Let’s switch fro
noses to sinuses.
So the sinuses can get infected
and this is sinusitis.
So this is an infection of the mucosal
lining of any of the paranasal sinuses.
Remember that sinuses are
different in children and adults.
You’re not born with
all your sinuses.
Let’s go through them.
The ethmoid sinuses are those
tiny ones right there on middle,
those are present at birth.
The maxillary sinus will usually show
up sometime in the first year of age.
And the sphenoid sinus will
show up shortly thereafter.
But the frontal sinuses don’t show up
typically until after 10 years of age.
So if a patient is complaining
of a frontal headache,
it’s probably not a sinusitis
if they’re under 10.
So how do we diagnose sinusitis?
Typically, what we do is we
assume in acute sinusitis
if a patient has had more than 10
days of nasal drainage and irritation
or less than 30
days of symptoms.
That’s acute sinusitis,
but it has to be more
than 10 days of symptoms
and it has to be
sort of unrelenting.
It’s continuing on, not
about to get better.
A subacute sinusitis is typically a
patient with 4 to 12 weeks of symptoms
and chronic sinusitis is typically
more than three months of symptoms.
So what are the organisms
in bacterial sinusitis?
Well, strep pneumoniae, non-typeable H.
flu, and Moraxella catarrhalis,
which are your classic ear infection
organisms, can also affect the sinuses.
But the sinuses can also have staph
aureus and a variety of anaerobes.
So it’s generally a very mixed
picture of an infection.
There are certain diseases that are more
associated with sinusitis than others.
So patients with cystic fibrosis are
often cursed with recurrent sinusitis.
Patients with Kartagener syndrome are
at increased risk for sinusitis.
And certain immune
deficiencies are also at risk.
Typically, humeral immune deficiency such
as low IgA, low IgG or Job’s syndrome,
which is hyper IgE syndrome or patients
with common variable immunodeficiency
which usually shows up
a little bit later.
So those are the immunodeficiencies that
are typically associated with sinusitis.
And these patients usually
get recurrent episodes.
So what are some other risk
factors for sinusitis?
Well, smoke exposure certainly like these
children, you’d have a risk factor,
but also second hand smoke exposure is
a common risk factor for sinusitis.
Also, frequent URI symptoms is
a risk factor for sinusitis
as is chronic allergic
So these very allergic kids may
be at more risk for sinusitis.
So how do we diagnose it?
Well, they have to have nasal
discharge for more than 10 days.
They need to have purulent
discharge and/or high fever.
And you should have generally,
facial pain and headache,
but that is less common in
children than it is in adults.
Sinus films are really not useful.
They’re really not useful
and a CT is diagnostic,
but there’s a high false positive rate
in that many people who are asymptomatic
will show up with sinusitis,
like you can see in this patient
with extensive sinus disease.
Or you might be unnecessarily
irradiating the patient.
So remember, children are at increased
risk for cancer with radiation exposure
doing more mitosis.
So we really want to avoid
radiation exposure in kids.
And so a CT of the sinuses
is really not indicated.
This is a clinical diagnosis.
More than 10 days of purulent
congestion and there’s your diagnosis.
What do we give them?
Well, typically, because
of the broad nature
of the organisms that
can cause the disease,
you start with amoxicillin/clavulanic acid.
If they’re allergic to penicillin,
you can also do clindamycin.
If there’s no improvement
in 72 hours,
discontinue the antibiotic
and consider another
cause like virus or
Therapy for seven days after
resolution of symptoms
is indicated so it’s usually
up to 10-day course.
In other words, start antibiotics.
On day three, if they’re
not getting better,
it’s probably not bacterial
sinusitis, you can stop the med.
If they are getting better,
continue for a 10-day course.
There’s no evidence that nasal
washers or steroid sprays
or anything like
that is beneficial.
Also, consider ear, nose and
throat referral for endoscopy
for severe or chronic
or unresolved cases.
They might have problem
in there like polyps
or they might have an underlying disorder,
which can be diagnosed by biopsy,
like Kartagener syndrome.
So that’s my review of
nasal problems in kids.
Thanks for your time.