The sinuses are hollow air-filled sacs lined by mucous membrane. The ethmoid and maxillary sinuses are present at birth. The frontal sinus develops during the 2 nd year and the sphenoid sinus develops during the 3 rd year.
What are the sinuses? (cont’d)
Sinuses have small orifices (ostia) which open into recesses (meati) of the nasal cavities.
Meati are covered by turbinates (conchae).
Turbinates consist of bony shelves surrounded by erectile soft tissue.
There are 3 turbinates and 3 meati in each nasal cavity (superior, middle, and inferior).
Considerations for Pediatrics
At birth, the ethmoid, sphenoid and maxillary sinuses are tiny and cause problems in infants and toddlers.
Frontal sinuses develop between 4-7 years of age, causing problems in school aged children and adolescents.
Inflammation of paranasal sinuses
What is sinusitis?
An acute inflammatory process involving one or more of the paranasal sinuses.
A complication of 5%-10% of URIs in children.
Persistence of URI symptoms >10 days without improvement.
Maxillary and ethmoid sinuses are most frequently involved.
How Does Sinusitis Develop?
Usually follows rhinitis, which may be viral or allergic.
May also result from abrupt pressure changes (air planes, diving) or dental extractions or infections.
Inflammation and edema of mucous membranes lining the sinuses cause obstruction.
This provides for an opportunistic bacterial invasion.
With inflammation, the mucosal lining of the sinuses produce mucoid drainage. Bacteria invade and pus accumulates inside the sinus cavities.
Postnasal drainage causes obstruction of nasal passages and an inflamed throat.
If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities.
Allergies, nasal deformities, cystic fibrosis, nasal polyps, and HIV infection.
High pollen counts
Day care attendance
Smoking in the home
Reinfection from siblings
Acute or Chronic Sinusitis?
Acute Sinusitis – respiratory symptoms last longer than 10 days but less than 30 days.
Subacute sinusitis – respiratory symptoms persist longer than 30 days without improvement.
Chronic sinusitis – respiratory symptoms last longer than 120 days.
Etiology of Sinusitis
70% of bacterial sinusitis is caused by:
Other causative organisms are:
Complications of Sinusitis
Orbital cellulitis or abscess
Intractable wheezing in children with asthma
Cavernous sinus thrombosis
Subjective Symptoms of Sinusitis
History of URI or allergic rhinitis
History of pressure change
Pressure, pain, or tenderness over sinuses
Increased pain in the morning, subsiding in the afternoon
Persistent nasal discharge, often purulent
Cough, worsens at night
Mouthing breathing, snoring
History of previous episodes of sinusitis
Sore throat, bad breath
Clinical Presentations of Sinusitis
Nasal mucosa is reddened or swollen
Percussion or palpation tenderness over a sinus
Nasal discharge, thick, sometimes yellow or green
Postnasal discharge in posterior pharynx
Swelling of turbinates
Boggy pale turbinates
Pale, Boggy Turbinates
Imaging studies, such as sinus radiographs, ultrasonograms, or CT scanning – indicated if child is unresponsive to 48 hours of antibiotics and if the child has a toxic appearance, chronic or recurrent sinusitis, and chronic asthma.
Laboratory studies, such as culture of sinus puncture aspirates.
Carcinoma of sinus
Structural defects (septum deviation)
Nasal foreign body
Pharmacological Plan of Care
Antimicrobials-treat for 10-14 days, depending upon severity, with one of the following:
Amoxicillin:20-40mg/kg/d in 3 divided doses(>20kg, 250mg tid)
Augmentin:25-45mg/kg/d in 2 divided doses(>20kg, 400mg q12) Use chewable or suspension if child is less than 40kg.
Pharmacological Plan of Care
Biaxin:15mg/kg/d in 2 divided doses(>30kg, 250mg q12)
Cefzil:15mg/kg/d in 2 divided doses (>35kg, 250mg bid)
Lorabid: 30mg/kg/d in 2 divided doses (>26kg, 400mg bid)
Other Relief Medications
Codeine – for severe pain
Rhinocort nasal spray – 2 sprays in each nostril every 12 hours for children over 6 years of age.
Acetaminophen or ibuprofen to relieve pain
Humidifier to relieve the drying of mucous membrances associated with mouth breathing
Increase oral fluid intake
Saline irrigation of the nostrils
Moist heat over affected sinus
Prolonged shower to help promote drainage
Child should not dive.
Child should not travel by airplane.
Urge parent to eliminate triggers in the home (dust, smoking)
Have all members of the family treated, if indicated.
Follow Up Guidelines
Instruct parent to call in 48 hours if condition of child has not improved.
Instruct parent to bring child in for a recheck in 2 weeks.
Guidelines for Referral
Child with complications or signs of invasive infection.
Child needing control of allergic rhinitis.
Child with chills and fever.
Child with persistent headache.
Child with edema of forehead, eyelids.
Child with orbital cellulitis
Austin, 9 years old, was seen in the clinic ten days ago, was diagnosed with rhinitis and sent home with instructions for increased fluids, decongestants, and rest.
Austin presents today with worsened symptoms of malaise, low-grade temperature, nasal discharge, night time coughing, mouth breathing, early morning pain over sinuses, and congestion.
Case Study (cont’d)
Physical findings for Austin:
Thick, yellow nasal discharge
Edematous, reddened nasal mucosa
Postnasal discharge visible in posterior pharynx
Tenderness of sinuses upon palpation
Case Study (cont’d)
Treatment: Austin weighs 90 lbs, or 40.8 kg
Amoxicillin – 250 mg tid po
Comfort measures – acetaminophen for pain relief
Moist heat applied to sinuses
Increased oral fluids
Boynton, R., Dunn, E., Stephens, G., & Pulcini, J. (2003) Manual of ambulatory pediatrics (5 th ed.). Philadelphia: Lippincott Williams & Wilkins.
Burns, C., Dunn, A., Brady, M., Starr, N., & Blosser, C. (2004). Pediatric primary care: A handbook for nurse practitioners (3 rd ed.). St. Louis, Missouri: Saunders.
Colyar, M. (2003). Well-child assessment for primary care providers. Philadelphia: F. A. Davis Company.
Tierney, L., Saint, S., & Whooley, M. (2005). Current essentials of medicine (3 rd ed.). New York: Lange Medical Books/McGraw-Hill.