Diagnosis

Acute rhinosinusitis (ARS) is a clinical diagnosis with the primary difficulty being distinguishing ARS from an uncomplicated viral URI or a “cold.” Although the signs and symptoms of an uncomplicated URI and ARS overlap, an uncomplicated URI typically begins to show evidence of improvement 7 to 12 days into the illness. ARS is diagnosed by the presence of 2 major, or 1 major and 2 or more minor criteria, which persist for more than 10 days ( Table 2 ). Acute sinusitis may have 3 patterns of illness: Onset with persistent symptoms, onset with severe symptoms, or worsening after initial improvement ( Table 3 ). Pediatric patients with ARS may be less likely than adults to complain of headache and fatigue; behavioral problems, such as irritability, are a more common finding.

The physical examination is not specific for ACR; findings including rhinorrhea and turbinate swelling, as well as edema and erythema of the nasal mucosa. Color and viscosity of the nasal secretions do not distinguish between a bacterial or viral illness.

Radiographic imaging is not indicated for the evaluation of ARS unless complications are suspected or confirmed. According to DeMuri and Wald, symptoms or signs suggesting complications of sinusitis include severe headache, seizures, focal neurologic deficits, periorbital edema or abnormal extraocular muscle function. Computed tomography (CT) is not helpful in diagnosing ARS because more than 80% of patients with an uncomplicated URI in 1 study had abnormal CT findings. Ultrasonography has been used for evaluating ARS with the maxillary sinuses being the primary focus of imaging. Ultrasonography may have a role in identifying the presence of fluid within a maxillary sinus with acceptable sensitivity and specificity when the 3 findings of mucosal thickening, an air–fluid level, and opacification are grouped together; however, ultrasonography has a high error rate with regard to mucosal thickening. The European position paper on rhinosinusitis and nasal polyps concluded that ultrasonography had limited usefulness for the diagnosis of rhinosinusitis.

Magnetic resonance imaging (MRI) is a highly sensitive means of detecting mucosal edema; however, the role of MRI for evaluating ARS even in a research setting is not clear. In a recent study, 60 children with symptoms of an acute URI were imaged with MRI. Twenty-six of these children with abnormal MRIs underwent a second MRI 2 weeks after the initial symptoms of a URI. Despite clinical improvement, 69% of the subjects continued to have major MRI abnormalities.

Treatment

Observation for up to 3 days after the diagnosis of ARS has been suggested as an acceptable approach for management based on rates of spontaneous improvement. Antibiotic therapy is the mainstay of medical therapy for ARS with the major challenge being the choice and duration of specific antibiotics. The choice of antibiotic should be based on the microbiology of ARS with awareness of local patterns of antibiotic resistance. A systematic review of the management of ARS identified 4 randomized, double-blind, placebo-controlled studies of antibiotic therapy for ARS. Placebo groups had a range of clinical improvement from 14% to 79%, whereas the treatment groups demonstrated clinical improvement from 50% to 81%. The difficulty in applying the results of this review stems from the heterogeneity of the methodology of these studies as well as the change in antibiotic resistance patterns noted over the years in which these studies were completed. There has not been conclusive evidence of the superiority of 1 antimicrobial over another; however, owing to current resistance trends, specific antibiotics are not recommended for the treatment of ARS, these being trimethoprim, clarithromycin and azithromycin.

Empiric antimicrobial therapy without identifying specific bacteria is a standard approach for ARS, given the invasive nature of obtaining culture material from a paranasal sinus. Studies in adult patients have shown a correlation between culture results from the middle meatus and the content of the maxillary sinus; however, similar studies have not been performed in children. One confounding factor with middle meatus cultures in children is that the middle meatus in asymptomatic children is often colonized with Streptococcus pneumonia , Haemophilus influenzae , or Moraxella catarrhalis . In addition, no recent studies of maxillary sinus aspirates have determined whether the microbiology of acute bacterial sinusitis has changed over the past 3 decades. The primary source of information about the prevalence of specific bacteria and resistance rates in the local community is extrapolated from middle ear cultures from patients with acute otitis media, because these cultures are more commonly obtained as part of surveillance programs. The introduction of the conjugated pneumococcal vaccine has been associated with a relative increase in the percentage of episodes of acute otitis media containing H influenza with a decrease in S pneumonia . These changes are likely to be similar for ARS and will impact recommendations for empiric antibiotic therapy.

Recommended first-line treatment for uncomplicated ARS is amoxicillin or amoxicillin–clavulanate. The standard dose of amoxicillin is appropriate unless there is a high prevalence of nonsusceptible pneumococcus in the community leading to a recommendation for starting with a higher dose of amoxicillin (90–100 mg/kg per day). Individual risk factors for resistant pneumococcus include daycare attendance, age less than 2 years, and having received an antibiotic within the past 30 days. An increased prevalence of beta-lactamase–producing organisms in the community supports the initial use of a broader spectrum antibiotic. For children who are more ill or younger than 2 years of age, the broader spectrum amoxicillin–clavulanate is recommended. Other antibiotic choices should be considered for patients with penicillin sensitivity. Published studies suggest that patients with type 1 sensitivity to penicillin can be safely treated with second- and third-generation cephalosporins.

The duration of antimicrobial therapy for ARS ranges from 10 to 28 days with 1 recommendation being to treat patients for 7 days beyond the resolution of symptoms. Persistent symptoms after 72 hours warrant a change in medical management. Antimicrobial treatment for ARS has not been shown to reduce the rate of complications associated with ARS.

Side effects from antimicrobial therapy must be a consideration; 1 investigator determined that approximately one half of patients on antibiotic therapy developed adverse effects, with 20% to 22% experiencing diarrhea.

Adjuvant therapies for ARS include antihistamines, decongestants, nasal irrigations, nasal steroids, mucolytic agents, humidification, nasal saline sprays, spicy food, and hot air. A systematic review of antihistamines and decongestants for ARS found no evidence to support the use of these medications for treating ARS. Although there may be transient improvement in symptoms with antihistamines and/or decongestants, there does not seem to be a positive impact on the duration of the illness. Additionally, adverse side effects from these interventions may offset any positive benefits. Corticosteroids may reduce cough and nasal drainage; outcomes 2 weeks after initiating treatment showed no differences when assessing outcomes at 3 weeks. Nasal irrigations have been associated with a reduction in symptoms and improved quality of life for acute sinusitis.

Diagnosis

The diagnosis of chronic rhinosinusitis (CRS) in children is based on symptoms persisting for more than 12 weeks with associated endoscopic or radiographic findings. The major and minor criteria used to diagnosis CRS are the same as those utilized for diagnosing ARS. The symptom complex for children includes cough, nasal congestion, and rhinorrhea. Children are less likely to articulate the presence of a headache and may present with irritability or a behavior disorder. The nasal examination can be accomplished with anterior rhinoscopy using an otoscope or a flexible endoscope because rigid endoscopy may be not tolerated by a young patient and could result in significant discomfort or injury with movement during the examination.

Plain radiographs may possess the sensitivity and specificity necessary to diagnose CRS with 1 study showing that a plain Water’s view had a sensitivity of 84.2% and a specificity of 76.6% when using nasal endoscopy as the reference standard. One challenge with plain radiographs is the inability to differentiate between a mass, polyp, infection, or mucosal disease in an opacified sinus. CT is now the preferred method for imaging the paranasal sinuses owing to its greater ability to demonstrate complex anatomy with superior resolution of both bone and soft tissue. A high false-positive rate of abnormalities requires careful correlation with clinical findings and history. Utilizing a CT scoring system, such as the Lund–McKay score increases the predictive value of CT imaging. Whereas adults without sinus disease should have a score of 0, children without active sinus disease may have a score of up to 3, with 5 being the cutoff for being consistent with sinus disease. The opacification/development ratio is a more recently developed scoring system and takes into account the developing sinuses of a pediatric patient and has been shown to have good correlation with the Lund–McKay score.

Concerns about radiation exposure have led to developing imaging protocols specifically designed to reduce radiation exposure. A higher threshold for obtaining a CT scan with greater reliance on a clinical diagnosis is also favored owing to concerns about radiation exposure.

MRI provides superior imaging of soft tissue compared with CT scans, with inferior imaging of bone. Soft tissue lesions, complications of sinusitis, and extension of disease beyond the paranasal sinuses are visualized well with MRI; however, the lack of information regarding bone makes MRI inadequate for surgical planning or intraoperative image guidance for sinus surgery.

Ultrasonography is a fourth imaging modality that has been used in evaluating CRS. The lack of radiation and wide availability of ultrasonography are attractive features; however, there is a high error rate with regard to mucosal thickening and relatively low sensitivity and specificity when comparing ultrasonography with antral lavage. These shortcomings led to the European position paper on rhinosinusitis and polyps to state that ultrasonography has limited usefulness in the diagnosis of CRS and, more globally, that the diagnosis of CRS does not require imaging.

Treatment

The primary treatment for CRS is medical therapy with long-term antibiotics being the primary type of medication. The recommended duration of therapy ranges from 3 to 6 weeks. The choice of antimicrobial is driven by knowledge of the microbiology of CRS. Bacteria associated with chronic CRS include S pneumonia , M catarrhalis, nontypeable H influenza, Staphylococcus aureus, Pseudomonas, and anaerobes. A broad-spectrum antibiotic should be chosen for first-line therapy, with similar antibiotics as used for ARS. Most patient are treated empirically with a broad spectrum antimicrobial because specific cultures of the sinuses are not routinely obtained before initiating treatment given the invasive procedures needed to obtain culture material. Fungal infections as contributing factors to pediatric CRS are not well described and the use of antifungal therapy for pediatric CRS is not prevalent.

The role of aerosolized topical antibiotic therapy for pediatric CRS has not been systematically evaluated.

Obtaining culture material to guide antibiotic therapy for CRS has been investigated using maxillary sinus aspiration to guide 1 to 4 weeks of intravenous therapy. Don and colleagues, reported on 70 patients treated with maxillary sinus aspiration, intravenous antibiotic therapy, and selected adenoidectomy with 62 (89%) having complete symptom relief. Several adverse events were noted in the study, including superficial thrombophlebitis, serum sickness, pseudomembranous colitis, and drug fevers.

Deckard and colleagues compared maxillary sinus irrigation and culture to endoscopic-guided middle meatus cultures and antral biopsy for patients also having an adenoidectomy. Patients received an extended course of 2 antibiotics after the procedures. The endoscopic-guided middle meatus cultures group had a shorter time to the resolution of nasal symptoms than the maxillary sinus irrigation group (mean, 4.9 vs 8.8 weeks; P = .01).

Adjuvant medical therapy consisting of antihistamines and decongestants for pediatric CRS has been used extensively with unproven benefit. Systemic antihistamines and decongestants may provide symptomatic improvement; however, the overall duration of the illness may not be affected. In addition, the effects of antihistamines and decongestants on mucosa and secretions may adversely affect the inherent physiologic mechanisms of the nose and sinuses to manage inflammation and infection.

Topical and systemic steroids are routinely used in combination with antimicrobial agents. Evidence suggests that topical steroids may hasten the resolution of symptoms of CRS when assessed in the short term, although ultimate resolution of CRS may be not be improved. Including steroids in the management of CRS may be influenced by suspected or proven allergic disease. Specifically, nasal steroids should be continued when an allergic patient is being treated for CRS.

Ozturk and colleagues, in a prospective, randomized study comparing amoxicillin–clavulanate with and without methylprednisolone, investigated the benefit of adding systemic steroids to oral antibiotics for the treatment of CRS. Both treatment arms showed improvement compared with baseline with the steroid treatment being significantly more effective with regard to reducing CT scores and total rhinosinusitis symptoms, as well as individual symptoms of nasal obstruction, postnasal drainage, and cough.

Intranasal irrigations with saline solutions are widely used for treating acute and chronic nasal conditions. Pediatric patients are capable of using nasal saline irrigations with various degrees of adult assistance. Few studies have assessed outcomes using saline irrigations, with the literature suggesting that, for pediatric patients without an underlying systemic disease, the addition of an antibiotic to the saline solution does not improve outcomes. This study reported that subjects had 95% compliance with irrigations. Evidence does suggest that using saline nasal irrigations is beneficial; however, no prospective, placebo-controlled studies provide definitive information regarding the benefit of nasal saline irrigations for pediatric CRS. In a study of 6 weeks of nasal saline irrigations for CRS, only 11 of 91 patients were recommended for endoscopic sinus surgery after treatment as an indication of treatment failure. The addition of an antibiotic or antifungal to the saline irrigation does not seem to improve outcomes.