Overview
Definition:
Acute bacterial sinusitis (ABS) is an acute inflammation of the sinonasal mucosa lasting less than 12 weeks, characterized by purulent nasal discharge and/or nasal obstruction or facial pain/pressure of at least 10 days' duration without evidence of preceding viral infection or characterized by a worsening of symptoms after an initial period of improvement ("double sickening")
It is a common pediatric illness.
Epidemiology:
Acute sinusitis is diagnosed in 5-10% of children with upper respiratory tract infections (URTIs)
Viral URTIs are the most common precipitating factor
Predisposing factors include allergic rhinitis, adenoid hypertrophy, immunodeficiency, and environmental irritants like smoke
Peak incidence is between 6 months and 4 years of age.
Clinical Significance:
Accurate diagnosis and appropriate management of ABS are crucial to prevent complications such as periorbital and orbital cellulitis, intracranial extension (meningitis, brain abscess), and chronic sinusitis
Early identification of children requiring antibiotics is important to prevent resistance and unnecessary treatment.
Clinical Presentation
Symptoms:
Persistent nasal discharge (purulent or colored) for >10 days
Persistent cough, especially nocturnal, for >10 days
Fever (>38°C or 100.4°F) and purulent nasal discharge present concurrently for at least 4 consecutive days, initially
Facial pain or pressure (difficult to elicit in young children, may manifest as irritability or behavioral changes)
"Double sickening" - worsening of nasal discharge, cough, or fever after initial improvement of a viral URI.
Signs:
Purulent nasal discharge on anterior rhinoscopy
Nasal mucosal swelling
Tenderness over the maxillary or frontal sinuses (may be elicited by palpation or percussion)
Otorrhea may be present if otitis media is concomitant
Fever
Postnasal drip may be observed on posterior rhinoscopy or inferred from throat clearing or gagging.
Diagnostic Criteria:
The diagnosis of acute bacterial sinusitis in children is primarily clinical
The Infectious Diseases Society of America (IDSA) guidelines and the American Academy of Pediatrics (AAP) recommend considering ABS in children with: 1
Persistent symptoms (>10 days) without improvement
2
"Severe" presentation: fever (>39°C or 102.2°F) and purulent nasal discharge for at least 3-4 consecutive days
3
"Double sickening" pattern.
Diagnostic Approach
History Taking:
Key questions include: Onset and duration of symptoms
Nature of nasal discharge (color, consistency)
Presence and pattern of cough (daytime vs
nocturnal)
Fever (highest recorded temperature, duration)
Presence of facial pain or pressure (and child's report of it)
Any preceding viral illness and subsequent improvement/worsening
History of allergies, asthma, adenoid hypertrophy, immunodeficiency
Exposure to cigarette smoke.
Physical Examination:
A complete head and neck examination is essential
Focus on: General appearance (toxic vs
well-appearing)
Vital signs (temperature, respiratory rate, heart rate)
Anterior rhinoscopy to assess nasal discharge (color, quantity, viscosity) and mucosal swelling
Palpation and percussion of sinuses for tenderness
Examination of the pharynx, ears (tympanic membranes), and neck lymph nodes
Funduscopic examination to rule out orbital involvement.
Investigations:
Routine laboratory investigations are generally not required for uncomplicated ABS in children, as diagnosis is clinical
Imaging studies are usually reserved for children with suspected complications or those who fail to respond to appropriate therapy
CT scan of the paranasal sinuses is the imaging modality of choice for evaluating complications, but is rarely indicated in uncomplicated cases
Plain radiographs are not useful
Nasal endoscopy may be used in select cases.
Differential Diagnosis:
Viral rhinosinusitis (most common, typically self-limiting)
Allergic rhinitis (seasonal or perennial, often associated with itching and sneezing)
Non-bacterial rhinosinusitis (e.g., fungal)
Foreign body in the nasal cavity
Adenoid hypertrophy with secondary inflammation
Nasopharyngeal masses
Dental infections (maxillary sinusitis)
Early stages of periorbital cellulitis.
Management
Initial Management:
Symptomatic management is key for most children
Saline nasal irrigations and sprays
Humidification
Adequate hydration
Rest
Analgesics and antipyretics (paracetamol or ibuprofen)
Avoidance of irritants like smoke.
Medical Management:
Antibiotic therapy is indicated for children meeting criteria for ABS (persistent symptoms, severe presentation, or double sickening)
First-line therapy: Amoxicillin (high-dose, 80-90 mg/kg/day divided BID or TID) for 10-14 days
Alternative for penicillin allergy: Cefdinir (14 mg/kg/day divided BID) or Clindamycin (10-15 mg/kg/day divided TID or QID)
If initial treatment fails or severe symptoms, consider Amoxicillin-clavulanate (Augmentin) (90 mg/kg/day of amoxicillin component BID) or broader-spectrum cephalosporins
Pneumococcal conjugate vaccines have reduced the incidence of invasive pneumococcal disease but not necessarily sinusitis.
Surgical Management:
Surgical management is rarely indicated for acute bacterial sinusitis
It may be considered for recurrent or chronic sinusitis, or in cases of complications not responding to medical therapy
Functional Endoscopic Sinus Surgery (FESS) is the procedure of choice for definitive management of chronic or recurrent sinusitis.
Supportive Care:
Monitoring for signs of complications is crucial
Education for parents regarding red flag symptoms that warrant immediate re-evaluation
Ensuring adequate fluid intake and rest
Follow-up as needed, especially if symptoms persist or worsen.
Complications
Early Complications:
Periorbital cellulitis: eyelid swelling and erythema
Orbital cellulitis: proptosis, ophthalmoplegia, pain with eye movements, decreased vision
Intracranial complications: meningitis, epidural abscess, subdural empyema, brain abscess
Osteomyelitis of facial bones.
Late Complications:
Chronic sinusitis
Recurrent sinusitis
Development of nasal polyps
Post-infectious cough syndrome.
Prevention Strategies:
Prompt treatment of viral URTIs and URIs
Management of underlying allergic rhinitis and asthma
Avoiding exposure to environmental tobacco smoke
Good hygiene practices to reduce viral transmission
Vaccination against pneumococcus and influenza.
Prognosis
Factors Affecting Prognosis:
Prompt diagnosis and appropriate antibiotic therapy are associated with favorable outcomes
Comorbidities such as immunodeficiency, asthma, or significant allergies may affect prognosis and increase the risk of recurrence or complications
Degree of bacterial resistance in the community.
Outcomes:
With appropriate treatment, the majority of children with acute bacterial sinusitis recover fully within 2-3 weeks
Persistent symptoms may require prolonged or different antibiotic regimens
Complications, if treated promptly, generally have good outcomes, but can lead to significant morbidity.
Follow Up:
Children treated with antibiotics should be advised to return if symptoms worsen or do not improve within 48-72 hours of starting therapy
A follow-up appointment may be scheduled in 2-3 weeks to ensure complete resolution, especially for those with severe initial presentations or complications
Recurrent cases may require referral to a pediatric otolaryngologist or allergist.
Key Points
Exam Focus:
DNB/NEET SS exam questions will focus on differentiating viral from bacterial sinusitis based on clinical criteria
High-yield points include diagnostic criteria (persistent symptoms, severe presentation, double sickening), first-line antibiotics (high-dose amoxicillin), and recognizing signs of complications.
Clinical Pearls:
Always consider viral URI as the most common cause of nasal symptoms in children
"Double sickening" is a critical clue for bacterial sinusitis
Don't hesitate to use saline nasal irrigation
it's safe and effective
Be vigilant for complications, especially in infants and immunocompromised children
Antibiotic stewardship is paramount.
Common Mistakes:
Over-prescription of antibiotics for viral rhinosinusitis
Incorrect dosing of antibiotics
Failure to consider complications when symptoms are severe or prolonged
Misinterpreting nasal discharge color as indicative of bacterial infection (colored discharge can occur in viral infections too)
Not adequately assessing for underlying allergic rhinitis.