Pediatric Rhinosinusitis – Chronic and Acute

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Pediatric Rhinosinusitis – Chronic and Acute

Pediatric Otolaryngology
Author Credentials 

William O. Collins, MD
Associate Professor
Department of Otolaryngology
University of Florida College of Medicine
Gainesville, FL

Module Summary

Children are frequently affected with upper respiratory infections, of which some develop into rhinosinusitis. Depending on the time course of the symptoms, rhinosinusitis can be classified as either acute or chronic. Proper diagnosis of rhinosinusitis in children is critical, as there are many other disease conditions with overlapping symptomatology but require different treatments. Treatment strategies can follow an escalation of care, from the least invasive options such as nasal saline rinses, allergy management and antibiotics, to surgical options such as adenoidectomy, balloon sinuplasty, or endoscopic sinus surgery.

Module Learning Objectives 
  1. Explain the clinical manifestations of rhinosinusitis in the pediatric patient, including symptomatology specific of both acute and chronic infections.
  2. Review the pathophysiology behind pediatric rhinosinusitis.
  3. Describe treatment options for pediatric patients suffering rhinosinusitis.
  4. Identify potential complications of rhinosinusitis, including orbital and intracranial.

Embryology

Learning Objectives 

To understand the embryologic development of the nose and paranasal sinuses.

References 
  1. Medina J, Hernandez H, Tom LW, et al. Development of the paranasal sinuses in children. Am J Rhinol. 1997;11(3):203-209.
  2. Wolf G, et al. Development of the paranasal sinuses in children: implications for paranasal sinus surgery. Ann Otol Rhinol Laryngol. 1993;102:705-711.

Anatomy

Learning Objectives 

To understand the anatomy pertinent to the development of rhinosinusitis, and its potential complications.

References 
  1. Davis WE, et al. Anatomy of the paranasal sinuses. Otolaryngol Clin North Am. 1996 Feb;29(1):57-74.

Pathogenesis

Learning Objectives 

To describe the factors which lead to development of rhinosinusitis in children:

  • Acute rhinosinusitis
  • Chronic rhinosinusitis
References 
  1. Cook PR, Nishioka GJ. Allergic rhinosinusitis in the pediatric population. Otolaryngol Clin North Amer. 1996 Feb;29(1):39-56.
  2. Clement PAR, Bluestone CD, Gordts F, Lusk RP, et al. Management of Rhinosinusitisin Children: Consensus Meeting, Brussels, Belgium, September 13, 1996. Arch Otolaryngol Head Neck Surg. 1998;124(1):31-34.
  3. Phipps CD, Wood WE, Gibson WS, et al. Gastroesophageal reflux contributing to chronic sinus disease in children: a prospective analysis. Arch Otolaryngol– Head Neck Surg. 2000;126(7):831-36.

Incidence

Learning Objectives 

To know the incidence of rhinosinusitis in children, including what constitutes an abnormally high number of annual episodes.

References 
  1. Nishioka GJ, Cook PR. Paranasal sinus disease in patients with cystic fibrosis. In Otolaryngol Clin North Amer: Pediatric Sinusitis. 1996 Feb;29(1):193-205.
  2. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. 1999;103(3 Pt 1):408-414.
  3. Cunningham JM, Chiu EJ, Landgraf JM, Gliklich RE. The Health Impact of Chronic Recurrent Rhinosinusitis in Children. Arch Otolaryngol Head Neck Surg. 2000;126(11):1363-1368.

Genetics

Learning Objectives 

To identify genetic conditions which predispose pediatric patients to rhinosinusitis:

  • Cystic fibrosis
References 
  1. Parsons DS, Greene BA. A treatment for primary ciliary dyskinesia: efficacy of functional endoscopic sinus surgery.  Laryngoscope. 1993 Nov;103(11 Pt 1):1269-72.
  2. Nishioka GJ, Cook PR. Paranasal Sinus Disease in Patients with Cystic Fibrosis. In Otolaryngol Clin North Amer: Pediatric Sinusitis. 1996 Feb;29(1):193-205.
  3. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. 1999;103(3 Pt 1):408-414.

Patient Evaluation

Learning Objectives 

To perform a thorough history and physical examination in a pediatric patient suspected of suffering from rhinosinusitis.

References 
  1. Aitken M, Taylor JA. Prevalence of clinical sinusitis in young children followed up by primary care pediatricians. Arch Pediatr Adolesc Med. 1998;152(3):244-48.
  2. Cunningham JM, Chiu EJ, Landgraf JM, et al. The health impact of chronic recurrent rhinosinusitis in children. Arch Otolaryngol Head Neck Surg. 2000;126(11):1363-368.
  3. Piccirillo JF, Merritt MG Jr, Richards ML. Psychometric and clinimetric validity of the 20-item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg. 2002;126(1):41-47.

Measurement of Functional Status

Learning Objectives 

To describe common validated instruments or tools used to quantify the effects of rhinosinusitis in pediatric patients.

References 
  1. Wald ER, Bordley WC, Darrow DH, et al. Clinical Practice Guideline: Management of Sinusitis. Pediatrics. 2001;108(3):798-808.
  2. Cunningham JM, Chiu EJ, Landgraf JM, et al. The health impact of chronic recurrent rhinosinusitis in children. Arch Otolaryngol Head Neck Surg 2000;126(11):1363-368.
  3. Piccirillo JF, Merritt MG Jr, Richards ML. Psychometric and clinimetric validity of the 20-item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg. 2002;126(1):41-47.

Imaging

Learning Objectives 

To describe the advantages and disadvantages of different imaging techniques available for use in pediatric patients with rhinosinusitis:

  • CT scanning
  • MRI
References 
  1. Manning SC, Biavati MJ, Phillips DL. Correlation of clinical sinusitis signs and symptoms to imaging findings in pediatric patients. Int J Pediatr Otorhinolaryngol. 1996 Sep;37(1):65-74.
  2. Willner A, Choi SS, Vezina LG, Lazar RH. Intranasal Anatomic Variations in Pediatric Sinusitis. Am J Rhinol. Sept-Oct. 1997;11(5):355-360.
  3. Lusk RP, McAlister B, el Fouley A. Anatomic Variations in Pediatric Chronic Sinusitis: A CT Study. Otolaryngol Clinics of North America. 1996;29(1):75-91.

Pathology

Learning Objectives 

To describe common histopathologic findings in pediatric patients with rhinosinusitis, and the implications towards understanding disease pathophysiology.

References 
  1. Shin SY, Choi GS, Park HS, Lee KH, Kim SW, Cho JS. Immunological investigation in the adenoid tissues from children with chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2009;141:91-96.
  2. Chan KH, Abzug MJ, Coffinet L, Simoes EAF, Cool C, Liu AH. Chronic Rhinosinusitis in Young Children Differs from Adults: a Histopathologic Study. J Pediatr. 2004;144:206-212.

Treatment

Learning Objectives 

To understand treatment strategies in pediatric patients with rhinosinusitis.

References 
  1. Parsons DS. Chronic Sinusitis: A Medical or Surgical Disease? In Otolaryngol Clin North Amer: Pediatric Sinusitis. 1996 Feb;29(1):1-9.
  2. Shoseyov D, Bibi H, Shai P, et al. Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol. 1998;101(5):602-605.
  3. Tomooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation. Laryngoscope. 2000;110(7):1189-193.
  4. Chow AW, Benninger MS, Brook I, et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012 Apr;54(8):e72-e112.

Medical Therapies

Learning Objectives 

To identify medical therapies for acute and chronic rhinosinusitis:

  • Nasal sprays/rinses
  • Allergy management
  • Antimicrobials
References 
  1. Brooks I, Gooch WM III, Jenkins SG, et al. Medical management of acute bacterial sinusitis. Recommendations of a clinical advisory committee on pediatric and adult sinusitis. Ann Otol Rhinol Laryngol. 2000 May;182:2-20.
  2. Clary RA. Acute inflammatory and infectious disorders of the nose and paranasal sinuses. In: Pediatric otolaryngology: principles and practice pathways. New York: Thieme; 2000: p. 465-74.
  3. Shoseyov D, Bibi H, Pintov S, et al. Treatment with hypertonic saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol. 1998;101(5):602-605.
  4. Parsons DS. Chronic Sinusitis: A Medical or Surgical Disease? In Otolaryngol Clin North Amer: Pediatric Sinusitis.1996 Feb;29(1):1-9.
  5. Don DM, Yellon RF, Casselbrant ML, Bluestone CD. Efficacy of a Stepwise Protocol that Includes Intravenous Therapy for the Management of Chronic Sinusitis in Children and Adolescents. Arch Otolaryngol Head Neck Surg. 2001;127(9):1093-1098.
  6. Garbutt JM, Goldstein M, Gellman E, Shannon W, Littenberg B. A Randomized, Placebo-Controlled Trial of Antimicrobial Treatment for Children with Clinically Diagnosed Acute Sinusitis. Pediatrics. 2001;107(4):619-625.

Pharmacology

Learning Objectives 

To understand the mechanism by which medical therapies treat rhinosinusitis in children.

References 
  1. Brooks I, Gooch WM III, Jenkins SG, et al. Medical management of acute bacterial sinusitis. Recommendations of a clinical advisory committee on pediatric and adult sinusitis. Ann Otol Rhinol Laryngol. 2000;182(Suppl):2-20.

Surgical Therapies

Learning Objectives 

To demonstrate surgical therapies for pediatric rhinosinusitis:

  • Adenoidectomy
  • Sinus tap and lavage
  • Balloon sinuplasty
  • Endoscopic sinus surgery
References 
  1. Lee D, Rosenfeld RM. Adenoid Bacteriology and Sinonasal Symptoms in Children. Otolaryngol Head Neck Surg. 1997;116(3):301-7.
  2. Brietzke SE, Brigger MT. Adenoidectomy outcomes in pediatric rhinosinusitis: A meta-analysis. Int J Pediatr Otorhinolaryngol. 2008;72:1541-1545.
  3. Vandenberg H. Efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg. 1997;123(7):675-8.
  4. Thottam PJ, et al. Functional endoscopic sinus surgery alone versus balloon catheter sinuplasty and ethmoidectomy: a comparative outcome analysis in pediatric chronic rhinosinusitis. Int J Pediatr Otorhinolaryngol. 2012;76:1355-1360.

Rehabilitation

Learning Objectives 

To identify long term sequelae in children who suffer from sinusitis, including the long term results of surgical treatments.

References 
  1. Bothwell MR, Piccirillo JF, Lusk RP, et al. Long-term outcome of facial growth after functional endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2002;126(6):628-34.
  2. Senior B, Wirtschafter A, Mai C, et al. Quantitative impact of pediatric sinus surgery on facial growth. Laryngoscope. 2000;110(11):1866-870.

Case Studies

  1. A 4 year old male presents to the ED with complaints of right eye swelling and surrounding erythema. He also has a 10 day history of purulent rhinorrhea, fevers, and facial tenderness.  What might be appropriate antibiotic choices? Would radiographic imaging be indicated in this case, and if so, which modality would be preferred? As you await the CT results, what potential findings on the CT scan would make you consider immediate surgical intervention?
  2. A 10 year old female presents to the outpatient clinic with a 6 month history of nasal congestion. What additional factors in her history would need to be present for you to start to consider chronic rhinosinusitis as the diagnosis? What adjunctive medical therapy would be recommended to start at this early stage? What would constitute “maximal medical therapy?”

Complications

Learning Objectives 

To identify possible complications from acute and chronic rhinosinusitis:

  • Orbital complications
  • Intracranial complications
References 
  1. Bothwell MR, Piccirillo JF, Lusk RP, et al. Long-term outcome of facial growth after functional endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2002;126(6):628-34.
  2. Gross RD, Sheridan MF, Burgess LP. Endoscopic sinus surgery complications in residency. Laryngoscope. 1997;107(8):1080-1085.
  3. Kinsella JB, Calhoun KH, Bradfield JJ, et al. Complications of endoscopic sinus surgery in a residency training program. Laryngoscope. 1995;105(10):1029-1032.
  4. Lusk RP, et al. Complications of sinusitis. In: Lusk RP, editor. Pediatric sinusitis. New York: Raven Press; 1992. p.127-46.
  5. Senior B, Wirtschafter A, Mai C, et al. Quantitative impact of pediatric sinus surgery on facial growth. Laryngoscope. 2000; 110(11):1866-870.
  6. Tana N, et al. Surgical treatment of subperiosteal abscess. Arch Otolaryngol Head Neck Surg. 2008; 134(7):764-767.
  7. Oxford LE, McClay J. Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children. Int J. Pediatr Otorhinolaryngol. 2006;70:1-9.

Review

Review Questions 
  1. What are the typical symptoms of acute rhinosinusitis in children? Chronic rhinosinusitis?
  2. What are some of the risk factors in children for the development of sinusitis?
  3. What are first line medical therapies for pediatric patients suffering from sinusitis?
  4. If antimicrobial agents are deemed necessary, which would be prescribed based on the time course of symptoms?
  5. At what point would surgical intervention be considered?  Which surgical interventions are most likely to render some improvement in clinical symptoms?
  6. What are the complications of acute rhinosinusitis in children?
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