus and structural abnormalities:
MT concha bullosa and paradoxical curvature of middle turbinate, stretching the OMC

40. Nasal Endoscopy

41. Clasification of the severity of polyposis by endoscopy
0 - No visible polyps
1 - Polyps confined to the middle meatus
2 - Polyps beyond middle meatus but did
not occlude the nasal cavity
3 - Polyps obstructing completely the nasal
cavity
Mackay IS y Lund VJ, 1997

42. Nasal / Sinusal Polyposis in Children
If nasal polyps are present in young children, MUST rule out:
Aspirin Exacerbated Respiratory Disease (AERD)
Cystic Fibrosis (CF)
Genetic involvement
But still most probably related to Perennial or Persistent Allergic Rhinitis
Polyps related to Perennial Non-Allergic Rhinitis are rare at this age

43. Etiology of CRS in Children
Infection:
Viral/Bacterial
Biofilms
Fungal?
Allergy
Allergic Rhinitis: Persistent > Intermittent
Gastroesophageal Reflux
Obstruction /Structural
Adenoid > Tonsils Hypertrophy
Septal deviation
Other: concha bullosa, Haller cells, agger nasi cells

44. Etiology of CRS in Children
Immunodeficiency
IgA deficiency
Transient Hipogammaglobulinemia
IgG sub-class deficiency ( IgG2 + IgG4)
Selective (polysaccaride) IgG deficiencies
CVI
Cystic Fibrosis
Ciliary Dyskinesia
Aspirin Exacerbated Respiratory Disease
Other: very uncommon

45. Hamilos D, JACI oct 2011

46. Conclusions: CRS is frequent in children
No one set of diagnostic criteria has been agreed on by all specialty groups
CRS in children have special features that are different of CRS in adult population
There are differences also in the clinical presentation of the different pediatric age groups
The diagnosis of CRS in children is based almost exclusively in clinical data. Use CT or endoscopy in selected cases.
There are very few controlled clinical studies of CRS in children. All Guidelines based in adult studies and transpolated to children.
The most common causes are bacterial infections and/or allergies. Other causes are really not frecuent or rare, but still have to rule out them if not responsive