clinical ● Rhinosinusitis Green nasal discharge in children

Consultant ENT Surgeon, Mr Michael Harney, on managing the child with a be given from the age of two years old; pseudoephedrine green discharging nose (e.g. Sudafed) from the age of six years. he child with a green No antibiotics. t h a n 1 0 d a y s, or w or s e n i n g a f te r other. The recommendation is discharging nose is a l Symptoms present for greater five days, satisfy the clinical cri- that these patients, with an Chronic sinusitis frequent clinical prob- than 10 days or worsening teria for a diagnosis of an acute acute rhinosinusitis, should be A green discharging blocked T lem. The clinician must symptoms after five days. rhinosinusitis (sinusitis is now treated with an antibiotic, such nose of three or more months’ be able to determine which cases Diagnosis — acute sinusitis. more correctly termed rhinosi- as amoxycillin or co-amoxiclav. duration is defined as a chronic need active intervention and l Symptoms present for longer nusitis, as the mucosal lining of Saline lavage has been shown rhinosinusitis. This would in- which cases need supportive than three months. Diagnosis the sinuses is continuous with to reduce bacterial counts, im- dicate that the problem lies treatment only. — chronic sinusitis. that of the rest of the nose, and prove ciliary function and in- in a chronic infection of the The diagnosis is based on therefore a ‘sinusitis’ is always duce vasoconstriction, reduc- paranasal sinuses. The typi- Diagnosis of allergic rhinitis is the duration of symptoms: Acute sinusitis associated with a ‘rhinitis’). ing nasal congestion. It is safe, cal narrative states that an ob- difficult in a child aged less than four l Symptoms present for The EPOS (European Position This duration differentiates and can be used in the younger struction in the sinus drainage less than 10 days or not Paper on Sinusitis) guidelines it from the common cold; rhi- infant. pathway causes an accumula- symptoms of ‘chronic sinusitis’ worsening after five days; state that children with col- nosinusitis and a common cold Decongestants can be given tion of secretions, which act as is two-fold. Firstly, by virtue of treat as a common cold — oured nasal discharge and a are frequently symptomatically for symptomatic relief; xy- a nidus for a chronic bacterial their large size, the adenoids can supportive measures only. blocked nose lasting longer indistinguishable from one an- lometazoline (Otrivine) can infection. The reality is prob- cause a physical nasal obstruc- ably somewhat more nuanced. tion. Secondly, the adenoids can Children with allergic rhinitis act as a repository for biofilm- are more symptomatic when for m i n g b a c te r i a , w h ic h c a n b e - they get a head cold; and dis- come quiescent during periods play symptoms of an URTI of antibiotic treatment, and re- more frequently. activate afterwards. T he adenoid s ca n ac t a s a r es- The size of the adenoids can ervoir for infection; infecting be assessed by a GP with a the nasal and sinus lining; and postnasal space X-ray. In a child being infected from sinonasal more than five years, an endo- infections. Allergy can cause scopic assessment is possible adenoid hypertrophy. The in- in an ENT setting. An enlarged terplay of sinusitis, allergic adenoid pad on X-ray increases rhinitis and adenoiditis needs the likely improvement in nasal to be considered when treating blockage from surgery, though this subgroup of children. The it is less sensitive for improve- EPOS guidelines suggest that ment in nasal discharge, which these children should have the c a n o cc u r w it h a d e n oid e c tom y, allergic component of their dis- independent of size. ease treated. Adenoidectomy is the first- Diagnosis of allergic rhinitis line surgical management for is difficult in the younger child chronic/recurrent acute rhi- less than four years of age. The nosinusitis in kids. This is usu- more typical symptoms of ally an overnight procedure. sneezing, itchy nose, watery Formal FESS surgery is rarely and itchy eyes develop later. A performed in children, as there clear, watery discharge is the are concerns that surgery may symptom most typical of aller- impair growth of the mid-face. gic rhinitis. Polyps are rare in kids and All children should have their presence requires investi- a saline rinse (e.g. Sterimar, gation for the presence of cystic Nasomist). Antihistamines fibrosis. Polyps are frequently can be given by the age of identified in children, but these one year (e.g. desloratadine usually turn out to be enlarged (Neoclarit yn)). Most nasal ster- inferior turbinates, secondary oid s ca n b e u se d f r om t he a ge of to allergic rhinitis. six years; fluticasone propion- Elevating the tip of the nose ate (Flixonase) is the only nasal and inserting the otoscope to steroid licensed for use from inspect the anterior nasal cav- OTHERS MAY PROMISE the age of four years; however, ity for mucopurulent discharge the higher-volume prescription can usually perform a quick WILD AND OUTLANDISH version is no longer available, examination of the anterior and the lower-volume, over- nose easily and painlessly and the-counter preparation has to to detect enlarged inferior tur- CLAIMS TO CURE OUR be used instead. Montelukast binates, usually indicating al- can be considered, particularly lergy. in children with concomitant A green-discharging nose CHRONIC HEALTH asthma. is characterised as a common The EPOS guidelines sug- cold, acute or chronic sinusi- SERVICE. gest that these children with tis, depending on its duration. chronic sinusitis should be Symptoms lasting less than considered for a two-six week 10 days (or not worsening af- IRISH MEDICAL TIMES course of antibiotics. Gastro- ter five days) need supportive oesophageal reflux disease has treatment only. been proposed as a cause of Treat acute sinusitis (symp- WON’T SELL ITS chronic sinusitis, and certain toms longer than 10 days or proponents recommend treat- worsening after five days) with READERS ANY SNAKE ing with proton pump inhibi- saline sprays and antibiotics, tors. However, the evidence for with additional oral or topi- this is scant and this author, cal decongestants as required. OIL SOLUTIONS quite frankly, thinks the asso- Consider long-term antibiotics ciation somewhat fanciful. (two-six weeks) in the chronic cases. Treat underlying allergy Surgical options if the symptoms are persistent. Adenoidectomy can be offered Adenoidectomy can be useful in Irish Medical Times is the only medical newspaper in Ireland to the child more than three recalcitrant cases. that is requested in writing by doctors and 92% request their years of age, with a chroni- IMT delivered to their home address. cally blocked, mucopurulently l Mr Michael Harney, discharging nose. The princi- ENT Consultant, ple behind adenoids causing Bon Secours Hospital, Cork.

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