1. SINUSITIS In Pediatric Age Group

5. Anatomy MAXILLARY ANT ETHMOID FRONTAL POST ETHMOID SPHENOID
LACRIMAL DUCTS
MIDDLE MEATUS
SUPERIOR MEATUS
INFERIOR MEATUS

6. Sinusitis
Development
MAXILLARY AND ETHMOID SINUSES DEVELOPS DURING 3RD & 4TH GESTATIONAL MONTH AND GROW IN SIZE UNTIL LATE ADOLESCENCE
SPHENOID SINUS PRESENTS BY 2 YEARS OF AGE
FRONTAL SINUS DEVELOPS DURING 5 AND 6 YRS.
Tabassum Z Imam, MD

7. Physiology THREE KEY ELEMENTS PATENCY OF THE OSTIA
FUNCTION OF THE CILIARY APPARATUS
QUALITY OF SECRETIONS

8. Factors Predisposing To Obstruction Of Sinus Drainage.
A. MUCOSAL SWELLING
Systemic disorder
Viral URI
Allergic inflammation
Cystic fibrosis
Immune disorder
Immotile cilia
Local insult
Facial trauma
Swimming, diving
Rhinitis medicamentosa
B. MECHANICALOBSTRUCTION
Choanal atresia
Deviated septum
Nasal polyp
Foreign body
Tumor
Ethmoid bullae
C. MUCUS ABNORMALITIES
Viral URI
Allergic inflammation
Cystic fibrosis

9. Epidemiology Occurs during viral respiratory season
Attendance at Day Care Center
School-age siblings in the household

10. Symptoms And Signs PERSISTENT >10 DAYS No appreciable improvement
Nasal discharge of any quality
Cough(must be present during day)
Malodorous breath
Facial Pain and headache are rare
If fever then low grade
May not appear very ill
SEVERE
High fever > 39 C
And
Purulent nasal discharge
Present for atleast 3-4 days
Headaches may be present
Periorbital swelling occasionally

11. Subacute Sinusitis 30 days to 4 months
Mild to moderate and often intermittent symptoms
Nasal discharge of any quality
Cough often worse at night
Low-grade fever may be periodic usually not prominent

12. Chronic Sinusitis Extremely protracted nasal symptoms
Discharge or congestion
or Cough
or both
Some cases rhinorhhea minimal or absent
Nasal congestion-mouth breathing-sore throat

13. Chronic Sinusitis Chronic headache usually on awakening
Intermittent fever
Malodorous breath
Secondary affects
fatigue, impaired sleep
decreased appetite
irritability

14. Physical Findings Mucopurulent discharge in nose or posterior pharynx
Nasal mucosa- erythematous
Throat- moderate injection
Ears- acute otitis or otitis with effusion
Paranasal sinus tenderness- occasionally
Periorbital edema-occasionally
Malodorous breath

15. Differential Diagnosis-Purulent Nasal Discharge
Uncomplicated viral URI
Group A Strep infection
Adenoiditis
Nasal foreign body

16. Differential Diagnosis- Nasal Symptoms
Persistent clear nasal discharge or nasal congestion
Allergic rhinitis- nasal discharge, congestion, sneezing, itchiness of eyes, nose, other mucous membranes, pale boggy mucosa, Dennies lines, allergic shiners, transverse crease on bridge of nose, headaches

17. Differential Diagnosis-Nasal Symptoms
Sinusitis
Differential Diagnosis-Nasal Symptoms
Nonallergic rhinitis resemble allergic rhinitis children -specific allergens cannot be demonstrated, IgE levels normal, radioallergosorbent test negative
Rhinitis Medicamentosa
Vasomotor Rhinitis
Tabassum Z Imam, MD

18. Differential Diagnosis-Cough
Reactive airway disease
GER CF
pertussis
Mycoplasma bronchitis TB

19. Diagnosis- Sinus Aspiration
Indications
failure to respond to multiple antibiotics
severe facial pain
orbital or intracranial complications
evaluation of an immunoincompetent host
Material should be sent for quantitative aerobic and anaerobic cultures
Density of atleast 104 colony-forming units/ml represents true infection

20. Diagnosis-Imaging Standard views
Anterioposterior
Lateral
Occipitomental
When children older than 1 have neither respiratory signs nor symptoms, their sinus radiographs are almost normal
Findings
acute-diffuse opacification,mucosal thickening of atleast 4 mm, or an air-fluid level
Significantly abnormal in 88% of children younger than 6

21. Diagnosis- CT Scans
Frequent abnormalities are found in patients with a “fresh common cold”
Indications
complicated sinus disease(either orbital or CNS complications)
numerous recurrences
protracted or nonresponsive symptoms(surgery is being contemplated)

22. Microbiology Streptococcus pneumoniae 30-40%
Haemophilus influenzae 20%
Moraxella catarrhalis 20%
Strep pyogenes 4%
Respiratory viral isolates 10%
adenovirus
parainfluenzae
influenzae
rhinovirus
Other rarer isolates- group A strep, group C strep, viridians strep, peptostrep, Moraxella species, Eikenella corrodens

23. Complications of Acute Bacterial Sinusitis
Preseptal cellulitis
Orbital cellulitis
Osteomyelitis
Subperiosteal orbital abscess
Subdural or Epidural Empyema
Meningitis
Brain abscess
Cortical thrombophlebitis
Cavernous or sagittal sinus thrombophlebitis

24. Treatment Amoxicillin Amoxicillin-potassium clavunate
Erythromycin/sulfisoxazole
Sulfamethoxazole/ trimethorphim
Cefaclor
Cefuroxime axetil
Cefprozil
Cefixime
Cefpodoxime proxetil
Ceftibuten
Loracarbef
Clarithromycin
Erythromycin

25. Treatment-Antimicrobials
Amoxicillin preferred in most cases
Situations when broader treatment appropriate
failure to improve on amoxicillin
residence in an area with high prevalence of beta-lactamase producing H.influenzae
occurrence of frontal or sphenoidal sinusitis
occurrence of complicated ethmoidal sinusitis
presentation of very protracted symptoms >30days

26. Treatment-Most Comprehensive Coverage
Amoxicillin/potassium clavunate
Erythromycin-sulfisoxazole
Cefuroxime axetil
Cefpodoxime
Proxetil
Azithromycin

27. Treatment
In patients with acute sinusitis 40-50% have spontaneous clinical cure rate
Penicillin-resistant pneumococci serious emerging problem- most susceptible to clindamycin and rifampin
Hospitalization- systemic toxicity or unable to take oral antimicrobials
cefuroxime
ampicillin/sulbactam
cefotaxime and vanc if suspecting penicillin-resistant strep pneumoniae

28. Treatment Clinical improvement is prompt
If no reduction of nasal discharge or cough in 48 hours reevaluate
Patients with brisk response- 10 days of treatment
If respond more slowly- treat until patient is symptom free plus 7 more days

29. Surgery Rarely required
Consider if orbital or central nervous system complications or
Failure of maximal medical therapy
Functional endoscopic sinus surgery (FESS)
1st stage- removal of uncinate process, ethmoid bulla, and variable number of anterior ethmoidal cells, maxillary sinus ostium enlarged and frontal recess diseased tissue is removed if present, occasionally a stent is placed
2nd stage- several weeks later- crusting, granulation tissue, adhesions, and stents are removed
Approximately 20-30% of those with extensive mucosal disease do not benefit

30. Absolute Indications for Surgery
Causing brain abscess or meningitis, subperiosteal/orbital abscess, cavernous sinus thrombosis, another contiguous infection, or an impending complication (Pott’s tumor)
Sinus mucocele or pyocele
Fungal sinusitis
Nasal polyps (massive )
Neoplasm or suspected neoplasm

31. Other Medications
Antihistamines, decongestants, and anti-inflammatory agents have not systematically been studied in children
May try these above agents

32. Recurrent Sinusitis Most common cause is recurrent viral URIs
day care attendance
presence of other school age siblings in house
Other predisposing conditions
allergic and nonallergic rhinitis CF
immunodeficiency disorder
ciliary dyskinesia
anatomical problem