SINUSITIS AND ITS MANAGEMENT DR NAUSHEEN QURESHI ASSISTANT PROFESSOR ENT DEPT HFH
Anatomy of sinuses
• Where are the sinuses?• Four pairs of paranasal sinuses – Frontal-above eyes in forehead bone – Maxillary-in cheekbones, under eyes – Ethmoid-between eyes and nose – Sphenoid-in center of skull, behind nose and eyes
EMBRYOLOGICAL DEVELOPMENT • 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
EMBRYOLOGICAL DEVELOPMENT • 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
DEFINATION AND INCIDENCE • 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
PATHOGENESIS: • 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
PATHOGENESIS: • 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.
PREDISPOSING FACTORS • Allergies, nasal deformities, cystic fibrosis, nasal polyps, and HIV infection. • Cold weather • High pollen counts • Day care attendance • Smoking in the home • Re-infection from siblings
SYMPTOMS: • 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 • Malaise • Low-grade temperature • Persistent nasal discharge, often purulent • Postnasal drip • Cough, worsens at night • Mouthing breathing, snoring • History of previous episodes of sinusitis • Sore throat, bad breath • Headache
CLINICAL FEATURES: • Periorbital edema • Cellulitis • 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 • Difficult transillumination • Swelling of turbinates • Boggy pale turbinates
DIAGNOSTIC TESTS: • 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.
MEDICAL TREATMENT • Acetaminophen or ibuprofen to relieve pain • Decongestants • Antihistamines • Nasal saline
ANTIBIOTIC TREATMENT: • 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) • CLAVUNATED AMOXICILLIN:25- 50mg/kg/d in 2 divided doses, Use suspension if child is less than 40kg.
FOLLOW UP INSTRUCTIONS Humidifier to relieve the drying of mucous membranes associated with mouth breathing • Increase oral fluid intake • Saline irrigation of the nostrils • Moist heat over affected sinus • Prolonged shower to help promote drainage
PATIENT EDUCATION: • 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. • 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.