Managing chronic sinus disease in children

Children rarely present with the same signs and symptoms as adults. And again, children have frequent upper respiratory tract infections (URI), on the average suffering between 6 and 8 URIs per year.

Even though symptoms of chronic sinusitis in the pediatric population are often non-specific, the diagnosis still rests largely on the history and physical examination.

Distinguishing recurrent URIs from chronic sinus disease is a major problem. In this age group, the duration and severity of upper respiratory tract symptoms can be important for diagnosing sinus disease. In general, most uncomplicated viral URIs in children last 5 to 7 days and produce mild to moderate symptoms.

Purulent rhinorrhea is the most prevalent symptom, but the discharge can also be clear or mucoid. Chronic cough is also common. Nasal obstruction, headache, low-grade fever, irritability, fatigue, and foul breath may also be present in varying degrees. Since these symptoms are relatively nonspecific, the nature of these symptoms can be clues to the diagnosis of chronic sinus disease.

Purulent rhinorrhea and chronic cough are more commonly seen in younger children, whereas an older child may have postnasal drip and a chronic sore throat. Older children also tend to complain of headaches, whereas the young child will often manifest pain as irritability, mood swings, and even resting the face on a cold surface to alleviate facial pain.

Antibiotics is the preferred treatment. Therapy should be maintained continuously for at least 3 to 4 weeks, and even as long as 6 weeks. Antibiotic selection is usually empiric, since it is difficult to obtain sinus aspirates in children without general anesthesia.

Topical steroids can be employed in resistant cases, since they may be of value in reducing mucosal edema and reestablishing ostial patency. The role of decongestants is unclear, although they have been shown to improve ostial and nasal patency in adults with chronic maxillary sinusitis.

Children with HIV infection do not commonly present with sinonasal complaints.

The allergic component of this disease can be treated with allergen avoidance and environmental control, topical steroids and saline irrigations, and antihistamines.

When maximal medical therapy fails, surgical intervention should be considered. Adenoidectomy may be of value in certain children with very large adenoids, but the relationship between adenoid hypertrophy and sinusitis is unclear.

It is also important to emphasize that pediatric endoscopic sinus surgery is a twostage procedure requiring two general anesthetics. A second look operation is necessary 2 to 3 weeks later for removing adhesions and granulation tissue.

Antrochoanal polyps, which are an important cause of chronic sinus disease in children, can also be treated endoscopically. Currently, therapy consists of simple avulsion of the nasal portion of the polyp with or without removal of the antral portion.

Cystic fibrosis (CF) is also a major cause of chronic sinus disease in children. The major head and neck manifestations are nasal polyposis and chronic sinusitis, and a sweat chloride test should be considered in children with refractory sinus disease or polyps.

Surgery should be resorted to only when clinically necessary. It is best to avoid surgical intervention at an early stage. In the absence of complications of sinusitis, a CT should be obtained only after maximal medical therapy has failed and when surgery is being contemplated.

One should remember that regardless of the surgical technique used, recurrence is the rule rather than the exception in cystic fibrosis patients because of the underlying mucosal defect.

The recurrence rate appears to be inversely related to the extent of intranasal surgery. However, morbidity also increases with the more extensive operation.

When chronic nasal obstruction or chronic purulent discharge is clinically significant and refractory to medical management, surgical intervention should be considered.

Endoscopic sinus surgery has been shown to improve symptoms and to have significantly less morbidity than traditional sinus surgery in CF patients.