Archive for June, 2014

SINUSITIS IN CHILDREN, DK JHA, MD

Friday, June 13th, 2014

Introduction:

Sinusitis is an inflammation of mucosal epithelial lining of paranasal sinuses.It is common in children but uncommonly diagnosed by Pediatricians due to low index of suspicion,although it has significant morbidity.Rhinitis is very common associate of this disease,so some paediatricians prefer to use the term Rhinosinusitis.

  • Sinusitis can occur at any age
  • ethmoidal and maxillary sinuses are present at birth but maxillary sinuses pneumatize at about 4 years of age,wherease the ethmoidal sinuses are well pneumatized at birth.
  • sphenoidal sinuses develop at about 5 years of age,wherease,frontal sinuses start to develop at about 7 years of age and continue pneumatization till early adolescent age i,e. 12 years of age
  • acute sinusitis is defined as symptoms of upto 4 weeks duration
  • subacute sinusitis is of 4 weeks to less than 12 weeks duration
  • chronic sinusitis, if 12 weeks or more of duration
  • recurrent sinusitis is 4 or more distinct episodes of sinusitis in one year
  • according to one study, 72% asthmatic children may have chronic sinusitis
  • Wherease 12% children with chronic sinusitis have asthma
  • chronic sinusitis is consistently associated with cystic fibrosis(CF)
  • The prevalence of chronic sinusitis in CF carrier is almost double the general population
  • Pansinusitis is a consistent features of primary ciliary dyskinesia(PCD),

 ETIOLOGY

  • Acute sinusitis is most commonly caused by viruses,like rhinivirus,influenza and parainfuenza virus,human metapneumovirus
  • bacterial causes in decreasing order of prevalence for acute sinusitis are
  • Streptococcus pneumoniae,Haemophilus influenzae,and Moraxella catarrhalis
  • chronic sinusitis is caused by Staphylococcus aureus,MRSA,Coagulase negative Staph aureus(CONS),alpha and beta Streptococcus and gram negatives in addition to causatives of acute condition.
  • causative organism in immunocompromised,diabetic and seriously ill subjects are pseudomonas,gram negatives,Mucor ,Rhizopus and Aspergillus in addition to causatives of acute and chronic conditions
  • Some children may have allergic sinusitis

 

PATHOGENESIS

  • Normally the paranasal sinuses are kept sterile by mucociliary system
  • In case of viral upper respiratory tract infections, the opening of sinuses in the meatus get blocked due to edeme and inflammations,so there is hinderance in washing out of sinuses which predispose to bacterial overgrowth.
  • In allergic individuals, aggregation of eosinophils occur in nasopharynx and sinuses which release major basic proteins ,which in turn hampers mucociliray function and causes inflammation
  • CFTR protein is essential for a good function of mucociliarry  system,as it helps in ionic transport across epithelium,but in cystic fibrosis and in the carrier stage of this disease ,due to mutations of this protein ,mucociliarry funtion is hampered
  • In csaes of PCD, movement of cilia are genetically defective
  • Nose blowing by children creats sufficient pressure to propel bacterial organisms from nasopharynx into sinuses
  • Imaging studies,have revealed mucosal thickeninging,,inflammation and edema in a setting of sinusitis

PPREDISPOSING FACTORS FOR RECURRENT OR CHRONIC SINUSITIS ARE

  •  Children with primary immunodeficiencies particularly IgG,IgG subclass,and IgA deficiency,children with phagocytic defects are predisposed
  • children with acquired immunodeficieny like malignancy,chemothrapy with neutropenia and lymphopenia,HIV infection are predisposed
  • Anatomical defects like cleft palate
  • Gastro-esophgeal reflux diseases
  • cocaine abuse
  • Allergic Rhinitis, Persistent Asthma,cystic fibrosis,Primary or secondary ciliary dyskinesia
  • Nasal foreign body like nasogastric tube,nasal polyp,nasotracheal intubation which blocks ostia of sinuses
  • Adenoid hypertrophy which blocks sinus ostia
  • Regular exposure to tobacco smoke

CLINICAL FEATURES

SYMPTOMS: symptoms of sinusitis are nonspecific, so high index of suspician should be kept to diagnose it.

Symptoms are:

  • cough,which persist for long time,more during day time,it can be the only symptom in some children
  • running nose,may be clear or purulent
  • nasal congestion or stuffiness,blocked nose
  • headache, not usual in children,may aggravate on bending forward,may be frontal,over vertex,may be referred to temporal or occipital region(sphenoidal sinusitis) depending on sinuses involved
  • decreased sense of smell(hyposmia)
  • bad breath odor(halitosis)
  • swelling of  periorbital region
  • persistent throat clearing habits due to pharyngeal irritation
  • pain over face,not usual in children or tooth pain of maxillary region, which aggravates on leaning forward
  • fever ,may be low grade or high grade
  • fullness or pressure sensation over ears
  • some older children complaints of giddiness

Signs: Clinical signs are difficult to appreciate in children,these are

  • tenderness over sinuses but usually not found in children,tenderness over maxillary sinuses or base of frontal sinuses just above inner canthi may be found in older children depending upon sinuses involved.
  • purulent nasal and post nasal secretions
  • nasal and facial erythma
  • nasal mucosal edema with blocked ostia of sinuses due to edema and inflammation,seen on anterior rhinoscopy
  • nasal polyp, blocking the sinus ostium
  • periorbital edema due to ethmoidal sinusitis

DIAGNOSIS

Diagnosis is mainly clinical:

According to American Academy of Pediatrics guideline 2013

  • Bacterial sinusitis should be suspected in children with symptoms of acute upper respiratory tract infection which starts as seveve and persists as severe with fever of 102 degreeF(39dC) for more than 3 days, OR
  • which deteriorates after initial improvement within 7-14 days,OR
  • which persists for more than 10-14 days
  • X-ray PNS waters view or caldwell view is helpful
  • CT scan of PNS should be done in case of severe disease or immunocompromised cases or any polyp is suspected within sinuses, as it may show abnormality in upto 50% of asymtomatic children.
  • diagnostic criteria on imaging are:
  • opacity,mucosal thickening of more than 5 mm or air-fluid level
  • complete blood count are not much helpful,peripheral blood eosinophilia may be seen in allergic individuals.
  • Aspiration and culture of sinus fluid is the only definite method of diagnosis, which is not possible routinely in immunocompetent child. It should be kept reserved for immunocompromised child, mainly to look for fungal infection.
  • SINUSITS

MANAGEMENT

Antimicrobials:

  • ACUTE SINUSITIS:
  • amoxicillin(high dose) 80 -90mg /kg body wt per day bid for 10-14 days OR 7 days after resolution of symptoms
  • In uncomplicated acute bacterial sinusitis amoxicillin 45 mg /kg body wt /day may work
  • clavulanic acid should be added if no response witin 48-72 hours OR
  • onset is severe OR
  • any risk factors for resistance like rcecnt use of antibiotics(in last 1-3 months) ,infections contracted in day care centre or age less than 2 years
  • Alternative medicines are cefuroxime,cefpodoxime ,cefdinir,azithromycin ,rifampicin.
  • In case of failure to these-imaging study should be done and surgical drainage should be considered.
  • CHRONIC SINUSITIS:
  • In view of high percentage of beta lactamase producing isolates in chronic sinusitis
  •  first line antibiotic should be amoxicillin+clavulanic acid for 21 days
  • if no improvement in symptoms ,additional 21 days course of another beta lactamase resistant antimicrobial should be given like
  • cefuroxime axetil,cefpodoxime,cefdinir.
  • Alternatives are cefotaxime, ceftriaxone and clindamycin or vancomycin or flluroquinolone.
  • FOR SERIOSULLY ILL OR IMMUNOCOMPROMISED CHILD:
  • cefepime or piperacillin+tazobactum +/- amphotericinB.

medicines for reduction of swelling:useful in chronic sinusitis

  • for severe nasal swelling 0.05% solution should be given intranasally ,3 drops into each nostril bid for 3 days
  • if swelling persist,oral pseudoephedrine or phenylepropalamine should be given for 7-10 days
  • if swelling again persists, intrnasal corticosteroid should be given for 3-6 weeks
  • If these measures are not working adequately,oral prednisolone should be given in the dose of 0.5mg/kg/day tapered over 5-7days
  • FOR ENHANCING EVACUATION OF SECRETIONS IN CHRONIC SINUSITIS:
  • saline irrigation
  • hot stem inhalation
  • COMPLICATIONS:,
  • Due to close proximation of paranasal sinuses to eyes and brain ,infections readily travel to these region causing
  • Orbital cellulitis,cavernous sinus thrombosis,epidural abscess,subdural empyema
  • Frontal sinusitis can cause edema and swelling of forehead due to osteomyelitis of frontal bone called pott puffy tumour
  • Mucocele usually occurs in chronic frontal sinusitis located near inner canthi which pushes eye causing diplopia

BIBLIOGRAPHY:

 

  • Diane E. Pappas and J.Owen Hendley:sinusitis ,Nelson Textbook of Pediatrics,19e: Kliegman,Stanton,St. Geme,Schor and Behrman:Saunders,An imprint of  Elsevier 1600 John F. Kennedy Blvd. Ste 1800,P hiladelphia, PA19103-2899:1436-1438
  •  Chobot R.: The incidence of sinusitis in asthmatic children. Am J Dis Child. 39:257 1930
  • Bullen S.S.: Incidence of asthma in 400 cases of chronic sinusitis. J Allergy. 4:402 1932
  • Welsh M.J., Ramsey B.W., Accurso F.: Cystic fibrosis. Childs B. Kinzler K.W. Vogelstein B. Molecular Basis of Inherited Disease. 2006 McGraw Hill New York 5121–5188
  • Wang X., Kim J., McWilliams R.: Increased prevalence of chronic rhinosinusitis in carriers of a cystic fibrosis mutation. Arch Otolaryngol Head Neck Surg. 131 (3):237–240 2005 15781764
  •  Anon JB (April 2010). “Upper respiratory infections”. Am. J. Med. 123 (4 Suppl): S16–25. doi:10.1016/j.amjmed.2010.02.003. PMID 20350632.
  •  Jump up to:a b c Christine Radojicic. “Sinusitis”. Disease Management Project. Cleveland Clinic. Retrieved November 26, 2012.
  • Jump up^ Pearlman AN, Conley DB (June 2008). “Review of current guidelines related to the diagnosis and treatment of rhinosinusitis”. Current Opinion in Otolaryngology & Head and Neck Surgery 16 (3): 226–30. doi:10.1097/MOO.0b013e3282fdcc9a.PMID 18475076.
  •  Jump up to:a b c d e f g h i Leung RS, Katial R (March 2008). “The diagnosis and management of acute and chronic sinusitis”. Primary care 35 (1): 11–24, v–vi.doi:10.1016/j.pop.2007.09.002. PMID 18206715.
  • Diament M.J., Senac M.O., Gilsanz V., et al.: Prevalence of incidental paranasal sinuses opacification in pediatric patients. A CT study. J Comput Assist Tomogr. 11:426–431 19873571583
  • Ah-See KW, Evans AS: Sinusitis and its management. BMJ. 334:358–361 2007 17303885
  • Coffinet L, Chan KH, Abzug MJ, et al.: Immunopathology of chronic rhinosinusitis in young children. J Pediatr. 154:757–758 2009
  • Harvey R, Hannan SA, Badia L, et al: Nasal saline irrigations for the symptoms of chronic rhinosinusitis (review). Cochrane Database Syst Rev (3):CD006394, 2007.
  • Lindbaek M, Butler CC: Antibiotics for sinusitis-like symptoms in primary care. Lancet. 371:874–876 2008 18342666
  • Operative Tech Otolaryngol Head Neck Surg. 15:37–41 200
  • Jump up^ Gwaltney JM, Hendley JO, Phillips CD, Bass CR, Mygind N, Winther B (February 2000). “Nose blowing propels nasal fluid into the paranasal sinuses”. Clin. Infect. Dis.30 (2): 387–91. doi:10.1086/313661. PMID 10671347.

  • Piccirillo JF: Acute bacterial sinusitis. N Engl J Med. 351:902–910 2004 15329428

  • Slavin RG, Spector RL, Bernstein IL: The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol. 116:S13–S47 2005 16416688

  • Steele RW: Rhinosinusitis in children. Curr Allergy Asthma Rep. 6:508–512 2006 17026877

  • Wald ER, Nash D, Eickhoff J: Effectiveness of amoxicillin/clavulanate potassium in the treatment of acute bacterial sinusitis in children. Pediatrics. 124:9–15 2009 19564277

  • Williamson IG, Rumsby K, Benge S, et al.: Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis.JAMA298:2487-2496 2007PMID 18056902
  • Recommendations adapted from American Academy of Pediatrics. Pickering LK, Baker CJ, Kimberlin DW, Long SS (eds): Red book: 2009 Report of the Committee on Infectious Diseases, 28th ed. Elk Grove Village, IL, American Academy of Pediatrics, 2009; and McMillan JA, Siberry GK, Dick JD, et al: The Harriet Lane handbook of pediatric antimicrobial therapy. Philadelphia, PA, Mosby Elsevier, 2009.Goytia VK, Giannoni CM, Edwards MS: Intraorbital and intracranial extension of sinusitis: comparative morbidity. J Pediatr. 158:486–491 2011  20970813
  • Harvey R., Hannan S.A., Badia L., et al.: Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. (3)2007 CD006394axillary sinusitis. JAMA. 298:2487–2496 2007 18056902

  • Jonnath Corren MD:The influence of upper airway disease on the lower airway:Kendig and Chernick’s disorders of the respiratory tract in children,Eighth edition:Elsevier Saunders 1600 John F Kennedy Blvd Ste 1800 Philadelphia,PA 19103-2899:749-752

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