Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

Chronic sinusitis is often difficult to diagnose in the pediatric age group since children rarely present with the same signs and symptoms as adults. In addition, children have frequent upper respiratory tract infections (URI), on the average suffering between 6 and 8 URIs per year. It may therefore be difficult to distinguish recurrent URIs from chronic sinus disease. In this age group, the duration and severity of upper respiratory tract symptoms can be important for diagnosing sinus disease. In general, most uncomplicated viral URIs in children last 5 to 7 days and produce mild to moderate symptoms. Even when the symptoms persist for 10 days, they are usually improved. Wald has defined acute sinusitis as the persistence of upper respiratory tract symptoms for more than 10, but less than 30 days, or when high fevers and purulent nasal discharge are present. When symptoms persist beyond 30 days, that is defined as subacute or chronic sinusitis.

The signs and symptoms of chronic sinusitis in children are not pathognomonic. Purulent rhinorrhea is by far the most prevalent symptom, but the discharge can also be clear or mucoid. Chronic cough is also common. Nasal obstruction, headache, low grade fever, irritability, fatigue, and foul breath may also be present in varying degrees. Since these symptoms are relatively nonspecific, the nature of these symptoms can be clues to the diagnosis of chronic sinus disease.

Chronic cough is an important finding. In Hollinger's study (1991) of 72 infants and children with chronic cough, sinusitis was the causative factor in 50% between the ages of 1 and 6, years and in 24% between the ages of 6 and 16. The cough must be present during the daytime. Simply having a nocturnal cough could be indicative of gastroesophageal reflux or of asthma.

Symptoms also vary with age. Purulent rhinorrhea and chronic cough are more commonly seen in younger children, whereas an older child may have post nasal drip and a chronic sore throat. Older children also tend to complain of headaches, whereas the young child will often manifest pain as irritability, mood swings, and even resting the face on a cold surface to alleviate facial pain.

The physical findings tend to be limited to rhinorrhea and mucosal congestion. Fever, sinus tenderness, and periorbital swelling are uncommon in cases of chronic disease. Adenoid hypertrophy may be present, and otitis media is seen more frequently in children with chronic sinusitis.

Despite the often nonspecific signs and symptoms of chronic sinusitis in the pediatric population, the diagnosis still rests largely on the history and physical examination. Imaging studies such as transillumination and ultrasound are of little value in this age group, and plain radiographs both over and underdiagnose sinus pathology in children.The sinuses are frequently opacified even in the absence of significant sinonasal symptoms, and 45% of children with chronic sinusitis will have normal plain films despite the presence of significant disease on CT scan.

Although sedation is usually necessary, coronal CT scanning is the imaging technique of choice for diagnosing mucosal disease and delineating the anatomy of the osteomeatal complex. In the absence of complications of sinusitis, a CT should be obtained only after maximal medical therapy has failed and when surgery is being contemplated. Medical management is generally considered to have failed when the symptoms do not improve with therapy, when they recur immediately after therapy is stopped, or when recurrent infections occur despite adequate courses of antibiotics.

The mainstay of treatment is with antibiotics. Therapy should be maintained continuously for at least 3 to 4 weeks, and even as long as 6 weeks. Antibiotic selection is usually empiric, since it is difficult to obtain sinus aspirates in children without general anesthesia. Studies of the microbiology of chronic sinusitis in children have shown that alphahemolytic streptococci, S. aureus, S. pneumoniae, H. influenzae, and Moraxella catarrhalis are the predominant organisms; S. aureus and anaerobic bacteria are more frequently encountered when symptoms have been present for more than one year. The majority of H. influenzae and M. catarrhalis organisms are betalactamase producing, so betalactamase resistant antibiotics such as Augmentin, Ceftin, Suprax, and Pediazole should be used. Topical steroids can be employed in resistant cases, since they may be of value in reducing mucosal edema and reestablishing ostial patency. The role of decongestants is unclear, although they have been shown to improve ostial and nasal patency in adults with chronic maxillary sinusitis.

When prolonged trials of medical management fail or when disease recurs promptly after cessation of therapy, an allergy and immunology evaluation should be obtained. A sweat test to rule out cystic fibrosis should also be considered. Muntz and Lusk found that 23% of their patients with refractory chronic sinusitis had significant allergies, another 23% had some form of immunodeficiency, and 26% had asthma. Evaluation includes skin testing, total serum IgE levels, quantitative immunoglobulin levels, IgG subclass levels, and responsiveness to pneumococcal and H. influenzae vaccines. The most common immunologic defects seen in these children are the IgG subclass deficiencies and vaccine hyporesponsiveness. Children with HIV infection do not commonly present with sinonasal complaints.

The allergic component of this disease can be treated with allergen avoidance and environmental control, topical steroids and saline irrigations, and antihistamines; immunotherapy should be reserved for children who cannot avoid the allergen or who cannot tolerate pharmacotherapy. The management of patients with immunodeficiencies includes antibiotics for acute exacerbations, possibly prophylactic antibiotics, and immunoglobulin replacement therapy for those with immunoglobulin deficiencies. Immunoglobulin replacement is not helpful in children with selective IgA deficiency.

When maximal medical therapy fails, surgical intervention should be considered. Adenoidectomy may be of value in certain children with very large adenoids, but the relationship between adenoid hypertrophy and sinusitis is unclear. Both nasal antral windows and antral lavage are of little benefit, and CaldwellLuc procedures in general should be avoided because of the risk to the developing tooth buds.

With the advent of endoscopic sinus surgery (ESS) in adults, studies were initiated to evaluate its safety and efficacy in children. Lusk and Muntz reported a 71% success rate in 168 patients with medically refractory disease. Success was defined as complete or near complete resolution of symptoms. This study did include children with immunodeficiencies and cystic fibrosis, although these patients were likely to require multiple procedures. Their only complications were mild middle meatal scarring in 2 patients. The longterm effects of ESS on facial skeletal development in children has yet to be determined.

Unlike in adults, it is important to emphasize that pediatric endoscopic sinus surgery is a twostage procedure requiring two general anesthetics. A second look operation is necessary 2 to 3 weeks later for removing adhesions and granulation tissue. A Gelfilm splint is placed into the middle meatus to prevent scarring at the time of the initial procedure, and one may be replaced during the second look operation. A full course of antibiotics is given for 4 weeks postoperatively or until the Gelfilm is extruded. Prophylactic antibiotics are used until the nasal cavity is free of crusting.

Antrochoanal polyps, which are an important cause of chronic sinus disease in children, can also be treated endoscopically. Currently, therapy consists of simple avulsion of the nasal portion of the polyp with or without removal of the antral portion. However, because of the relatively high risk of recurrence after simple avulsion, an attempt should be made to deal with the antral component of the disease. Kamel in 1990 reported on 22 patients who underwent endoscopic removal of these polyps through a middle meatal antrostomy. In order to completely remove the disease and leave the healthy mucosa behind to reepithelialize the sinus, complete endoscopic removal of the mucosa at the origin of the polyp within the maxillary antrum was emphasized. No recurrences were found after two years of followup.

Cystic fibrosis (CF) is also a major cause of chronic sinus disease in children. The major head and neck manifestations are nasal polyposis and chronic sinusitis, and a sweat chloride test should be considered in children with refractory sinus disease or polyps. The incidence of nasal polyps has been reported to be anywhere between 6.7% and 28%. The pathogenesis of the polyps is unknown, but it has been hypothesized that the highly viscous mucous associated with CF results in dilatation of the nasal mucous glands, thereby causing compression of the terminal capillaries and leading to mucosal edema and prolapse.

Clinical signs and symptoms of chronic sinusitis develop in approximately 11% of CF patients. The most common organisms involved in the infection are Pseudomonas aeruginosa, alphahemolytic streptococci, and nontypable H. influenzae. It is important to emphasize that the diagnosis of chronic sinusitis in these patients is purely a clinical one, based upon physical signs and symptoms, since 92% to 100% of CF patients after the age of 8 months will have opacified sinuses regardless of the presence or absence of sinonasal symptoms. Because of this, CT scanning is best reserved for patients in whom operative intervention is being considered.

Treatment classically consists of oral antibiotics. They should be given for a minimum of 3 weeks and are often necessary for 4 to 6 weeks. Intranasal steroids are also used, although their efficacy has not been documented in any controlled studies in this population.

When chronic nasal obstruction or chronic purulent discharge is clinically significant and refractory to medical management, surgical intervention should be considered. It is important to bear in mind that regardless of the surgical technique used, recurrence is the rule rather than the exception in CF patients because of the underlying mucosal defect. Early surgical intervention should be avoided if possible and surgery only undertaken when clinically necessary. The majority of procedures can be performed on an outpatient basis, but the pulmonary status should be optimized prior to surgery, including home IV antibiotics if necessary. It is also prudent to obtain clotting studies preoperatively because of the possibility of malabsorption of fatsoluble vitamins such as vitamin K.

Surgical treatment includes simple nasal polypectomy, polypectomy combined with a classic sinus procedure, or endoscopic sinus surgery. Clinically significant recurrences have been reported to occur in 54% to 89% of patients after nasal polypectomy alone. On the other hand, fewer recurrences and longer symptomfree intervals are obtained when polypectomy is combined with intranasal ethmoidectomy and CaldwellLuc procedures. In fact, the recurrence rate appears to be inversely related to the extent of intranasal surgery. However, morbidity also increases with the more extensive operation.

Endoscopic sinus surgery has been shown to improve symptoms and to have significantly less morbidity than traditional sinus surgery in CF patients. It has yet to be determined whether ESS has comparable recurrence rates as conventional procedures in these patients.

Case Presentation

A 9-year-old male presented with a one year history of progressive nasal obstruction and snoring. He had experienced no sinonasal symptoms prior to that time. His nasal obstruction was initially confined to the left side but gradually became bilateral. He developed mucoid rhinorrhea, was unable to blow his nose, and he developed severely hyponasal speech. He denied epistaxis. He was treated by his pediatrician with antihistamines and decongestants for presumed allergic rhinitis, without effect, and was subsequently referred to an allergist. However, skin testing was negative, and "adenoid hypertrophy" was noted on examination. He was then referred to the BTGH Otolaryngology Clinic for further evaluation.

Physical examination showed that the right nasal cavity was clear. A mucoid discharge was present on the left, and a fleshy, polypoid mass could be visualized originating from the middle meatus and extending posteriorly, filling the nasopharynx. The inferior portion of the mass could be seen within the oropharynx. A CT scan was performed, which revealed a low density, nonenhancing mass involving the left maxillary sinus and extending into the nasal cavity and nasopharynx, consistent with an antrochoanal polyp. He underwent left endoscopic sinus surgery, and the polyp was amputated at the maxillary sinus ostium and removed transorally. Some additional thickened mucosa within the ostium was removed, and a middle meatal antrostomy was performed. A Gelfilm stent was placed within the middle meatus to prevent synechia formation. Postoperatively, he was started on antibiotics and intranasal steroids, and he underwent endoscopic examination under anesthesia with removal of granulation tissue and crusts two weeks later.

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