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Clinic Curriculum: Sinusitis

Naomi Laventhal Page 1 of 6

Sinusitis COMPETENCIES Know the common clinical presentations of acute and chronic sinusitis in children Know the microbiology of acute and chronic sinusitis Understand the workup of acute and chronic sinusitis Know the indications for radiologic evaluation and surgical referral Know the treatment of acute and chronic sinusitis: drug(s) of choice, alternative drugs, ineffective drugs Know indications for surgical referral Know the potential complications of sinusitis CASE: A mother brings her 8 year old daughter to your outpatient pediatric clinic complaining of 3 days of cough, rhinorrhea, and low-grade fever. The mother is concerned that her daughter may have sinusitis. She is not febrile in the office, however, and your physical exam is notable only for cloudy nasal discharge. You reassure the mother that this is most likely a viral URI. One week later your patient returns to clinic, now with the complaint of thick, green nasal discharge, fever to 38.8, persistent cough and sore throat, and 2 days of right-sided tooth pain. She is febrile in the office and on exam you now find erythematous swelling of the nasal mucosa bilaterally and purulent nasal drainage. You diagnose acute sinusitis and prescribe a 10 day course of amoxicillin (90 mg/kg/day in 3 divided doses). QUESTIONS: 1. What are the common presentations of sinusitis? 2. What is the microbiology of acute maxillary sinusitis? 3. How is the diagnosis of acute sinusitis confirmed? 4. What is the treatment of acute sinusitis? 5. What are the signs and symptoms of chronic sinusitis? 6. What are the indications for radiologic evaluation? 7. What is the treatment for chronic sinusitis? 8. When is surgery indicated? 9. What is the microbiology of chronic sinusitis? 10. What are the potential complications of acute sinusitis? References: 1. Nelson Textbook of Pediatrics 17th Edition 2. Goldsmith, A.J., Rosenfeld, R.M. Treatment of pediatric sinusitis. Pediatric Clinics of North America. 2003, 50; 2. 3. Subcommittee on Management of Sinusitis and Committee on Quality Improvement (American Academy of Pediatrics). Clinical Practice Guideline: Management of sinusitis. Pediatrics 2001, 108; 3. 4. Don, D.M., Yellon, R.F., Casselbran, M.L., Bluestone, C.D. Efficacy of a stepwise protocol that includes intravenous antibiotic therapy for the management of chronic sinusitis in children and adolescents. Arch Otolaryngol Head Neck Surg. 2001, 127:109398.

Clinic Curriculum: Sinusitis

Naomi Laventhal Page 2 of 6

5. Baroody, F.M. Pediatric Sinusitis. Arch Otolaryngol Head Neck Surg. 2001, 127:10991101. 6. MD Consult Clinical Topic Tours- Sinusitis 7. Pediatric Rhinosinusitis Pathophysiology and Management (Dr. Baroody's power point from noon lecture, April 2004).

Clinic Curriculum: Sinusitis

Naomi Laventhal Page 3 of 6

Sinusitis COMPETENCIES Know the common clinical presentations of acute and chronic sinusitis in children Know the microbiology of acute and chronic sinusitis Understand the workup of acute and chronic sinusitis Know the indications for radiologic evaluation and surgical referral Know the treatment of acute and chronic sinusitis: drug(s) of choice, alternative drugs, ineffective drugs Know indications for surgical referral Know the potential complications of sinusitis CASE: A mother brings her 8 year old daughter to your outpatient pediatric clinic complaining of 3 days of cough, rhinorrhea, and low-grade fever. The mother is concerned that her daughter may have sinusitis. She is not febrile in the office, however, and your physical exam is notable only for cloudy nasal discharge. You reassure the mother that this is most likely a viral URI. One week later your patient returns to clinic, now with the complaint of thick, green nasal discharge, fever to 38.8, persistent cough and sore throat, and 2 days of right-sided tooth pain. She is febrile in the office and on exam you now find erythematous swelling of the nasal mucosa bilaterally and purulent nasal drainage. You diagnose acute sinusitis and prescribe a 10 day course of amoxicillin (90 mg/kg/day in 3 divided doses). Questions: 1. What are the common presentations of sinusitis? Persistent URI symptoms lasting greater than 10 days or worsening after 5 to 7 days suggest secondary bacterial infection. On exam, the nasal mucosa shows mucopurulent discharge and erythema and swelling of the nasal turbinates, but these findings may be seen in uncomplicated URI and must be correlated with the history to diagnosis sinusitis. 2. What is the microbiology of acute maxillary sinusitis? Haemophilus influenzae (20%) Moraxella catarrhalis (20%) S. pneumoniae (30%) The remaining 30% have sterile aspirates of the maxillary sinuses. 3. How is the diagnosis of acute sinusitis confirmed? Though plain x-rays of the sinuses are likely to be abnormal (complete opacification, mucosal thickening > 4 mm, air fluid levels), such results may also be seen with viral upper respiratory infections and are unlikely to alter treatment plan. Acute sinusitis is a clinical diagnosis that can be made without imaging studies.

Clinic Curriculum: Sinusitis

Naomi Laventhal Page 4 of 6

There is no minimally invasive method of obtaining cultures that will aid in the diagnosis and sinus aspiration is not routinely necessary for diagnosis of acute sinusitis. 4. What is the treatment of acute sinusitis? For children < 2 yrs of age w/uncomplicated acute bacterial sinusitis that is mild to moderate in degree of severity, who do not attend day care, and have not recently been treated with an antimicrobial, amoxicillin is recommended at either a usual dose of 45 mg/kg/d in 2 divided doses or a high dose of 90 mg/kg/d in 2 divided doses. If the patient is allergic to amoxicillin, either cefdinir (14 mg/kg/d in 1 or 2 doses), cefuroxime (30 mg/kg/d in 2 divided doses, or cefpodoxime (10 mg/kg/d once daily) can be used (if the allergic reaction was not a type 1 hypersensitivity reaction). In cases of severe allergic reactions, clarithromycin (15 mg/kg/d in 2 divided doses) or azithromycin (10 mg/kg/d on day 1, 5 mg/kg/d x 4 days as a single daily dose) can be used. Therapy for the penicillin-allergic patient who is known to be infected with penicllin-resistant S.pneumoniae is clindamycin at 30-40 mg/kg/d in 3 divided doses. If patients do not improve while on regularly dosed amoxicillin (45 mg/kg/d), have recently been treated with an antimicrobial, have an illness that is moderate or more severe, or attend day care, therapy should be initiated with high dose amoxicillin-clavulanate (80-90 mg/kg/d of amoxicillin in 2 divided doses), or with the cephalosporins listed above, in order to treat beta-lactamase producing organisms. A single dose of ceftriaxone (50 mg/kd/d) given IM or IV can be used when vomiting precludes the use of oral agents. Oral antibiotic therapy can begin 24 hours later. Neither trimethoprim-sulfamethaxazole nor erythromycin-sulfisoxazole are appropriate choices. Failure of a second antibiotic course or severe, acute illness warrants otolaryngology consultation for maxillary sinus aspiration. IV cefotaxime or ceftriaxone may alternately be used as therapy with surgical consultation reserved for those patients who fail this treatment modality. Empiric duration of therapy is 10,14, 21, or 28 days with an alternative suggestion of treatment for 7 days following resolution of symptoms (with a 10 day minimum). Orally administered decongestants and antihistamines are of unproven benefit in the treatment of acute sinusitis. There is no evidence that these agents will improve the course or severity illness and are not recommend as adjuvant therapy. 5. CASE (Continued): You schedule a follow-up appointment in two weeks and when the patient returns her mother tells you that her symptoms have not improved. At this time you prescribe a 14 day course of Augmentin, but again in two weeks her mother informs you that though her symptoms have not worsened, they have not completely resolved. Her mother adds that she has noticed nighttime cough. You schedule a CT of the paranasal sinuses and refer to a pediatric otorhinolaryngologist for further evaluation and treatment. What are the signs and symptoms of chronic sinusitis? The signs and symptoms of chronic sinusitis are the same as those of acute sinusitis, but the diagnosis is made when these are present for > 12 weeks with failure of a 3-4 week oral course of antibiotics. Chronic sinusitis is also frequently characterized by acute exacerbation with symptoms returning to baseline after treatment.

Clinic Curriculum: Sinusitis

Naomi Laventhal Page 5 of 6

6. What are the indications for radiologic evaluation? CT scans of the paranasal sinuses should be reserved for patients in whom surgery is being considered as a management strategy (i.e. those who present with complications of acute bacterial sinusitis or those who have persistent or recurrent infection unresponsive to medical management). 7. What is the treatment for chronic sinusitis? Prolonged oral antibiotic therapy (3 to 6 weeks) with Augmentin (ideally with high-dose amoxicillin) or a second generation cephalosporin (excluding cefaclor). Treatment also includes control of concomitant conditions such as allergic disease and GER and may also include topical nasal steroid sprays. (See above for more extensive recommendations on antibiotic treatment). 8. When is surgery indicated? Surgery is indicated when maximal medical therapy has failed and other contributing diagnoses has have been ruled in or out and managed optimally. Adenoidectomy is the initial procedure of choice, with endoscopic sinus surgery (ESS) reserved for those patients in whom all other treatment modalities have failed. 9. What is the microbiology of chronic sinusitis? Haemophilus influenzae (32%) Alpha-hemolytic streptococcus (20%) Moraxella catarrhalis (14%) S. pneumoniae (12%) Coagulase-negative staphylococcus (12%) 10. What are the potential complications of acute sinusitis? For example, consider this case: In your pediatric clinic a 14 year old boy presents with his mother. In taking a history, you find that the patient has had worsening cough, fever, rhinorrhea, and headache for the last 3 weeks. He was seen in your clinic one week prior to today's visit and prescribed an antibiotic but his mother was not able to fill the prescription. His mother reports that his right eye appears red and swollen, and that he "hasn't been himself" for last 2 days. You tell the family that you are concerned about serious complications of acute sinusitis and refer him the affiliated hospital's ED for emergent CT scan of the brain and orbits and admission for IV antibiotic therapy (ceftriaxone). This is a medical emergency because the following complications can occur during the course of the illness: Periorbital cellulites/sympathetic edema Subperiosteal abscess

Clinic Curriculum: Sinusitis

Naomi Laventhal Page 6 of 6

Orbital abscess Orbital cellulitis Cavernous sinus thrombosis Osteomyelitis of the frontal bone (Pott's puffy tumor) Meningitis Subdural empyema Epidural abscess Brain abscess References: 8. Nelson Textbook of Pediatrics 17th Edition 9. Goldsmith, A.J., Rosenfeld, R.M. Treatment of pediatric sinusitis. Pediatric Clinics of North America. 2003, 50; 2. 10. Subcommittee on Management of Sinusitis and Committee on Quality Improvement (American Academy of Pediatrics). Clinical Practice Guideline: Management of sinusitis. Pediatrics 2001, 108; 3. 11. Don, D.M., Yellon, R.F., Casselbran, M.L., Bluestone, C.D. Efficacy of a stepwise protocol that includes intravenous antibiotic therapy for the management of chronic sinusitis in children and adolescents. Arch Otolaryngol Head Neck Surg. 2001, 127:109398. 12. Baroody, F.M. Pediatric Sinusitis. Arch Otolaryngol Head Neck Surg. 2001, 127:10991101. 13. MD Consult Clinical Topic Tours- Sinusitis 14. Pediatric Rhinosinusitis Pathophysiology and Management (Dr. Baroody's power point from noon lecture, April 2004). Submitted by Naomi Laventhal Reviewed by Barrett Fromme

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