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

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https://www.sciencephoto.com/media/728470/view

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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

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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)

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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.

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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.

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.