Paediatric Rhinosinusitis
Paediatric acute rhinosinusitis is one of the most common conditions presenting to GPs and paediatricians. It is also one of the most commonly overtreated — the vast majority of episodes are viral, self-limiting, and do not require antibiotics. Distinguishing bacterial from viral rhinosinusitis, and knowing when specialist referral is warranted, avoids unnecessary antibiotic exposure and identifies the minority of children who need further assessment or management.
Definition and Diagnosis
Paediatric acute rhinosinusitis is defined as the sudden onset of two or more of: nasal obstruction, discoloured nasal discharge, and cough — lasting less than twelve weeks. The diagnosis of a bacterial rather than viral cause is generally made in one of three clinical scenarios: symptoms lasting more than ten days without improvement; a pattern of initial improvement followed by worsening (“double sickening”); or a severe presentation with high fever, copious purulent discharge, and significant facial pain or swelling.
These criteria matter because in uncomplicated cases of less than ten days duration, current guidelines recommend symptomatic treatment only — not antibiotics. The distinction between viral and bacterial rhinosinusitis cannot be made reliably on symptom character or examination alone, which is why duration and clinical pattern are the key diagnostic criteria rather than the colour of the nasal discharge or the appearance of the throat.
Pathophysiology
Acute rhinosinusitis typically begins with a viral upper respiratory tract infection. The viral infection causes mucosal inflammation, increased mucus production, and obstruction of the sinus ostia — the narrow drainage openings through which the sinuses drain into the nasal cavity. When the ostia are obstructed and mucociliary transport is impaired, the stagnant environment within the sinus becomes favourable for secondary bacterial infection. The most commonly isolated bacteria from maxillary sinus cultures are Streptococcus pneumoniae (approximately 30%), Haemophilus influenzae (20%), and Moraxella catarrhalis (20%). Routine use of the pneumococcal conjugate vaccine has reduced the frequency of S. pneumoniae infections over the past two decades.
Several factors predispose children to acute rhinosinusitis: any form of rhinitis (allergic or non-allergic), anatomical variations affecting drainage, immune deficiency, cystic fibrosis, primary ciliary dyskinesia, environmental factors including parental smoking, and attendance at childcare. Adenoiditis in younger children — particularly those under five — can present similarly to, and co-exist with, acute rhinosinusitis, and should be specifically considered in this age group.
Assessment
The diagnosis is primarily clinical, based on history from parents. Examination findings are often limited to observation of nasal congestion and discharge. It is worth attempting to visualise inside the nose — using the largest otoscope speculum available — to look for mucosal inflammation, the colour of mucus, and the presence of polyps. The posterior pharynx may show mucus draining posteriorly. Tonsillar hypertrophy may suggest co-existing adenoid enlargement.
There are no examination findings that reliably distinguish bacterial from viral infection. Imaging is not routinely indicated — CT scans in children with uncomplicated rhinosinusitis typically show mucosal thickening that is non-specific and does not guide management. Imaging is reserved for children with suspected complications, failure to respond to treatment, or atypical presentations. Nasal culture is not routinely required but may be useful in children who fail to respond to a first course of antibiotics.
Management
For children with uncomplicated acute rhinosinusitis of less than ten days duration, current guidelines recommend symptomatic management — saline nasal irrigation, appropriate analgesia, and where clinically indicated, a short course of topical nasal decongestant. Children with symptoms persisting beyond ten days without improvement, a double-sickening pattern, or a severe initial presentation can be offered antibiotic treatment or three further days of watchful observation. Where antibiotics are prescribed, amoxicillin with or without clavulanate is the recommended first-line agent.
Children with a single episode of acute rhinosinusitis that responds to appropriate management do not require specialist referral. Referral to an ENT specialist is appropriate for children with recurrent episodes (four or more per year), complications, failure to respond to treatment, suspected underlying conditions predisposing to recurrence, or persistent symptoms beyond twelve weeks (which would meet the criteria for chronic rhinosinusitis).
In the management of paediatric chronic rhinosinusitis, adenoidectomy plays a specific role — removal of the adenoids reduces the bacterial reservoir in the nasopharynx and improves sinus drainage in children where adenoid hypertrophy is a contributing factor. It is particularly effective in younger children and is often considered before functional endoscopic sinus surgery in the paediatric setting.
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Dr Roth’s Clinical Perspective
The most common question I get from parents is whether their child needs antibiotics. For most episodes of acute rhinosinusitis in children — viral, less than ten days, no severe features — the honest answer is no. The natural history of viral rhinosinusitis is resolution within ten to fourteen days regardless of antibiotic treatment, and antibiotic prescribing for uncomplicated viral illness contributes to resistance without improving outcomes. I find that explaining the double-sickening pattern to parents is useful — they then know specifically what to watch for and when to come back, which is more helpful than either prescribing reflexively or telling them to wait without criteria.
For children referred with recurrent rhinosinusitis, adenoidectomy is genuinely underutilised. The adenoids are a significant bacterial reservoir in younger children, and their removal can substantially reduce the frequency of recurrent infections. It is a short, well-tolerated procedure and the results in appropriately selected children are often very good. I consider it before FESS in most paediatric cases.
— Dr Jason Roth, MBBS, FRACS (ORL-HNS)
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
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