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. Pediatric Sinusitis The clinical presentation of sinusitis in the pediatric patient is quite variable. In younger patients there are no specific localizing symptoms and complaints often overlap with those heard in patients with nasal obstruction or allergies, thus obscuring the diagnosis. Our understanding of chronic sinusitis in the pediatric population is limited by the multifactorial nature of the disease. Because both the immune response and the anatomy are developing in children, there is reason to believe that the pathophysiology of pediatric sinusitis is different from sinusitis in adults. Estimates of the incidence of sinusitis are hampered by the lack of precise definitions and diagnostic criteria. Wald et al has estimated that 0.5% to 5% of all upper respiratory tract infections are complicated by acute sinusitis. The average child has between 6 and 8 URI's per year, making sinusitis a common problem in the pediatric population. Few studies have examined the microbiology of chronic sinusitis in the pediatric population, and studies that have addressed the issue have supported different conclusions. Brook, in 1981, evaluated patients who had sinus "symptoms" for 3 weeks. Culture of the maxillary antrum revealed a predominance of anaerobic organisms. More recent studies using stricter inclusion criteria have not supported this finding; Lusk and coworkers demonstrated aerobic Staphylococcus, Streptococcal species, Hemophilus and Moraxella in ethmoid bulla of patients undergoing endoscopic sinus surgery. Cultures obtained from the maxillary antrums of children with acute sinusitis reveal a predominance of Streptococcus pneumoniae followed closely by Moraxella and Hemophilus influenzae. Unfortunately no studies exist that were performed in children in which bacteriologic efficacy has been assessed by sinus culture before and after treatment. From the adult literature there are 4 separate series of patients which include 194 patients. Bacteriologic cure rates after 10 days of oral antibiotics averaged 91% (range 71% to 100%). According to Wald et al. the spontaneous cure rate of acute sinusitis is 40%. Most patients respond to an initial course of Amoxicillin. Again, there do not exist studies that examine the optimum duration of treatment for acute sinusitis. Most patients respond clinically within 48 to 72 hours of initiating antibiotic treatment. Treatment is carried out 1 week past the resolution of symptoms. For more protracted courses of sinusitis, therapy is extended to 30 days. An interesting and as yet unstudied issue is the role of prophylaxis in patients with recurrent acute sinusitis. Tonsil and adenoid hypertrophy may present with many of the same symptoms as chronic sinusitis. Investigations have shown an association with adenotonsillitis and sinusitis; however, most of these papers were retrospective and/or lacked follow-up. The role of tonsillectomy and adenoidectomy in the treatment of chronic sinusitis remains unclear. Obstructive adenoid tissue may predispose to nasal obstruction and sinusitis, but no well- designed work supports this premise in a scientific fashion. The effectiveness of antral lavage has had mixed reviews in the literature. Creation of a nasal-antral window through the inferior meatus is a technique that disregards the natural pattern of mucociliary flow. These windows almost never remain patent. Muntz and Lusk reviewed the St. Louis experience with inferior meatal antrostomies in 1990 and found that this procedure was not appropriate as a primary modality except in children with ciliary dyskinesia. A more physiologic approach to the paranasal sinuses appears to be the middle meatal antrostomy. Kennedy in 1987 studied 75 patients in whom 117 middle meatal antrostomies were performed. Of the patients who were followed for more than 4 months, 98% had patent ostea. Ninety-two of these patients were symptom free or had a marked reduction of symptoms. Endoscopic ethmoidectomy in children is a relatively new modality and the indications for surgery are still not well-defined. Most patients have undergone maximal medical therapy as well as appropriate workup for allergies, cystic fibrosis and underlying immune deficiencies. Unfortunately, "maximal medical therapy" has not been well-defined. There is emerging a group of patients in whom the efficacy of endoscopic sinus surgery is becoming clear. Lusk and Parsons have shown that up to 80% of patients with either reactive airway disease or debilitating symptoms that interfere with daily life will have reduction of their symptoms. Case Presentation A 13-year-old white male with steroid-dependent asthma presented to the Otolaryngology clinic with a 3 year history of nasal congestion, night time cough, purulent rhinorrhea and occasional headaches. In the past he had been treated with 10 to 14 day courses of oral antibiotics for presumed acute and subacute sinusitis. There was no history of recurrent pneumonia nor any laboratory evidence of underlying immunodeficiency. Allergy testing revealed multiple environmental allergies and immunotherapy was initiated. Despite a full 4 weeks of beta lactamase stable antibiotics and intranasal steroids, his symptoms persisted. CT scanning of the paranasal sinuses revealed obstruction of the osteomeatal complex bilaterally and ethmoid disease. It was decided between the Otolaryngology and Pediatrics services to perform endoscopic middle meatal antrostomies and bilateral anterior and middle ethmoidectomies. His postoperative course has been significant for a marked decrease in the number and severity of asthma exacerbations; he is currently on maintenance immunotherapy and has no significant nasal complaints. Bibliography Brook I. Bacteriologic features of chronic sinusitis in children. JAMA 1981;246:967. Diament MJ. Prevalence of incidental paranasal sinus opacification in pediatric patients: a CT study. J Comput Tomogr 1987;11:426-431. Drettner B. Pathophysiology of paranasal sinuses with clinical implications. Clin Otolaryngol 1980;5:272-284. Eichel B. Ethmoiditis: pathophysiology and medical management. Otolaryngol Clin North Am 1985;18:15-28. Freedman HM, Kern EB. Complications of intranasal ethmoidectomy: a review of 1000 consecutive operations. Laryngoscope 1979;89:421-434. Gwaltney JM, et al. Etiology and antimicrobial treatment of acute sinusitis. Ann Otol Rhinol Laryngol Suppl 1981;90:68-71. Kennedy D, Zinreich SJ, Rosenbaum A, et al. Functional endoscopic sinus surgery theory and diagnosis. Arch Otolarygol 1985;111:576-582. Kennedy DW, et al. Endoscopic middle meatal antrostomy: theory, technique and patency. Laryngoscope 1987;97:1-9. Lusk RP, Muntz HR. Endoscopic sinus surgery in children with chronic sinusitis. Laryngoscope 100;:654-658. Maniglia AJ, et al. Rare complications following ethmoidectomies: a report of 11 cases. Laryngoscope 1981;91:1234-1244. Messerklinger W. Endoscopy of the Nose. Baltimore: Urban & Schwarzenberg, 1978. Messerklinger W. On the drainage of the normal frontal sinus of man. Acta Otolaryngol 1967:63:178-181. Muntz HR, Lusk RP. Bacteriology of the ethmoid bullae in children with chronic sinusitis. Arch Otolaryngol Head Neck Surg 1991;117:179-181. Parsons DS, Phillips SE. Functional endoscopic surgery in children. A retrospective analysis of results. Laryngoscope 1993;103:899-903. Reimer A, et al. The mucociliary activity of the upper respiratory tract. III: A functional and morphological study of human and animal material with special reference to maxillary sinus disease. Acta Otolarygol Suppl 1978;355:3-20. Revonta M, Suonpaa J. Diagnosis of subacute maxillary sinusitis in children. J Laryngol Otol 1981;95:133-140. Rice DH, Schaefer SD. Endoscopic Paranasal Sinus Surgery. New York: Raven Press, 1988. Rubenstein JB, Handler S. Orbital and periorbital cellulitis in children. Head Neck Surg 1982;5:15-21. Scheffer J. The genesis development and adult anatomy of the nasofrontal region in man. Am J Anat 1916;20:125-146. Shapiro GG, et al. Immunologic defects in patients with refractory sinusitis. Pediatrics 1991;87:311-316. Stakiewicz JA. Complications of endoscopic intranasal ethmoidectomy. Laryngoscope 1987;97:1270-1273. Stammberger H. Endoscopic endonasal surgery: concepts in treatment of recurring rhinosinusitis. Otolaryngol Head Neck Surg 1986;94:143-156. Wald ER, et al. Acute maxillary sinusitis in children. New Engl J Med 1981;304:749-754 Wald ER. Acute sinusitis and orbital complications in children. Am J Otolaryngol 1983;4:424-427. Wald ER, et al. Comparative effectiveness of amoxicillin and amoxicillin-clavulanate potassium in acute paranasal sinus infections in children: a double blind placebo-controlled trial. Pediatrics 1986;77:795-802. Wald ER. Epidemiology pathophysiology and etiology of sinusitis. Pediatr Infect Dis 1985;4:S51-S54. Wald ER. Sinusitis in children. Pediatr Infect Dis J 1988;7:S150-158 Wald ER, et al. Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor. J Pediatr 1987;104:297-303. Wilson TG. The aetiology of chronic rhinitis and sinusitis in children. J Laryngol Otol 1965;79:365-383. Ylikoski J, Savolainen S. The bacteriology of acute maxillary sinusitis. ORL J Otorhinolaryngol Relat Spec 1989;51:175-181. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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