Chronic Rhinosinusitis in Children

1
Chronic Rhinosinusitis in Children

• Clinical Presentation
• Hector Stone-Aguilar, M.D.
• Pediatric Allergy Immunology
• Hospital San Jose de Hermosillo
• Universidad del Valle de Mexico

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Clinical presentation of CRS in Children
The problem

• To fully define chronic sinusitis has been
  difficult
• There is a wide variation in clinical expression
  of the disease
• Discordance between patient symptoms and
  objective findings
• No one set of diagnostic criteria has been agreed
  on by all specialty groups

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Clinical presentation of CRS in Children
The problem

• Clinical criteria to diagnose CRS, as well as the
  predictive value of these criteria, are not well
  defined, specially in children
• Historically, the diagnosis of CRS was based on
  several clinical symptoms, similar to acute RS,
  but usually less severe
• However, none of these symptoms are specific to
  sinusitis

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Definition of Sinusitis

• Inflammation of 1 or more of the paranasal
  sinuses
• Acute Sinusitis less than 4 weeks/duration
• Subacute Sinusitis 4 to 12 weeks/duration
• Chronic Sinusitis longer than 12 weeks Some
  guidelines also requiring
• Failure to respond to treatment
• One positive imaging study

Dykewicz M, JACI Feb 03
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Definition of Rhinosinusitis

• Inflammation of the nose and paranasal sinuses
  characterized by two or more symptoms, one of
  which should be either nasal blockage/obstruction/
  congestion or nasal discharge (anterior/posterior
  nasal drip)
• facial pain/pressure
• reduction or lost of smell

EPOS Guidelines, Rhinology 2007
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Rhinosinusitis
OHNS , 1997
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Definition of Chronic Rhinosinusitis

• More than 12 weeks of symptoms without complete
  resolution
• Can be subdivided in
• Chronic Rhinosinusitis with Nasal Polyps
• Chronic Rhinosinusitis without Nasal Polyps
• CRS also may be susceptible to exacerbations

EPOS Guidelines, Rhinology 2007
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CRS Symptom-based Diagnosis

• 73.15 of the nonallergic patients with symptom
  based diagnosed CRS
• 65.34 of the allergic patients with
  symptom-based diagnosed CRS
• Had No CT and endoscopic pathology
  (Endoscopic score 0 CT score 0)

Tahamiler R, Allergy 2007
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Chronic Rhinosinusitis in Children

• In general
• The main symptoms associated with rhinosinusitis
  in children are rhinorrhea, nasal obstruction,
  mouth breathing, hyponasal speech, and snoring
• but

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Diagnosing CRS in Children Special issues

• Infants and Pre-school children
• Signs/symptoms difficult to evaluate
• Congestion (very subjective/indirect/parents
  biass)
• Only anterior rhinorrhea is reported
• Symptoms impossible to evaluate
• Posterior discharge
• Sense of smell
• Headache / toothache / facial pain
• Symptoms very unspecific
• Cough, irritability, fever, fatigue/decreased
  activity, etc.

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Diagnosing CRS in Children Special issues

• Infants and Pre-school children
• Anterior Rhinoscopy Limited data
• Anterior third of nasal cavity
• Osteomeatal zone difficult to reach, even w/use
  of topical decongestant
• Nasal Endoscopy Ideal but impossible to perform
  without sedation or anesthesia
• CT scan Also requieres sedation or anesthesia
• Sedation/anesthesia increases costs and risks
• Increased value of plain X-Rays at this age ??

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Severity of Sinusitis

• Disease severity can be divided into
• Mild (0-3 points)
• Moderate (4-7 points)
• Severe (8-10 points)
• Using a 10-point scoring system or
• Visual Analogue Scale (VAS)

EPOS Guidelines, Rhinology 2007
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Clinical presentation of CRS in Children

• Diagnosis must be based in a combination of
• Clinical symptoms and evolution
• Age-group related
• Previous treatments (type and duration)
• Likelihood of allergy involvement Family
  history, allergy stigmata, personal history of
  other allergic diseases (AD or Asthma)
• Clinical Signs
• Anterior rhinoscopy and/or Nasal endoscopy
• Imaging support
• Plain X-Rays
• CT scans
• MRI

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Chronic Rhinosinusitis in Children

• By definition, needs to be at least 12 weeks old
  (3 m.o.)
• Ethmoid and maxillary sinuses present at birth
• Clinical presentation strongly related to the
  specific pediatric age group
• Infants Persistent or recurrent rhinorrhea
  after an acute febrile URIs ( AOM,
  Rhinopharyngitis, Bronchitis)
• Pre-schoolars Persistent rhinorrhea and nasal
  congestion w/adenoid and tonsil hypertrophy,
  serous OM, allergies and asthma.
• Scholars and adolescents Nasal obstruction,
  headaches, sore throath, hyposmia, irritability,
  sleep disturbances, etc. (PAR or PNAR)

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Clinical presentation of CRS in Children

• In infants and preschool childrens, most cases of
  CRS are a chronologic extension of acute
  infectious sinusitis (viral bacterial)
• In contrast, in older children or adolescents
  most CRS cases are not an infectious disease but
  an inflammatory disease, much akin to asthma.

Jones NS, Curr Opinion Pulm Med, 2000
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Clinical evolution of Viral URIs
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When to suspect CRS in INFANTS

• Continuous or intermittent RHINORRHEA
• Anterior, posterior or both
• Usually clear initially (days or weeks)
• Colored (greenish or yellowish) more dense
  secretions
• It can alternate clear and colored secretions
• Nasal CONGESTION
• Mild at the beginning
• Worsening in an intermittent pattern in absence
  of appropriate treatment
• Not as bad as other age groups
• Objective findings mouth breathing, snoring

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When to suspect CRS in INFANTS

• COUGH
• A prominent feature of sinusitis at this age
• Starts as Dry cough usually for several days
• Can continue with wet cough all the way
• Intermittent along the day, not very intense
• Can start or worse at night or bedtime
• Usually associated with posterior rhinorrhea
• Also associated with coarse and audible ronchi
• Maybe a better predictor than rhinorrhea about
  the outcome

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When to suspect CRS in INFANTS

• FEVER
• Usually present at the beginning of the clinical
  picture
• Low or mid grade
• Fades away after few days (with or without
  treatment)
• Can not be present at all
• Can relapse in the course of the disease
  (worsening)
• Its absence doesnt rule out the possibility of
  chronic infection

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When to suspect CRS in INFANTS

• Other possible symptoms
• Irritability
• Bad appetite
• Sleep disturbances
• Trouble to got sleep
• Restless sleeping
• Nocturnal awakenings
• Halitosis
• Reduced general activity

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When to suspect CRS in INFANTS

• Physical signs, NASAL
• Rhinorrhea (anterior)
• Pale and enlarged turbinates
• Mucosal edema
• Hyperemic mucosa
• Middle meatus colored discharge

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Rhinoscopy
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Muco-purulent discharge in the Sinus Ostium zone
Middle turbinate
Lateral nasal wall
Purulent mucus
Septum
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When to suspect CRS in INFANTS

• Physical signs, GENERAL
• Posterior rhinorrhea
• Mouth breathing
• Pallor
• Dark infra-orbital shiners
• Halitosis
• Tympanic opacity, retraction or hyperemia
• Enlarged tonsils
• Granular (cobblestone) adenoid tissue in the
  pharynx
• rude breathing
• Coarse rhonchi on chest examination

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Serous Otitis Media
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Enlarged Adenoids Cause or consequence ?
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Chronic Rhinosinusitis in PRE-SCHOLARS

• Not necessarily associated to respiratory
  infection
• Mostly related to allergies and asthma
• Difficult to distinguish from PAR. Same sort of
  signs and symptoms
• Usually considered a complication of allergic
  rhinitis
• Nasal or sinusal polyps not frequent at this age

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Chronic Rhinosinusitis in PRE-SCHOLARS
Differences with CRS in Infants

• Congestion more prominent than rhinorrhea
• Cough frequently related to asthma or BHR
• Headaches, frequently mild or intermittent
• Hyposmia rarely reported
• Halitosis
• Clear or thick mucoid rhinorrhea
• Paler and more enlarged turbinates
• Intense edema of nasal mucosa

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Chronic Rhinosinusitis in School children and
adolescents

• Moderate to severe nasal congestion/obstruction
• Snoring
• Sleeping problems
• Dry mouth and sore throat at mornings
• Headaches
• Mild to severe
• Frequent or intermittent
• Frontal, maxillary or occipital
• Rhinorrhea
• Posterior gt anterior
• Halitosis

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Chronic Rhinosinusitis in School children and
adolescents

• Daytime somnolence
• Tiredness
• Poor concentration altered school performance
• Hyposmia
• Dysgeusia
• Middle ear
• Hypoacusia, Popping, Buzzing
• Polyps More frequent than the other pediatric
  groups

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Consequences of chronic nasal congestion

• Snoring
• Oral breathing
• Hyponasal speech
• Sleep disturbances
• Obstructive Sleep Apneas (OSA)
• Dry mouth
• Sore throath
• Headaches
• Daytime somnolence
• Poor concentration
• Tiredness
• Facial and dental changes

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CRS DiagnosisPlain X Rays Useful?
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Plain X-rays vs. CT scan in Sinusitis

•  The sensitivity of Plain X-Ray compared to CT
  was
• 77 (30/39)
• The specificity of the radiograph to CT was 81
  (25/31). 
• The positive likelihood ratio is 4.05 and
• The negative likelihood ratio is 0.28.
• Conclusions - The difference between radiographs
  and CT for diagnosing sinus disease in this
  population is relatively small but favors CT exam.

Garcia, DP Radiographic imaging studies in
pediatric chronic sinusitis  J Allergy Clin
Immunol, 94523-530, 1994.
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CRS DiagnosisCT scan Gold standard ?
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Limited CT Scan
Garcia D, JACI sept 1994
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Sinusitis severity Index (grading)(Glicklich)

• Grade 0 mucosal thickening of 2 mm in any
  sinusal wall
• Grade 1 Any unilateral disease or abnormality
• Grade 2 Bilateral disease limited to ethmoid or
  maxillary sinuses
• Grade 3 Bilateral disease with frontal or
  sphenoidal involvement (any)
• Grade 4 Pansinusitis.

Emmanuel IA, Otolaryngology Head Neck Surg 2000
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(No Transcript)
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CRS DiagnosisCT scan Gold standard ?
HWANG et al, OHNS april, 2003
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CRS DiagnosisCT scan Gold standard ?
Unilateral involvement of the right maxillary
sinus and structural abnormalities MT concha
bullosa and paradoxical curvature of middle
turbinate, stretching the OMC
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Nasal Endoscopy
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Clasification of the severity of polyposis by
endoscopy

• 0 - No visible polyps
• 1 - Polyps confined to the middle meatus
• 2 - Polyps beyond middle meatus but did
• not occlude the nasal cavity
• 3 - Polyps obstructing completely the nasal
• cavity

Mackay IS y Lund VJ, 1997
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Nasal / Sinusal Polyposis in Children

• If nasal polyps are present in young children,
  MUST rule out
• Aspirin Exacerbated Respiratory Disease (AERD)
• Cystic Fibrosis (CF)
• Genetic involvement
• But still most probably related to Perennial or
  Persistent Allergic Rhinitis
• Polyps related to Perennial Non-Allergic Rhinitis
  are rare at this age

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Etiology of CRS in Children

• Infection
• Viral/Bacterial
• Biofilms
• Fungal?
• Allergy
• Allergic Rhinitis Persistent gt Intermittent
• Gastroesophageal Reflux
• Obstruction /Structural
• Adenoid gt Tonsils Hypertrophy
• Septal deviation
• Other concha bullosa, Haller cells, agger nasi
  cells

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Etiology of CRS in Children

• Immunodeficiency
• IgA deficiency
• Transient Hipogammaglobulinemia
• IgG sub-class deficiency ( IgG2 IgG4)
• Selective (polysaccaride) IgG deficiencies
• CVI
• Cystic Fibrosis
• Ciliary Dyskinesia
• Aspirin Exacerbated Respiratory Disease
• Other very uncommon

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Hamilos D, JACI oct 2011
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Conclusions

• CRS is frequent in children
• No one set of diagnostic criteria has been agreed
  on by all specialty groups
• CRS in children have special features that are
  different of CRS in adult population
• There are differences also in the clinical
  presentation of the different pediatric age
  groups
• The diagnosis of CRS in children is based almost
  exclusively in clinical data. Use CT or
  endoscopy in selected cases.
• There are very few controlled clinical studies of
  CRS in children. All Guidelines based in adult
  studies and transpolated to children.
• The most common causes are bacterial infections
  and/or allergies. Other causes are really not
  frecuent or rare, but still have to rule out them
  if not responsive