sinusitis in children

angus shao

definition

• inflammation of 1 or more of the paranasal sinuses

• acute sinusitis: <4 weeks• subacute sinusitis: 4 to 12 weeks• chronic sinusitis: > 12 weeks – some guidelines also requiring :• failure to respond to treatment• one positive imaging study

definition

EPOS Guidelines, Rhinology 2012

etiology

• multifactorial– local factor–host factor–environmental

pathophysiology

• bacteriology• CD4+ Lymphocytes and eosinophils • adenoids

"Microbiology of Sinusitis", Proceedings of the American Thoracic Society, Vol. 8, No. 1 (2011), pp. 90-100.

Tomassen P, Van Zele T, Zhang N, Perez-Novo C, Van Bruaene N, Gevaert P, et al.Pathophysiology of chronic rhinosinusitis.Proceedings of the American Thoracic Society. 2011 Mar;8(1):115-20.

iImpossible to differentiate between adenoid hypertrophy/adenitis and sinusitis

clinical

• full history and exam• anterior rhinoscopy – middle meatus, IT, mucosa, pus

• nasoendoscopy (if tolerated)– middle meatus, adenoid bed, nasopharynx

• oral cavity– Drainage, cobble stoning, tonsillar hypertrophy

• polys – Rule out CF, AFS

clinical

• video

however…• S/S difficult to evaluate in infants and

preschool children:– congestion (very subjective/indirect/parent’s bias)– only anterior rhinorrhea is reported– sense of smell– headache/toothache/facial pain– cough, irritability, fever, fatigue etc unspecific symptoms– examination difficult, endosocpy almost impossible

Jones NS, Acute and chronic sinusitis in children. Curr Opinion Pulm Med, 2000 May;6(3):221-5

Severity of Sinusitis• Disease severity can be divided into:– Mild (0-3 points)– Moderate (4-7 points)– Severe (8-10 points)

• Using a 10-point scoring system or Visual Analogue Scale (VAS)

EPOS Guidelines, Rhinology 2012

consider

• allergic rhinitis• asthma• GERD• immune deficiency• primary ciliary dyskinesia• cystic fibrosis

investigation

• culture• allergy skin testing/RAST• immunodeficiency testing• CT scan– poor sensitivity and specificity

• MRI for complications– orbital– intracranial

Radiologic correlates of symptom-based diagnostic criteriafor chronic rhinosinusitis Otolaryngol Head Neck Surg 2003;128:489-96

medical treatment

EPOS Guidelines, Rhinology 2012

surgical treatment

• adenoidectomy: improvement in 70%

• FESS: improvement in ~ 86% with 0.6% complication

FESS

surgical treatment

• FESS meta analysis: improvement in 82-100%, complication rate 1.6%

• no impact on facial skeleton growth

treatment

EPOS Guidelines, Rhinology 2012

Question

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