Overview
Definition:
Chronic sinusitis (CS) in children is defined as an inflammation of the nasal and paranasal sinuses lasting for at least 12 weeks, characterized by persistent symptoms that impair quality of life and often respond poorly to initial medical management
It is distinct from acute sinusitis which resolves within 4 weeks.
Epidemiology:
Chronic sinusitis affects approximately 2-5% of children
It is a leading cause of pediatric outpatient visits for respiratory symptoms
Recurrent acute rhinosinusitis (RARS) is a common precursor
Prevalence may be higher in children with allergic rhinitis or immune deficiencies.
Clinical Significance:
Uncontrolled chronic sinusitis can lead to significant morbidity in children, including impaired sleep, reduced school performance, facial pain, persistent nasal obstruction, and risk of serious complications such as orbital cellulitis or intracranial infections
It poses a significant challenge for pediatricians and otolaryngologists, requiring a thorough understanding of management options for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Persistent nasal obstruction or congestion
Purulent anterior or posterior nasal discharge
Facial pain, pressure, or headache
Reduced sense of smell or taste
Cough, especially nocturnal, often worse with exertion or lying down
Post-nasal drip
Fatigue and irritability
Decreased school performance
Persistent bad breath (halitosis).
Signs:
Anterior rhinoscopy may reveal thick, purulent discharge in the nasal cavity, especially in the middle meatus
Nasal mucosal swelling and pallor or erythema
Cobblestoning of the posterior pharyngeal wall due to post-nasal drip
Palpation of the face over the sinuses may elicit tenderness in older children
Examination of the tympanic membranes for signs of otitis media with effusion is also important
Adenoid hypertrophy may be evident on anterior rhinoscopy or posterior rhinoscopy/nasoendoscopy.
Diagnostic Criteria:
The EPOS (European Position Paper on Rhinosinusitis and International Consensus) guidelines and similar pediatric consensus statements define chronic rhinosinusitis in children based on the presence of anterior or posterior nasal discharge and/or nasal obstruction/congestion for at least 12 weeks, accompanied by either facial pain/pressure or reduced sense of smell/taste, or by objective evidence of inflammation (e.g., purulent discharge on nasal endoscopy, or CT scan showing mucosal disease)
A subset of patients may have recurrent acute rhinosinusitis meeting specific criteria.
Diagnostic Approach
History Taking:
Detailed history of symptom duration, frequency, and severity
Character of nasal discharge (color, consistency)
Presence of nasal obstruction
Associated symptoms like cough, fever, facial pain
History of allergies, asthma, or eczema
Previous treatments and response
Family history of sinusitis or allergies
Red flags: unilateral symptoms, recurrent epistaxis, vision changes, neurological symptoms, significant facial deformity, failure to thrive.
Physical Examination:
Complete head and neck examination
Thorough nasal endoscopy is crucial for objective assessment of mucosal inflammation, presence and character of discharge, and adenoid size
Assess for tympanic membrane abnormalities
Evaluate for signs of atopy (allergic shiners, Dennie-Morgan lines).
Investigations:
Nasal endoscopy is the gold standard for diagnosis in older children, visualizing the nasal cavity and osteomeatal complex
For younger children or when surgery is contemplated, CT scan of the paranasal sinuses can confirm mucosal thickening, fluid levels, or bony changes, but is often not necessary for initial diagnosis
Allergy testing (skin prick or IgE) is indicated if atopy is suspected
Microbiological cultures from nasal discharge or sinus aspirates are usually reserved for refractory cases or suspected complications.
Differential Diagnosis:
Allergic rhinitis, non-allergic rhinitis (vasomotor rhinitis), adenoid hypertrophy alone, foreign body in the nose, dental infections, viral upper respiratory infections, cystic fibrosis, primary ciliary dyskinesia, immunodeficiency disorders, tumors (rare).
Management
Medical Management:
First-line therapy includes nasal saline irrigations and intranasal corticosteroids (e.g., fluticasone propionate, mometasone furoate, starting at age 2-6 years depending on formulation)
Antibiotics are reserved for acute exacerbations or when there is strong suspicion of bacterial infection, typically for 10-14 days (e.g., amoxicillin/clavulanate, second or third-generation cephalosporins)
Oral decongestants and antihistamines may provide symptomatic relief but are not primary treatments
Macrolide antibiotics (e.g., azithromycin) may be used long-term in selected cases for their anti-inflammatory effects
Antifungal therapy is generally not indicated unless specific fungal sinusitis is confirmed.
Surgical Management:
Adenoidectomy is indicated for chronic sinusitis primarily when adenoid hypertrophy is considered a significant contributing factor to nasal obstruction, Eustachian tube dysfunction, or persistent sinus drainage issues, especially when medical management fails
It is typically considered in children over 3-4 years of age
Functional Endoscopic Sinus Surgery (FESS) is reserved for severe, refractory cases in older children or adolescents, focusing on widening the osteomeatal complex to improve sinus drainage
Indications include persistent symptoms despite maximal medical therapy, recurrent acute bacterial sinusitis exacerbations, or complications.
Adenoidectomy Vs Medical Therapy Comparison:
Medical therapy is the cornerstone for managing chronic sinusitis and should be tried first for at least 4-6 weeks
Adenoidectomy is considered when adenoid hypertrophy is significant and contributes to the sinusitis symptoms or when medical therapy is insufficient
Studies suggest adenoidectomy can be effective in reducing symptoms and recurrence rates in carefully selected pediatric patients with chronic sinusitis associated with adenoid hypertrophy, often leading to a significant improvement in quality of life
The decision involves balancing the risks and benefits of surgery against continued medical management.
Supportive Care:
Environmental control of allergens
Adequate hydration
Humidification of air
Education on proper nasal hygiene
Monitoring for signs of complications
Nutritional assessment if failure to thrive is a concern.
Complications
Early Complications:
Bleeding post-adenoidectomy
Pain
Dehydration
Infection at the surgical site
Nasal regurgitation of food.
Late Complications:
Persistent nasal obstruction or sinonasal symptoms
Recurrence of sinusitis
Eustachian tube dysfunction leading to otitis media with effusion
Voice changes (hyponasality)
Palatal insufficiency (rare, particularly with aggressive adenoidectomy).
Prevention Strategies:
Proper patient selection for adenoidectomy
Meticulous surgical technique
Strict adherence to postoperative care instructions
Prompt recognition and management of any signs of infection or bleeding
Optimizing medical management post-operatively.
Prognosis
Factors Affecting Prognosis:
Severity and duration of symptoms
Presence of underlying conditions like allergies, asthma, or immunodeficiencies
Patient adherence to medical therapy
Effectiveness of surgical intervention (if performed).
Outcomes:
With appropriate medical or surgical management, most children experience significant symptom improvement and a reduction in the frequency of exacerbations
Long-term outcomes are generally good, though some children may have persistent or recurrent issues requiring ongoing management
Adenoidectomy can lead to sustained symptom relief in carefully selected patients.
Follow Up:
Regular follow-up with an otolaryngologist or pediatrician is essential to monitor symptom resolution, assess for recurrence, and adjust management as needed
For surgically treated patients, follow-up may involve nasal endoscopy to assess healing and patency of the sinuses
Long-term monitoring for comorbid conditions like asthma or allergies is also important.
Key Points
Exam Focus:
Differentiate chronic sinusitis from recurrent acute sinusitis
Understand EPOS criteria for diagnosis
Recall first-line medical management (saline, intranasal steroids) and indications for antibiotics
Know when adenoidectomy is indicated in pediatric chronic sinusitis and its expected benefits
Be aware of complications of adenoidectomy and sinusitis itself.
Clinical Pearls:
Nasal endoscopy is invaluable in diagnosing and managing pediatric chronic sinusitis, especially in older children
Emphasize consistent use of nasal saline irrigations and intranasal corticosteroids for optimal medical therapy
Adenoid hypertrophy is a key consideration in persistent pediatric sinusitis, often warranting evaluation for adenoidectomy
Consider underlying atopy or immunodeficiency in refractory cases.
Common Mistakes:
Over-reliance on antibiotics for chronic inflammation without addressing underlying causes
Inadequate trial of intranasal corticosteroids
Delaying adenoidectomy evaluation in cases of significant adenoid hypertrophy contributing to sinusitis
Not considering allergic rhinitis or other differential diagnoses thoroughly
Failing to perform adequate follow-up.