CHAPTER 195 Pediatric Chronic Sinusitis
The diagnosis of acute and chronic sinusitis is a common primarily clinical diagnosis. It is associated with significant morbidity. In a quality of life assessment, Cunningham1 and colleagues found that sinusitis had a more significant impact on children and their families than asthma, juvenile rheumatoid arthritis, and other chronic disorders.
Pediatric sinusitis is estimated to complicate approximately 5% to 10% of upper respiratory infections in early childhood.2 Because children average six to eight upper respiratory illnesses per year, sinusitis is a very common problem.
Etiology
Age is clearly one of the most significant etiologic factors in pediatric sinusitis.3 Because of their immature immune system, children are more likely to develop upper respiratory tract viral infections and associated acute sinusitis. A strong association has been recognized between sinusitis and respiratory viral infections. Viral infections are thought to cause significant ciliary dysfunction by decreasing the ciliary beat frequency or destroying the ciliary blanket.4 These changes result in inflammation and edema that obstructs the ostium and increases the chance of establishing a bacterial infection of the sinuses. The ciliary dysfunction and edema will interrupt the drainage in the osteomeatal complex, predisposing the patient to the development of acute and possibly chronic sinusitis. As the ciliary function improves, the sinuses clear and the infection resolves in 80% of patients. The role of allergy in chronic sinusitis remains controversial. Rachelefsky5 and coworkers6 were the first to point out an association between allergic symptoms and sinusitis in children. The allergic reaction also will be associated with edema, and the same pathophysiology may be present. Huang7 studied this issue for 5 years in children with perennial allergic rhinitis (PAR) and seasonal allergic rhinitis (SAR). Huang found that the prevalence of sinusitis was significantly higher among patients with PAR than among those with SAR, regardless of age or season. The patients with mold allergy PAR had a higher risk than those with nonmold allergies. Huang concluded that mold allergy is an important risk factor for sinusitis.
According to Ponikau and colleagues,8 allergic fungal sinusitis may be an important factor in polypoid disease in adults. A strong correlation does appear to exist between the allergic response and fungal infections in some patients. The presentation of pediatric patients with allergic fungal sinusitis is different from that of adults. Children have more malleable bones and therefore incur a higher incidence of obvious abnormalities of their facial skeletons. Obstruction and the disease appear to be more unilateral.
The incidence of sinusitis and that of seasonal allergic symptoms do not, however, show a high degree of correlation. Numerous studies show that approximately 50% of children with sinusitis also have allergies; however, cause and effect have not been definitively demonstrated. A long-standing association among asthma, allergies, and chronic sinusitis is recognized. Dixon and associates9 found a strong correlation between asthmatics and patients with rhinitis or sinusitis. In a recent study, Riccio and coworkers10 found that allergic asthmatic children with chronic rhinosinusitis have a typical Th2 cytokine pattern. Nonallergic asthmatic children share a similar pattern. Riccio’s group postulated that these findings suggest the existence of a common pathophysiologic mechanism shared by upper and lower airways, consistent with the concept of unified airway disease. This concept of unified airway disease has been increasingly recognized.11
Gastroesophageal reflux disease (GERD) may be associated with chronic sinusitis.9 The incidence of GERD in children is not known, but Bothwell and associates are convinced that GERD is present in a majority of children with chronic sinusitis and effective treatment of the reflux can prevent sinus surgery.12 Chambers and colleagues13 found that GERD was the only reliable historical symptom that predicted a bad outcome in adults. There is, however, conflicting information in the literature. Suskind and coworkers14 studied patients undergoing antireflux surgery and who had failed medical management. In this very young group of patients (younger than 2 years), only two patients (14%) had severe chronic sinusitis and otitis media. Yellon and colleagues15 also found an incidence of sinusitis in only 10% of patients with esophagitis proved by biopsy. These two studies lead one to conclude that sinusitis is not associated with GERD. Without a doubt, some children have sinusitis associated with GERD. Reflux may be intermittent and cannot be identified with a 24-hour pH probe study. If present, the GERD should be treated with a proton pump inhibitor, which could possibly prevent the need for surgery. Some investigators have recommended empirical therapy with a proton pump inhibitor before proceeding with surgical management.16
Imaging
It is now clear that plain films do not adequately image the pediatric sinuses.17 In the setting of acute sinusitis, Gwaltney and associates18 showed a high incidence of opacification of the anterior ethmoid and maxillary sinuses with acute rhinovirus infections. For assessing the status of sinuses, the coronal CT study remains the imaging method of choice. Plain films do not reveal the true status of sinusitis in children.19 In general, sinusitis is a clinical diagnosis, and radiographic imaging is not necessary in children for confirmation. This is in contrast with adults, for whom most otolaryngologists (73%) feel that a CT scan is required to confirm the diagnosis.20 CT scans should be obtained when both the parents and the surgeon feel that surgical intervention is warranted. The CT scan is used primarily to look for anatomic abnormalities that would increase the risk of surgical complications and to help document the presence of disease. The CT scan should be obtained after a trial of maximum medical management that would include broad-spectrum antibiotics and topical nasal steroid sprays for at least 3 to 4 weeks. The CT scan should be obtained at the end of this course of management. It is difficult to assess the meaning of positive findings on a CT scan that has been obtained without prior medical management. It also is important to avoid being forced by an anxious or frustrated parent into operating on a child whose CT scan shows minimal disease. The best way to prevent this is to warn the parents, before obtaining the CT scan, that a small amount of disease does not necessarily require surgical intervention.
Treatment
Irrigation of the nose has been found to be efficatious; however, in the child, compliance can be a significant issue. Irrigation with saline has been found to be as effective as use of topical vasoconstrictors.21 If the child can cooperate, irrigations should be included as a primary modality.
In general, cultures of the nasal cavity have not been readily used in the pediatric population. In fact, many laboratories will not run routine cultures of the nose. The literature is mixed regarding the efficacy of directed cultures. Jiang and coworkers22,23 have shown that the bacteriology of the middle meatus was different from that found in the ethmoid bulla. They therefore concluded that the bacteriologic findings in the middle meatus may not reflect the real bacteriology in chronic sinusitis. Other studies have shown that bacteriologic findings in the middle meatus have a high correlation with antral punctures.24 In the cooperative patient, endoscopically directed cultures of the middle meatus may be very useful, particularly in communities with increased resistance. If the patient is uncooperative, then broad-spectrum antibiotics would be appropriate.
