SINUSITIS

Anatomy

• Paranasal Sinuses

Where are the sinuses?

• Four pairs of paranasal sinuses – Frontal-above eyes in forehead

bone– Maxillary-in cheekbones, under

eyes– Ethmoid-between eyes and nose– Sphenoid-in center of skull,

behind nose and eyes

What are the sinuses?

• The sinuses are hollow air-filled sacs lined by mucous membrane. The ethmoid and maxillary sinuses are present at birth. The frontal sinus develops during the 2nd year and the sphenoid sinus develops during the 3rd year.

What are the sinuses? (cont’d)

• Sinuses have small orifices (ostia) which open into recesses (meati) of the nasal cavities.

• Meati are covered by turbinates (conchae).

• Turbinates consist of bony shelves surrounded by erectile soft tissue.

• There are 3 turbinates and 3 meati in each nasal cavity (superior, middle, and inferior).

Considerations for Pediatrics

• At birth, the ethmoid, sphenoid and maxillary sinuses are tiny and cause problems in infants and toddlers.

• Frontal sinuses develop between 4-7 years of age, causing problems in school aged children and adolescents.

Sinusitis

• Inflammation of paranasal sinuses

What is sinusitis?

• An acute inflammatory process involving one or more of the paranasal sinuses.

• A complication of 5%-10% of URIs in children.

• Persistence of URI symptoms >10 days without improvement.

• Maxillary and ethmoid sinuses are most frequently involved.

How Does Sinusitis Develop?

• Usually follows rhinitis, which may be viral or allergic.

• May also result from abrupt pressure changes (air planes, diving) or dental extractions or infections.

• Inflammation and edema of mucous membranes lining the sinuses cause obstruction.

• This provides for an opportunistic bacterial invasion.

Development (cont’d)

• With inflammation, the mucosal lining of the sinuses produce mucoid drainage. Bacteria invade and pus accumulates inside the sinus cavities.

• Postnasal drainage causes obstruction of nasal passages and an inflamed throat.

• If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities.

Predisposing Factors

• Allergies, nasal deformities, cystic fibrosis, nasal polyps, and HIV infection.

• Cold weather• High pollen counts• Day care attendance• Smoking in the home• Reinfection from siblings

Acute or Chronic Sinusitis?

• Acute Sinusitis – respiratory symptoms last longer than 10 days but less than 30 days.

• Sub acute sinusitis – respiratory symptoms persist longer than 30 days without improvement.

• Chronic sinusitis – respiratory symptoms last longer than 120 days.

Etiology of Sinusitis

70% of bacterial sinusitis is caused by:• Streptococcus pneumoniae• Haemophilus influenzae• Moraxella catarrhalisOther causative organisms are:• Staphylococcus aureus• Streptococcus pyogenes,• Gram-negative bacilli• Respiratory viruses

Complications of Sinusitis

• Orbital cellulitis or abscess• Meningitis• Brain abscess• Intractable wheezing in children with asthma• Cavernous sinus thrombosis• Subdural empyema

Subjective Symptoms of Sinusitis

• History of URI or allergic rhinitis• History of pressure change• Pressure, pain, or tenderness over sinuses• Increased pain in the morning, subsiding in the afternoon• Malaise• Low-grade temperature• Persistent nasal discharge, often purulent• Postnasal drip• Cough, worsens at night• Mouthing breathing, snoring• History of previous episodes of sinusitis• Sore throat, bad breath• Headache

Clinical Presentations of Sinusitis

• Periorbital edema• Cellulitis• Nasal mucosa is reddened or swollen• Percussion or palpation tenderness over

a sinus• Nasal discharge, thick, sometimes yellow

or green• Postnasal discharge in posterior pharynx• Difficult transillumination• Swelling of turbinates• Boggy pale turbinates

Pale, Boggy Turbinates

Diagnostic Tests

• Imaging studies, such as sinus radiographs, ultrasonograms, or CT scanning – indicated if child is unresponsive to 48 hours of antibiotics and if the child has a toxic appearance, chronic or recurrent sinusitis, and chronic asthma.

• Laboratory studies, such as culture of sinus puncture aspirates.

Differential Diagnoses

• Allergic rhinitis• Non-allergic rhinitis• Infectious rhinitis• Drug-induced rhinitis• Nasal polyps• Dental abscess• Carcinoma of sinus• Cluster headache• Structural defects (septum deviation)• Nasal foreign body

Pharmacological Plan of Care

• Amoxicillin:90mg BID for 10 days or • Azithromycin 12mg for 5 days

(penicillin allergy).• Paracetamol 15mg every 6 hrs• Salt water gargle.

Pharmacological Plan of Care

• Adults:Paracetamol 500mg Tid 5 days• Amoxycillin 500mg BID 10 days• Ofloxacin 400mg BID for 10 days• (penicillin allergy)• Salt water gargle

Patient Education

• Avoid allergy triggers,antihistamine or nasal corticosteroids

• Eat fruits & vegetables,• Reduces stress,• Wash hands and maintain

hygiene.• Avoid smoke and pollution

hydration

Follow Up Guidelines

• Instruct parent to call in 48 hours if condition of child has not improved.

• Instruct parent to bring child in for a recheck in 2 weeks.

Guidelines for Referral

• Child with complications or signs of invasive infection.

• Child needing control of allergic rhinitis.• Child with chills and fever.• Child with persistent headache.• Child with edema of forehead, eyelids.• Child with orbital cellulitis