PEDIATRIC ACUTE SINUSITIS by ao111

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									                       Acute Sinusitis in Pediatrics




Dr. Mu’taz Sulatan / Pediatrician / Department of Pediatrics June 2004
Acute Sinusitis
 in Pediatrics
  Dr. Mu’taz Sultan
       Pediatrician

 Department of Pediatrics

   Makassed Hospital
      June 2005
                             Background
                                                    • The ethmoid & the
                                                      maxillary sinuses form in
Sphenoid sinus                   Maxillary sinus      the 3rd to 4th gestational
                                    Frontal sinus
                 Ethmoid sinus                        mo and, accordingly,are
                                                      present at birth.
                                                    • The sphenoid sinuses
                                                      are generally
                                                      pneumatized by 5 years
                                                      of age .
                                                    • The frontal sinuses
                                                      appear at age 7 to 8
                                                      years but are not
                                                      completely developed
                                                      until late adolescence..
                 SINUSITIS
• In 1996, 13 million patients had diagnosed
  as sinusitis in USA .
• Viruses caused the vast majority of acute
  sinus inflammation .
   – 87% with rhinovirus cold had abnormal
     sinus CTS .
   – Estimated 5-13% of URIs in children
     complicated by bacterial sinusitis (Ped
     2001).
   – Even when clinician have high degree
     of suspicion for acute bact sinisitis only
     correct in <50% .
             Definitions
• Acute bacterial sinusitis :Bacterial infection of
  the paranasal sinuses lasting less than 30 days .

• Subacute bacterial sinusitis : infection lasting
  between 30 and 90 days .

• Chronic sinusitis :Episodes of inflammation of
  the paranasal sinuses lasting more than 90 days .

• Recurrent acute bact sinusitis : 3 episodes of
  acute bacterial sinusitis in 6 months or 4 episodes
  in 12 months.
Pathophysiology of acute
   bacterial sinusitis
 • Obstruction of the sinus ostis,
   inspissated mucus and paralysis of
   celia ; all caused by colds viruses.
 • Inflammation caused by allergies lead
   to obstruction of the ostia .
 • Nasal flora trapped in closed space
   ,inflammatory response with influx of
   PMNs and cytokines with eventual
   mucosal damage .
            Etiology
• Acute and subacute pathogens :
  – Streptococcus pneumoniae - 20-30%

  – Nontypeable Haemophilus influenzae -
    15-20%

  – Moraxella catarrhalis - 15-20% (not as
    common in adults)

  – Streptococcus pyogenes (beta-
    hemolytic) - 5%
                  Etiology
• Chronic sinusitis :
  – The role of infection is controversial .
  – Noninfectious conditions:
     • allergy .
     • cystic fibrosis .
     • gastroesophageal reflux .
     • Cilliary dysfunction .
AAP Recommendations for the
 Management of Sinusitis in
        Children
• clinical practice guideline developed by the
  American Academy of Pediatrics (AAP)
  provides evidence-based
  recommendations for physicians to
  diagnose, evaluate, and treat patients
  between one and 21 years of age who
  present with uncomplicated acute,
  subacute, and recurrent acute bacterial
  sinusitis .
Recommendations
 Methods for diagnosis
• The gold standard for the diagnosis of acute
  bacterial sinusitis is the recovery of bacteria in
  high density from the cavity of paranasal sinuses .

• But not recommended for the routine diagnosis
  (not feasible) .
Recommendation 1
• The diagnosis of acute bacterial sinusitis is
  based on the clinical criteria in children who
  present with upper respiratory symptoms
  that either persistent or severe .
                Sinusitis
          clinical diagnosis

– Persistent symptoms : greater than 10 days with
  no improvement that include:
  • nasal or postnasal discharge of any quality .

  • day time cough (may be worse at night ) .

  • Less common complains include low grade fever
    fatigue malodorous breath or periorbital edema .
       Sinusitis
  clinical diagnosis


– Severe symptoms : include a temp of at
  least 39C and purulent nasal discharge
  present for at least 3-4 consecutive days in
  a child who seems ill .
               Sinusitis
        clinical diagnosis
Physical examination does not
 contribute substantially to the diagnosis
 of acute bacterial sinusitis .
Facial pain is unusual and facial
 tenderness is rare and unreliable finding .
Periorbital swelling is suggestive of
 ethmoid sinusitis .
The value of transillumination of the
 sinuses is controversial and found to be
 unreliable in children younger than 10
 years .
                Sinusitis
               Laboratory
• Laboratory assessment :
   – Routine laboratory testing is not
     recommended in the initial evaluation.
   – Organisms recovered from the
     nasopharyngeal washing do not reflect the
     organism found in sinus aspirate (Wald et al
     1998).
                    Sinusitis
                    Laboratory

– Sinus aspiration and culture may need to
  be considered in :
   • Sever illness and toxic looking child .
   • Immunocomproised child .
   • Suppurative or intracranial complications
       Recurrent sinusitis
• Recurrent acute bacterial sinusitis :
  3 episodes of acute bacterial sinusitis in 6
  months or 4 episodes in 12 months.

  – The most common cause is recurrent viral
    upper respiratory infections .

  – Other predisposing conditions :
     • allergic rhinitis :60% of patients with
       refractory sinusitis had increased total
       immunoglobulin E (IgE) or marked skin
       reactivity .
   Recurrent sinusitis
– Other predisposing conditions :
   • Anatomical abnormalities ,( deviated
     septum ) .
   • Immune deficiencies .
   • cystic fibrosis .
   • ciliary disorders .
 Recommendation2

• Imaging studies are not necessary
  to confirm a diagnosis of clinical
  sinusitis in children below 6 years
  of age .
Sinusitis
Imaging
   • In children with persistent or
     protracted symptoms
     predicted significantly
     abnormal radiographs:
      – Complete opacifications.
      – Mucosal thickening .
      – Air fluid level
        in 88% of children below 6
        years and 70% after 6 years .
 Abnormal Imaging in Children with
  Upper Respiratory Symptoms
Age Range        Imaging       % Abnormal
                 Mechanism
6 months-15      Plain films   15-57%
years
Infants and      Computed      18-67%
children         tomography
                 scan
Young children   Computed      100%
Glasier et al    tomography
                 scan
           Sinusitis
           Imaging
• Radiographs can be safely omitted before 6 years
  but still controversial after 6 years.

• Paranasal sinus abnormalities are nonspecific
  ,often present without sinusitis and may last longer
  than clinical symptoms .
      Recommendation 3

• CT scans for the paranasal sinuses
  should be reserved for patients in
  whom surgery is considered as a
  management strategy.
           Sinusitis
             CT Scan
• CTS of the paranasal sinuses indicated in :

  – Suspected subperiosteal or orbital abscess
    ,otolaryngology consultation is recommended .

  – Suspected intracranial complications .

  – Persistent or recurrent infections not
    responding to medical treatment .
   Recommendation 4

• Antibiotics are recommended for the
  management of acute bacterial
  sinusitis to achieve a more rapid
  clinical cure .
                Sinusitis
               treatment
• Children receiving antimicrobial therapy
  recovered more quickly and more often
  than those receiving placebo (Wald et al).
• A recent study has challenged the notion
  that children identified as acute sinusitis on
  clinical ground will benefit from
  antimicrobial therapy (Garbutt et al Ped
  2001).
     Calculation of the Likelihood that a Child With
    Acute Bacterial Sinusitis Will Fail Treatment With
            Standard Doses of Amoxicillin
Bacterial     Prevalence Spontaneous   Prevalence Failure to
species                  Cure Rate     of Resistance Amoxicillin


Strep            30          15%           25%           3%
Pneumonia


H.               20          50%           50%           5%
Influenzae

M.               20       50-              100%        5-10%
Catarrhalis
                         75%
                  Sinusitis
                 treatment
• Amoxicillin is still the first line therapy .
• Approximately 80% of children with acute
  bacterial sinusitis will respond to treatment
  with amoxicillin in the absence of any risk
  factors which are:
   – Attendance at day care .
   – Recent recipient (<90 days) of antimicrobial .
   – Age less than 2 years .
                  Sinusitis
                 treatment
• Patients with risk factors for resistant
  strains , not improving on usual dose of
  amoxicillin or with moderate or more
  severe illness should be initiated with high
  dose amoxicillin-clavulanate .
• Alternative therapies include cefuroxime ,
  cefdinir ,cefporoxim .
• If the patient is allergic to amoxicillin
  clarithromycin or azithromycin can be
  used .
                      Sinusitis
• Neither trimethoprim-sulfamthoxazole nor
  erythromycin-sulfisoxazole are appropriate
  choices .
• Two options for patients not improving on
  second coarse of AB or who are acutely ill :
  – Ceftriaxone IV.
  – Consult an otolaryngologist for consideration of
    sinus aspiration.
• Suggestion has been made to continue
  antibiotics for 7 days after clinical
  improvement.
   Age 1- 21 yr                        Mild-
 With persistent or                  moderate Sx
    Sever URTI



                          Daycare                      No daycare
                        attendance

 Sever Sx

                                Recent A.b Rx       No recent A.b Rx




Give:                                              Penicillin allergy
-Amox/clav (high dose                              a) Mild: cefuroxime
Cefuroxime                  No penicillin          Cefpodoxime
Cefpodoxime                 allergy: give          Cefdinir
cefdinir                    Usual-high             b) anaphylaxis:
                            dose Amoxicillin       Azithromycine
                                                   clarithromycine
                      Dosages
A. High dosage amoxicillin = 90mg/kg/day in 2 divided
   doses. High dose amox/clav = 90mg/kg/day amox;
   6.4 mg/kg/day clav in 2 divided doses
B. Usual dose amox = 45 mg/kg/day in 2 divided doses
C. Most patients with penicillin allergy will tolerate
   Cephalosporins. If allergy manifests as anaphylaxis
   macrolides should be given instead of
   Cephalosporins:
  1. Cefuroxime: 30mg/kg/day in 2 divided doses
  2. Cefpodoxime 10mg/kg/day once daily
  3. Cefdinir 14 mg/kg/day once daily
  4. Azithromycin 10 mg/kg on day 1; 5mg/kg x 4 days once
     daily.
  5. Clarithromycin 15mg/kg/day in 2 divided doses
     Recommendation 5
• For adjuvant therapy no
  recommendations are made based
  on controversial or limited data
  .Available agents include :
   – Nasal saline irrigation .
   – Antihistamine and decongestants .
   – Topical intranasal steroid .
   – Mucolytic agents .
       Recommendation 6
• No recommendations are made for
  antibiotic prophylaxis based on limited
  and controversial data .
   – Concerns regarding the increasing
     prevalence of antibiotic-resistant
     organism .
   – More appropriate to initiate
     evaluation for predisposing factors
     for recurrent sinusitis .
      Recommendation 7

• No recommendations are made for
  complementary / alternative
  medicine for prevention or
  treatment of rhinosinusitis based on
  limited and controversial data .
    Recommendation 8
• Children with complications or
  suspected complications of acute
  bacterial sinusitis should be
  treated promptly and
  aggressively .
• This should include referral to
  otolarungiologist with
  consultation of ophthalmologist
  and neurosurgeon strong
  recommendation based on
  strong consensus .
Complications of sinusitis

 • Orbital and periorbital inflamation are the
   most common complications of acute
   sinusitis :
    –   Periorbital cellulitis .
    –   Subperiosteal abscess .
    –   Orbital abscess .
    –   Orbital cellulitis .
 • Suppurative complications generally require
   surgical drainage .
Complications of sinusitis

 • Patients with altered mental status ,signs of
   increased intracranial pressure or nuchal
   rigidity require CT scanning of the brain , orbit
   and sinuses to exclude intracranial
   complications .
Preseptal cellulitis
Orbital cellulitis
Subperiosteal abscess
Sphenoid sinusitis
Brain abscess
Cavernous sinus thrombosis
• The diagnosis of acute bacterial sinusitis is based on
  clinical criteria.

• antibiotic therapy should be reserved for patients who
  have clear and severe symptoms of bacterial disease
  (not a pill for every ill).

• Imaging studies has limited role in diagnosis.

• Use of amoxicillin as first-line therapy .

• Suspected complications of acute bacterial sinusitis
  should be treated immediately and aggressively.
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