The full guide to sinusitis in children (and adults)

Let’s start from the basics – what are the sinuses?

As mentioned in the chapter about rhinosinusitis – the sinuses are those air-filled spaces that we all have in our skulls. Their walls are covered with a mucous membrane, similar to the one found in the respiratory tract. This mucous membrane produce mucous that drains into the small orifices and into the nasal space. When there is too much of this mucous, it can get infected, and it is then referred to as “snot”.
In addition, the mucous membranes of the sinuses contain lots of small hairs, and their role is to push this mucous into the sinus’ functional drainage opening.

What is the function of the sinuses? Why do we have them?

That’s a good question. I have to confess, in a humble way, that the precise role of the sinuses is not fully understood. There are several different hypotheses about their role in adults and children. These include:
• Reduction of the weight of the skull – in children this plays an important role, and it makes it easier for the vertebrae and the entire body to carry the weight of the head, which is relatively heavy compared to the rest of the body.
• Primary protection from head traumas.
• To provide resonance to our voice to give it its uniqueness. If you’ve ever tried to sing with congested sinuses, you probably recall how hard it is.
• The sinuses and their development throughout childhood and adolescence plays an important role in the design of our face and has an effect on its development.

What are the names of the different sinuses and when do they develop?

As you read the following paragraph, take a look at the image attached at the same time.
The frontal sinuses (in the forehead, above the eyebrows) – these sinuses begin developing at the age of 7-8 years and are complete by adolescence.
The maxillary sinuses (on the sides of the nose, behind the cheek bones) – this is a congenital sinus, but it begins functioning and starts containing air only at the age of 4 years. By the way, this is the sinus that causes the most trouble and infections.
The ethmoidal sinuses (between the eyes) – this sinus is active and full of air already at birth.
The sphenoidal sinuses (behind the eyes) – these sinuses start developing usually around the age of 5 years.

What does “development of the sinuses” mean? Can children have sinusitis?

As you have read above, sinuses are structures that develop with age. Both in size and aeration, during the first few years of life, and later during adolescence. Therefore, sinusitis is more common among older people compared to younger people.
But practically speaking, babies can develop sinusitis in the sinuses that already contain air at that age.

Wait a second, doc – what was this entire introduction for? What is sinusitis?

In simple terms: sinusitis is an inflammation of the sinuses.
This inflammation can develop as a result of infection or other reasons (usually allergies). It can also be either acute or chronic, as you will see below.

So, if I have a runny nose, does that mean I have sinusitis?

This is an important question, and understanding the answer will help us a lot as we move forward.
The answer to this is a yes.
In most cases of colds, the simplest of colds, we have, among other stuff, a component of sinusitis. MRIs performed on children with runny noses has shown congestion and edema in the mucous membranes of the nose (sinusitis) in about 68% of cases.
More about children – children experience infections in their upper respiratory tracts about 6-8 times a year, and adults about 2-3 times a year. According to these statistics, the number of sinusitis among people worldwide, yearly, is huge.
Fortunately, sinusitis does not require any special therapy and most cases are simply viral and therefore, our job, as physicians, is to detect those few cases (in children this is estimated to be about 0.5-2% of all viral colds) where the sinusitis is bacterial and requires intervention. How can we detect these cases? Find out below.

Is there a specific classification for sinusitis, depending on how long it lasts?

Certainly. This classification is very helpful.
Acute sinusitis – this refers to sinusitis that lasts less than a month. This is, of-course, the most common type of sinusitis, and it presents several days following a mild viral infection in the upper respiratory tract, and in most cases this sinusitis resolves spontaneously, without treatment.
Sub-acute sinusitis – this type of sinusitis lasts between 1-3 months, and it is obviously a complication and direct continuation of acute sinusitis
Chronic sinusitis – this sinusitis lasts longer than 3 months
It is obvious that most people experience acute sinusitis, but to us, as care providers, being able to distinguish between the different types is important, because each has its own causes including different bacteria.

Let’s move on – how does sinusitis develop?

In short, there is a specific obstruction to the opening of the drainage of a sinus. That means, that it is all a matter of drainage. Therefore, I always tells my patients that a plumber could probably be more helpful than me when it comes to sinusitis.
That same inflammation can then go on to obstruct the opening. In other words, it can turn into the chicken and egg type of situation.
The causes for obstruction to the opening of the drainage vary:
• Infections caused by viruses, bacteria or fungi. This is obviously the most common cause in children.
• Atopic diseases (allergies) – due to the congestion, those that experience allergic rhinitis or asthma have a higher risk of developing sinusitis
• Anatomic problems – I’d like to talk about an additional group of people, mainly adults that experience recurrent episodes of sinusitis. In addition to all those that think they have sinusitis every time they get a cold for 2 days (which is obviously not true) there are certain types of people who end up with a long an irritating episode of sinusitis every time they have a mild viral infection. The assumption is that those adults have an anatomical structural abnormality that predisposes them to real, recurrent sinusitis. This group of people should undergo imaging of the bones of their face (such as CT) and should be managed by a profession ENT specialist.
• Thick mucus that cannot drain out of the sinus space. Such as in patients with cystic fibrosis.
• A congenital disorder in the mucosal hairs (immotile cilia syndrome) that prevents drainage of the mucous outside the opening.
• Allergy to medications, chemical environmental substances, or other types of fungi.
• Smoking and exposure to smoke
• Prolonged exposure to chemical substances that trigger the respiratory tract.
• A weak immune system.
• Inflammatory disorders such as Wegner’s granulomatosis and sarcoidosis.
• An injury, trauma or surgery in the face.
• Obstruction of the sinus drainage as a result of a polyp or foreign object
• Tooth infection that spreads to the maxillary sinus.

How is sinusitis detected?

In short – with the help of medical history and physical examination.
Keep in mind that the purpose is to distinguish between a real sinusitis and an infection in the upper respiratory tract, such as a cold.
Making the correct diagnosis is important here, because a cold or infection in the upper respiratory tract do not warrant antibiotic treatment, and you know what we think about wise use of antibiotics on this website…

How can you tell whether a simple cold has turned into a bacterial sinusitis that requires treatment?

This is the most important and most difficult question, ever.
At the beginning of the infection, it is hard to distinguish between viral and bacterial sinusitis. Knowing the length of time the symptoms have lasted may be helpful. If the symptoms last longer than 10 days, or if the patient experiences relief of symptoms but an additional worsening within one week, this could indicate bacterial infection.
Usually, the patient presents with congestion and productive cough, that worsen with time.
In exceptional cases, the patients may experience purulent discharge from one or both sides.
Fever – sometimes, it is usually not high, but most of the time the patient does not have fever.
Other findings include halitosis (bad breath), hyposmia (decreased sense oF smell) and periorbital edema.
In short, the diagnosis is not clear cut and is not always obvious, and most of the time the physician has to use their clinical intuition to make the diagnosis.

What about headaches, or tenderness on percussion of the sinuses?

These signs are not very common in children and become more reliable in adolescents and adults. These include:
Headache and facial pain
Sinus tenderness. Sometimes the apin worsens with the head is moved from side to side or when the person looks down.
Teeth pain or gum pain when eating.

What about auxiliary tests for detecting sinusitis?

X-rays? I have already mentioned how MRIs (which are more sensitive than simples x-rays) often show signs of viral, non-specific sinusitis. Therefore, it is obvious that facial x-rays are an awful technique for diagnosing sinusitis.
CT? On the one hand it may be able to give us a good image and provide us with information about the ratio of fluid to air in the sinuses, sinus blockage and thickening of the inner part of the sinus. On the other hand, it is almost impossible to differentiate between a simple cold and sinusitis. So, CTs are used mostly to detect complications.
And endoscopic examination under local anesthesia? this allows the physician to examine the air spaces with the help of a small camera that is inserted into the nose, and to determine whether the drainage of the sinus is normal. The advantage of using this technique is the ability to detect structures that may cause difficulties with breathing, such as polyps, enlarged tonsils and deviations to the nasal septum.
Drainage of the sinuses? okay, this is clearly not a routine examination but it’s important for you to recognize that it is done in hospitals, in specific patients. An ENT physician will insert a needle into the skin or bone (or through the gums) to aspirate inflammatory fluid. This fluid is cultured in the lab in order to isolate the bacteria causing the infection. Once the bacteria is isolated (it takes about 2 days), an appropriate antibiotic can be chosen. This is not a common way of diagnosis because this test is invasive.

How is acute sinusitis treated?

Since acute sinusitis is usually the result of viral infections, it does not usually require special treatment beyond supportive treatment. In difficult or persistent cases, when bacterial infections are suspected, antibiotic treatment is considered.

So, the treatment for sinusitis is antibiotics?

Listen carefully, this is important.
a. Most cases of sinusitis are viral, and therefore treatment is not required
b. If bacterial infection is suspected – adequate antibiotic coverage is required
c. In addition to antibiotics – in children there is no evidence that decongestants/nasal steroids help with recovery (in adults this is certainly part of the treatment), but I am always for “helping the antibiotics” with a nasal spray, to help drainage.

What kind of antibiotic is adequate for sinusitis?

This depends on the case, but our series of simple penicillin, usually Amoxicillin, are the treatment of choice.
Again, I like going back to those people that stop me at the supermarket and swear that Amox-clav is the only antibiotic that works for them. I want to tell those people 2 things:
a. Let me do my grocery shopping in peace
b. Either you have misdiagnosed yourselves, or you have been misdiagnosed, and a simpler drug would have given you similar results. In my opinion, using wider spectrum antibiotics such as Amox-clav or cefuroxime should be kept for persistent cases or those who have risk factors for more resistant bacteria.

How is chronic sinusitis treated?

Chronic sinusitis is a lot less common and should be managed by an experienced ENT specialist. In healthy people, the range of bacteria that should be taken into consideration is wider than in acute cases, and therefore the workup and management should be carried out wisely.

What about allergic sinusitis?

Keep in mind that in younger people, a rhinitis or sinusitis may conceal a viral infection that got complicated with bacteria that are found in these areas.
In older children, adolescents and certainly adults – allergic sinusitis can develop and I suggest consulting with a pediatric allergologist for further investigations.

Is sinusitis contagious?

Real bacterial sinusitis isn’t.
But the trigger to the sinusitis can be contagious, if the sinusitis developed as a result of a viral infection, cold or flu.

When can a child return to school or daycare following sinusitis?

When the child is feeling better, they can return to regular activities.

In summary, wow. This wasn’t an easy chapter to write. Nonetheless, I hope I have helped you be able to make better decisions, together with your physician, about the health of your child or children.

Good luck.