Pediatric Rhinosinusitis

1. Pediatric Rhinosinusitis

3. Embryology Maxillary Sinus first to develop at day 65 of gestation seen on plain films at 4-5 months Biphasic growth(0-3 &7-12) slow expansion until 18 years Ethmoid Sinus develop in third month of gestation ethmoids seen on radiographs at one year enlarges to reach adult size at age 12 Sphenoid Sinus originates in fourth gestational month from posterior part of nasal cavity pneumatization begins at age 3 rapid growth to reach sella by age 7 and adult size at age 18 Frontal Sinus begins in fourth month of gestation from superior ethmoid cells seen on radiographs at age 5-6 grows slowly to adult size by adolescence

4. Max: 1=newborn, 2=12 yrs, 3=adult sphenoid: 1=newborn, 2=3yo, 3=5yo, 4=7yo, 5=12yo, 6=adult, (7=presphenoid) frontal: 1=nasal septum, 2=middle nasal concha, 3=orbit, 4=newborn, 5=1yo, 6=4yo, 7=7yo, 8=12yo, 9=adultMax: 1=newborn, 2=12 yrs, 3=adult sphenoid: 1=newborn, 2=3yo, 3=5yo, 4=7yo, 5=12yo, 6=adult, (7=presphenoid) frontal: 1=nasal septum, 2=middle nasal concha, 3=orbit, 4=newborn, 5=1yo, 6=4yo, 7=7yo, 8=12yo, 9=adult

5. The Mucociliary TransportSystem It functions as a barrier by removing bacteria, pollen and other inhaled particulate matter from the sino-nasal system - from the sinuses which are normally sterile to the nasal cavity which is often full of bacteria

6. Factors involved in maintenanceof Sinus Mucosal Health Patency of ostia Proper amount/viscosity of mucus Functional ciliary transport mechanism Intact immune system

7. Disrupted mucociliary system Recurrent viral URTI Allergen inflammation Immune disorders Immotile Cilia Syndrome Cystic Fibrosis Gastronasal Reflux Disease

8. Normal mucociliary conveyorbelt system

9. Disrupted mucociliary conveyorbelt system

10. Pathogenesis Ostia obstruction creates increasingly hypoxic environment within sinus Retention of secretion results in inflammation and bacterial infection Secretion stagnate, obstruction increases, cilia and epithelial damage become more pronounced Most common inciting event is viral URI

11. Definitions Acute: symptoms often inseparable from URI and include rhinorrhea, daytime cough, nasal congestion, infrequent low-grade fever, otitis media, irritability and headache. Key in diagnosis of sinusitis is persistence beyond 7-10 days or worsening of symptoms at around 7 days Severe Acute Sinusitis: purulent rhinorrhea, high fever, periorbital edema Recurrent: complete resolution between episodes and 3 or more episodes in six months or more than 4 episodes in one year Subacute: signs and symptoms lasting three weeks to three months Chronic: signs and symptoms lasting longer than three months

12. incidence Children average 6-8 URIs per year 5%-13% of URIs are complicated by secondary bacterial infection of paranasal sinuses. Acute sinusitis is much less common in young children than routine URTI or adenoiditis.

13. The Seven Cardinal Symptomsof Chronic Sinusitis 1. Chronic nasal obstruction 100 % 2. Prolonged purulent nasal discharge 90 % 3. Postnasal drainage 63 % 4. Chronic cough 71 % 5. Malodorous/fetid breath 67 % 6. Headaches 90 % 7. Behavioral changes 63 %

14. Diagnosis Physical Examination Anterior rhinoscopy with otoscope in younger children Tenderness over sinuses Periorbital edema and discoloration Flexible and rigid endoscopy in older child Most specific-- mucopurulence, periorbital swelling, facial tenderness

16. DIAGNOSIS May be a challenge due to Lack of specificity in signs & symptoms Lack of ability to communicate complaints Lack of compliance for physical examination

17. Adjunctive Tests Imaging usually not indicated for uncomplicated patients. CT scan may be indicated if suppurative complications suspected, patient fails to improve after treatment or as pre-operative study Ideally should be obtained after several weeks of medical therapy Major bony anatomic abnormalities unusual in children Mucosal inflammation common incidental finding in children and strongly related to viral URI Incidence of sinus mucosal inflammation drops off after age 7 to 8

18. Adjunctive Tests Sinus aspirate is indicated in severe toxic illness, acute illness not responsive to antibiotics within 72 hours, immunocompromised patients, suppurative complications and workup for fever of unknown origin Oropharyngeal/Nasopharyngeal swabs do not correlate with sinus aspirate Endoscopically guided middle meatus swab correlates fairly well with sinus aspirate

19. Microbiology Similar to adults: Streptococcus pneumoniae, Moraxella catarralis, nontypeable Hemophilus influenzae ICU patients/cystic fibrosis: Pseudomonas aeruginosa, Staphyloccus aureus Resistant organisms more common in patients already treated with multiple rounds of antibiotics, children in day care, children who have received antibiotic therapy in the last 30 days Chronic pathogens may include Alpha-hemolytic streptococci S. aureus Nontypeable H. inflluenzae M. catarrhalis Anaerobic bacteria Pseudomonads

20. Refractory Rhinosinusitis Consider associated conditions Allergy Immune deficiency Asthma Gastroesophageal reflux disease Cystic Fibrosis Primary Ciliary Dyskinesia (Immotile Cilia Syndrome) Allergic Fungal Sinusitis

21. Allergy Major contributing factor in rhinosinusitis Similar pathogenesis as viral etiology with obstruction -- mucostasis --hypoxia � colonization Itching mucous membranes, clear rhinorrhea, eczema, food intolerance, nasal congestion, stuffiness, fluctuating rhinorrhea, sneezing, cough, behavioral changes, headaches, facial pressure. AR is reported to be present in up to 40% at some point in childhood AR is associated with up to 80% of cases of CRS Family history of allergy Serologic or skin testing should be considered in all children with unresponsive sinusitis

22. Allergy Avoidance clean, allergy proof house, filter, no pets, air conditioning Pharmacotherapy antihistamines, nasal steroids, mast cell stabilizers Immunotherapy

23. Immune Deficiency History of frequent otitis media, pneumonia and sinusitis may suggest a primary or secondary immunodeficiency state Serum immunoglobulins and IgG subclasses should be checked as well as ability to respond to capsular antigens of S. pneumoniae and H. influenzae Treatment in primarily medical Patients may benefit from IVIG therapy Genetic counseling for patient and family may be appropriate

24. Asthma Sinusitis and asthma frequently associated: same underlying disease process or causal relationship? Sinonasal/bronchial reflex Aspiration Treatment of sinusitis whether medical or surgical reduces use of bronchodilators, improves pulmonary symptoms

25. Gastroesophageal Reflux Disease Many pediatric patients experience improvement in their chronic sinonasal symptoms after a trial of antireflux medicine GERD theorized to have direct effect on nasal mucosa, initiating inflammatory response with edema and impaired mucociliary clearance Phipps in 2000 reported a prospective trial in which 63% CRS patients were found to have esophageal reflux by pH probe; 32% demonstrated nasopharyngeal reflux Bothwell in 1999 reported 89% of pediatric candidates for FESS avoided surgery with treatment for GERD

26. Cystic Fibrosis Autosomal recessive disease Mutation of CFTR protein Patients develop chronic pulmonary disease in childhood; also affected with sinusitis and nasal polyposis, pancreatic insufficiency and biliary cirrhosis anasal polyps in the pediatric age group are rare sweat chloride test or referral for genetic evaluation pseudomonas or S. aureus are suggestive of CF Recent studies suggest heterozygous mutations in the CFTR gene are associated with chronic rhinosinusitis

27. Primary Ciliary Dyskinesia History of chronic otitis media, chronic sinusitis and chronic bronchitis or bronchiectasis Kartagener�s syndrome: sinusitis, situs inversus, bronchiectasis and male infertility) Diagnosis established with inferior or middle turbinate or tracheal biopsy

28. Allergic Fungal Sinusitis Allergic reaction to aerosolized fungi, usually of the dematiceous species Treatment is surgical with perioperative oral steroid and post-operative topical steroids+Immunotherapy High recurrence rate, requires close follow up Findings in children different than adult findings Children more frequently have abnormalities of their facial skeleton More likely to have unilateral disease

29. Kuhn and Swain, 2003 Major criteria Type I IgE-mediated hypersensitivity Nasal polyps Characteristic CT findings Allergic mucin Positive fungal smear Minor criteria Asthma Unilateral predominance Bone erosion on CT Fungal culture Charcot-Leyden crystals Serum eosinophils

32. Complications Orbital: Orbital complications more common in children than adults Most common is medial subperiosteal abscess Intracranial: More common in adolescents/adults Include meningitis (most common), epidural abscess, subdural abscess, intracerebral abscess,

33. Orbital Complications Classified by Chandler: I. Preseptal cellulitis II. Orbital cellulitis III. Periorbital abscess IV. Orbital abscess V. Cavernous sinus thrombosis Spread by direct extension via osseous structures or indirectly via valveless venous plexuses Obtain CT scan with contrast if orbital involvement suspected

34. Stage I�Preseptal Cellulitis Eyelid edema, erythema and normal globe movement Stage I in children more likely due to cutaneous lesions or hematogenous seeding rather than sinusitis

35. Stage II�Orbital Cellulitis Proptosis, Chemosis, Edema, Pain Dilated pupil Visual loss Ophthalmoplegia Afferent pupillary defect

36. Stage III�Periorbital Abscess Proptosis with globe displacement inferolaterally, decreased EOM, vision decreased IVAbx with external or endoscopic drainage of abscess and involved sinus

37. Stage IV�Orbital Abscess orbital abscess severe proptosis and chemosis usually no globe displacement opthalmoplegia present Impaired visual acuity

38. Stage V�Cavernous Sinus Thrombosis Progressive symptoms Proptosis and fixation CN II, IV, VI Meningitis High mortality High fever, bilateral symptoms

39. Intracranial Complications Meningitis, Epidural Abscess, Intracerebral Abscess, Pott�s Puffy Tumor Neurosurgical Consultation, high-dose antimicrobial therapy, drainage of intracranial abscess planned in concert with drainage of affected sinus Frontal sinus is most implicated sinus: venous drainage of the frontal sinus via small diploic veins extending through sinus wall; these communicate with venous plexi of dura, periorbita and cranial periostuem

40. Medical Treatment Acute Sinusitis: Young children with mild to moderate ARS, amoxicillin at normal or high dose Amoxil-allergic patients, treat with a cephalosporin�severe allergy, treat with macrolide Nonresponders, more severe initial disease, those at high-risk for resistant strep, treat with high dose amoxil/clavulanate Parenteral ceftriaxone for children not tolerating oral meds Duration of therapy is usually 10-21 days or until symptoms resolve plus 10 days

41. Medical Treatment Chronic Rhinosinusitis 4 to 6 week course of beta lactam stable antibiotic Adjuvant therapy with nasal steroids commonly employed Antihistamines especially if underlying allergic condition suspected Mucolytics may thin secretions

42. Clinical Practice Guideline: Management of Sinusitis Pediatrics 2001 Acute bacterial sinusitis: bacterial infection of the paranasal sinuses lasting less than 30 days in which symptoms resolve completely Subacute bacterial sinusitis: bacterial infection of paranasal sinuses lasting between 30-90 days in which symptoms resolve completely Recurrent acute bacterial sinusitis: episodes of bacterial infection of the paranasal sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic Chronic sinusitis: episodes of inflammation of the paranasal sinuses lasting more than 90 days. Residual respiratory symptoms persist such as rhinorrhea, nasal obstruction, or cough Acute bacterial sinusitis superimposed on chronic sinusitis: patients with residual respiratory symptoms develop new respiratory symptoms. When treated with antimicrobials, the new symptoms resolve, but underlying residual symptoms persist

43. Recommendations Antibiotics are recommended for management of ABS to achieve more rapid clinical cure Children with uncomplicated ABS with mild to moderate severity not attending daycare are recommended to be treated with either amoxicillin 45 mg/kg/d in 2 divided doses or 90 mg/kg/d in 2 divided doses For PCN allergic patients: cefdinir (14 mg/kg/d in 1-2 doses), cefuroxime (30 mg/kg/d in 2 doses), cefpodoxime (10 mg/kg/d 1 dose), clarithromycin (15 mg/kg/d 2 doses), azithromycin (10 mg/kg/d on day 1, and 5 mg/kg/d for 4 days) If symptoms are severe, or refractory usual amoxicillin or other antimicrobial, or daycare is attended high-dose amoxicillin-clavulinate (80-90 mg/kg/d in 2 doses) or IM ceftriaxone (50 mg/kg single dose) followed by oral therapy is recommended Duration of therapy may be 10, 14, 21, or 28 days but alternative suggestion is 7 days of therapy beyond resolution of symptoms

44. Recommendations After failure with oral antibiotics IV cefotaxime or ceftriaxone are recommended Maxillary sinus aspiration Children with complicated or suspected complications of ABS should be treated promptly and aggressively and have appropriate consultations with an otolaryngologist, infectious disease specialist, ophthalmologist, and neurosurgeon Maxillary sinus aspiration IV ceftriaxone (100 mg/kg/d in 2 doses) or ampicillin-sulbactam (200 mg/kg/d in 4 doses) Vancomycin (60 mg/kg/d in 4 doses) CT scan Orbital or CNS involvement Inadequate data for recommendations for nasal steroids and decongestants

45. Surgical Management Adenoidectomy FESS Only after maximal medical therapy has failed and patient has been screened and treated for any underlying conditions Concern for developing nasal and sinus anatomy in children and possibility of altering facial growth

46. Clement, 1998

47. Adenoid tissue has been found to be a reservoir for pathogenic bacteria Hypertrophic adenoids obstruct the nasopharynx leading to stasis of secretions and bacterial overgrowth Overall success rate for adenoidectomy in the treatment of chronic sinusitis is 50% What is the role Adenoidectomy?

48. What is the role Adenoidectomy vs FESS? Ramadan, 2004 Surgical management of chronic sinusitis in children Prospective nonrandomized study over 10 years 202 children (2 � 13 y) enrolled and 18 lost to follow up Documented sinusitis on H&P and CT No response to at least 26 weeks of treatment with an antibiotic as decongestant or 6 or more episodes of sinusitis Allergy evaluation and managment Three groups Group 1: Adenoidectomy and FESS Group 2: FESS alone Group 3: Adenoidectomy alone 12 month follow up assessment

49. Results Group 1 (FESS+A) 87.3% symptom improvement 7.6% revision rate Group 2 (FESS only) 75% symptom improvement 12.5% revision rate Group 3 (A only) 51.6% symptom improvement 25% revision rate Ramadan, 2004

50. Wolf, 1995 The endoscopic endonasal surgical technique in the treatment of chronic recurring sinusitis in children 124 post FESS children evaluated by questionnaire No clinically significant disturbance in facial bone development Mean age 12 y 4% of patients were <5 y Most rapid period of growth of sinuses is between 1-4 y No major complications FESS and Facial Growth

51. Bothwell, 2002 (Wash. U) Long�term outcome of facial growth after functional endoscopic sinus surgery Retrospective review of quantitative anthropometric analysis using 12 parameters and qualitative analysis of 67 children diagnosed with CRS with age-matched controls 46 patients underwent FESS 21 patients did not undergo FESS 10 year follow up

52. Caucasian population (normal data available) Sinus CT reviewed and scored by Pediatric Rhinosinusitis CT Scoring System 0 = no disease 1 = <50% disease 2 = >50% disease 3 = complete opacification

53. Bothwell, 2002 (Wash. U) Quantitative anthropometric analysis Single reviewer Qualitative assessment of facial growth Single reviewer, blinded Results: No statistically significant difference for anthropometric measurements for (CRS) with FESS, (CRS) without FESS, and normal control groups On qualitative evaluation, the overall score for the non-surgical group was worse than the score for the FESS group

54. Pediatric FESS Safety and Efficacy Hebert, 1998 Meta-analysis of outcomes of pediatric functional endoscopic sinus surgery 8 articles with 832 patients, 50 unpublished patients Positive outcome with FESS: 88.7% Mean follow up 3.7 years Major complication rate 0.6% 6 of 8 articles reported complications 2 blood loss requiring transfusion 2 meningitis

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