1. Diagnose and manage pediatric sinusitis.

2. Discuss the differences between acute, subacute, recurrent, and chronic sinusitis in children.

3. List the indications for pediatric sinus surgery.

4. Describe the latest trends in the prevalence of pediatric respiratory Staphylococcus aureus infections.

5. Explain the prognostic significance of the severity of nasal polyposis in children with cystic fibrosis.

Acute Bacterial Sinusitis: Medical Management
Jean A. Wiedeman, MD, PhD, Associate Professor, Department of Pediatrics, Section of Infectious Diseases, University of California, Davis, Health System, Sacramento

Pediatric sinusitis: poorly understood; no simple reliable diagnostic tests; findings on physical examination limited; diagnosis often made on history alone; defined as inflammation of normally sterile sinuses due to bacterial infection; acute bacterial sinusitis (ABS) thought to be common in childhood, although exact incidence unknown; usually preceded by viral upper respiratory infection (URI); 2% to 13% of URIs thought to progress to ABS; most children experience at least one episode of ABS before kindergarten; maxillary and ethmoid sinuses commonly involved in younger children; frontal sinus involvement more common at >10 yr of age

Uncomplicated viral URI: lasts ≈1 wk, with daily improvement after first few days; fever occurs early and is short- lived; most respiratory symptoms also resolve or improve significantly in ≤1 wk

Acute bacterial sinusitis: defined as upper respiratory tract symptoms that persist past time of typical URI resolution (including influenza); symptoms may worsen from days 7 to 10

Diagnosis: persistent symptoms (10-30 days) including cough and nasal discharge; halitosis (younger children); older children may complain of headache or facial pain, sinus pressure, maxillary or dental pain, and pharyngitis; fever not prominent symptom; distinguish between single long episode and multiple consecutive URIs; with viral URI, purulent rhinorrhea usually does not appear until days 3 to 4; with severe ABS, purulent rhinorrhea and high fever may appear concurrently; patients may appear ill (but not toxic) and complain of intense headache, often behind eye; facial pain unusual in younger children; with few specific symptoms and unreliable transillumination, history most important for diagnosis

Subacute sinusitis: defined by American Academy of Pediatrics (AAP) as daytime cough and/or nasal discharge plus low-grade fever lasting 30 to 90 days

Recurrent sinusitis: 4 episodes of ABS within 12 mo, or 3 episodes within 6 mo; consider comorbidities; day care possible risk factor; rule out cystic fibrosis (CF), immunodeficiency, ciliary dyskinesia, and anatomic problems

Chronic sinusitis: symptoms lasting >90 days, or 6 episodes of ABS within 1 yr; bacteriology poorly defined (subacute and recurrent sinusitis share similar bacteriology with uncomplicated sinusitis); Staphylococcus aureus and anaerobes often implicated

Diagnosis

Radiographic imaging: study data—persistent symptoms predict abnormal radiographs in 88% of children <6 yr of age and ≈70% of those >6 yr of age (Wald et al, 1986); 75% of sinus aspirates from children with abnormal radiographs yielded high concentrations of bacteria (Wald et al, 1981); in view of these findings, AAP guidelines state that radiographs can be safely omitted for diagnosis of uncomplicated sinusitis in children <6 yr of age; when imaging indicated—plain radiographs technically difficult in younger children and no longer recommended; computed tomography (CT) gold standard but adds complexity and expense to evaluation; consider for older children and those with recurrent or chronic disease (benefits for older children with uncomplicated ABS not yet established); imaging recommended for any child for whom surgery considered

Guidelines: diagnosis must be made clinically, especially in younger child; incidental findings (eg, mucosal thickening, opacification, or air fluid levels) do not indicate treatment unless patient has symptoms; CT with contrast gold standard, especially if symptoms worsening or disease severe, if patient toxic, or surgery under consideration; magnetic resonance imaging (MRI) with gadolinium helpful for imaging soft tissue or when intracranial involvement suspected

Antibiotics: many studies marked by bias and flawed design; however, good data suggest appropriate use produces faster clinical cure and prevents suppurative complications; AAP recommends antibiotics when symptoms persist >10 days

Microbiology: sinus aspirates gold standard of diagnosis; tympanocentesis good surrogate; meatal cultures and cultures of nasal discharge not helpful (do not accurately represent sinus organisms); major organisms Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis; S pneumoniae—resistance decreased with introduction of conjugated pneumococcal vaccine; resistance now increasing and varying among strains; outcome data show vaccine-associated decrease in disease significantly greater than minimal upswing in new resistant strains; S pneumoniae recovered in ≈30% of aspirates and has nationwide resistance rate of 20%; mechanism of resistance alteration of penicillin-binding protein, so addition of β-lactamase inhibitor to antibiotic therapy not helpful

Treatment: according to 2001 AAP recommendations, 80% of children with uncomplicated ABS and no risk factors (eg, day care attendance, antibiotics within last 90 days, age <2 yr) respond to standard dose of amoxicillin (45 mg/ kg per day, divided twice daily); amoxicillin failure rate ranges from 3% to 10%; higher doses recommended to treat intermediate resistance recommended for children <2 yr of age who do not have other risk factors; for mild-to- moderate disease or children with day care attendance or history of antibiotic therapy within last 90 days, amoxicillin-clavulanate 45 to 90 mg/kg per day, divided twice daily, recommended; cefdinir, cefuroxime, or cefpodoxime recommended for children with penicillin allergy not consistent with type 1 hypersensitivity (anaphylaxis); clarithromycin or azithromycin recommended for children with penicillin allergy consistent with type 1 hypersensitivity; improved clinical response should occur within 48 to 72 hr; treat until symptoms gone plus an additional 7 days, or for 10 days; poor or no response—reasons include misdiagnosis and ineffective antibiotics; adjuvant therapy— no role for prophylactic antibiotics; saline nose drops may prevent crusting and help liquify secretions; most other adjuvant and alternative therapies controversial or ineffective

Sinus Surgery—When, How, and Does it Help?
Harlan R. Muntz, MD, Professor, Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, University of Utah, School of Medicine, and Primary Children’s Medical Center, Salt Lake City

Cystic fibrosis: surgical management important; sinus abnormalities common; ranges from asymptomatic mucoperiosteal thickening to severe polyposis requiring frequent surgical removal; indications for surgery—severe nasal obstruction; severe headaches; preparation for lung transplantation; facial deformities secondary to polyposis; deteriorating pulmonary function; remind family that surgery relieves symptoms but does not cure disease; repeat operations may be necessary; patients may have anteroposterior ethmoid, maxillary, or sphenoid disease; sinus mucocele in neonate almost always sign of CF; ≈10% to 20% of children with CF ultimately need sinus surgery; in one study, 50% of children needed ≥1 additional surgery within 2 yr

Orbital and periorbital complications of acute sinusitis: signs and symptoms include lid edema, chemosis, proptosis, retro-orbital pain (may seem disproportionate to other symptoms in child with immune deficiency), diplopia, visual impairment (decreased acuity or pupillary reflex; suggests pressure on optic nerve or retinal venous engorgement), headache, and mild neurologic symptoms; postseptal pathology—chemosis, proptosis, limited extra-ocular movement, deviation of globe; external approach to abscess drainage—Lynch incision (between medial canthus and midline of nose); operation also opens sinuses to relieve source of abscess; effective but associated with high morbidity

Endoscopic sinus surgery (ESS): associated with significantly reduced length of stay and duration of periorbital edema, compared to open surgery; also no scar

Chronic sinusitis: defined as sinus symptoms lasting >90 days; associated pain and limitation of activities have greater impact on quality of life than asthma or juvenile rheumatoid arthritis; however, medical management usually sufficient; comorbidities common (in one study, potential surgical candidates improved with aggressive treatment for gastroesophageal reflux); also consider aggressive allergy management; chronic sinusitis probably multifactorial; presence of biofilms in maxillary and ethmoid sinuses well documented; S aureus dwelling in nose may contribute to inflammation and swelling of nasal tissues; long-term goal of therapy to relieve symptoms and improve quality of life; topical nasal steroid spray and saline washes seem to help, although few hard data available; antibiotics may be effective if taken for >10 days, especially if combined with other medications; antileukotrienes may help; poor correlation between symptoms and same-day CT

Surgery: considered safe and effective, although few outcome studies conducted; orbital or skull-base complications rare; ≈7% of patients need reoperation; no discernible effect on facial growth, according to 10-yr follow-up study; multivariate analysis showed ESS superior to adenoidectomy alone in 2 studies of children with confirmed sinus disease; in retrospective study of 99 children, rate of success (defined as no need for revision surgery) 73% in children aged <6 yr, 89% in those >6 yr (p=0.04); in properly selected patients, ESS can diminish symptoms of sinusitis; however, children usually need concurrent medical management

Staphylococcus Aureus Infections: Nationwide Trends
Iman Naseri, MD, Staff Physician, Department of Otolaryngology–Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA

Retrospective review of pediatric methicillin-resistant S aureus (MRSA) epidemiology: MRSA defined as resistant to all β-lactam agents, including cephalosporins; few studies to date have examined pediatric head and neck infections

Goals of this study: to identify trends in antibiotic susceptibility over 6 yr

Source of data: surveillance network (national peer-reviewed microbiologic database that includes >300 hospitals across United States

Study design: all pediatric S aureus head and neck infections between 2001 and 2006 examined; 3 anatomic sites (oropharynx-neck, sinonasal, otologic) studied; demographic as well as susceptibility data collected

Results: data obtained on 21009 patients; 52% of patients male; average age 6.7 yr; prevalence highest in oropharynx-neck region (60% of infections); 78% of infections methicillin-sensitive; 22% MRSA, and of those, 47% also clindamycin-resistant, with prevalence increasing steadily since 2001, including unexplained spike in 2005; prevalence of MRSA highest among children with otologic infections (34%)

Conclusion: alarming increase in pediatric head and neck infections caused by S aureus, including MRSA; disparities in empiric treatment may contribute to differences observed by geographic region; judicious use of antibiotics and increased awareness in diagnosis and treatment recommended to reduce further development of antimicrobial resistance; prospective multi-institutional studies needed

Managing Chronic Sinusitis, Nasal Polyposis, and Assessing the Need for Revision ESS in Patients with CF
Scott Rickert, MD, Resident in Otorhinolaryngology, New York Presbyterian Hospital, NY

Background: altered chloride transport across cell membrane causes multisystem dysfunction in patients with CF; otolaryngologic manifestations include nasal obstruction and chronic rhinosinusitis; prevalence approaches 100%, with ≈25% requiring surgical intervention; study data (Crockett, 1987)—40 patients underwent polypectomy or sinus procedure plus polypectomy; latter group had significantly less need for revision surgery; sinus procedure involved intranasal ethmoidectomy and Caldwell-Luc operation; long hospital stay; ESS—associated with shorter hospital stay and diminished pain; however, no data correlating symptom severity and nasal polyposis, and (until this study) no objective findings that predict outcomes identified

Study goals: observe extent of nasal polyposis endoscopically in CF patients before first surgical intervention; follow patients prospectively and document need for revision ESS (RESS); compare need for RESS among patients with varying degrees of polyposis

Design: retrospective chart review (data recorded prospectively) of CF patients who underwent ESS and subsequent prospective follow-up for 1 to 16 yr; need for surgery determined by symptoms and overall status, not endoscopic or CT findings; surgery deemed necessary when symptoms significant, persistent, and more conservative measures exhausted

Polyp grading system: grade A—minimal disease, with medialization of lateral nasal wall; grade B—moderate nonobstructive polyps; grade C—extensive polyposis causing nasal obstruction

Results: 49 patients underwent 77 procedures; mean age of patients 10.5 yr; average duration of follow-up 7.3 yr; 3 deaths unrelated to study; 1 patient underwent lung transplantation; no intraoperative or postoperative complications; of patients who underwent RESS, none had grade A disease, 3 had grade B, and 11 had grade C; of patients with grade B disease, average time to RESS 39.7 mo (no further RESS required); among patients with grade C disease, total of 25 procedures required, with average of 23.8 mo between procedures; need for RESS significantly higher for patients in grade C, than those in grades A or B; difference between grades A and B just missed significance

Conclusions: extent of polyposis at presentation predicted need for future surgery, especially among patients with grade C disease, compared to grades A and B; CF patients live longer today, so quality-of-life issues becoming increasingly important; 90% of patients with grade A or B polyposis needed only one operation within follow-up period of 7.2 yr; of 19 patients with grade C disease, 8 did not require RESS during follow-up period of 7.8 yr; preoperative endoscopic grading of polyps a “useful and statistically significant way of prognosticating whether patients will need revision surgery,” specifically those with extensive polyposis