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Snotty Noses – When Is It Sinusitis? Objectives

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Snotty Noses – When Is It Sinusitis? Objectives 11/2/2019 Snotty Noses – When is it Sinusitis? Uma Ramaswamy, MD Objectives • Identify and medically manage acute rhinosinusitis • Recognize signs/symptoms of pediatric chronic rhinosinusitis (PCRS) • Recognize refractory or complicated sinusitis • When to refer to ENT 1 11/2/2019 https://www.sciencephoto.com/media/728470/view https://www.sciencephoto.com/media/728470/view 2 11/2/2019 Physiology and Function • Humidification • Temperature modification • Filtration of inspired air • Olfaction https://openi.nlm.nih.gov/imgs/512/28/2719610/PMC2719610_1465-9921-10-61-2.png https://hosting.med.upenn.edu/otocme/wp-content/uploads/sites/25/2016/12/pci4-300x183.jpg Pediatric Rhinosinusitis • Inflammation of the nasal cavity and paranasal sinuses Two or more symptoms • Nasal obstruction/congestion • Nasal Discharge – Anterior – Rhinorrhea – Posterior – Post-nasal drip (PND) • Cough • Facial Pain or Pressure • Fever 3 11/2/2019 Contributing Factors • Anatomic Factors • Infectious Agents – Bacterial versus Viral • Biofilms • Adenoids • Allergic Rhinitis • Immunodeficiency • Primary Ciliary Dyskinesia • Cystic Fibrosis Differential Diagnosis of Pediatric Sinusitis • Allergic rhinitis • Chronic invasive fungal sinusitis • Cystic fibrosis • Sinonasal neoplasm • Immotile cilia • Upper respiratory tract infection syndrome/Primary ciliary dyskinesia • Unilateral choanal atresia – Kartagener syndrome (situs • Adenoid hypertrophy inversus, chronic sinusitis, and bronchiectasis) • Nasal foreign body • Odontogenic • Immunodeficiency (immunoglobulin [Ig]A, IgG • Sinonasal polyposis subclass) 4 11/2/2019 Uncomplicated URI 0-3 days 3-5 days 5-7 days 7-10 days Fever (+) (-) (-) (-) Yellow, Rhinorrhea Clear Clear Improving mucoid Cough (-) (+) (+) (-) Wald ER, Pediatrics, 132(1): Jul 2013. Guidelines: Pediatric Acute Bacterial Rhinosinusitis (ABRS) Clinician should make a presumptive diagnosis of acute bacterial sinusitis in the following situations: • Persistent illness (rhinorrhea and/or cough) > 10 days without improvement • Worsening course (rhinorrhea, cough +/- fever) AFTER initial improvement • Severe onset (fever > 102.2 and purulent rhinorrhea) for at LEAST 3 days Why? Other presentations are most likely viral illness 5 11/2/2019 Guidelines: Pediatric ABRS STRONG RECOMMENDATION Clinicians should NOT obtain imaging (plain X-ray, CT, MRI) Why? Imaging has a high likelihood of being abnormal and doesn’t help make a diagnosis Guidelines: Pediatric ABRS Clinicians should obtain a contrast-enhanced CT and/or an MRI with contrast whenever a child is suspected of having an orbital or CNS complications of acute bacterial sinusitis Why? You don’t want to miss an infection that may require IV antibiotics +/- surgery 6 11/2/2019 Guidelines: Pediatric ABRS Alternate Recommendation Treatment Persistent illness > 10 days without 3B: Antibiotic therapy* (rhinorrhea and/or improvement Observation for (* esp if complication, 3 additional days cough) another infection like AOME (decreases risk of or underlying conditions like developing antibiotic RAD, CF, immunodef) resistance and side effects like diarrhea) Worsening course AFTER initial (rhinorrhea, cough 3C: Antibiotic therapy improvement +/- fever) Severe onset For at LEAST (fever > 102.2 and 3 days 3A: Antibiotic therapy purulent rhinorrhea) Guidelines for Pediatric Acute Bacterial Sinusitis < 2 yrs or mod – > 2 yrs severe illness Mild to moderate symptoms Amoxicillin Amoxicillin-clavulanate No risk factors 45 mg/kg/day BID 80-90 mg/kg/day BID Risk factors: daycare, Amoxicillin-clavulanate Amoxicillin-clavulanate recent abx (<4 wks) 80-90 mg/kg/day BID 80-90 mg/kg/day BID High community prevalence of Amoxicillin Amoxicillin-clavulanate non-susceptible S. pneumo 80-90 mg/kg/day BID 80-90 mg/kg/day BID SPECIAL CONSIDERATIONS Type 1 PCN allergy: Non-Type 1 (delayed allergy): Clindamycin + cefixime or PCN allergy Cefdinir, cefuroxime, or Linezolid + cefixime or cefpodoxime Levofloxacin Rocephin 50 mg/kg IM x 1* + PO antibiotics when taking PO Unable to take PO *Additional IM doses if remain febrile > 24 hrs 7 11/2/2019 Guidelines: Pediatric ABRS Why? Reassess patient at 72 hours Majority of symptom improvement occurs within the first 3 days of therapy Initial management Worse in 72 hours Not improved in 72 hours Shared decision: antibiotic therapy vs. Observation Initiate antibiotic therapy continued observation Shared decision: continue amoxicillin Amoxicillin High dose amoxicillin-clavulanate vs. high dose amoxicillin-clavulanate Clindamycin + cefixime vs. High dose amoxicillin- Shared decision: continue current Linezolid + cefixime vs. clavulanate therapy vs. alternate therapy (at left) Levofloxacin Guidelines: Pediatric ABRS Poor scientific evidence to support use of most adjuvant agents Therapy Evidence/Support Intranasal steroids Might help, confidence for benefit lacking, min risk Saline irrigation Might help, confidence for benefit lacking, min risk Antihistamines Do not use except to treat concurrent allergy Decongestants Insufficient data to support use* There is potential for harm and no proven benefit from over-the-counter cough and cold medications in children younger than 6 years. These substances are among the top 20 substances leading to death in children <5 years old. 8 11/2/2019 Recurrent Acute Sinusitis • Symptoms lasting >7-10 days (usually requiring antibiotics) • Occurring 4+ times per year • Referral to assess for possible anatomic obstruction Subacute Sinusitis • Symptoms lasting >4 weeks but <12 weeks • Acute sinusitis refractory to medical management • May require culture directed antibiotics • Referral to assess for possible anatomic obstruction 9 11/2/2019 Pediatric Chronic Rhinosinusitis (PCRS) ≥ 90 days (12 weeks) • Colored rhinorrhea/PND • Nasal obstruction • Facial pressure May benefit from • Cough surgery and require • Objective data long-term follow up – Endoscopic findings: mucosal edema, nasal polyps – CT scan Subtypes of Chronic Rhinosinusitis • With nasal polyps • Without nasal polyps • Allergic fungal rhinosinusitis (AFRS/AFS) • Chronic invasive fungal sinusitis 10 11/2/2019 Nasal Polyps • Allergy • Chronic sinusitis • Allergic fungal (rhino)sinusitis (AFRS/AFS) • Asthma • Aspirin sensitivity • Churg-Strauss • Nonallergic rhinitis with eosinophilia syndrome (NARES) • Ciliary disorders • Cystic fibrosis https://www.dreamresearchgroup.com/2014/12/nasal-polyps.html https://www.slideshare.net/mdeepin/nasal-polyp-31909588 Allergic Fungal Rhinosinusitis • Physiology: allergy to mold/fungus (documented) • Usually unilateral in pediatric population • Does not require treatment with antifungals/antibiotics • Definitive diagnosis and treatment is via surgery 11 11/2/2019 Maximal Medical Treatment of PCRS • Topical nasal steroid spray daily • Nasal saline irrigations 1-2 times daily • 3 weeks of antibiotic therapy – Culture directed antibiotics when necessary • +/- steroids Nasal Saline Irrigations • Purified/Distilled water (never tap water) • Warm 10-15s prior to placing in bottle • Saline packet • Instructions: tilt head forward, keep mouth open • Bottle good for 3 months 12 11/2/2019 When to Refer • Recurrent acute sinusitis • Subacute sinusitis • When maximal medical therapy has failed for PCRS • Allergic fungal sinusitis • Immunodeficiency/PCD/CF Surgical Management for Sinusitis Adenoidectomy • Consensus for adenoidectomy for treatment up to 6 years • Less consensus on those aged 6 – 12 years • No consensus in those aged 13 years or older • Tonsillectomy (without adenoidectomy) is ineffective treatment for PCRS Functional Endoscopic Sinus Surgery (FESS) • Relieve anatomic obstruction • Allow for better access for topical therapies 13 11/2/2019 Endoscopic Sinus Surgery • ESS effective when medical management and adenoidectomy have failed • CT scan prior to ESS • ESS does not cause impairment of facial growth • Consensus that postoperative debridement not essential component of treatment Complications of Sinusitis Complication # % Preseptal cellulitis 15 26 Orbital celluitis 5 8.7 Subperiosteal abscess orbit 8 14 Orbital abscess 5 8.7 Epidural abscess 5 8.7 Subgaleal abscess 6 10 Subdural abscess or empyema 6 10 Sagittal sinus thrombosis 2 3.5 Brain abscess 2 3.5 Dacryocystitis 2 3.5 Total 57 Stokken J, Gupta A, Krakovitz P, Anne S. Rhinosinusitis in children: a comparison of patients requiring surgery for acute complications versus chronic disease. Am J Otolaryngol. 2014 Sep-Oct;35(5):641-6. 14 11/2/2019 Summary ENT REFERRAL • Recurrent acute sinusitis • Chronic sinusitis • Subacute sinusitis • Complicated sinusitis • First-line surgical treatment is usually adenoidectomy in those less than 13 • FESS is used to relieve obstruction and improve access for topical therapy • Complications of sinusitis likely require hospital admission and multidisciplinary management References Brietzke SE, et al. Clinical Consensus Statement: Pediatric Chronic Rhinosinusitis. Otolaryngology– Head and Neck Surgery. 2014, Vol. 151(4) 542–553. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970 Sep;80(9):1414-28. Runkle K. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. The Cochrane Database of Systematic Reviews, (10), CD007909. Onesimo R, Scalzone M, Valentini P, Caldarelli M. Pott’s puffy tumour by Streptoccocus intermedius a rare complication of sinusitis. BMJ Case Reports. 2011; doi:10.1136/bcr.08.2011.4660. Stokken J, Gupta A, Krakovitz P, Anne S. Rhinosinusitis in children: a comparison of patients requiring surgery for acute complications versus chronic disease. Am J Otolaryngol. 2014 Sep-Oct;35(5):641-6. Wald ER, et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics. July 2013, 132 (1) e262-e280. 15.
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