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