SINUSITIS

Anatomy

Paranasal Sinuses

Lateral View of Sinuses

 Where are the sinuses?

Four pairs of paranasal sinuses

 Frontal-above eyes in forehead bone
 Maxillary-in cheekbones, under eyes
 Ethmoid-between eyes and nose
 Sphenoid-in center of skull, behind nose and eyes
 What are the sinuses?

The sinuses are hollow air-filled sacs lined by mucous

membrane.
 The ethmoid and maxillary sinuses are present at birth.
The sphenoid sinus develops during the 5th year and
frontal sinus develops during the 7th year and the
 What are the sinuses? (cont’d)
Sinuses have small orifices (ostia) which open into
recesses (meati) of the nasal cavities.
Meati are covered by turbinates (conchae).
Turbinates consist of bony shelves surrounded by
erectile soft tissue.
There are 3 turbinates and 3 meati in each nasal
cavity (superior, middle, and inferior).
The paranasal sinuses are normally sterile,
maintained by the mucociliary clearance system.
 Sinusitis

Inflammation of paranasal sinuses

 What is sinusitis?

Sinusitis is an acute inflammatory process involving one

or more of the paranasal sinuses.
A complication of 5%-10% of URIs in children.
Persistence of URI symptoms >10 days without
improvement.
Maxillary and ethmoid sinuses are most frequently
involved.
 How Does Sinusitis Develop?

Usually follows rhinitis, which may be viral or allergic.

May also result from abrupt pressure changes (air
planes, diving) or dental extractions or infections.
Inflammation and edema of mucous membranes lining
the sinuses cause obstruction.
This provides for an opportunistic bacterial invasion.
 Development (cont’d)

With inflammation, the mucosal lining of the sinuses

produce mucoid drainage. Bacteria invade and pus
accumulates inside the sinus cavities.
Postnasal drainage causes obstruction of nasal passages and
an inflamed throat.
inflammation and edema may block sinus drainage and
impair mucociliary clearance of bacteria. The growth
conditions are favorable and high titers of bacteria are
produced.
If the sinus orifices are blocked by swollen mucosal lining,
the pus cannot enter the nose and builds up pressure inside
the sinus cavities.
 Predisposing Factors of sinusitis
1. Allergies
2. anatomic defects such as cleft palate and nasal
deformities
3. Cystic fibrosis
4. nasal polyps
5. URT infections
6. Cold weather
7. Children with immune deficiencies
8. High pollen counts
9. Smoking in the home
10. Nasal foreign bodies
 Acute or Chronic Sinusitis?

Acute Sinusitis – respiratory symptoms last longer than

10 days but less than 30 days.
Subacute sinusitis – respiratory symptoms persist
longer than 30 days without improvement.
Chronic sinusitis – respiratory symptoms last longer
than 120 days.
 Etiology of Sinusitis

Most common causes

70% of bacterial sinusitis is caused by:
 Streptococcus pneumonia
 Haemophilus influenza
 Moraxella catarrhalis

Less common causes

Other causative organisms are:
 Staphylococcus aureus
 Streptococcus pyogenes
 Gram-negative bacilli
 Respiratory viruses
 Complications of Sinusitis

Orbital cellulitis or abscess

Meningitis
Brain abscess
Intractable wheezing in children with asthma
Cavernous sinus thrombosis
Subdural empyema
 Subjective Symptoms of Sinusitis

nasal congestion
History of pressure change
Pain and pressure over sinuses
Increased pain in the morning, subsiding in the
afternoon
Malaise
Fever
Persistent nasal discharge, often purulent
Postnasal drip
Cough, worsens at night
History of URI or allergic rhinitis
Subjective Symptoms of Sinusitis con.. .

Mouthing breathing
Snoring
History of previous episodes of sinusitis
Sore throat
bad breath
Headache
 Clinical Presentations of Sinusitis

Tenderness over a sinus on percussion or palpation

Nasal discharge, thick, sometimes yellow or green

Postnasal discharge in posterior pharynx

Nasal mucosa is reddened or swollen

Swelling of turbinates
 Diagnostic Tests

The diagnosis of acute bacterial sinusitis is based solely

on history and physical examination
Imaging studies, such as:
 sinus radiographs

 CT scanning
 Indicated:
 if child is unresponsive to 48 hours of antibiotics
 if the child has a toxic appearance
 chronic or recurrent sinusitis, and chronic asthma.
Laboratory studies, such as culture of sinus puncture
aspirates.
 Differential Diagnoses

 Allergicrhinitis
 Non-allergic rhinitis

 Nasal polyps

 Dental abscess

 Carcinoma of sinus

 Cluster headache

 Structural defects (septum deviation)

 Nasal foreign body

 Pharmacological Plan of Care

Antimicrobials-treat for 10-14 days, depending upon

severity, with one of the following:
Amoxicillin:20-40mg/kg/d in 3 divided doses(>20kg,
250mg tid)
Augmentin:25-45mg/kg/d in 2 divided doses(>20kg,
400mg q12) Use chewable or suspension if child is less
than 40kg.
Penicillin allergenic patients give cefuroxime,
clarithromycin, or azithromycin.
 Other Relief Medications

 Analgesics and antipyretics (Acetaminophen or ibuprofen)

 Mucolytics
 Rhinocort nasal spray – 2 sprays in each nostril every 12 hours
for children over 6 years of age.
 Decongestants
 Antihistamines
 Nasal saline
 Non-pharmacological treatment

o Humidifier to relieve the drying of mucous membranes

associated with mouth breathing
o Increase oral fluid intake
o Saline irrigation of the nostrils
o Moist heat over affected sinus
o Prolonged shower to help promote drainage
 Patient Education

Child should not dive.

Child should not travel by airplane.
Urge parent to eliminate triggers in the home (dust,
smoking)
Have all members of the family treated, if indicated.
 Follow Up Guidelines

 Instruct parent to call in 48 hours if condition of child has not

improved.
 Instruct parent to bring child in for a recheck in 2 weeks.