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772 SECTION 12: Pediatrics Nose and Sinus Disorders in Infants and Children Joanna S. Cohen Dewesh Agrawal ACUTE BACTERIAL SINUSITIS Acute bacterial sinusitis is a bacterial infection of one or more of the paranasal sinuses lasting <30 days. 1 The most common predisposing factor is a viral upper respiratory infection (URI). The incidence of viral URIs in children age 6 to 35 months is approximately six episodes per patient-year, with approximately 8% of those becoming complicated by acute bacterial sinusitis. Bacterial sinusitis in children is most common in the 12 to 23 months age group, probably because these children are most likely to be in day care, predisposing them to URIs. 2,3 The cost of acute pediatric bacterial sinusitis in the United States is approximately $20,000 per hospitalized patient, and a large geographic variation in healthcare utilization exists. 4 Total healthcare costs in the United States incurred from treating sinusitis in children <12 years of age had been estimated at close to $2 billion a year. PATHOPHYSIOLOGY The sinuses are air cavities lined with ciliated columnar epithelium that helps mucus clearance by pushing mucus and debris out of the sinus ostia into the nasal cavity. Blockage of the ostia by mucus and inflam mation predisposes to bacterial sinusitis. The ethmoid and maxillary sinuses are present at birth and are most commonly involved in sinusitis in children. The sphenoid sinuses form at 3 to 5 years of age. The frontal sinuses do not appear until 7 to 8 years of age and remain incompletely pneumatized until late adolescence. The most common predisposing factors for acute bacterial sinusitis are diffuse mucositis secondary to viral rhinosinusitis in about 80% and allergic inflammation in about 20%. 6 Less common predisposing factors include nonallergic rhinitis, cystic fibrosis, dysfunctional or insufficient immunoglobulins, ciliary dyskinesia, and anatomic abnormalities. The most common pathogen of acute bacterial sinusitis is Streptococcus pneumoniae, recovered in 30% of children with acute sinusitis. Nontypeable Haemophilus influenzae and Moraxella catarrhalis are each recovered in 20%.7,8 CLINICAL FEATURES Children with acute bacterial sinusitis typically present with high fever and purulent nasal discharge. Headache, particularly behind the eye, is variable. Complaints of facial pain in children are rare. 2 Parents may report halitosis. The physical examination findings of acute bacterial sinusitis are often similar to those of uncomplicated viral sinusitis, with swollen and erythematous turbinates and mucopurulent discharge. However, reproducible unilateral tenderness to percussion or direct pressure of the frontal or maxillary sinus may indicate acute bacterial infection, and periorbital edema might indicate ethmoid sinusitis. 2 Transillumination of the maxillary sinuses is unreliable in children <10 years of age. 9 DIAGNOSIS Although the gold standard for diagnosis of acute bacterial sinusitis is the recovery of ≥10 4 colony-forming units/mL of bacteria from the paranasal sinuses, sinus aspiration is painful and impractical in the ED.7 Therefore, diagnosis is often based on clinical criteria that help to dis tinguish acute bacterial sinusitis from an uncomplicated viral URI in an ill-appearing child (Table 123-1).
recovery of ≥10 4 colony-forming units/mL of bacteria from the paranasal sinuses, sinus aspiration is painful and impractical in the ED.7 Therefore, diagnosis is often based on clinical criteria that help to dis tinguish acute bacterial sinusitis from an uncomplicated viral URI in an ill-appearing child (Table 123-1). 1,10 Imaging studies should not be obtained to differentiate acute bac terial sinusitis from viral URI because of the high incidence of sinus mucosal abnormalities in patients with simple upper respiratory symp toms or no clinical symptoms at all.1 In one study, mucosal sinus changes were evident in 97% of infants who had a URI in the 2 weeks preceding a cranial CT done for unrelated reasons. 11 Plain films have limited utility because they require correct positioning that is technically difficult in young children, and there is only a 70% to 75% correlation of culture confirmation with abnormal-appearing sinus radiographs. 12 A paranasal sinus CT with contrast or an MRI with contrast is, however, recommended for suspected orbital or CNS complications of bacterial sinusitis, including preseptal or postseptal cellulitis, subperiosteal abscess, cav ernous sinus thrombosis, osteomyelitis of the frontal bone (Pott’s puffy tumor), subdural empyema, epidural or brain abscess, and meningitis. 1,12 TREATMENT Patients with mild symptoms suggestive of a viral infection can be observed for 7 to 10 days, with no antibiotics prescribed. However, if symptoms persist or are severe (see Table 123-1), suspect acute bacterial sinusitis and prescribe antibiotics to speed recovery, prevent suppurative complications, and minimize asthma exacerbations in susceptible children. Antibiotic treatment for acute sinusitis is outlined in Table 123-2 and Figure 123-1. Decongestants, antihistamines, and nasal irrigation are not effective for children with acute bacterial sinusitis. 13 Adjunctive therapy with intranasal steroids (e.g., fluticasone propionate, one to two sprays per nostril daily, or beclomethasone, one to two sprays per nostril twice a day) has modest benefits and may be considered. 1,14,15 Complications of acute bacterial sinusitis are rare but usually involve the orbit or CNS. If suspected, obtain a contrast-enhanced CT scan or an MRI if possible. 16 Proptosis or impairment of extraocular muscle movement suggests orbital inflammation, usually from extension of an ethmoidal infection (Figure 123-2). Frontal and sphenoidal inflammation can lead to intracranial extension, causing frontal lobe and subdural abscesses as well as meningitis and empyema. IV antibiotics are needed, and surgical management may be necessary. Consult an ophthalmolo gist and/or neurosurgeon promptly for complications. 1 For further discussion of the management of periorbital and orbital sinusitis, see Chapter 122, “Eye Emergencies in Infants and Children. ” CHRONIC BACTERIAL SINUSITIS Chronic rhinosinusitis is an inflammatory process involving the mucosa of the nose and sinuses that lasts >3 months. 17 Factors associated with chronic sinusitis include older age, allergic rhinitis, recurrent viral URIs, immunodeficiency, ciliary dyskinesia, anatomic abnormalities, and fungal colonization of the sinuses. 18 The most common organisms identi fied are α-hemolytic Streptococcus, H. influenzae, and S. pneumoniae .19 Chronic sinusitis has been linked to asthma, and treatment of chronic sinusitis reduces asthma symptoms.
RIs, immunodeficiency, ciliary dyskinesia, anatomic abnormalities, and fungal colonization of the sinuses. 18 The most common organisms identi fied are α-hemolytic Streptococcus, H. influenzae, and S. pneumoniae .19 Chronic sinusitis has been linked to asthma, and treatment of chronic sinusitis reduces asthma symptoms. In addition to the more common pathogens seen in acute bacte rial sinusitis, chronic sinusitis may also be caused by Staphylococcus aureus, anaerobes, and, rarely in children, fungi, including Aspergillus, Fusarium, Bipolaris, Curvularia lunata , and Pseudallescheria boydii.20 Antibiotics for chronic sinusitis should cover the usual pathogens of acute sinusitis as well as aerobic and anaerobic β-lactamase–producing bacteria. Commonly used oral antimicrobial agents include amoxicillin-clavulanate (20 to 25 milligrams/kg PO twice daily), clindamycin (8 milligrams/kg PO three times daily), and the quinolones (moxifloxacin, 400 milligrams PO daily) for adolescents. 21 Chronic bacterial sinusitis is treated with prolonged antibiotics, typically for at least 4 weeks.22 CHAPTER TABLE 123-1 Clinical Features of Acute Bacterial Sinusitis10 Persistent symptoms lasting >10 d without improvement Nasal or postnasal discharge and/or Daytime cough Worsening course Worse or new onset of nasal discharge, daytime cough, or fever after initial improvement Severe onset Fever ≥39°C (102.2°F) Purulent nasal discharge for ≥3 d Tintinalli_Sec12_p0669-0996.indd 772 8/2/19 7:51 PM
symptoms lasting >10 d without improvement Nasal or postnasal discharge and/or Daytime cough Worsening course Worse or new onset of nasal discharge, daytime cough, or fever after initial improvement Severe onset Fever ≥39°C (102.2°F) Purulent nasal discharge for ≥3 d Tintinalli_Sec12_p0669-0996.indd 772 8/2/19 7:51 PM CHAPTER 123: Nose and Sinus Disorders in Infants and Children 773 For patients with chronic sinusitis who have failed antibiotic trials and nasal saline irrigation, otolaryngology referral is recommended for complete evaluation with nasal endoscopy and consideration of surgi cal options. 22 Definitive therapies commonly involve adenoidectomy and rarely balloon catheter sinus dilation or endoscopic sinus surgery, in which the ostiomeatal area is opened, antrostomies are created, and ethmoid partitions are removed. 23,24 Endoscopic sinus surgery has an estimated success rate of 83% in a combined pediatric and adult study.25 In the pediatric population, however, a less invasive approach known as a functional endoscopic sinus surgery , which is essentially a drainage procedure, has good efficacy, with 90% of patients showing marked reduction in symptoms. SPECIAL POPULATIONS Patients with recurrent acute rhinosinusitis, characterized by multiple episodes of sinusitis between which signs and symptoms resolve com pletely, may benefit from prolonged antibiotic prophylaxis with azithromycin. 27 Children with recurrent or refractory sinusitis should be evaluated for immune deficiencies with quantitative immunoglobulin levels, immunoglobulin G subclasses, immunoglobulin A, and T- and B-cell counts. The most commonly diagnosed immune deficiencies in patients presenting with recurrent or refractory sinusitis are selective immunoglobulin A deficiency, common variable immunodeficiency, and immunoglobulin G subclass deficiency. 28 Children with cystic fibrosis have thick mucus that predisposes them to sinusitis. Cystic fibrosis is primarily diagnosed through sweat chloride testing. Suspect cystic fibrosis in a child who presents with nasal polyps or chronic sinusitis, particularly in conjunction with failure to thrive and chronic cough. ALLERGIC RHINITIS Allergic rhinitis is an immunoglobulin E–mediated chronic or recur rent inflammatory response of the nasal mucosa that is induced by an allergen and typically affects children >2 years old. The worldwide prevalence of symptoms of allergic rhinoconjunctivitis is 2.2% to 14.6% in children age 6 to 7 years old and 4.5% to 45.5% in adolescents age 13 to 14 years old. 29 Approximately 80% of children with asthma have allergic rhinitis, and allergic rhinitis makes it more difficult to control asthma, making it an important topic for the emergency medicine physician caring for children. Yes Moderate/Severe symptoms Mild symptoms Child presenting with suspected acute bacterial sinusitis Treat with amox/clav, cefuroxime, cefpodoxime, or cefdinir Child in day care or recently treated with antibiotics? Child under 2 years old Prevalence of S. pneumoniae greater than 10% in the community Standard dose amoxicillin Treat with high-dose amoxicillin If allergic to PCN, tx with cefuroxime, cefpodoxime, cefdinir, azithromycin, or clarithromycin Improved? No: returns for further management ENT referral for nasal endoscopy and consideration of surgical intervention Y es: follow up with PCP Yes FIGURE 123-1. Management of uncomplicated acute bacterial sinusitis in children. amox = amoxicillin; clav = clavulanate; ENT = ear, nose, and throat; PCN = penicillin; PCP = primary care provider; tx = treat.
gement ENT referral for nasal endoscopy and consideration of surgical intervention Y es: follow up with PCP Yes FIGURE 123-1. Management of uncomplicated acute bacterial sinusitis in children. amox = amoxicillin; clav = clavulanate; ENT = ear, nose, and throat; PCN = penicillin; PCP = primary care provider; tx = treat. TABLE 123-2 Antibiotic Treatment for Bacterial Sinusitis Clinical Scenario Additional Factors Treatment Duration of Treatment Mild symptoms or age >2 y Not in day care, no antibiotics in past 4 weeks Amoxicillin 20–25 milligrams/kg PO twice daily 10–28 d 7 d beyond resolution of symptoms >10% resistant Streptococcus pneumoniae prevalence Amoxicillin 45 milligrams/kg PO twice daily Moderate-severe symptoms or age <2 years or attending day care or recent amoxicillin administration Amoxicillin 45 milligrams/kg with clavulanate 3.2 milligrams/kg PO twice daily (use Augmentin® ES formulation with 600 milligrams amoxicillin and 42.9 milligrams clavulanate per 5 mL) Vomiting or unable to tolerate oral antibiotics Ceftriaxone 50 milligrams/kg IV/IM once a day Substitute PO agent when tolerable Penicillin allergic Only consider cephalosporins with nonsevere or non–type I hypersensitivity penicillin allergy Cefdinir 7 milligrams/kg PO twice daily Cefuroxime 15 milligrams/kg PO twice daily Cefpodoxime 5 milligrams/kg PO twice daily 10–28 d 7 d beyond resolution of symptoms Tintinalli_Sec12_p0669-0996.indd 773 8/2/19 7:51 PM
lergic Only consider cephalosporins with nonsevere or non–type I hypersensitivity penicillin allergy Cefdinir 7 milligrams/kg PO twice daily Cefuroxime 15 milligrams/kg PO twice daily Cefpodoxime 5 milligrams/kg PO twice daily 10–28 d 7 d beyond resolution of symptoms Tintinalli_Sec12_p0669-0996.indd 773 8/2/19 7:51 PM 774 SECTION 12: Pediatrics PATHOPHYSIOLOGY Seasonal allergic rhinitis (commonly known as hay fever) is usually caused by airborne allergens such as pollen, whereas perennial allergic rhinitis is usually caused by dust mites, animal dander, and mold. Allergic rhinitis is an immunoglobulin E–mediated inflammatory response in the nasal mucosa that occurs after sensitization with a specific aller gen. Immunoglobulin E binding triggers mast cell degranulation and subsequent histamine release. The binding of histamine to the hista mine-1 receptor on nasal neurons and nasal vasculature is the ultimate mechanism responsible for the nasal itch, sneeze, rhinorrhea, and nasal obstruction of allergic rhinitis. CLINICAL FEATURES Allergic rhinitis presents with clear rhinorrhea, nasal pruritus, and sneezing. Ocular symptoms, such as conjunctival hyperemia and pruri tus, may coexist. Symptoms can lead to sleep disturbance, limitations in activity, and poor school performance. DIAGNOSIS Patients with allergic rhinitis report symptoms of paroxysmal sneez ing, nasal pruritus, rhinorrhea, oropharyngeal pruritus, hyperemia, and ocular pruritus. On physical examination, there may be hypertrophy and edema of the nasal turbinates with associated pale, bluish hue or pallor along with clear secretion from the nares. While it can be difficult to differentiate allergic rhinitis from nonallergic rhinitis, certain physical features may be helpful. For instance, the presence of a horizontal nasal crease (“allergic salute”) is more likely to be associated with allergic rhinitis, while Dennie-Morgan folds (a fold or line in the skin below the lower eyelid caused by edema in atopic dermatitis) are more likely to be associated with nonallergic rhinitis. 31 Concomitant wheezing suggests an association with asthma. A patient with severe symptoms who does not respond to treatment may warrant a referral to an allergist for skin testing to detect immediate hypersensitivity reactions to allergens. Total immunoglobulin E levels are neither sensitive nor specific for atopic disease. TREATMENT Treatment involves recommending environmental controls such as avoidance of allergens and irritants, including pollutants and cigarette smoke. Nasal saline irrigation with a syringe or spray reduces the use of antibiotics and other medications. Intranasal steroids, such as fluticasone furoate nasal spray, are effec tive for treatment of allergic rhinitis. 34 Intranasal corticosteroids reduce inflammation of the nasal mucosa. Daily morning dosing minimizes the impact on the hypothalamic-pituitary-adrenal axis. Oral antihistamines are also commonly used to treat allergic rhinitis, but there is a lack of evidence for the benefit of oral antihistamine therapy in addition to topical nasal steroids for children with allergic rhinitis. 35 Second-generation antihistamines, such as loratadine (5 milligrams daily for age 2 to 6 years; 10 milligrams daily for >6 years of age) and cetirizine (2.5 to 5.0 milligrams daily for age 2 to 6 years; 5 to 10 milligrams daily for >6 years of age), are preferable because they are less likely to cross the blood–brain barrier and therefore cause less sedation than first-generation antihistamines such as diphenhydramine and hydroxyzine. Other therapies target the immune system directly. Montelukast, a leukotriene receptor antagonist, and disodium cromoglycate, a mast cell stabilizer, have been used with success for symptom reduction.
barrier and therefore cause less sedation than first-generation antihistamines such as diphenhydramine and hydroxyzine. Other therapies target the immune system directly. Montelukast, a leukotriene receptor antagonist, and disodium cromoglycate, a mast cell stabilizer, have been used with success for symptom reduction. 36,37 Sublingual and subcutaneous immunotherapy has also been shown to be effective in improving symptoms of allergic rhinitis in children. 38-40 NASAL FOREIGN BODIES Foreign body insertion is a common pediatric complaint in the ED. Foreign bodies in the external ear canal predominate, followed by nasal foreign bodies. Children who insert objects into their nose are, in general, younger than patients with auditory foreign body insertion. 37 Although pharyngeal foreign bodies can present in adults, nasal foreign bodies are almost exclusively a pediatric problem. Common objects include beads, paper, rocks, toy parts, and organic material such as peas, corn, seeds, nuts, and legumes. CLINICAL FEATURES The child with a nasal foreign body may present with local pain (23% to 55%), nasal discharge (7% to 36%), epistaxis, or admission by the child. Alternatively, the parent may witness the child placing something in the nose, or the object may be found during routine child care. Most children with nasal foreign bodies are asymptomatic. DIAGNOSIS Most nasal foreign bodies can be directly visualized. Have a high index of suspicion for a nasal foreign body in an appropriately aged child who presents with persistent, unilateral, purulent, foul-smelling nasal discharge (Figure 123-3). TREATMENT Before attempting instrumentation, try less invasive removal using positive-pressure techniques. These include nose blowing in older children while occluding the opposite nostril or applying oral positive pressure by having the parent occlude the unaffected nostril, cover the child’s mouth with their own, and blowing (“parent kiss”); finally, a bag-valve mask can be used in a manner similar to the parent kiss. These techniques are successful in more than one half of cases. 42 For more invasive methods, the key to successful removal is immobilization. Approximately 20% of patients undergoing nasal foreign body removal in the ED are given procedural sedation, most commonly with ketamine. 43 Place the child in a supine position, and pretreat the nasal mucosa with topical 1% lidocaine FIGURE 123-2. Sinusitis. Adolescent with pansinusitis complicated by periorbital cellulitis. The patient was also found to have osteomyelitis of the frontal bone (Pott’s puffy tumor). [Reproduced with permission from Knoop K, Stack L, Storrow A: Atlas of Emergency Medicine, 2nd ed. © 2002, McGraw-Hill, Inc., New York.] Tintinalli_Sec12_p0669-0996.indd 774 8/2/19 7:51 PM