Pediatric Sinusitis

Pediatric RhinosinusitisPediatric Rhinosinusitis

AnatomyAnatomy

Maxillary SinusMaxillary Sinus first to develop at day 65 of gestationfirst to develop at day 65 of gestation seen on plain films at 4-5 monthsseen on plain films at 4-5 months slow expansion until 18 yearsslow expansion until 18 years

Ethmoid SinusEthmoid Sinus develop in third month of gestationdevelop in third month of gestation ethmoids seen on radiographs at one yearethmoids seen on radiographs at one year enlarges to reach adult size at age 12enlarges to reach adult size at age 12

Sphenoid SinusSphenoid Sinus originates in fourth gestational month from posterior part of nasal originates in fourth gestational month from posterior part of nasal

cavitycavity pneumatization begins at age 3pneumatization begins at age 3 rapid growth to reach sella by age 7 and adult size at age 18rapid growth to reach sella by age 7 and adult size at age 18

Frontal SinusFrontal Sinus begins in fourth month of gestation from superior ethmoid cellsbegins in fourth month of gestation from superior ethmoid cells seen on radiographs at age 5-6seen on radiographs at age 5-6 grows slowly to adult size by adolescencegrows slowly to adult size by adolescence

DefinitionsDefinitions

AcuteAcute: symptoms often inseparable from URI and include : symptoms often inseparable from URI and include rhinorrhea, daytime cough, nasal congestion, infrequent low-rhinorrhea, daytime cough, nasal congestion, infrequent low-grade fever, otitis media, irritability and headache. Key in grade fever, otitis media, irritability and headache. Key in diagnosis of sinusitis is persistence beyond 7-10 days or diagnosis of sinusitis is persistence beyond 7-10 days or worsening of symptoms at around 7 daysworsening of symptoms at around 7 days Severe Acute Sinusitis: purulent rhinorrhea, high fever, periorbital Severe Acute Sinusitis: purulent rhinorrhea, high fever, periorbital

edema edema

RecurrentRecurrent: complete resolution between episodes and 3 or : complete resolution between episodes and 3 or more episodes in six months or more than 4 episodes in one more episodes in six months or more than 4 episodes in one yearyear

SubacuteSubacute: signs and symptoms lasting three weeks to three : signs and symptoms lasting three weeks to three monthsmonths

ChronicChronic: signs and symptoms lasting longer than three months : signs and symptoms lasting longer than three months

PathogenesisPathogenesis

Ostia obstruction Ostia obstruction creates increasingly creates increasingly hypoxic environment hypoxic environment within sinuswithin sinus

Retention of secretion Retention of secretion results in inflammation results in inflammation and bacterial infectionand bacterial infection

Secretion stagnate, Secretion stagnate, obstruction increases, obstruction increases, cilia and epithelial cilia and epithelial damage become more damage become more pronouncedpronounced

Most common inciting Most common inciting event is viral URIevent is viral URI

DiagnosisDiagnosis

Physical ExaminationPhysical Examination Anterior rhinoscopy with otoscope in Anterior rhinoscopy with otoscope in

younger childrenyounger children Tenderness over sinusesTenderness over sinuses Periorbital edema and discolorationPeriorbital edema and discoloration Flexible and rigid endoscopy in older childFlexible and rigid endoscopy in older child Most specific-- mucopurulence, periorbital Most specific-- mucopurulence, periorbital

swelling, facial tendernessswelling, facial tenderness

Adjunctive TestsAdjunctive Tests

Imaging usually not indicated for uncomplicated patients. CT Imaging usually not indicated for uncomplicated patients. CT scan may be indicated if suppurative complications suspected, scan may be indicated if suppurative complications suspected, patient fails to improve after treatment or as pre-operative patient fails to improve after treatment or as pre-operative studystudy

Ideally should be obtained after several weeks of medical therapyIdeally should be obtained after several weeks of medical therapy Major bony anatomic abnormalities unusual in childrenMajor bony anatomic abnormalities unusual in children Mucosal inflammation common incidental finding in children and Mucosal inflammation common incidental finding in children and

strongly related to viral URIstrongly related to viral URI Incidence of sinus mucosal inflammation drops off after age 7 to 8Incidence of sinus mucosal inflammation drops off after age 7 to 8

Sinus aspirate is indicated in severe toxic illness, acute illness Sinus aspirate is indicated in severe toxic illness, acute illness not responsive to antibiotics within 72 hours, not responsive to antibiotics within 72 hours, immunocompromised patients, suppurative complications and immunocompromised patients, suppurative complications and workup for fever of unknown originworkup for fever of unknown origin

Oropharyngeal/Nasopharyngeal swabs do not correlate with sinus Oropharyngeal/Nasopharyngeal swabs do not correlate with sinus aspirateaspirate

Endoscopically guided middle meatus swab correlates fairly well Endoscopically guided middle meatus swab correlates fairly well with sinus aspiratewith sinus aspirate

MicrobiologyMicrobiology

Similar to adults: Similar to adults: Streptococcus pneumoniae, Moraxella catarralis, Streptococcus pneumoniae, Moraxella catarralis, nontypeable Hemophilus influenzaenontypeable Hemophilus influenzae

ICU patients/cystic fibrosis: ICU patients/cystic fibrosis: Pseudomonas aeruginosa, Staphyloccus Pseudomonas aeruginosa, Staphyloccus aureusaureus

Resistant organisms more common in patients already treated with Resistant organisms more common in patients already treated with multiple rounds of antibiotics, children in day care, children who multiple rounds of antibiotics, children in day care, children who have received antibiotic therapy in the last 30 dayshave received antibiotic therapy in the last 30 days

Chronic pathogens may includeChronic pathogens may include Alpha-hemolytic streptococciAlpha-hemolytic streptococci S. aureusS. aureus Nontypeable Nontypeable H. inflluenzaeH. inflluenzae M. catarrhalisM. catarrhalis Anaerobic bacteriaAnaerobic bacteria PseudomonadsPseudomonads

Medical TreatmentMedical Treatment

Acute Sinusitis:Acute Sinusitis: Young children with mild to moderate ARS, Young children with mild to moderate ARS,

amoxicillin at normal or high doseamoxicillin at normal or high dose Amoxil-allergic patients, treat with a cephalosporinAmoxil-allergic patients, treat with a cephalosporin

—severe allergy, treat with macrolide—severe allergy, treat with macrolide Nonresponders, more severe initial disease, those Nonresponders, more severe initial disease, those

at high-risk for resistant strep, treat with high dose at high-risk for resistant strep, treat with high dose amoxil/clavulanateamoxil/clavulanate

Parenteral ceftriaxone for children not tolerating Parenteral ceftriaxone for children not tolerating oral medsoral meds

Duration of therapy is usually 10-21 days or until Duration of therapy is usually 10-21 days or until symptoms resolve plus 10 dayssymptoms resolve plus 10 days

Medical TreatmentMedical Treatment

Chronic RhinosinusitisChronic Rhinosinusitis 4 to 6 week course of beta lactam stable 4 to 6 week course of beta lactam stable

antibioticantibiotic Adjuvant therapy with nasal steroids Adjuvant therapy with nasal steroids

commonly employedcommonly employed Antihistamines especially if underlying Antihistamines especially if underlying

allergic condition suspectedallergic condition suspected Mucolytics may thin secretionsMucolytics may thin secretions

Refractory RhinosinusitisRefractory Rhinosinusitis

Consider associated conditionsConsider associated conditions AllergyAllergy Immune deficiencyImmune deficiency AsthmaAsthma Gastroesophageal reflux diseaseGastroesophageal reflux disease Cystic FibrosisCystic Fibrosis Primary Ciliary Dyskinesia (Immotile Cilia Primary Ciliary Dyskinesia (Immotile Cilia

Syndrome)Syndrome) Allergic Fungal SinusitisAllergic Fungal Sinusitis

AllergyAllergy

Major contributing factor in rhinosinusitisMajor contributing factor in rhinosinusitis Similar pathogenesis as viral etiology with obstruction -- Similar pathogenesis as viral etiology with obstruction --

mucostasis --hypoxia – colonizationmucostasis --hypoxia – colonization Itching mucous membranes, clear rhinorrhea, eczema, food Itching mucous membranes, clear rhinorrhea, eczema, food

intolerance, nasal congestion, stuffiness, fluctuating intolerance, nasal congestion, stuffiness, fluctuating rhinorrhea, sneezing, cough, behavioral changes, rhinorrhea, sneezing, cough, behavioral changes, headaches, facial pressureheadaches, facial pressure

AvoidanceAvoidance clean, allergy proof house, filter, no pets, air conditioningclean, allergy proof house, filter, no pets, air conditioning

Pharmacotherapy Pharmacotherapy antihistamines, nasal steroids, mast cell stabilizersantihistamines, nasal steroids, mast cell stabilizers

ImmunotherapyImmunotherapy

Immune DeficiencyImmune Deficiency

History of frequent otitis media, pneumonia and sinusitis may History of frequent otitis media, pneumonia and sinusitis may suggest a primary or secondary immunodeficiency statesuggest a primary or secondary immunodeficiency state

Serum immunoglobulins and IgG subclasses should be Serum immunoglobulins and IgG subclasses should be checked as well as ability to respond to capsular antigens of checked as well as ability to respond to capsular antigens of S. pneumoniaeS. pneumoniae and and H. influenzaeH. influenzae Must have laboratory with age-appropriate normsMust have laboratory with age-appropriate norms Chronic pediatric sinusitis associated with IgG2 deficiencyChronic pediatric sinusitis associated with IgG2 deficiency Consistent low total immunoglobulin defines common Consistent low total immunoglobulin defines common

variable hypoglobulinemiavariable hypoglobulinemia Treatment in primarily medicalTreatment in primarily medical Patients may benefit from IVIG therapyPatients may benefit from IVIG therapy Genetic counseling for patient and family may be appropriateGenetic counseling for patient and family may be appropriate

AsthmaAsthma

Sinusitis and asthma frequently Sinusitis and asthma frequently associated: same underlying disease associated: same underlying disease process or causal relationship?process or causal relationship? Sinonasal/bronchial reflexSinonasal/bronchial reflex AspirationAspiration

Treatment of sinusitis whether medical Treatment of sinusitis whether medical or surgical reduces use of or surgical reduces use of bronchodilators, improves pulmonary bronchodilators, improves pulmonary symptomssymptoms

Gastroesophageal Reflux Gastroesophageal Reflux DiseaseDisease

Many pediatric patients experience improvement in Many pediatric patients experience improvement in their chronic sinonasal symptoms after a trial of their chronic sinonasal symptoms after a trial of antireflux medicineantireflux medicine

GERD theorized to have direct effect on nasal mucosa, GERD theorized to have direct effect on nasal mucosa, initiating inflammatory response with edema and initiating inflammatory response with edema and impaired mucociliary clearanceimpaired mucociliary clearance

Phipps in 2000 reported a prospective trial in which Phipps in 2000 reported a prospective trial in which 63% CRS patients were found to have esophageal 63% CRS patients were found to have esophageal reflux by pH probe; 32% demonstrated reflux by pH probe; 32% demonstrated nasopharyngeal refluxnasopharyngeal reflux

Bothwell in 1999 reported 89% of pediatric candidates Bothwell in 1999 reported 89% of pediatric candidates for FESS avoided surgery with treatment for GERDfor FESS avoided surgery with treatment for GERD

Cystic FibrosisCystic Fibrosis

Autosomal recessive diseaseAutosomal recessive disease Mutation of CFTR proteinMutation of CFTR protein Patients develop chronic pulmonary disease in Patients develop chronic pulmonary disease in

childhood; also affected with sinusitis and nasal childhood; also affected with sinusitis and nasal polyposis, pancreatic insufficiency and biliary polyposis, pancreatic insufficiency and biliary cirrhosiscirrhosis

If surgery contemplated, check coagsIf surgery contemplated, check coags Recent studies suggest heterozygous mutations in Recent studies suggest heterozygous mutations in

the CFTR gene are associated with chronic the CFTR gene are associated with chronic rhinosinusitisrhinosinusitis Raman found that 12.1% of CRS patients harbored CFTR Raman found that 12.1% of CRS patients harbored CFTR

mutations compared with the expected rate of 3-4%mutations compared with the expected rate of 3-4% Wang found a 7% incidence of CFTR mutation in 123 CRS Wang found a 7% incidence of CFTR mutation in 123 CRS

patients compared to 2% in a control grouppatients compared to 2% in a control group

Primary Ciliary DyskinesiaPrimary Ciliary Dyskinesia

History of chronic otitis media, History of chronic otitis media, chronic sinusitis and chronic chronic sinusitis and chronic bronchitis or bronchiectasisbronchitis or bronchiectasis

Kartagener’s syndrome: sinusitis, Kartagener’s syndrome: sinusitis, situs inversus, bronchiectasis and situs inversus, bronchiectasis and male infertility)male infertility)

Diagnosis established with inferior or Diagnosis established with inferior or middle turbinate or tracheal biopsymiddle turbinate or tracheal biopsy

Allergic Fungal SinusitisAllergic Fungal Sinusitis

Allergic reaction to Allergic reaction to aerosolized fungi, usually of aerosolized fungi, usually of the dematiceous speciesthe dematiceous species

Treatment is surgical with Treatment is surgical with perioperative oral steroid perioperative oral steroid and post-operative topical and post-operative topical steroidssteroids

High recurrence rate, High recurrence rate, requires close follow uprequires close follow up

Findings in children Findings in children different than adult findingsdifferent than adult findings Children more frequently Children more frequently

have abnormalities of their have abnormalities of their facial skeletonfacial skeleton

More likely to have More likely to have unilateral diseaseunilateral disease

ComplicationsComplications

Orbital:Orbital: Orbital complications more common in Orbital complications more common in

children than adultschildren than adults Most common is medial subperiosteal Most common is medial subperiosteal

abscessabscess Intracranial:Intracranial:

More common in adolescents/adultsMore common in adolescents/adults Include meningitis (most common), epidural Include meningitis (most common), epidural

abscess, subdural abscess, intracerebral abscess, subdural abscess, intracerebral abscess, cavernous sinus thrombosisabscess, cavernous sinus thrombosis

Orbital ComplicationsOrbital Complications

Classified by Chandler:Classified by Chandler: I. Preseptal cellulitisI. Preseptal cellulitis II. Orbital cellulitisII. Orbital cellulitis III. Periorbital abscessIII. Periorbital abscess IV. Orbital abscessIV. Orbital abscess V. Cavernous sinus thrombosisV. Cavernous sinus thrombosis

Spread by direct extension via osseous structures Spread by direct extension via osseous structures or indirectly via valveless venous plexusesor indirectly via valveless venous plexuses

Obtain CT scan with contrast if orbital involvement Obtain CT scan with contrast if orbital involvement suspectedsuspected

Stage I—Preseptal CellulitisStage I—Preseptal Cellulitis

Eyelid edema, Eyelid edema, erythema and erythema and normal globe normal globe movementmovement

Stage I in children Stage I in children more likely due to more likely due to cutaneous lesions or cutaneous lesions or hematogenous hematogenous seeding rather than seeding rather than sinusitissinusitis

Stage II—Orbital CellulitisStage II—Orbital Cellulitis

Proptosis, Proptosis, Chemosis, Edema, Chemosis, Edema, PainPain Dilated pupilDilated pupil Visual lossVisual loss OphthalmoplegiaOphthalmoplegia Afferent pupillary Afferent pupillary

defectdefect

Stage III—Periorbital Stage III—Periorbital AbscessAbscess

Proptosis with globe Proptosis with globe displacement displacement inferolaterally, inferolaterally, decreased EOM, decreased EOM, vision decreasedvision decreased

IVAbx with external IVAbx with external or endoscopic or endoscopic drainage of abscess drainage of abscess and involved sinusand involved sinus

Stage IV—Orbital AbscessStage IV—Orbital Abscess

orbital abscessorbital abscess severe proptosis severe proptosis

and chemosisand chemosis usually no globe usually no globe

displacementdisplacement opthalmoplegia opthalmoplegia

presentpresent Impaired visual Impaired visual

acuityacuity

Stage V—Cavernous Sinus Stage V—Cavernous Sinus ThrombosisThrombosis

Progressive Progressive symptomssymptoms

Proptosis and Proptosis and fixationfixation

CN II, IV, VICN II, IV, VI MeningitisMeningitis High mortalityHigh mortality High fever, bilateral High fever, bilateral

symptomssymptoms

Intracranial ComplicationsIntracranial Complications Meningitis, Epidural Abscess, Meningitis, Epidural Abscess,

Intracerebral Abscess, Pott’s Puffy Intracerebral Abscess, Pott’s Puffy TumorTumor

Neurosurgical Consultation, high-Neurosurgical Consultation, high-dose antimicrobial therapy, drainage dose antimicrobial therapy, drainage of intracranial abscess planned in of intracranial abscess planned in concert with drainage of affected concert with drainage of affected sinussinus

Frontal sinus is most implicated Frontal sinus is most implicated sinus: venous drainage of the frontal sinus: venous drainage of the frontal sinus via small diploic veins sinus via small diploic veins extending through sinus wall; these extending through sinus wall; these communicate with venous plexi of communicate with venous plexi of dura, periorbita and cranial dura, periorbita and cranial periostuemperiostuem

Surgical ManagementSurgical Management

AdenoidectomyAdenoidectomy FESSFESS

Only after maximal medical therapy has failed and patient Only after maximal medical therapy has failed and patient has been screened and treated for any underlying has been screened and treated for any underlying conditionsconditions

Concern for developing nasal and sinus anatomy in Concern for developing nasal and sinus anatomy in children and possibility of altering facial growthchildren and possibility of altering facial growth