Chronic sinusitis and Rhinosinusitis in children

Chronic sinusitis (predisposing factors, causes, treatment) and Rhinosinusitis in children

 

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Chronic sinusitis is a common condition which refers to persisting inflammation of paranasal sinuses where:

  • Chronic means lasts for a long period (usually more than 12 weeks ).
  • Sinus refer to paranasal sinuses (small cavities in skull bone present around the nose ).
  • itis is a suffix mean inflammation.

Chronic sinusitis is usually associated with rhinitis ,so it is also called Rhinosinusitis.

 

Types of Sinusitis:

 

  • Acute sinusitis : it starts usually with cold like symptoms. It may start suddenly and last 2-4 weeks.
  • Subacute sinus inflammation usually lasts 4 to 12 weeks.
  • Chronic sinusitis lasts longer, commonly occur on top of acute sinusitis.
  • Recurrent sinusitis occurs several times a year.

 

Predisposing Factors:

 

Local factors:

 

Any disease or clinical condition block drainage of secretions present in the nose or paranasal sinuses can result in chronic sinusitis . this is because blockage of drainage and stagnation of secretions is a good media for bacterial growth.

  • Repeated attacks of acute rhinitis.
  • Nasal polyps.
  • Pharyngeal tonsillitis (spread of infection).
  • Swollen inferior ethmoidal concha.
  • Immotile cilia (may be congenital).
  • Barotruma.
  • Studies showed that gastro-esophageal reflux plays an important role in development of chronic sinusitis.

 

General factors:

 

  • Low resistancy.
  • Overcrowdings.

 

Causes of Chronic Sinusitis

 

Chronic sinusitis occurs usually due to untreatment or partial treatment of acute sinusitis (repeated attacks ), but it can be also chronic from the beginning.

 

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Causative organisms:

 

Acute rhinosunsitis:

 

  • Strept. Pneumonaie
  • Hemophilus influenza
  • Moraxella catarrhalis

 

Chronic sinusitis:

 

  • Gram +ve bacteria as staphylococcus aureus
  • Gram –ve bacteria
  • Anaerobes
  • Fungi

 

Influenza & common cold:

 

  • Chronic sinusitis can also occur due to exposure of the patient to repeated attacks of influenza, in this case influenza virus can find his way to paranasal sinuses causing harm to respiratory epithelium lining paranasal sinuses which finally results in chronic sinusitis.
  • Sinusitis of dental origin is anaerobic infection which can lead to offensive discharge.

 

Routes of infection

 

Nasal

 

  • Extention of infection : rhinitis then secondary infection.
  • Passage of infected material.
  • Nasogastric tube.
  • Nasal back.
  • Infected water.

 

Dental

 

  • Dental caries.
  • Oro- antral fistula . Both can lead to maxillary sinusitis.

 

External

 

  • Fracture maxilla reaching to the sinuses (rare).

 

Pathology

 

Obstruction of the ostio-meatal complex (which connect the nose with the paranasal sinus) due to:

 

  • Oedema of rhinitis
  • Deviated septum
  • Allergy
  • Polyp

 

Can result in blockage of drainage and stagnation of secretions with destruction of cilia . stagnant secretion is a good media for bacterial growth.

 

Chronic Sinusitis Types & Clinical Picture

 

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Chronic sinusitis has the same signs & symptoms of acute sinusitis but it differs in:

 

  • It lasts longer.
  • Acute sinusitis is commonly associated with fever.

 

General picture

 

Symptoms:

 

1) General:

  • Fever, headache, malaise ( if acute only ).

 

2) Local:

  • Nasal obstruction in case of chronic sinusitis (unilateral or bilateral)
  • Nasal discharge, mucopurulent (unilateral or bilateral): the discharge is anterior and posterior nasal.

 

Facial pain and headache:

  • Its site over the affected sinus.
  • Increases by coughing, straining, leaning forwards.
  • More severe in the morning.

 

Chronic Sinusitis Signs

 

1) General:

 

High temperature and rapid pulse (if acute)

 

2) Local:

Inspection: oedema (occurs only with complications)

Palpation: tenderness over the affected sinus.

Anterior ٌhinoscopy and Nasal endoscopy:

  • Congestion and oedema of nasal mucosa. (if acute)
  • Mucopurulent discharge in:
  1. Middle meatus = sinusitis of anterior group
  2. Superior meatus = sinusitis of posterior ethmoid
  3. Sphenoethmoidal recess = sphenoidal sinusitis

 

  • Posterior rhinoscopy: post-nasal discharge.

 

In addition to the general picture ,each sinus has specific manifestations as following:

 

1- Maxillary Sinusitis

 

Symptoms:

 

  • History of dental problems.
  • The nasal discharge is offensive (dental cause).
  • Facial pain over the cheek ,referred to the ear and teeth.

 

Signs:

 

  • Palpation: tenderness over the cheek (if acute).
  • Anterior rhinoscopy and Nasal endoscopy: Discharge in posterior part of middle meatus.
  • Oral examination may show dental problems.

 

2- Frontal Sinusitis

 

Symptoms:

 

Facial pain over the forehead . (called periodic headache due to negative pressure in the sinus) ,the pain has characteristic periodicity ,it starts in the morning ,increase in the mid-day ,and then decrease gradually in the night.

 

Signs:

 

  • Palpation: tenderness over the forehead and floor of the sinus (if acute).
  • Anterior rhinoscopy and Nasal endoscopy: Discharge in posterior part of middle meatus.

 

3- Ethmoidal Sinusitis

 

Symptoms:

 

Facial pain:

  • Over the inner canthus in case of anterior ethmoidal sinusitis .( N.B: Anterior Ethmoidal sinus is the commonest sinus to be inflamed).
  • Retroprital in posterior ethmoidal sinusitis.

 

 

Signs:

 

Palpation:

Tenderness over the inner canthus ( if acute )
Anterior rhinoscopy and Nasal endoscopy: 

  • Discharge in middle meatus in case of Anterior Ethmoidal sinusitis.
  • Discharge in superior meatus in case of posterior Ethmoidal sinusitis.
  • Nasal Polypi (may be seen in chronic sinusitis).

 

4- Sphenoidal Sinusitis

 

symptoms:

 

Facial pain: retro-orbital ,referred to the occipital region.

Signs:

 

Nasal endoscopy: discharge in sphenoethmoidal recess.

 

Chronic Sinusitis Complications

 

Extension of infection beyond the muco-periosteal limit of the sinus.

 

Causes:

 

  • Acute sinusitis especially in children.
  • Acute exacerbation on top of chronic sinusitis.

 

Orbital complications:

 

The ethmoid is the commonest source for orbital complications and it is separated from the orbit by thin palate of bone called lamina-papyracea which is sometimes dehiscent.

 

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Chronic Sinusitis Clinical picture (5 stages)

 

1- Orbital oedema:

  • Occur due to venous obstruction.
  • Oedema of upper eyelid.

 

2- Orbital cellulitis:

  • Oedema of upper eyelid.
  • Pain in the eye chemosis.
  • Proptosis.
  • Ophthalmoplegia.
  • Reversible diminution of vision.

 

3- Extra-periosteal abcess:

  • Collection of pus outside the orbital periosteum.
  • Pain become throobing.

 

4- Orbital abcess:

  • Collection of bus within the orbit due to rupture of orbital periosteum.
  • The diminution of vision is irreversible (optic atrophy).

 

5- Cavernous sinus thrombosis:

  • Extention of thrombosis through the ophthalmic vein.

 

Complications of posterior group of sinuses may lead to:

 

A- Orbital apex syndrome

 

Compression of structures passing through superior orbital fissure and optic foramen:

  • Compression of ophthalmic vein results in oedema of upper eyelid.
  • Compression of ophthalmic nerve of 5th cause pain over forehead.
  • Compression of optic nerve causes diminution of vision.

 

B- Superior orbital fissure syndrome

 

Compression of structures passing through the superior orbital fissure only (ophthalmic vein and nerve, 3rd, 4th, 6th cranial nerves)

 

C- Optic neuritis

 

Osteomyelitis of Frontal Bone

 

Symptoms:

 

  • Pain and swelling of forehead.
  • Discharge fistula after rupture of subperiosteal abscess.

 

Signs:

 

Tender fluctuant swelling of the forehead.

 

Investigation: CT is diagnostic.

 

Treatment:

  • Medical : hospitalization and systemic antibiotics.
  • Surgical : drainage of abscess and treatment of sinusitis .

 

Cavernous Sinus Thrombosis

 

Causes:

 

Spread of infection from:

a) skin sepsis.

b) sinusitis.

c) orbital infection.

d) suppuratinos of the pharynx : through the emissary vein to cavernous sinus.

e) lateral sinus thrombophlebitis.

 

Clinical picture:

 

General: fever, headache, and mailase .

 

Local:

  • Oedema of upper eyelid.
  • Chemosis .
  • Proptosis.
  • Ophthalmoplegia.
  • Diminution of vision which may end fatally by blindness.

 

Investigations:

 

  • CT with contrast.
  • MRV (mangnetic resonance venography)

 

Treatment:

 

Medical:

  • Hospitalization.
  • Systemic antibiotics (intravenous) that cross the blood brain barrier.
  • Anticoagulants as heparin.

 

Surgical:

  • Treatment infected sinuses after recovery.

 

Mucocele

 

Cystic expansion of the sinus with mucus, when infected it is called pyocele.

 

Causes:

 

Obstruction of the sinus ostium due to:

  • Traumatic: surgical (after nasal surgery) or accidental.
  • Neoplastic: osteoma.
  • Inflammation: fibrosis of the ostiun.

 

Sites:

 

  • Frontal, ethmoid or fronto-ethmoid.
  • Other sinuses: very rare.

 

Pathogenesis:

 

  • Obstruction of sinus ostium
  • Retention of mucus
  • Expansion
  • Thinning out of bony wall of the sinus
  • Destruction of this bony wall

 

Clinical picture:

 

Symptoms:

  • Facial pain and headache
  • Swelling and proptosis

 

Signs:

  • swelling: 

 

Above the medical half of the eye in frontal mucocele, Medial to the eye in ethmoidal mucocele. It shows egg – shell crackling (due to thinning out of bony wall) then it becomes fluctuant (due to destruction of bony wall) .

  • proptosis:

 

It pushes the eyeball Downwards and laterally in frontal mucocele, Laterally in ethmoidal mucocele.

  • secondary infection:

 

Cause pyocele which leads to fever, throbbing pain and may rupture (fistula).

 

Investigations

 

  • X-ray: opacity and loss of scalloped appearance of Frontal sinus.
  • CT: more diagnostic.

 

Treatment

 

  • Marsupialization of the inferior wall of the mucocele by endoscopic sinus surgerly

 

Chronic Sinusitis Investigation & Treatment

 

Investigations

 

  • X-ray (sinus view): it shows opacity or fluid level.
  • Culture and sensitivity of discharge.
  • CT (in chronic and recurrent acute cases).

 

It shows opacity of the infected sinus and conditions of the Ostiomeatal complex (OMC). It is mandatory as a pre-operative investigation to detect any anatomical abnormality such as low cribriform plate, dehiscent carotid or optic nerve.

 

Treatment

 

Medical

  • Complete bed rest with plenty of warm fluids in acute cases.
  • Systemic antibiotics according to culture and sensitivity.
  • A decongestant nasal drops as Xylometazoline (avoid prolonged use as it leads to rhinitis medicamentosa).
  • Steam inhalation.
  • Warm fomentations over the affected sinus.
  • Treatment of predisposing factor (if present).

 

Surgical

  • Indications :

 

a- Failure of medical treatment.

b- Complicated sinusitis.

 

  • Nowadays FESS (functional endoscopic Sinus Surgery ) is the standard surgical treatment for chronic and recurrent sinusitis; in which the diseased mucosa is removed while the healthy mucosa is preserved with restoration of sinus drainage.

 

Old surgical procedure

 

All these procedures became obsolete.

  1. Maxillary sinusitis: antral puncture and lavage. Intra-nasal inferior antrostomy or Cald-well LUC operation to remove the sinus mucosa .
  2. Frontal sinusitis: trephine operation ( opening the floor and placement of tube) or osteoplastic Flap operation in which the sinus is obliterated by fat.
  3. Ethmoidal sinusitis: external ethmoidectomy.
  4. Sphenoidal sinusitis: external spheno-ethmoidectomy.

 

Rhinosinusitis in Children

 

It is usually maxillary or ethmoidal as other sinuses starts to developing later (4th year).

Predisposing Factors

 

1) General:

  • respiratory tract viral infection as common cold and exanthemata.
  • Allergic rhinitis either perennial or seasonal.
  • Mucociliary defects as in cystic fibrosis (viscid mucus) and kartagner’s syndrome (immotile cilia).
  • Low immunity of children.

 

2) Local:

Adenoid: causes nasal obstruction and stagnation of mucus.

 

Causative Organism

 

Hernophilus influenza, strept, pneumonia and/or moraxilia catarrhalis.

 

Clinical picture

 

Acute sinusitis:

  • Fever is more severe in children.
  • Nasal obstruction and mucopurulent discharge.
  • Oedema at the roof of the nose and between eyes may be present (soft bone).

 

Chronic sinusitis:

  • persistent nasal obstruction and mucopurulent discharge.
  • symptoms of descending infection as recurrent pharyingitis, cough and otitis media.
  • complications are more common especially the orbital as the lamina papyaracea is thin in children.

 

Treatment

 

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Medical:

  1. Systemic antibiotics and analgesic antipyretics.
  2. Decongestant nasal drops and saline irrigation.
  3. Anti-allergic treatment.

 

Surgical:

  • Adenoidectomy
  • FESS is rarely needed as in complicated cases and after failure of medical treatment.

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