Chronic Sinusitis in Children

Chronic sinusitis is often difficult to diagnose in children since they rarely present with the same signs and symptoms as adults. In addition, children have frequent upper respiratory tract infections (URI). It may be difficult to distinguish recurrent URIs from chronic sinus disease. The duration and severity of upper respiratory tract symptoms in children can be important for diagnosing sinusitis. In general, most uncomplicated viral URIs in children last 5 to 7 days and produce mild to moderate symptoms. Even when the symptoms persist for 10 days, they are usually improved. Acute sinusitis is defined as the persistence of upper respiratory tract symptoms for more than 10, but less than 30 days, or when high fevers and purulent nasal discharge are present. When symptoms persist beyond 30 days, it is defined as subacute or chronic sinusitis.

Symptoms
The signs and symptoms of chronic sinusitis in children are not pathognomonic. Purulent rhinorrhea is by far the most prevalent symptom, but the discharge can also be clear or mucoid. Chronic cough is also common. Nasal obstruction, headache, low-grade fever, irritability, fatigue, and foul breath may also be present in varying degrees. Since these symptoms are relatively nonspecific, the nature of these symptoms can be clues to the diagnosis of chronic sinus disease.

Chronic cough is an important finding. In children with chronic cough, sinusitis was the causative factor in children between the ages of 1 and 16. The cough is present during the daytime. Simply having a nocturnal cough could be indicative of gastroesophageal reflux or of asthma and not necessarily of chronic sinusitis.

Symptoms also vary with age. Rhinorrhea and chronic cough are more commonly seen in younger children, whereas an older child may have postnasal drip and a chronic sore throat. Older children also tend to complain of headaches, whereas the young child will often manifest pain as irritability, mood swings, and even resting the face on a cold surface to alleviate facial pain.

Treatment
The most popular treatment of sinusitis is with antibiotics. Antibiotic treatment should be maintained continuously for at least 3 to 4 weeks, and even as long as 6 weeks. Antibiotic selection is usually empiric, since it is difficult to obtain sinus aspirates in children without general anesthesia. Topical steroids can be employed in resistant cases, since they may be of value in reducing mucosal edema and reestablishing ostial patency. The role of decongestants is unclear, although they have been shown to improve ostial and nasal patency in adults with chronic maxillary sinusitis.

Because there are now bacteria that are resistant to antibiotics, so that the antibiotic may not be able to fight the infection, some guidelines also make recommendations on which antibiotics are most likely to be effective to treat children with sinusitis.

For children who are not at risk of having an infection caused by resistant bacteria, they may be treated with a regular dose of amoxicillin. If your child is not improving with amoxicillin, or is at risk of having a resistant bacterial infection, then high dose amoxicillin should be used.

Children that fail to respond to two antibiotics may be treated with intravenous cefotaxime or ceftriaxone and/or a referral to an ENT specialist.