Rhinosinusitis in children
I’m excited. Can you guess why?
Because I am going to write this entire chapter off the top of my head. Rhinosinusitis is an illness (it’s probably better to refer to it as a condition) that has never been explained properly in any pediatric textbook.
Diagnoses like Streptococcosis or Staphylococcosis (see more below), are
diagnoses that have been slowly disappearing from our study books and this has caused
increased confusion among the medical community.
On the one hand, rhinosinusitis is a real diagnosis, and a good pediatrician is usually able to find those few children who have this condition and by doing so can greatly improve these little patients’ quality of life. However, a good pediatrician who is extra enthusiastic about this diagnosis and tends to over-diagnose it, will find him/herself over-prescribing antibiotics.
It is really all about balance. Just like everything else in life.
What is rhinosinusitis?
‘Rhino’ = nose and ‘sinus’ = sinuses. Those same air-filled empty spaces we all have in our skulls.
Rhinosinusitis is an inflammation/infection that manifests mainly with runny fluids in the nose and sinuses. Why not just keep it simple and call it sinusitis?
Because in children under the age of 4-5 these empty spaces in the skull are not fully developed and ventilated, and so when referring to young children, it is more correct to use the term rhinosinusitis.
When bacteria secondarily settle in rhinorrhea that is already present, which is usually caused by viral pathogens, they may cause a condition that is referred to as rhinosinusitis in children and sinusitis in adults.
What kind of bacteria am I talking about? All the bacteria that are part of our normal respiratory flora. One of the less common bacteria is the infamous streptococcus (and then the condition is referred to as Streptococcosis, and it will often present more aggressively and be accompanied by fever) and sometimes staphylococcus (named Staphylococcosis, and includes Staphlococci complications).
Is rhinosinusitis an allergy?
Usually, this condition is not an allergy in younger kids. It is usually a viral infection (rhinitis) that underwent secondary bacterial infection.
In older children, adolescents and adults, there is a condition that is referred to as allergic sinusitis.
What are the signs and symptoms of rhinosinusitis?
See the attached image. It is that of a child who suffers from yellowish/green fluid running from his nose for several weeks. The parents usually complain that when they come to pick them up from day-care the child always has green boogers in their nostrils.
These are usually children that are under the age of 5.
These kids also find it difficult to breathe, especially during the night. They cough a lot during the night and their cough often wakes them up from their sleep. Really poor kiddos.
Often, the skin over their nostrils and nose is irritated and red and they may also carry a foul breath odour.
So, on the one hand, these children are not very really ill, they are able to continue going to day-care or kindergarten, and they do not present with fever (if they do, then it is because they also caught a viral infection on top of their rhinosinusitis). On the other hand, they are not 100 percent healthy either.
So, is this sinusitis?
Yes and no.
Yes, because it obviously manifests very similar to sinusitis.
No, because it happens in young children who do not have fully developed sinuses, yet.
Real sinusitis is a condition that older children suffer from.
How else is pediatric rhinosinusitis characterized?
You know how sometimes children receive antibiotics – for an ear infection (read more here), strep throat (more here) or when pneumonia is suspected (not that common in children, read more here). What I do is when I take my patient’s medical history, I ask whether the runny nose and general well-being of the child happened to improve when he was started on antibiotics (usually penicillin), for one of the reasons mentioned above. Many families claim that it did, and that a while after the antibiotics were stopped, the symptoms recurred.
Also, this is a prolonged condition. It does not just last for one or two weeks.
There are no findings upon physical examination beyond the runny nose and the post-nasal drip seen along the back of the child’s throat.
Do the children suffer from a headache as well? It depends. Headache is not a very common symptom in children. And remember, this isn’t classic sinusitis.
What should I be aware of?
Children with one-sided rhinorrhea and foul odour need to see an otolaryngologist as soon as possible to rule out the presence of a foreign object in one of the nostrils. Sometimes, old beads or other small objects are found in the nostrils.
Children with recurrent episodes of rhinosinusitis (or sinusitis in older adults) need to undergo further workup in search for an anatomical anomaly in the area or an immune deficiency.
How is rhinosinusitis treated?
Before we discuss possible treatment options, I think the more important question to be asked is – when does treatment need to be considered?
Not all children with runny nose need to be treated with medication. Not even those who have had a runny nose for a week and crackles overnight and have visited the office three times already.
The need for medical treatment should be considered in children with typical and prolonged symptoms (at least 3 weeks) and only after having explained the condition to the parents. How should they be treated? Usually a simple penicillin (for example, amoxicillin) is sufficient. For how long? This is a condition that usually requires a relatively long duration of treatment, approximately 10 days.
In children who have already received many courses of amoxicillin for one reason or another, amoxicillin-clavulanate (600) may be considered (read more about the different types of amoxicillin-clavulanate here).
Is there anything else that needs to be done in addition to antibiotic treatment?
Nasal steroidal sprays may be considered. Despite having said that in young children this is not usually an allergic condition, the intent behind steroidal treatment is the reduction of edema, opening up of the pores that need to be opened up and allowing the passageway to dry up.
What is the problem with rhinosinusitis?
There are two problems that need to be considered:
1. As I mentioned previously, over-diagnosis. The pediatrician needs to choose those children who he/she thinks will benefit from treatment, otherwise the pediatrician will find themselves prescribing antibiotics all day, everyday.
2. This condition tends to recur in children – I do not know whether this is due to an underlying anatomical condition in these children but often times children that receive treatment improve… until they catch the next cold, when all their signs and symptoms return. And obviously, we have no interest in giving multiple courses of antibiotics. It’s annoying. I agree.
To summarize, this is a common medical condition in pediatrics. It cannot be taught in our books and the pediatrician needs to have good clinical instincts in order to pick out those children that will benefit from treatment.
And when it works, it is wonderful. The child transitions from anaerobic to aerobic breathing and it is a beautiful scene.