Presentation on theme: "Chronic Rhinosinusitis in Children Clinical Presentation Hector Stone-Aguilar, M.D. Pediatric Allergy & Immunology Hospital San Jose de Hermosillo Universidad."— Presentation transcript:
Chronic Rhinosinusitis in Children Clinical Presentation Hector Stone-Aguilar, M.D. Pediatric Allergy & Immunology Hospital San Jose de Hermosillo Universidad del Valle de Mexico
Clinical presentation of CRS in Children 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 The problem:
Clinical presentation of CRS in Children 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 The problem:
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
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
Rhinosinusitis OHNS, 1997
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
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
In general : The main symptoms associated with rhinosinusitis in children are rhinorrhea, nasal obstruction, mouth breathing, hyponasal speech, and snoring but… Chronic Rhinosinusitis in Children
Diagnosing CRS in Children: Special issues Infants and Pre-school children Signs/symptoms difficult to evaluate: Congestion (very subjective/indirect/parents 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.
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 ??
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
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 Clinical presentation of CRS in Children
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)
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
Clinical evolution of Viral URIs
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
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 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 doesnt rule out the possibility of chronic infection 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 When to suspect CRS in INFANTS
Physical signs, NASAL : – Rhinorrhea (anterior) – Pale and enlarged turbinates – Mucosal edema – Hyperemic mucosa – Middle meatus colored discharge When to suspect CRS in INFANTS
Muco-purulent discharge in the Sinus Ostium zone Lateral nasal wall Middle turbinate Purulent mucus Septum
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 When to suspect CRS in INFANTS
Serous Otitis Media
Enlarged Adenoids: Cause or consequence ?
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 Chronic Rhinosinusitis in PRE-SCHOLARS
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 Chronic Rhinosinusitis in PRE-SCHOLARS Differences with CRS in Infants
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 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 Chronic Rhinosinusitis in School children and adolescents
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 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.
CRS Diagnosis: CT scan: Gold standard ?
Limited CT Scan Garcia D, JACI sept 1994
Emmanuel IA, Otolaryngology Head Neck Surg 2000 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.
CRS Diagnosis: CT scan: Gold standard ? HWANG et al, OHNS april, 2003
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
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
Nasal / Sinusal Polyposis in Children If nasal polyps are present in young children, MUST rule out: 1.Aspirin Exacerbated Respiratory Disease (AERD) 2.Cystic Fibrosis (CF) 3.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
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
Hamilos D, JACI oct 2011
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