Paediatric acute rhinosinusitis – advice to doctors and parents
Dr Roth gives an outline of the current recommendations for the diagnosis and management of paediatric acute rhinosinusitis for primary care physicians.
Definition of paediatric acute rhinosinusitis
Paediatric acute rhinosinusitis is one of the most common problems present to primary care practitioners across the world. Paediatric acute rhinosinusitis is defined as the sudden onset of nose and sinus inflammation causing two or more of nasal obstruction, discoloured nasal discharge or cough for less 12 weeks. A diagnosis of paediatric acute rhinosinusitis of bacterial rather than viral origin is generally made in one of 3 situations:
- Nasal discharge, congestion or cough lasting more than 10 days
- An increase in the symptoms of an upper respiratory tract infection after initial improvement (a “double sickening”)
- A very severe upper respiratory tract infection (high fevers, copious green nasal discharge, cough or severe pain)
Paediatric acute rhinosinusitis typically begins with a viral infection that causes epithelial damage and cytokine upregulation as well as activating the parasympathetic nervous system. Activated inflammatory pathways in the nasal mucosa cause oedema, fluid extravasation, mucus production and obstruction of the sinus ostia. Mucociliary transport is disrupted through either paralysis of the cilia or from obstruction of sinus ostia. Impaired ventilation and drainage of the sinuses creates a favourable environment for bacterial infection.
The most frequently isolated organisms from maxillary sinus cultures are S. pneumonia (30%), H. influenza (20%) and M. Catarrhalis (20%). The routine use of the pneumococcal conjugate vaccine is reducing the frequency of S. pneumoniae infections.
There are a range of factors that can predispose to paediatric acute rhinosinusitis episodes. These include any type of rhinitis (allergic or non-allergic), certain medical conditions (cystic fibrosis, immune deficiency, ciliary dyskinesia) and environmental factors (parental smoking, daycare).
Adenoiditis in younger patients (up to 5 years) may also contribute significantly. This can have a very similar presentation to acute rhinosinusitis with anterior and posterior nasal drainage. Often it co-exists. The diagnosis can usually only be made by direct visualisation of the adenoids by nasendoscopy.
Making the diagnosis
Typically we are relying on a history from the child’s parents when making the diagnosis. Examination findings may be limited to observation of a blocked, runny nose. It is important to consider alternative diagnoses of a simple viral rhinosinusitis, an intranasal foreign body, adenoiditis, cystic fibrosis and choanal atresia/stenosis.
It is important to try and visualise inside the child’s nose. This can be achieved by using the largest speculum of an otoscope. Look for mucosal inflammation, polyps, the colour of mucus. The oral cavity may show mucus draining posteriorly and tonsillar hypertrophy (which may suggest large adenoids as well). There are unfortunately no definite physical findings that confirm an infection is bacterial rather than viral.
Obtaining a culture is usually not necessary unless the patient has failed to respond to medical management after 48-72 hours or if the child appears extremely ill and toxic. Imaging is generally not necessary.
Current clinical guidelines recommend symptomatic treatment for children with uncomplicated acute rhinosinusitis of less than 10 days duration. Children with complications, concomitant disease that could be exacerbated by acute rhinosinusitis or symptoms that have lasted 10 days without any sign of a improvement can be offered antibiotic treatment or 3 further days of observation. Amoxicillin with or without clavulanate is recommended. If amoxicillin is chosen without clavulanate, the child should be reviewed at 72hrs to ensure there is a response. For children allergic to pencillin a second or third generation cephalosporin as monotherapy may be appropriate.
An intranasal corticosteroid nasal spray is also indicated. Nasal decongestants, antihistamines and nasal irrigations are not effective in paediatric acute rhinosinusitis.
Complications from paediatric acute rhinosinusitis are uncommon but can be serious. They can be divided into orbital (70%), intracranial (20%) and ossesous (10%). Orbital complications include preseptal celluliits,, orbital cellulitis and an orbital abscess. Look for eye pain, pain with eye movement, perobital oedema, diplopia and photophobia. Intracranial complications include an epidural, subdural or brain abscess, meningitis, cerebritis or sagittal or cavernous sinus thrombosis. Look for severe lethargy, headaches, cranial neuropathies, seizures or focal neurologic deficits. Osseous complications include osteomyelitis of the frontal and maxillary bones. Look for localised tenderness and redness of the overlying skin. Complications require intravenous antibiotics and usually (apart from preseptal cellulitis) a CT scan of the paranasal sinuses. Surgical treatment may sometimes be needed in addition to intravenous antibiotics.
Parents concerned that their child may be suffering from bacterial rhinosinusitis should first consult with their primary care doctor. If first line treatment is failing, complications are suspected or symptoms are persisting for longer than 12 weeks, referral to an ENT specialist may be appropriate.