Chapter 30. Rhinosinusitis

Rhinitis and sinusitis are frequently referred to as two separate and distinct disease processes. However, since the mucosa of the nasal cavity and sinuses are contiguous, rhinitis and sinusitis often coexist, making a distinction on clinical presentation difficult. Therefore, rhinosinusitis may serve as a more appropriate term1 to define a “group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses.”2

The inflammation resulting in rhinosinusitis can be multifactorial including viral infections, bacterial infections, and allergic processes. This varied etiology of rhinosinusitis in children makes the management of the condition challenging for pediatricians. Defining the etiology of rhinosinusitis is paramount to guiding therapeutic interventions. Definitions based on the patient's history and clinical presentation have been created to categorize rhinosinusitis as acute, subacute, recurrent, chronic, and acute superimposed on chronic (Table 30–1).2,3 Practitioners are encouraged to utilize these definitions to guide their therapeutic decisions.

Estimates of the incidence and prevalence of rhinosinusitis are varied. This is likely attributable to the inclusion of different subcategories of rhinosinuisitis in various estimates of disease burden. In adults suffering an acute viral upper respiratory infection there is often concominant evidence of paranasal sinus inflammation, a finding that supports the diagnosis of viral rhinosinusitis.4,5 Based on this, there are over 1 billion episodes of all-cause rhinosinusitis each year in the United States.4 More important to the practitioner is the rate at which a viral process progresses to acute bacterial rhinosinusitis. Approximately 0.5–2% of patients with viral upper respiratory infections progress to bacterial rhinosinusitis. This translates into 5–20 million cases of acute bacterial rhinosinusitis each year.4

Attempts to quantify the burden of acute bacterial rhinosinusitis in children have also been performed. Progression from viral upper respiratory infection to bacterial disease is thought to be more frequent in pediatric cases at a rate of 5–10%.6 The rate of progression to a bacterial infection may be as high as 13% in children attending daycare.7 In one prospective study, 135 (6.7%) of 2013 children aged 2–15 years presenting with upper respiratory symptoms had radiographic evidence of maxillary sinusitis and met the definition for acute or subacute bacterial rhinosinusitis.8 In 35 (26%) of 135 patients, acute bacterial rhinosinusitis was thought to be preceded by allergic symptoms while all others were thought to be preceded by a viral illness.8 These data support earlier evidence suggesting that acute bacterial rhinosinusitis usually occurs as a superinfection following inflammation secondary to a viral illness or less commonly from allergic symptoms.9 The peak incidence of acute bacterial sinusitis in this pediatric population was in patients 3–6 years of age.8

Few data exist regarding the prevalence of chronic sinusitis in children. One published account suggested that 24% of children presenting for evaluation at an Ear Nose and Throat clinic was related to the complaint of a “chronic runny nose.”10 This dearth of information likely reflects the difficulty in identifying patients with chronic rhinosinusitis versus patients with recurrent acute episodes of viral or bacterial rhinosinusitis. Additionally, the primary etiologies for chronic rhinosinusitis are often noninfectious, making it even more challenging.3

Regardless of the etiology, it is clear that the health expenditures related to rhinosinusitis are substantial. The costs attributed to the treatment of rhinosinusitis in 1996 were estimated at $5.8 billion of which $1.8 billion was for children younger than 12 years.11

As discussed above, viral infections are a predominant cause of upper respiratory infections that also involve the sinuses. It is reasonable to assume that the pathogens causing viral rhinosinusitis are the same as those seen in the common cold. In one adult study, rhinovirus was isolated in over half of the patients with viral rhinosinusitis.12 Other common viral pathogens include coronavirus, respiratory syncytial virus, influenza, parainfluenza, and adenovirus.13

The bacterial organisms implicated in acute and subacute bacterial rhinosinusitis are similar to the pathogens seen in acute otitis media. Results from maxillary aspirates in 79 children diagnosed with acute bacterial rhinosinusitis revealed 28% with Streptococcus pneumoniae, 19% with Moraxella catarrhalis, and 19% with nontypeable Haemophilus influenzae. Group A and C Streptococcus, Eikenella corrodens, and Peptostreptococcus were each isolated from fewer than 2% of cultures; approximately 30% of children had negative cultures.14 Similar bacteriology was noted in 40 children undergoing sinus aspirate for subacute rhinosinusitis.15

A number of studies attempting to define the pathogens associated with chronic rhinosinusitis have been performed.16–21 However, the results of these studies were not consistent. This is likely a result of the varied inclusion criteria adopted by the authors and methods for culture attainment and processing. The initial study evaluating bacterial pathogens in children with chronic rhinosinusitis showed anaerobes in all children cultured.16 Subsequent studies also showed anaerobes but at a much lower rate.17 Similar to acute and subacute rhinosinusitis, S. pneumoniae, M. catarrhalis, and nontypeable H. influenzae are frequently isolated in patients with more chronic symptoms.19,21Staphylococcus aureus has also been isolated in a small percentage of children with chronic rhinosinusitis.17,18,21

Sinus Anatomy and Development

Knowledge of the development of the paranasal sinuses is helpful to the clinician to understand the pathogenesis of rhinosinusitis. There are four paired sinuses: maxillary, ethmoid, sphenoid, and frontal. It is often taught that infants and small children do not yet have paranasal sinuses and therefore cannot have sinusitis. In reality, the ethmoid, maxillary, and sphenoid sinuses although small are present at birth (Figure 30–1). The overall growth of the sinuses is slow in the first 6 years of life. The ethmoid sinuses are the first to become pneumatized, which takes place at birth. The maxillary sinuses are pneumatized at age 4 and by the time a child reaches the age of 7–8 years, the inferior portion of the maxillary sinuses has extended to the level of the nasal cavity floor. Further growth into the maxilla is a continued process and dependent on the loss and descent of teeth. The sphenoid sinuses are pneumatized at the age of 5. The frontal sinuses are the last sinuses to develop. The point of origin of the frontal sinuses is the primary frontal sinus ostium. When the upper edge of the infundibulum frontalis (cupola) reaches the same level as the roof of the orbit, one can start to distinguish a real frontal sinus. This is often evident on radiograph between 7 and 8 years of age. Maturation of the frontal sinuses is not until late adolescence.22

Sinus Physiology

Three components are thought to be necessary for the normal functioning of the paranasal sinuses23: (1) patency of the sinus ostia, (2) function of the mucociliary apparatus, and (3) quality of the secretions. Obstruction of the ostia or impaired mucociliary function can result in impaired sinus drainage, leading to the development of rhinosinusitis.

There are two sinus meati. The first is the middle meatus, which drains the maxillary, anterior ethmoid, and frontal sinuses. The second is the superior meatus, which drains posterior ethmoid and sphenoid sinuses.24 The narrow caliber of the ostia and the narrow passageways in the ethmoids predispose children younger than 8 years of age to obstruction resulting in more diffuse sinus involvement.25,26 Factors influencing ostial obstruction can be divided into those that cause mucosal edema and those due to mechanical obstruction (Table 30–2).23,27 The most frequent etiology in children for ostial obstruction is a viral upper respiratory infection. As discussed above, inflammation second to allergies is less common but still a frequent cause of mucosal edema in children.9 There is a three- to fourfold increased risk for recurrent coryza and sinus problems in children with smoking mothers compared to children from nonsmoking families.28 Some specific mechanical factors include a deviated septum and hyperinflation of local structures shown in Figure 30–2.

Under normal circumstances the sinuses are thought to be sterile with intermittent and transient colonization by nasopharyngeal bacteria. The mucocilliary apparatus functions to clear the sinuses of this transient contamination of bacteria. When the nasal ostia are obstructed and/or mucociliary activity is impaired, bacterial growth can ensue, leading to acute bacterial rhinosinusitis.29

History and Physical

Current definitions of rhinosinusitis are primarily based on the duration of symptoms in patients and clinical presentation, making the practitioner's history and physical examination integral to the diagnosis. The history should focus on the duration and trend of current symptoms, presence of predisposing conditions, environmental exposures, and history of sick contacts (Table 30–3). The history associated with rhinosinusitis is often dependent on age. Younger children are frequently unable to completely communicate with their parents or the physician. Therefore, the clinician should be alert to less specific symptoms, such as irritability, anorexia, frequent throat clearing, and severe halitosis. Older children and adolescents have complaints similar to adults, such as headache, facial pain, and pressure, maxillary dental pain, anosmia, and pharyngitis.30

Although there is not one physical finding that allows for definitive diagnosis of rhinosinusitis, a number of pertinent positives can aid in the diagnosis. The focused physical examination should include evaluation of the patient's facial appearance. Specifically, the clinician should look for the presence of periorbital edema or evidence of allergic shiners. Percussion of the maxillary and frontal sinuses may reveal facial tenderness. Upon examination of the oropharynx halitosis, tonsillar and adenoid hyperplasia, pharyngitis or lymphoid hyperplasia of the posterior pharynx would support the presence of rhinosinusitis. The cervical lymph nodes may be moderately enlarged or slightly tender. Transillumination is most helpful when there is asymmetry, however, the sensitivity of this finding is relatively poor (i.e., many children with bacterial sinusitis will not have asymmetric findings on transillumination).

Anterior rhinoscopy, although sometimes technically difficult in a young child, should be routinely performed. Direct visualization can be obtained in a simple way by tilting the nose tip upwards. Toddlers have wide noses with round nostrils, allowing for examination of the head of the inferior turbinates and assessment for the presence and character of secretions. For a more thorough examination, an otoscope should be used. When examining the nares, the clinician should note the appearance of the mucosa and presence of any draining fluid. The nasal and pharyngeal mucosa often appears erythematous while any drainage is typically yellow to greenish and of varying viscosity.

In some cases, endoscopy may be necessary and provides more useful information compared to anterior rhinoscopy. This is especially true if the history suggests the presence mechanical obstruction such as with polyps, foreign bodies, tumors, or septal deviations. Moreover, it allows a direct sampling of the middle meatus in cases where a bacterial culture is desired. Fiberoscopy has been shown possible under local anaesthesia for a majority of children. Those of toddler age may be more prone to resist such an examination.31 Nasal endoscopy can be performed with a flexible fiberscope or rigid nasal scope. Fiberoscopy is a good tool in viewing the nasal cavity and the nasopharynx (including the size and condition of the adenoids), but it is not very adequate for visualising the middle meatus in a child. Rigid nasal endoscopy allows better visualization of the middle meatal structures. This procedure in children can only be performed under general anesthesia (Figure 30–3). In general, endoscopy should be reserved for more complicated rhinosinusitis cases and be performed by an experienced ear, nose, and throat (ENT) physician.

Signs and Symptoms of Rhinosinusitis

Rhinorrhea and cough are the most frequent presenting symptoms in all forms of sinusitis occurring in 54–80% and 50–83% of cases, respectively. Cough is present during the day and night, although it is often noted to be worse at nighttime. Persistence of daytime cough is frequently the symptom that brings a child to medical attention. Fever and pain are less common but still frequent complaints appearing in 50–63% and 29–32% of cases, respectively.32 Certain symptoms may help the clinician categorize acute sinusitis as severe or nonsevere (Table 30–4). In severe sinusitis, the fever is often high (more than 39°C), the nasal discharge is purulent and copious, and there may be associated periorbital swelling and facial pain.

Chronic rhinosinusitis should be suspected in children with very protracted symptoms including nasal discharge or cough that lasts for more than 12 weeks. Although the nasal discharge is purulent, it may be thin and clear, and occasionally it is minimal or absent. Cough and throat clearing is more prominent, present during the daytime and reported to be more common at night. Furthermore, nasal obstruction or mouth breathing are frequent (70–100%) and often accompanied by otitis media or otitis media with effusion. Morning periorbital swelling may be noted by the parents because of secondary compression of the superior ophthalmic veins in the context of ethmoid sinus inflammation.

The differential diagnosis for rhinosinusitis should focus on illnesses that result in rhinorrhea such as a viral upper respiratory infection or allergies. A foreign body should be considered in a child with persistent foul-smelling unilateral drainage. Patients with unilateral periorbital swelling may be suffering from preseptal or orbital cellulitis. The presence of headache or vomiting in addition to fever should prompt consideration of an intracranial complication of sinusitis (Table 30–5).

Equally important as the differential diagnosis is the number of underlying conditions that can predispose a patient to recurrent bacterial rhinosinusitis or result in rhinosinusitis that is recalcitrant to appropriate therapy (Table 30–2).33 Allergies can be contributing factors in the severity and persistence of rhinosinusitis. If a careful history suggests the possibility of allergic rhinosinusitis, then it is reasonable to refer the patient for allergic testing.

Recurrent and chronic rhinosinusitis can be a common clinical presentation of various immune deficiencies. Common variable immune deficiencies have been found in children with recurrent infections including rhinosinusitis. Children with recurrent infections were shown to have significantly lower IgG2 and IgG4 levels, reduced specific pneumococcal antibodies in the IgG2 class, or reduced opsonization for staphylococci and H. influenzae.33 Additionally, some patients who lack IgA antibodies and patients with acquired immune deficiencies (e.g. treatment for malignancies, organ transplants, acquired immunodeficiency syndrome (AIDS), drug-induced immune suppression) have an increased number of more severe respiratory infections. Patients suspected of having an underlying immune deficiency because of recurrent or persistent rhinosinusitis may require some of the following laboratory analyses: complete blood count with differential, quantitative immunoglobulins with IgG subclasses, and vaccine specific IgG levels for tetanus, diphtheria, pneumococcus, and H. influenzae type b, and HIV testing. In addition, sinus aspirate for culture may be useful to guide subsequent antibiotic therapy.

Sinusitis is a common problem in children with cystic fibrosis (CF). CF patients commonly have nasal polyps in the middle meatus34 with partial or complete opacification of the anterior complex (anterior ethmoid, maxillary and frontal sinuses) and sometimes opacification of the posterior complex (posterior ethmoid and/or sphenoid sinuses) (Figures 30–4 and 30–5). When suspected, a pilocarpine sweat test should be ordered.

Primary ciliary dyskinesia (PCD) is an inherited condition in which there are functional or structural abnormalities of the patient's cilia (Figure 30–6). PCD is often associated with rhinosinusitis and bronchiectasias, which typically develop later in life. This diagnosis should be considered in any neonate with recurrent bronchial or nasal symptoms beyond what would be typically expected. At least half of children diagnosed with PCD had respiratory or ENT symptoms soon after birth.35 In the older child, PCD may present as atypical asthma, severe gastroesophageal reflux, chronic rhinosinusitis (rarely with polyps), or chronic and severe otitis media with effusion. Diagnosis is confirmed by inspection of ciliary beat frequency from a biopsy of the nasal mucosa.

Gastroesophageal reflux disease (GERD) may be a cause of chronic nasal discharge and obstruction. Patients suffering from GERD may present with chronic cough, hoarseness and stridulous respiration, recurrent croup, and pharyngotracheitis.36 Upper endoscopy may reveal cobblestone appearance of the mucosa of the laryngohypopharynx, inflammation of the upper airway, posterior glottic erythema, or edema. The diagnosis can also be confirmed by 24-hour esophageal pH monitoring.

Craniofacial disorders can contribute to chronic sinus disease. The most common craniofacial anomalies causing chronic rhinosinusitis are cleft palate and choanal atresia. Other factors might be regurgitation of food and saliva into the nasal cavity, inducing chronic irritation of the mucosa. Septal deviations and anomalies of the middle meatus (concha bullosa, oversized bulla etc.) are more frequently seen in older children (Figure 30–2). These anomalies do not directly result in rhinosinusitis. However, on occasion, the anomaly can lead to obstruction of the middle meatus, allowing for development of rhinosinusitis.

Acquired mechanisms of mechanical obstruction can include trauma, adenoid hyperplasia, prolonged nasogastric tube placement, polyps, and tumor. Similar to the obstruction from the congenital disorders listed above, these acquired conditions can result in the development of rhinosinusitis. An acquired mechanical obstruction can be suspected by careful history and physical examination and confirmed by endoscopy or computed tomography imaging. When polyps are identified in a child, an evaluation for CF should be done.

There is growing evidence that rhinosinusitis may be linked to refractory asthma. In some patients with longstanding asthma, airway remodelling can result in a component of irreversible airflow obstruction. Most of the asthmatic children with chronic and recurrent rhinosinusitis show changes in the respiratory tract and on computed tomography examination. These changes include sinus-mucosal thickening and concha hypertrophy.37 The improvement of asthma after treatment of rhinosinusitis suggests that rhinosinusitis may actually be a trigger for asthma.38

Most experts agree that the diagnosis of rhinosinusitis should be based primarily on a careful history and physical examination. In patients where symptoms persist despite appropriate interventions, further studies including sinus samples for culture and radiographic imaging may be warranted.1–3

Microbiology

Although culture is the gold standard for diagnosis of bacterial rhinosinusitis, it is often not performed because of the necessity of a somewhat invasive procedure.4,39 When sinus cultures are desired, endoscopically guided middle meatal sampling is preferable to antral puncture sampling as it does not require general anesthesia. The indication for microbiological sampling are (1) a severe illness or a toxic condition, (2) an acute illness that does not improve with medical therapy within 48–72 hours, (3) an immunocompromised host, and (4) presence of suppurative intraorbital or intracranial complications.1 Only the recovery of a high density of bacteria (>104 colony-forming units per mL) ensures that the culture results reflect actual sinus infection. Isolation of an organism at a density below 104 colony-forming units suggests the presence of sinus colonization or culture contamination from nasopharyngeal organisms.4,39

Radiographic Imaging

The use of radiographic imaging for diagnosis of rhinosinusitis remains controversial. Most experts agree that in the initial evaluation of rhinosinusitis, imaging is unnecessary. Certainly the diagnosis of rhinosinusitis should never be based on radiograph results alone. When ordered, radiographs should only support a diagnosis that is based on the history and physical examination. Various imaging modalities such as plain radiographs, computed tomography scans, and magnetic resonance imaging have been used to evaluate the sinuses. A negative result on plain radiograph supports the absence of bacterial sinusitis and may direct the clinician to an alternative diagnosis.40 However, in children, a clinical examination consistent with rhinosinusitis was found to highly correlate with abnormalities on sinus radiographs.41 Given the high correlation between the physical examination and radiograph results as well as the fact that radiographs can only evaluate the maxillary and frontal sinuses, they are likely not necessary to make a diagnosis.3,42

Computed tomography imaging can provide the clinician with a more detailed evaluation of the all paranasal sinuses as well as the local anatomy. The indications for ordering a computed tomography scan in a child are the same as the indications listed above for microbiological sampling.1 Additionally, computed tomography scans are often necessary whenever surgical intervention may be considered.3 Magnetic resonance imaging should never be used in routine sinus evaluation because diffuse sinus mucosal thickening is often an incidental finding. Magnetic resonance imaging is most useful when intracranial complications of rhinosinusitis are suspected or in an immunocompromised patient when invasive fungal rhinosinusitis is a concern. Additionally, magnetic resonance imaging may also be helpful when differentiating a tumor from surrounding edema.43

Depending on the recent history of the patient and the clinical presentation, a number of therapeutic options exist for the clinician managing rhinosinusitis. The potential role of antibiotics, adjuvant therapies, and surgical management are each discussed below. Initial categorization of the patient with rhinosinusitis as viral or bacterial in origin as well as acute, subacute, or chronic is necessary before proceeding with therapeutic decisions.

Antibiotics

Patients with symptoms lasting for less than 10 days likely have a viral illness or suffer from allergic rhinosinusitis and thus will not benefit from antibiotics. These patients may or may not improve with symptomatic therapies such as oral or topical decongestants, oral analgesics, and topical antiinflammatory drugs. Those patients with persistent or worsening symptoms beyond 10 days are more likely to have a bacterial rhinosinusitis.

Clearly patients presenting with a severe illness or toxic condition or patients with a suspected or proven suppurative complication of rhinosinusitis should receive parenteral antibiotics. However, significant controversy exists as to the necessity of antibiotics for the child with bacterial rhinosinusitis in the outpatient setting. The initial randomized controlled trial comparing antibiotics with placebo in pediatric outpatients with clinical and radiographic diagnosis of acute bacterial rhinosinusitis showed more rapid and complete recovery in those receiving antibiotics. Interestingly, 60% of the children receiving placebo did ultimately recover without antibiotics.41 More recently, pediatric44 and adult45 randomized controlled trials reported no difference in the antibiotic treatment group versus the placebo group with regard to timing and completeness of recovery. Unfortunately, the pediatric study was limited because of the use of low-dose antibiotic therapy while the adult study included a number of patients who did not have at least 10 days of symptoms at presentation.

In an attempt to limit outpatient antibiotic prescribing practices, the 2001 American Academy of Pediatric guidelines recommend the initiation of antibiotics only when a child is diagnosed with acute bacterial rhinosinusitis based on clinical examination and duration of symptoms.3 Similarly other expert panels suggest reserving outpatient antibiotic use for patients with severe acute rhinosinusitis and in some patients when nonsevere acute rhinosinusitis accompanies other comorbid illnesses (i.e. asthma, acute otitis media).1

Definitive data guiding the duration of therapy once antibiotics are initiated are lacking. Current recommendations include 10 days,3 10–14 days or longer if symptoms persist1, or 7 days beyond symptom resolution.46 Some evidence does exist in adults to suggest the effectiveness of shorter durations such as 3–5 days.47 Randomized controlled trials are needed to further define the most appropriate duration. At this time, 10 days of therapy is likely adequate. Most important to the clinician is that the patient show clinical improvement after 48–72 hours of therapy. If improvement does not take place, the patient should be reevaluated.

Choice of Antibiotics

As previously stated, the bacterial pathogens most frequently isolated in acute and subacute bacterial rhinosinusitis are S. pneumoniae, nontypeable H. influenzae, and M. catarrhalis. The reader should be aware that a vast majority of nontypeable H. influenzae and all M. catarrhalis isolates are beta-lactamase producers making amoxicillin ineffective. Despite this, the American Academy of Paediatrics still recommends amoxicillin at a dose of 45 mg/kg/d as a first-line agent because of its general effectiveness, safety and tolerability, low costs and narrow spectrum.3 Furthermore, based on acute otitis media data, infections secondary to nontypeable H. influenzae and M. catarrhalis are more likely to resolve spontaneously.48

Increasing rates of S. pneumoniae resistance to penicillin may warrant the initial use of high-dose amoxicillin (80–90 mg/kg/d). Patients who attend daycare, those younger than 2 years of age, or those who have received antibiotics in the past 90 days are more likely to have a pneumococcal infection that is resistant to amoxicillin. 49,50 The reader should consult their local resistance patterns for pneumococcus as they can vary from region to region. Patients with more severe symptoms at presentation (Table 30–4) or those who do not respond to initial amoxicillin therapy should be given high-dose amoxicillin therapy in conjunction with clavulanate at 6.4 mg/kg/d. The clinician should be aware that only certain preparations of combination amoxicillin/clavulanate allow for increasing the dose of amoxicillin to 80–90 mg/kg/d while maintaining the appropriate dose of clavulanate. This is important because administration of clavulanate above 6.4 mg/kg/d may result in gastrointestinal side effects.

Patients with a nontype 1 allergic history to amoxicillin can be prescribed a third-generation oral cephalosporin such as cefdinir (14 mg/kg/d). In cases of serious allergic reactions, clindamycin (25 mg/kg/d) or clarithromycin (15 mg/kg/d) can be used. Clindaymcin will only have activity against S. pneumoniae and will not be effective against nontypeable H. influenzae or M. catarrhalis. Recent analysis of pneumococcal isolates from across the United States suggests a high rate of resistance to trimethoprim/sulfamethoxazole, cefuroxime, and azithromycin.51,52 These agents should be avoided when possible for empirical therapy of bacterial rhinosinusitis. Ceftriaxone at 50 mg/kg/d either intravenously or intramuscularly can be used in children with vomiting. Once vomiting subsides, oral therapy can be initiated to complete the antibiotic course.3

Although fluoroquinolones, especially levofloxacin, have good activity against the bacterial pathogens of rhinosinusitis, they are not routinely recommended for use in children. In cases where resistant organisms require the use of a fluoroquinolone, the physician should consider consultation with an infectious disease specialist.

Antibiotic Prophylaxis

Antibiotic prophylaxis is often not recommended given the concerns for promoting antimicrobial resistance. Certain high-risk children (immunodeficiency, CF, PCD, and craniofacial anomalies) may require prophylaxis in the setting of recurrent disease. The decision to initiate prophylaxis in these patients should be weighed against the risk of limiting antibiotic options over time secondary to resistance.

Antibiotics and Chronic Rhinosinusitis

Children suffering from chronic rhinosinusitis are likely to have an underlying condition that predisposes them to persistent obstruction of the sinus ostia, resulting in chronic symptoms.53 The use of antibiotics in this setting is controversial. Antibiotics have been shown to stop the purulent rhinorrhea for a short period of time, but on long-term follow-up, they do not have a significant curative effect.19 In children with chronic rhinosinusitis complicated by frequent acute exacerbations, an initial course of antibiotics may be prudent. In this setting, antibiotic therapy should be directed at the organisms commonly associated with acute or subacute rhinosinusitis. The choice of antibiotic should also cover Streptococcus pyogenes, S. aureus, and anaerobes, which are sometimes isolated in patients with chronic symptoms. Amoxicillin/clavulanate is a reasonable first-line choice in this setting.

If symptoms do not improve after 1 week of therapy, it is unlikely that bacterial infection is the cause for the chronic symptoms. The physician should instead evaluate for other predisposing conditions (Table 30–2).53 Patients with suspected or confirmed methicillin-resistant S. aureus should be referred to an infectious disease specialist for further management.

Adjuvant Therapy

A number of adjuvant therapies for rhinosinusitis exist including antihistamines, decongestants, topical intranasal steroids, and saline nasal irrigation. Unfortunately, there is little scientific evidence for the effectiveness of any of them. Recently, the Food and Drug Administration (FDA) has recommended against the use of systemic cough and cold remedies in children younger than 2 years of age and questioned their safety in children older than 2.54 Given this recommendation and the lack of efficacy data, the use of systemic antihistamines and decongestants in children should be avoided.

Theoretically the use of intranasal corticosteroids should improve acute rhinosinusitis by reducing tissue inflammation and relieving ostial obstruction.30 However, based on the few studies to date, there are little data to support their use in acute bacterial rhinosinusitis. Two adult studies showed that the use of flunisolide or momethasone in combination with antibiotics provided only a modest benefit in reduction of symptoms.55,56 A single pediatric study evaluating budesonide nasal spray also showed just modest improvements during the second week of therapy.57 In studies of chronic rhinosinusitis, minimal to no benefit was appreciated when compared to placebo.58 These agents should be reserved for the treatment of nasal inflammation secondary to allergies.

Nasal saline sprays and nasal saline drops have not been rigorously evaluated. Using saline washes at body temperature twice a day may help decrease the viscosity of nasal cavity secretions and enhance sinus drainage and ventilation.59 Given the limited side effects and minimal cost, it is reasonable to suggest them to patients for potential symptomatic relief.

Physicians can aid their patients in discussing proper techniques for nose blowing as nose blowing has been identified as a potential risk factor for the development of acute bacterial sinusitis. This is based on the observation in adults where after nose blowing contrast was seen in one or more of the sinuses of all volunteers.60 If one blows the nose with both nostrils closed, intranasal pressures can be very high and potentially result in hyperinflated ethmoid air cells.61 Therefore, patients should be advised not to blow the nose with both nostrils closed. On the contrary, keeping one nostril open during nose blowing can help to clear the nasal cavity from secretions without generating excessively high pressures.

Surgical Management

Surgical interventions are often emergently necessary for various complications (see the section on Complications) of rhinosinusitis and sometimes are performed electively in patients with symptoms that persist after attempts at medical management fail (Table 30–6). Elective surgery should be considered as a last resort therapy for pediatric patients with isolated rhinosinusitis and only after consultation with a pediatric ENT physician. Various surgical approaches have been implemented for the relief of rhinosinusitis. Adenoidectomy is one of the oldest, fastest, and simplest of all ENT operations, and carries minimal risk and morbidity. It is most often performed if the amount of adenoid tissue in the nasal pharynx seems large enough to cause obstruction, to serve as a reservoir for bacterial pathogens, or when almost the entire surface area of the adenoid is covered with biofilm.62 Overall, an adenoidectomy can be expected to improve the symptoms in approximately 50% of patients with chronic rhinosinusitis.63–65

When maximal medical therapy and adenoidectomy have failed, functional endoscopic sinus surgery (FESS) may be performed. “Functional” implies that the surgery's goal is for the restoration of ventilation and drainage of all sinuses (Figure 30–7B). With this technique, the ethmoid is cleared from disease endonasally with the help of rigid endoscopes. A nasoantral window is created in the middle meatus, allowing for removal of diseased mucosa. FESS should be individually tailored to each case by the pediatric ENT specialist.

Complications of rhinosinusitis occur more frequently in children, young adolescents, and patients with depressed immune function. The most concerning complications of rhinosinusitis in children are infections of the orbital content and intracranial abscesses. A high index of suspicion for these complications is mandatory as they can be life-threatening when not diagnosed early and adequately treated. Other less severe complications are bony osteitis, osteomyelitis, and local complications such as mucoceles and antrachoanal polyps.

Orbital Complications

Unilateral orbital symptoms in the presence of purulent rhinorrhea are highly suggestive of orbital complications of rhinosinusitis. In rare cases, bilateral orbital edema may exist from the start.66 The routes of expansion of an infection in the ethmoid toward the orbit can be direct via a bony dehiscence at the level of the lamina orbitalis (papyracea) or os lacrimale or indirect via arterial, venous, or lymphatic seeding. The most common germs for orbital complications in children are H. influenzae, streptococci species, and staphylococci species. When orbital cellulitis progresses rapidly or fails to respond to intravenous antibiotics, a subperiostal abscess should be suspected. Asymmetric proptosis and limitations of ocular mobility are symptoms that suggest the presence of a subperiostal abscess (Figure 30–8).

Less frequently, compression of the optic nerve can result in color impairment and vision loss requiring emergent surgical intervention. When the initial unilateral signs progressively become bilateral, a posterior extension beyond the limits of the orbit with associated cavernous sinus thrombosis must be suspected. In this setting, there may be bilateral axial proptosis in combination with cranial nerve III, IV, and VI palsies. Diagnosis can usually be made on clinical examination, but should be confirmed with magnetic resonance imaging. Presence of a subperiostal abscess that does not respond to intravenous antibiotics should be drained via an endonasal endoscopic approach (Figure 30–9).

Intracranial Complications

Intracranial complications are present in 3% of the patients admitted into the hospital for treatment of severe rhinosinusitis67 (Figures 30–10 and 30–11). The most common presenting signs and symptoms apart from nasal and orbital symptoms are headache (75%), fever (44%), mental status changes (30%), motor deficit (38%), seizures (19%), nausea and vomiting (19%), and respiratory distress or arrest (6%).68 The clinician should also be aware of signs of increased intracranial pressure such as bradycardia, pappilloedema, hypertension, nausea, vomiting, decreased consciousness, and dilated pupil(s) (ominous sign suggesting transtentorial herniation).

These patients almost always have involvement of the frontal sinuses and frequently suffer from pansinusitis. In rare cases, isolated sphenoiditis (cerebellar abscess via the sinus petrosus inferior) or maxillary sinusitis (cerebellar abscess via the plexus venosus pterigoideus) can cause intracranial complications (Figure 30–11). Osteomyelitis of the anterior wall of the frontal bone (tabula externa) will cause a subperiostal abscess of the forehead via venous vessels. This is often referred to as “Pott's puffy tumor” (Figure 30–12). Osteomyelitis of the posterior wall (tabula interna) will induce a thrombophlebitis of the valveless diploic veins of “Breshet,” which serve as a conduit for the spread of the infection to the intracranial space.68,69

When intracranial complications are suspected, the clinician should seek consultation with an infectious disease specialist, an ENT surgeon, and potentially a neurosurgeon. Empiric antibiotics should include vancomycin (active against Gram-positive organisms), a third-generation cephalosporin (active against Gram-negative microbes), and metrodinazole (active against anaerobes). Surgical intervention is often necessary in addition to antibiotics. All involved sinuses need to be drained especially the frontal sinus, which needs adequate postoperative ventilation and drainage. Additionally, intracranial fluid collection (especially subdural and cerebral abscesses) need to be drained neurosurgically69 (Figure 30–13).

Rare Complications

An extremely rare intracranial complication of rhinosinusitis is an extradural hematoma, which presents as a combination of extradural hematoma and rhinosinusitis in the absence of trauma (Figure 30–14). Hematologic studies and lumbar puncture are required after a computed tomography scan or magnetic resonance image have excluded the possibility of herniation.

Osteomyelitis of the maxilla in infancy is primarily a staphylococcal infection of an unerupted tooth (coronitis) and the surrounding bone. The swelling of the soft tissue over the maxilla is considerably more extensive than in acute sinusitis and involves the soft tissues of the maxillary region and eyelids. Appropriate antibiotics are indicated (Figures 30–15 and 30–16).

Mucoceles are epithelial-lined mucus-containing sacs that fill the whole sinus or a compartment of the sinus. They can originate from the sinus mucosa after chronic infection, or iatrogenic or external trauma of the sinuses. Pressure on the bone from the mucocele can flatten or deform the bony contour of the sinuses. The diagnosis is confirmed by computed tomography scan (to visualize the bony structures) and magnetic resonance imaging (to confirm compartmentalization). It is important to know before the surgery the existence of compartmentalization to get an adequate surgical drainage of the mucocele during surgery.

Antrachoanal polyps are mucous polyps protruding from the choana. They are mostly unilateral and originate in the majority of cases from the maxillary sinus and can obstruct the nasopharynx (Figure 30–17). They mostly occur in children older than 10 years but the youngest patient seen by the author was only 3 years of age.70 The cause of the disease is unclear but some theorize that the disease is a result of reflux. The symptoms are mainly unilateral purulent nasal secretions with a history of mouth breathing and snoring. The diagnosis is done by rigid endoscopy or fiberoscopy. Computed tomography scans will show the origin of the antrachoanal polyp, which is necessary for adequate surgical removal.