Pediatric Primary Care (59 page)

•  Cervical lymphadenitis.

•  Mastoiditis.

b.  Acute rheumatic fever.

c.  Post-strep glomerulonephritis.

J.  Education.

1.  Transmission is person to person via respiratory tract secretions.

2.  Medication compliance is essential.

3.  May return to school/daycare 24 hours after beginning antibiotic therapy.

IX. RHINOSINUSITIS

A.  Etiology.

1.  Each case of viral rhinitis is also rhinosinusitis, because mucous membranes of nasal passages, sinus cavities are identical.

2.  Sinusitis is inflammation of mucous membranes lining paranasal sinuses, commonly used to describe bacterial rhinosinusitis.

3.  Factors that increase risk of sinusitis are:

a.  Smoke exposure.

b.  Cold and dry inspired air.

c.  Preceding or concurrent URI.

d.  Allergic rhinitis.

e.  Swimming.

f.  Gastroesophageal reflux.

g.  Cystic fibrosis.

h.  Immunodeficiency.

i.  Ciliary dyskinesia.

j.  Factors associated with nasal obstruction.

4.  Stagnation of secretions occurs within sinus cavities, becoming culture medium for bacteria.

5.  Common pathogens.

a.  Streptococcus pneumoniae.

b.  
Haemophilus influenzae
.

c.  Moraxella catarrhalis (becoming most common in children).

B.  Occurrence.

1.  Complication of 5-10% of viral upper respiratory illnesses in children.

2.  In young children, occurs primarily in maxillary sinuses, ethmoids secondly.

3.  Frontal sinusitis is rare prior to age 10 years.

C.  Clinical manifestations.

1.  Acute and persistent nasal and sinus symptoms for 10-30 days.

a.  Subacute: clinical symptoms for 4-12 weeks.

b.  Chronic: symptoms lasting at least 12 weeks.

c.  Recurrent: 4+ incidents/year with complete resolution in interim.

d.  Mild: 10-14 days of persistent anterior or posterior rhinorrhea (discharge)–of any quality, without improvement and fatigue.

e.  Moderate: 10 days of nasal congestion, fever, increased maxillary or frontal tenderness/pressure.

f.  Severe-high fever > 102°F and purulent nasal discharge for at least 3 days in a child who seems ill.

2.  May complain of cough (daytime, often worsening at night), rhinorrhea, postnasal secretions, halitosis, dental pain, headache, fatigue, ear pressure, snoring, nasal speech.

D.  Physical findings.

1.  Fever.

2.  Nasal speech.

3.  Halitosis.

4.  Purulent drainage in posterior pharynx and/or nose.

5.  Nasal mucosa may be erythematous and swollen.

6.  Face over paranasal sinuses may be tender to palpation.

7.  Headache, especially when bending over.

8.  Sinuses opaque, especially in older children.

9.  Puffiness around eyes.

10.  Proptosis, impaired extraocular movements: associated with orbital infection.

E.  Diagnostic tests.

1.  X-rays–findings on plain radiographs correlate poorly with disease and should not be used.

2.  CT scan of paranasal sinuses: indicated in complicated, severe, or recalcitrant cases.

F.  Differential diagnosis.

1.  Viral URI.

2.  Allergic rhinitis.

3.  Drug induced (rhinitis medicamentosa).

4.  Tumors: polyps, neoplasms, adenoidal hypertrophy.

5.  Foreign body.

6.  Septal deviation, choanal atresia.

G.  Treatment.

1.  Acute bacterial rhinosinusitis (ABRS) in children.

a.  Mild symptomatology and no antibiotics within past 4-6 weeks.

•  Amoxicillin (90 mg/kg/day) for 10 days.

•  High-dose amoxicillin-clavulanate ES: 90 mg/kg/day, (based on amoxicillin component) divided bid.

•  Cefpodoxime proxetil, cefuroxime axetil, cefdinir, cefprozil.

b.  Mild disease and
have
received antibiotics within previous 4-6 weeks or in moderate disease.

•  High-dose amoxicillin-clavulanate ES (same dose).

•  Cefdinir if allergic.

•  Azithromycin or clarithromycin if severely allergic.

c.  Consider switch in medications if no response in 72 hours.

2.  Chronic sinusitis: may need to treat for 4 weeks.

3.  Normal saline nasal sprays: assists drainage and ventilation.

4.  Topical nasal steroids: may decrease swelling of turbinates and aid ostia to drain.

5.  Mucolytics: may help mucous clearance.

6.  Antihistamines: helpful if allergic component.

7.  Decongestants: controversial benefit.

8.  Humidified air.

9.   Encourage fluids.

H.  Follow up.

1.  Patient to call if no response to medications in 72 hours.

2.  Recheck in 2 weeks.

3.  Referral to ENT or allergist if indicated or refractory.

I.  Complications.

1.  Orbital cellulitis.

2.  Intracranial complications such as cavernous sinus thrombosis, subdural empyema, brain abscess.

3.  Exacerbation of asthma.

4.  Optic neuritis.

5.  Osteomyelitis of maxilla or frontal bone.

J.  Education.

1.  Prevention: Avoid allergens and treat allergies when appropriate.

2.  Encourage humidified air at home unless it exacerbates mildew, mold allergies.

3.  Emphasize that most rhinitis and sinusitis are viral in etiology and antibiotics are not indicated.

4.  Encourage compliance with prescribed antimicrobial agents.

5.  Advise patient against diving (including scuba).

BIBLIOGRAPHY

American Academy of Pediatrics Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guideline: management of sinusitis.
Pediatrics.
2001;108(3):798-808.