Sinusitis in children

1. Sinusitis in children Presented by Theera Rojanapremsuk

2. References ??????? ?? ?????????? Clinical practice guideline : management of sinusitis : AMERICAN ACADEMY OF PEDIATRICS :Volume 108, Number 3 :September 2001 SINUSITIS IN CHILDREN : Dept. of Otolaryngology, UTMB, Grand Rounds ,Kyle L. Kennedy, M.D. November 1, 1995 Up to date 13.1

3. Sinuses Sinuses are moist air spaces within the bones of the face around the nose Human have 4 pairs of sinuses The ethmoid and the maxillary sinuses form in the third to fourth gestational month 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.

5. Sinusitis

6. Sinusitis Sinusitis is the inflammation/infection of 1 or more paranasal sinuses It is traditionally subdivided into - acute (symptoms lasting <3 wk) - subacute (symptoms lasting 3 wk to 3 mo) - chronic (symptoms lasting >3 mo).

7. Anatomy and physiology The maxillary, ethmoid, frontal and sphenoid are air-containing spaces that are lined by pseudostratified, columna epithelium bearing cilia The sinus mucosa contain goblet cells, which secrete that aids in trapping inhales particle and debris

10. Osteomeatal complex

11. Pattern of the mucociliary clearance is essential for the proper health of the function of the paranasal sinuses (PNS) The middle meatus is functional importance , as it serves as a drainage pathway for the maxillary, ethmoid and frontal sinuses

12. Epidemiology An estimated more than 30 million patients in US have sinus disease. Although the exact incidence of sinusitis in the pediatric population is unclear Upper respiratory infections (URIs) are one of the most common presentations A viral infection associated with the common cold is the most frequent etiology of acute sinusitis Approximately 5-13% of URTIs are complicated by bacterial sinusitis

13. Pathogenesis

15. Predisposing factors 1. Local factor - cold or rhinitis - allergy - nasal polyp - foreign body - deviated of nasal septum 2. Systemic factor - cystic fibrosis - defective ciliary function - immuno- compromised host

16. Microbial etiology Viruses are the most frequent cause of rhinosinusitis viruses are known to predispose to subsequent bacterial infection via such mechanisms as viral-induced impairment of the mucociliary apparatus.

17. Microbial etiology

18. Diagnosis Sign and symptom Physical examination Radiologic tests

19. sign and symptom of sinusitis Nasal congestion Purulent discharge Maxillary tooth discomfort Hyposmia Facial pain or pressure that is worse when bending forward

21. Sign and symptoms In pediatric patients, most URIs last 5-7 days. By 10 days, the URI almost always improves. Most rhinoviral infections improve within 7-10 days so the complaint of persistent or worsening symptoms may indicate a developing bacterial sinusitis. Pediatric patients may complain of a daytime cough and persistent nasal discharge. Complaints of facial pain and headache are rare in children.

22. Younger kids typically have cold-like symptoms, including a stuffy or runny nose and slight fever if child develops a fever after the third or fourth day after cold symptom begin, it could sinusitis In older children and teens, the most frequent symptoms of sinusitis are a daytime dry cough that doesn't improve after the first 7 days of cold symptoms, fever, worsening congestion, dental pain, ear pain, or tenderness in the face.

24. Physical examination - Facial tenderness to palpation is present - Nasal mucosa is inflammation, redness and swelling - Purulent secretions in the middle meatus (highly predictive of maxillary sinusitis) - Complete opacification of sinus on transillumination is present.

27. Radiologic tests Plain film CT scan MRI

28. Plain film - caldwell for frontal and ethmoid - Water’s for maxillary and sphenoid - submentovertex and lateral for sphenoid

31. Plain film

33. CT scan - CT scanning is the criterion standard for evaluation - Indications for obtaining a CT of the sinuses include 1. evidence of severe, persistent sinus disease following maximal medical therapy 2. sinus disease in the immunocompromised patient 3. suspicion of a suppurative complication of sinus disease.

34. CT scan

36. Therapy Non-medical treatment Medical theray Surgical therapy

37. Supportive treatment Avoid cigarette smoking Drink plenty of liquids Steam (e.g. showers or baths) to loosen secretions Warm facial packs for 5-10 minutes 3-4 times a day to promote drainage Saline nasal spray or drops may provide some relieve Adequate rest Elevate head of bed to promote sinus drainage

38. Medical therapy Acetaminophen or ibuprofen Decongestants Antihistamine Mucoevacuants Antibiotics

39. Antibiotics Amoxicillin remains as efficacious as newer drugs : 80-90 MKD divided bid for 10-14 days (maximum dose 2-3 g/day) If not improvement : in 48-72 hrs ceftriaxone or amoxicillin-clavulanate 80-90 MKD divided bid for 7-10 days Other treatment alternatives : cefdinir, cefpodoxime, cefuroxime For severe allergies : azithromycin or clarithromycin

40. For the treatment of recurrent or chronic sinusitis, a more lengthy course of therapy, usually with a beta lactamase- resistant antibiotic, is desirable 3-4 week course of an appropriate antibiotic In the immunocompromised patient, prophylactic antibiotic regimens are often utilized in addition to aggressive general management.

42. Surgical therapy Indirect sinus procedure - septoplasty - adenoidectomy Direct sinus procedure - antral lavage & sinus aspiration - Nasal antral windows - Middle meatal antrostomy

44. Complication Orbital involvement - Preseptal cellulitis - Eyelid edema, erythema, normal globe movement - Orbital cellulitis - Proptosis, chemosis - Periorbital abscess - Proptosis with globe displaced inferolaterally, decreased extraocular muscle movement - Orbital abscess - Severe proptosis, impaired visual acuity, fixed globe, toxic patient - Cavernous sinus thrombosis - High fever, bilateral symptoms

45. Intracranial involvement - Intracranial involvement usually occurs subsequent to direct spread from sphenoid or frontal sinus disease. - Subdural and frontal lobe abscesses are most common. -Meningitis may occur