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Pediatric rhinosinusitis 1997-otolaryngology---head-and-neck-surgery


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Pediatric rhinosinusitis 1997-otolaryngology---head-and-neck-surgery

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Pediatric rhinosinusitis 1997-otolaryngology---head-and-neck-surgery

  1. 1. Pediatric rhinosinusitis RODNEYP.LUSK,MD,and JAMESA. STANKIEWICZ,MD,St. Louis, Missouri, and Chicago, IlLinois Pediatric rhinosinusitis is often misdiagnosed and inappropriately treated. On the one hand, all upper res- piratory viral infections may be considered acute rhi- nosinusitis and therefore treated with antibiotics. On the other hand, some physicians and parents view puru- lent rhinorrhea as part of "growing up" and do not inter- vene with medical management. Over the past several decades much has been learned about chronic rhinosinusitis in children. II is now rec- ognized that infections of the nasal mucosa and sinuses are actually a continuum of disease, that rhinitis or rhi- nosinusitis rarely occurs in isolation, and that most pediatric sinus infections begin with an upper respirato- ry tract viral infection and progress to a bacterial sinus infection. The natural history of pediatric chronic rhinosinusi- tis is not well understood. Rhinosinusitis is a multifac- torial disease, and predisposing factors change in importance over time. For example, the maturing immune system and enlarging anatomy of the sinuses may be factors that separate pediatric chronic rhinosi- nusitis from adult chronic rhinosinusitis. 13 Other spe- cial conditions yet to be defined as predisposing factors for chronic rhinosinusitis in children are allergy,4 air pollution, 5 gastroesophageal reflux,6-8 day care set- tings, and enlarged tonsils and adenoids. Although sig- nificant growth retardation does not seem to occur after surgery, it remains a concern. DIAGNOSIS Definition Rhinosinusitis, which is the preferred term, acknowledges that most sinus infections start in the nasal passages as part of a continuum of disease. 9 Viral From the Department of Pediatric Otolaryngology, St. Louis Children's Hospital (Dr. Lusk), and the Department of Otolaryngology-Head and Neck Surgery, Loyola University, Chicago,Ill.(Dr.Stankiewicz). Reprint requests: Rodney R Lusk, MD, Department of Pediatric Otolaryngology, St. Louis Children's Hospital, One Children's Place, St. Louis,MO 63110. OtolaryngolHeadNeck Surg 1997;117:$53-$57. Copyright © 1997 by the AmericanAcademy of Otolaryngology- Head and NeckSurgeryFoundation,Inc. 0194-5998/97/$5.00+ 0 23/0/83511 rhinitis cannot be differentiated from rhinosinusitis on clinical grounds alone. Isolated rhinitis probably exists, but isolated sinusitis is rare. I° Signs and Symptoms The diagnosis of rhinosinusitis is usually based on the clinical evidence and the duration of symptoms. In the first 7 to 10 days of illness it is virtually impossible to tell the difference between an upper respiratory tract infection and rhinosinusitis. In some circumstances, however, an acute infection may rapidly progress to complicated rhinosinusitis. In acute rhinosinusitis the signs and symptoms last longer than 10 days. Chronic rhinosinusitis is associated with low-grade symptoms that persist more than 12 weeks, although acute exacer- bations can occur in chronic infection. Recurrent acute rhinosinusitis consists of repeated acute episodes, with the signs and symptoms resolving completely between episodes. In patients who are being treated with antibi- otics, it is often difficult to differentiate chronic rhino- sinusitis from acute rhinitis on the basis of the signs and symptoms alone, because the clinical features may be masked by the drugs. The signs and symptoms of pediatric rhinosinusitis are listed in Table 1.11-t4 Severe symptoms and compli- cations are usually associated with acute rhinosinusi- tis. I5 The signs and symptoms associated with chronic rhinosinusitis include nasal congestion, rhinorrhea, headaches, irritability, day and night cough, postnasal discharge, and halitosis. 3,t2-14,16 Testing Cultures may be necessary if infections do not respond to conventional treatment (i.e., antibiotics that cover ~3-1actamase-prodncing bacteria) or if symptoms return within 1 week after antibiotic therapy is stopped. There is no consensus on whether middle meatal cul- tures can substitute for sinus punctures. 10,17,18Cultures from the middle meatus or the ethmoid bulla appear to give the best results in chronic rhinosinusitis. 19-21 Cultures are necessary in the following situations: when a child is severely ill or toxic, when symptoms progress despite appropriate medical management, when the child is immunocompromised, and when sup- purative complications are present. The most likely S53
  2. 2. S54 LUSKand STANKIEWICZ Otolaryngology- Head and Neck Surgery September 1997 Table 1. Signs and symptoms of pediatric rhinosinusitis Rhinosinusitis Sign/symptom Nonsevere Severe Rhinorrhea Yes Yes: frank, purulent Nasal congestion Yes Yes Headaches, facial pain May be present Yes Fever None or low grade High grade Frequent cough Yes Yes Postnasal discharge Mild Mild Data from Wald ER. N Engl J Med 1992;326:319-23; Wald ER. Ann Oto/Rhinol Laryngol Supp11992;155:37-41; Muntz HR et al. In: Lusk RP, editor. Pediatric sinusitis. New York: Raven Press; 1992. p. 1-5;Parsons DS et al. Otolaryn9ol Clin North Am 1996;29:11-25. Table 2. Indications for endoscopic sinus surgery Absolute indications Complete nasal obstruction caused by the following: Cystic fibrosis Allergic fungal sinusitis Antrochoanal polyps Other causes of nasal polyps Intracranial complications Cavernous sinus thrombosis Mucoceles and mucopyoceles Subperiosteal or orbital abscess Traumatic injury to optic canal (decompression) Dacryocystorhinitis from rhinosinusitis Allergic or invasive fungal rhinosinusitis Meningoencephaloceles Cerebrospinal fluid leaks Tumors of the nasal cavity or sinuses Relative indications Subacute rhinosinusitis after failure of optimal medical therapy Chronic rhinosinusitis after failure of optimal medical therapy Recurrent acute rhinosinusitis occurring frequently enough that patient takes antibiotics most of the time causes of infection are Staphylococcus aureus, Streptococcus pneumoniae, Moraxella (Branhamella) catarrhalis, and Haemophilus influenzae. 15,20-22 Imaging is not needed to make the diagnosis of rhi- nosinusitis in all children. Controversy exists concern- ing the value of diagnostic ultrasound examination, but this modality appears to be of little use in children. 23-28 Transillumination is of no value in diagnosing rhinosi- nusitis in children. 24Although sinus radiographs are of little use in assessing the ethmoid sinuses or the sphe- noid and frontal sinuses in small children, they can be helpful in diagnosing acute maxillary sinusitis in older children. 29-32 Computed tomographic scanning is indi- cated if endoscopic sinus surgery is being considered or if symptoms indicate that medical management has failed.33-37 The workup should also include investigations for allergy,38-43immune deficiency, 38'4°'44-47cystic fibrosis, 48- 51 ciliary disorders,52-54and gastroesophageal reflux.8 MEDICAL MANAGEMENT Antibiotics and nasal steroids may mask the signs and symptoms of acute and chronic rhinosinusitis. It is also important to remember that the current practice of using broad-spectrum antibiotics for less well-docu- mented infections is likely to increase resistant strains of bacteria.55 Antibiotics may be given for bronchitis and acute otitis media as necessary. The severely ill or toxic child with symptoms of purulent rhinorrhea, nasal obstruc- tion, cough, and headache should be treated with oral antibiotics, whereas the severely ill or toxic child with evidence of suppurative complications should be treat- ed with intravenously administered antibiotics that are effective against H. influenzae, S. pneumoniae, and M. catarrhalis.10,17,56-59 Nonsevere acute rhinosinusitis may be treated with amoxicillin. If no improvements occur in 48 to 78 hours, the antibiotic should be changed to a ~}-lacta- mase stable agent. An oral ~-lactamase stable agent should be used for the initial therapy of severe acute rhinosinusitis and for the treatment of prolonged symp- tomatic chronic rhinosinusitis. For chronic rhinosinusitis a 4- to 6-week course of antibiotics is appropriate. 1°,6°-62 For acute rhinosinusi- tis 10 to 14 days of antibiotic therapy is appropri- ate. 10,63,64If symptoms continue or recur within 5 to 7 days after antibiotic therapy is stopped, the infection should be considered persistent. However, the infection should be considered a new one in a child who was free of symptoms for 2 or more weeks and who was not tak- ing antibiotics. If the symptoms progress after 72 hours of antibiotic therapy, it is appropriate to reevaluate the patient, to change to a broader spectrum antibiotic, or to obtain a culture from the middle meatus. SURGICAL MANAGEMENT Complications of acute rhinosinusitis such as subpe- riosteal abscess, orbital cellulitis, or intracranial abscess must receive aggressive surgical management.
  3. 3. Otolaryngology- Head and Neck Surgery Volume 117 Number 3 Part 2 LUSKand STANKIEWICZ $55 Adenoidectomy In children with rhinosinusitis characterized by moderate to severe nasal obstruction caused by adenoid hypertrophy, adenoidectomy has been shown to be ben- eficial, although not statistically valid, as the cause of resolution.65-69 The degree of symptomatic improve- ment is greatest when the adenoid pads are large.7° Therefore adenoidectomy should be considered as a first-line treatment in a child with rhinosinusitis symp- toms and an obstructive adenoid pad. The size of the adenoid is best assessed with flexible endoscopy of the nasopharynx, but the degree of obstruction can also be documented on a lateral radi- ograph. The lateral tomogram on the sinus computed tomography scan will show good definition of the nasopharynx and allow evaluation of the adenoids. Antral Lavage As a diagnostic corollary of fluid in the maxillary sinus, air-fluid levels on radiographs or computed tomography scans are the only reliable predictors of retrievable fluid.7°-72 Most of the literature discussing lavage was published in the early 1980s; r.hese studies related the procedure to the diagnostic criteria for rhi- nosinusitis, the bacteriology of the illness, and the effi- cacy of sinusitis treatment. 72 Antral lavage is not a viable therapeutic modality for the treatment of rhinosinusitis, because it involves only the maxillary sinus and not the ethmoid sinuses.73-75 Although lavage is no longer used as a therapeutic modality, it remains a valuable diagnostic tool in the immunocompromised patient. An accepled use for lavage is where disease is primarily maxillary. Nasal Antrol Window The nasal antral window (inferior antrostomy) was popularized as a less aggressive and more effective method of treating rhinosinusitis than the Caldwell-Luc procedure. 75 In 1941 Hilding76 cited the nasal antral window as a safer and better procedure than antrostomy of the natural maxillary sinus ostium, because it was less likely to cause infection of the maxillary sinus in a rabbit animal model. Kennedy et al.77,78 cited Proetz79 as being concerned about the possibility of traumatizing the natural ostium with this procedure. Wilkerson8° repopularized the nasal antral window, and it is now frequently used with endoscopic sinus surgery]v,78 The inferior antrostomy has not been a successful modality for treating rhinosinusitis. 81-83 One reason is that the cilia continue to beat toward the obstructed nat- ural ostium. In addition, the diseased ethmoid sinuses are not addressed. Exceptions for placing an inferior antros- tomy include cilial dysfunction and cystic fibrosis. Endoscopic Sinus Surgery Pediatric endoscopic surgery became a viable option after success was demonstrated with adult endoscopic sinus surgery77,84-87 and special instruments were developed for use in children. 19Because of the smaller anatomy, pediatric sinus procedures are thought to require greater technical skill and more meticulous surgery than the same procedures in adults. Frontal and sphenoid sinuses are rarely entered in children. 19,62,88 Because pediatric rhinosinusitis in chil&en is usual- ly located in the anterior ethmoid and maxillary sinus- es, extensive surgery usually is not necessary. Instead, children generally require only a limited procedure con- sisting of anterior ethmoidectomy and possibly maxil- lary antrostomy. In an anterior ethmoidectomy the entire uncinate process is removed. The dissection is carried through the bulla and posteriorly to the basal lamella. The lateral dissection goes to the lamina papyracea. If a maxillary antrostomy is neces- sary,19,64,88-91 a conservative enlargement of the natur- al ostium seems effective. Generally, the ostium remains patent and appears to function well most of the time.78 Absolute and relative indications for endoscopic sinus surgery are listed in Table 2. Children with under- lying immune deficiency, cystic fibrosis, allergy, asth- ma, and mncociliary dyskinesia are more likely to require surgical intervention. Only a small number of children with rhinosinusitis will actually require surgery. In the authors' practice each pediatrician refers an average of one or two patients per year for the eval- uation of chronic rhinosinusitis. Approximately one third of these referred children will require surgery. Good outcomes occur in a large percentage of chil- dren who undergo endoscopic procedures. 19,64,92,93 Most parents who have realistic expectations (i.e., who understand that their children will continue to have viral upper respiratory tract infections) believe that their children are significantly improved after the surgery. CONCLUSION More research is necessary to examine the patho- physiology of pediatric rhinosinusitis and its medical and surgical treatment. Prospective controlled trials are also needed to evaluate the available surgical modali- ties. REFERENCES 1. Van der VekenPJ, ClementPA, BuisseretT, et al. Age-related CT-scanstudyof the incidenceof sinusitis in children.Am J Rhinol 1992;45-8.(gradeA) 2. GrossCW.The diagnosisand managementof sinusitisin chil- dren. Surgicalmanagement:an otolaryngologist'sperspective. PediatrInfectDis 1985;4:$67-72. (gradeB)
  4. 4. S56 LUSK and STANKIEWICZ Otolaryngology- Head and Neck Surgery September 1997 3. Wald ER, Gue~TaN, Byers C. Upper respiratory tract infections in young children: duration of and frequency of complications. Pediatrics 1991;87:129-33. (grade B) 4. Manning SC, Vuitch F, Weinberg AG, et al. Allergic aspergillo- sis: a newly recognized form of sinusitis in the pediatric popula- tion. Laryngoscope 1989;99:681-5. (grade B) 5. Koltai PJ. Effects of air pollution on the upper respiratory tract of children. Otolaryngol Head Neck Surg 1994;111:9-11. (grade B) 6. Hamilos DL. Gastroesophageal reflux and sinusitis in asthma. Clin Chest Med 1995;16:683-97. (grade B) 7. Holinger LD, Sanders AD, Chronic cough in infants and chil- dren: an update. Laryngoscope 1991;101:596-605. (grade A) 8. Barbero GJ. Gastroesophageal reflux and upper airway disease: a commentary. Otolaryngol Clin North Am 1996;29:27-38. (grade B) 9. 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  5. 5. Otolaryngology- Head and Neck Surgery Volume 117 Number 3 Part 2 LUSKand STANKIEWICZ $5,7 51. Cepero R, Smith RJ, Catlin FI, et al. Cystic fibrosis--an oto- laryngologic perspective. Otolaryngol Head Neck Surg 1987;97:356-60. (grade B) 52. Fontolliet C, Terrier G. Abnormalities of cilia and chronic sinusitis. Rhinology 1987;25:57-62. (grade B) 53. Karja J, Nuutinen J. Immotile cilia syndrome in children. Int J Pediatr Otorhinolaryngol 1983;5:275-9. (grade B) 54. Scheeren RA, Keehnen RM, Meijer CJ, et al. Defects in cellular immunity in chronic upper airway infections are associated with immunosuppressive retroviral pl5E-like proteins. Arch Otolaryngol Head Neck Surg 1993;119:439-43 (grade A) 55. McCaig LF, Hughes JM. Trends in antimicrobial drug prescrib- ing among office-based physicians in the United States. JAMA 1995;273:214-9. (grade C) 56. Otten FW, Grote JJ. Treatment of chronic max:llary sinusitis in children. ~[ntJ Pediatr Otorhinolaryngol 1988;15:269-78. (grade C) 57. 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