CHRONIC RHINOSINUSITIS IN CHILDREN

Kasman Habib, Delfitri Munir

INTRODUCTION
 Children (6–8 times) upper respiratory viral
illness, 0.5–5% Acute Rhinosinusitis (ARS).

 The clinical symptoms :

 Nasal stuffiness
 Colored nasal discharge
 Cough with resultant sleep disturbance
 Facial pain/headache (in older children)
INTRODUCTION
 ARS <4 weeks
 subacute 4-12 weeks and
 CRS >12 weeks.
ETIOLOGY AND PATHOGENESIS
 “Osteomeatal complex (OMC) Focus Of
Pathology
 Bacteria such as Staphylococcus aureus.

 Inflammatory mediators.

 Systemic factors such as Cystic fibrosis

 Their ability to clear normal mucous secretions

depends on three major factors: ostial patency,
ciliary function, and mucous consistency.
CASE STUDY
 Chief Complaint.
 A 5-year-old girl
 nasal stuffiness
 colored nasal discharge
 cough for the past few weeks.

 History.
 Has been stuffy and having a cough mainly at night
 This has been going on for some time over the past
year.
 treated with antibiotics better but then it
starts again
CASE STUDY
 Physical Examination.
 normal vital signs.
 Heart and lung sounds are normal.
 Examination of the head and neck :
 a nasal septum deviated to the right.
 Anterior rhinoscopy, bilateral hypertrophy of the inferior
turbinates with mucopurulent discharge.
 Ears are clear, tympanic membranes intake.

 Oral cavity is clear, no enlargement of the tonsils.

 No submucous cleft is noted.

DIAGNOSIS
 first 7-10 days viral

worsen / complication develops / not improving by

10 days TREAT

 Attention given to:

 nasal septum
 all visible turbinates
 presence of colored discharge
DIAGNOSIS
 Laboratory tests
 sedimentation rate
 white blood cell counts
 C-reactive protein levels.

 CT scan
 complication
 failed medical therapy
 considered for surgery.
TREATMENT

 The case presented :

nasal stuffiness
colored nasal discharge CRS
Cough > than 12 weeks,
colored discharge on anterior rhinoscopy.

The goal of treatment

Reduce the mucosal inflammation

Relieving the blockage of the ostia

Impairment of mucociliary flow
TREATMENT
 Empiric treatment: oral antibiotic
 ARS :

1st line : oral amoxicillin.

patient doesnt get better in 48–72 hours
antibiotic : amoxicillin with clavulanic acid.
 CRS :

1st line : amoxicillin with clavulanic acid (3-4

weeks) adequate penetration of the sinus
mucosa and efficacy against S. aureus and
anaerobes
TREATMENT
 Medical management
 Topically corticosteroids :Fluticasone,
beclomethasone, budesonide, and mometasone are
popular choices
 nasal decongestants for symptomatic use.
not longer than 3-4 days can cause rebound
congestion with chronic use.

 treatment failure culture and sensitivity from

sinus secretions guide antibiotic choice
TREATMENT FAILURES
 Treatment failure
 Severe signs
 including bleeding
 orbital symptoms Possibly Surgical
 facial swelling Intervention
 uncertainty regarding diagnosis
 Presence of nasal polyposis

 CT scan can be obtained after at least 3-week course

of antibiotics

 MRI : evaluation of complications, soft tissue

involvement, and suspected neoplasia.
TREATMENT FAILURES
 The case presented
Further evaluation:
 patient had mucopurulence bilaterally.
 After treatment with 20 days of antibiotics and
topical nasal steroids with nasal saline washes

CT Scan

blockage of her osteomeatal complex area with mucosal

thickening in both maxillary sinuses
FIGURE 1: LATERAL PLAIN X-RAY SHOWING AIR-
FLUID LEVEL IN THE MAXILLARY SINUS
FIGURE 2: AN ENDOSCOPIC VIEW USING A 2.7MM ZERO-
DEGREE RIGID SCOPE SHOWING ENLARGED ADENOIDS.
FIGURE 3: CORONAL CT SCAN OF THE SINUSES DEMONSTRATING
SIGNIFICANT DISEASE IN BOTH ETHMOIDS AND MAXILLARY SINUSES
WITH BLOCKAGE OF THE OMC.
SURGICAL MANAGEMENT
 In children adenoidectomy
The success rate , 50–60%

 Sinus Wash at the time of adenoidectomy

will flush the sinuses

 a culture for antibiotic guidance.

Success rate with this procedure was 88%.

SURGICAL MANAGEMENT
Functional endoscopic sinus surgery (FESS)

 Minimally invasive procedures to restore the

natural drainage pathways of the paranasal
sinuses.
 Performed under general anesthesia

 Indicated in patients with CRS who fail medical

therapy or have complications of disease.
 Medical management with antibiotics and
intranasal steroids may continue postoperatively,
specifically if the children have allergic rhinitis.
OUTCOMES AND SUMMARY
The case presented
 patient had an adenoidectomy with a sinus wash
of her maxillary sinuses
 CT Scan : severe asthma based on her CT scan.

 There were no operative complications.

 Postoperatively she was given culture-directed

oral antibiotics for 14 days.
OUTCOMES AND SUMMARY
 At-six-month follow up, there was no reported
sinus infections and her symptoms were much
improved.
 She continues to use her topical nasal steroid.

 Her asthma was much improved that her parents

reported discontinuation of all of her asthma
medications
CONCLUSIONS
 CRS is a common disease in children which was
shown to have significant impact on the quality
of life of these children.
 In the majority of cases medical treatment is very
successful;
 However, in a small percentage surgical
treatment may need to be entertained specifically
in those children with asthma.
 Proper patient selection, counseling, and follow
up are essential for a favorable surgical outcome.
THANK YOU
ANATOMI HIDUNG & SINUS PARANASAL

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KOMPLEK OSTIOMEATAL (KOM)

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