MAUI, HAWAII — Look for clues and comorbidities to diagnose sinusitis, a condition that is overdiagnosed and misdiagnosed in children.
When examining with an otoscope or nasal speculum, look at the location and the character of the secretions, and see if they are clear, thin, and strandy, suggestive of an allergic process, or mucoid and purulent, suggesting infection, Dr. Seth M. Pransky said at a meeting sponsored by the University Children's Medical Group and the American Academy of Pediatrics.
See whether the secretions are truly coming from the sinuses. A foul odor may be present. A look after decongesting the nose may be helpful, said Dr. Pransky, director of pediatric otolaryngology at Rady Children's Hospital, San Diego.
Children with chronic sinusitis feel miserable, with primary symptoms of nasal congestion, cough, nasal discharge, and headache or facial pain, Dr. Pransky explained. He added that ancillary symptoms include foul breath, sore throat, postnasal drip and throat clearing, as well as nausea, vomiting, and other gastrointestinal complaints. But note that fever often is absent.
Sinusitis may complicate upper respiratory infections, which may develop six to eight times per year, with 10 days per episode, he said, “meaning a good proportion of the time, a child is going to be ill, especially in the winter months.”
Gastroesophageal reflux disease (GERD) may be another factor. Most pediatric otolaryngologists believe there is some relationship between GERD and otitis, rhinitis, and sinusitis, as well as laryngeal problems, he noted. Reflux therapy has been supported by research that showed improvement of sinus symptoms for many patients with sinusitis (Arch. Otolaryngol. Head Neck Surg. 2000:126:831-6).
When considering the need for antibiotics he said, a culture should be taken from the middle meatus. “A culture from the nasopharynx is not sufficient, is not accurate, and does not reflect sinus disease.”
Choices for treatment may include the use of antibiotics, oral or nasal steroids, antihistamine therapy with sprays or oral agents, a leukotriene receptor antagonist, anticholinergic sprays, mast cell stabilizers, nasal saline sprays, decongestants, mucolytics, and GERD medications. “But, in reality, all of this is not needed,” he pointed out. It's important to determine what's appropriate for the individual child.
There probably is no role for parenteral antibiotics for chronic sinus disease, Dr. Pransky said at the meeting, also sponsored by California Chapter 2 of the AAP.
When using oral steroids, consider the duration, dose, complications, and other concerns.
When using topical steroids—cortico-steroid sprays, which are more classically used—consider appropriate age limitations, difficulty of administration, and issues of penetration, absorption, and duration. “They are approved now down to 2 years, and there's one preparation that's for even younger [children],” Dr. Pransky observed, adding that there is no real concern regarding impact on growth from their use.
Corticosteroid sprays are difficult to use, he noted. Parents should administer nasal sprays because children often do not self-administer them effectively, he advised. Parents should be taught how to administer the sprays correctly because directions from the package insert are inadequate.
Adjuvant therapies, including mucolytics, decongestants, and xylitol, are probably not helpful, he said. But saline solutions for nasal irrigation are “extremely valuable,” as they help clear out “dry, crusty secretions to get the normal physiological function of the nose going.” But keep in mind that the impact of saline solutions on ciliary function is unclear.
A comprehensive medical evaluation should precede surgical interventions, he said, because pediatric sinusitis is much more a medical disease than a problem that requires direct sinus surgery. Allergies should be assessed in all children before considering surgery because of an overlap in symptoms and a comorbidity rate that exceeds 50%.
Plain films frequently are misinterpreted in radiologic assessments, Dr. Pransky emphasized. “They're very difficult to interpret in a young child.”
X-rays of routine viral respiratory infections look like sinusitis, but it could be that the child simply has a cold, he continued. CT scans should not be taken during the winter respiratory infection season nor during or immediately after a respiratory infection. Keep in mind that one CT scan alone is not enough; it should be repeated before any surgical intervention.
In looking at the anatomy, assess the turbinates, he advised. When appropriate, an inferior turbinate reduction can be helpful. “The technology has improved over the years; we don't take the turbinates out. We don't do anything to the mucosa. We'll do a submucosal resection. And the current form of therapy is to do a radiofrequency ablation of the turbinate.” As a result, not only is the airflow improved, but medications [also] can be used more effectively—as they can be more directly targeted without obstruction.