SINUSITIS

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SINUSITIS

• Rhonda Lesniak
• Primary Care II

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Anatomy

• Paranasal Sinuses

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Anatomy

• Lateral View of Sinuses

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Where are the sinuses?

• Four pairs of paranasal sinuses
• Frontal-above eyes in forehead bone
• Maxillary-in cheekbones, under eyes
• Ethmoid-between eyes and nose
• Sphenoid-in center of skull, behind nose and eyes

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What are the sinuses?

• The sinuses are hollow air-filled sacs lined by
  mucous membrane. The ethmoid and maxillary
  sinuses are present at birth. The frontal sinus
  develops during the 2nd year and the sphenoid
  sinus develops during the 3rd year.

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What are the sinuses? (contd)

• Sinuses have small orifices (ostia) which open
  into recesses (meati) of the nasal cavities.
• Meati are covered by turbinates (conchae).
• Turbinates consist of bony shelves surrounded by
  erectile soft tissue.
• There are 3 turbinates and 3 meati in each nasal
  cavity (superior, middle, and inferior).

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Considerations for Pediatrics

• At birth, the ethmoid, sphenoid and maxillary
  sinuses are tiny and cause problems in infants
  and toddlers.
• Frontal sinuses develop between 4-7 years of age,
  causing problems in school aged children and
  adolescents.

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Sinusitis

• Inflammation of paranasal sinuses

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What is sinusitis?

• An acute inflammatory process involving one or
  more of the paranasal sinuses.
• A complication of 5-10 of URIs in children.
• Persistence of URI symptoms gt10 days without
  improvement.
• Maxillary and ethmoid sinuses are most frequently
  involved.

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How Does Sinusitis Develop?

• Usually follows rhinitis, which may be viral or
  allergic.
• May also result from abrupt pressure changes (air
  planes, diving) or dental extractions or
  infections.
• Inflammation and edema of mucous membranes lining
  the sinuses cause obstruction.
• This provides for an opportunistic bacterial
  invasion.

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Development (contd)

• With inflammation, the mucosal lining of the
  sinuses produce mucoid drainage. Bacteria invade
  and pus accumulates inside the sinus cavities.
• Postnasal drainage causes obstruction of nasal
  passages and an inflamed throat.
• If the sinus orifices are blocked by swollen
  mucosal lining, the pus cannot enter the nose and
  builds up pressure inside the sinus cavities.

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Predisposing Factors

• Allergies, nasal deformities, cystic fibrosis,
  nasal polyps, and HIV infection.
• Cold weather
• High pollen counts
• Day care attendance
• Smoking in the home
• Reinfection from siblings

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Acute or Chronic Sinusitis?

• Acute Sinusitis respiratory symptoms last
  longer than 10 days but less than 30 days.
• Subacute sinusitis respiratory symptoms persist
  longer than 30 days without improvement.
• Chronic sinusitis respiratory symptoms last
  longer than 120 days.

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Etiology of Sinusitis

• 70 of bacterial sinusitis is caused by
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Other causative organisms are
• Staphylococcus aureus
• Streptococcus pyogenes,
• Gram-negative bacilli
• Respiratory viruses

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Complications of Sinusitis

• Orbital cellulitis or abscess
• Meningitis
• Brain abscess
• Intractable wheezing in children with asthma
• Cavernous sinus thrombosis
• Subdural empyema

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Subjective Symptoms of Sinusitis

• History of URI or allergic rhinitis
• History of pressure change
• Pressure, pain, or tenderness over sinuses
• Increased pain in the morning, subsiding in the
  afternoon
• Malaise
• Low-grade temperature
• Persistent nasal discharge, often purulent
• Postnasal drip
• Cough, worsens at night
• Mouthing breathing, snoring
• History of previous episodes of sinusitis
• Sore throat, bad breath
• Headache

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Clinical Presentations of Sinusitis

• Periorbital edema
• Cellulitis
• Nasal mucosa is reddened or swollen
• Percussion or palpation tenderness over a sinus
• Nasal discharge, thick, sometimes yellow or green
• Postnasal discharge in posterior pharynx
• Difficult transillumination
• Swelling of turbinates
• Boggy pale turbinates

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Pale, Boggy Turbinates
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Diagnostic Tests

• Imaging studies, such as sinus radiographs,
  ultrasonograms, or CT scanning indicated if
  child is unresponsive to 48 hours of antibiotics
  and if the child has a toxic appearance, chronic
  or recurrent sinusitis, and chronic asthma.
• Laboratory studies, such as culture of sinus
  puncture aspirates.

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Differential Diagnoses

• Allergic rhinitis
• Non-allergic rhinitis
• Infectious rhinitis
• Drug-induced rhinitis
• Nasal polyps
• Dental abscess
• Carcinoma of sinus
• Cluster headache
• Structural defects (septum deviation)
• Nasal foreign body

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Pharmacological Plan of Care

• Antimicrobials-treat for 10-14 days, depending
  upon severity, with one of the following
• Amoxicillin20-40mg/kg/d in 3 divided
  doses(gt20kg, 250mg tid)
• Augmentin25-45mg/kg/d in 2 divided doses(gt20kg,
  400mg q12) Use chewable or suspension if child is
  less than 40kg.

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Pharmacological Plan of Care

• Biaxin15mg/kg/d in 2 divided doses(gt30kg, 250mg
  q12)
• Cefzil15mg/kg/d in 2 divided doses (gt35kg, 250mg
  bid)
• Lorabid 30mg/kg/d in 2 divided doses (gt26kg,
  400mg bid)

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Other Relief Medications

• Codeine for severe pain
• Rhinocort nasal spray 2 sprays in each nostril
  every 12 hours for children over 6 years of age.

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OTC Medications

• Acetaminophen or ibuprofen to relieve pain
• Decongestants
• Antihistamines
• Nasal saline

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Non-pharmacological treatment

• Humidifier to relieve the drying of mucous
  membrances associated with mouth breathing
• Increase oral fluid intake
• Saline irrigation of the nostrils
• Moist heat over affected sinus
• Prolonged shower to help promote drainage

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Patient Education

• Child should not dive.
• Child should not travel by airplane.
• Urge parent to eliminate triggers in the home
  (dust, smoking)
• Have all members of the family treated, if
  indicated.

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Follow Up Guidelines

• Instruct parent to call in 48 hours if condition
  of child has not improved.
• Instruct parent to bring child in for a recheck
  in 2 weeks.

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Guidelines for Referral

• Child with complications or signs of invasive
  infection.
• Child needing control of allergic rhinitis.
• Child with chills and fever.
• Child with persistent headache.
• Child with edema of forehead, eyelids.
• Child with orbital cellulitis

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Case Study

• Austin, 9 years old, was seen in the clinic ten
  days ago, was diagnosed with rhinitis and sent
  home with instructions for increased fluids,
  decongestants, and rest.
• Austin presents today with worsened symptoms of
  malaise, low-grade temperature, nasal discharge,
  night time coughing, mouth breathing, early
  morning pain over sinuses, and congestion.

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Case Study (contd)

• Physical findings for Austin
• Thick, yellow nasal discharge
• Edematous, reddened nasal mucosa
• Postnasal discharge visible in posterior pharynx
• Periorbital swelling
• Tenderness of sinuses upon palpation

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Case Study (contd)

• Treatment Austin weighs 90 lbs, or 40.8 kg
• Amoxicillin 250 mg tid po
• Comfort measures acetaminophen for pain relief
• Moist heat applied to sinuses
• Increased oral fluids
• Rest

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References

• Boynton, R., Dunn, E., Stephens, G., Pulcini,
  J. (2003) Manual of ambulatory pediatrics (5th
  ed.). Philadelphia Lippincott Williams
  Wilkins.
• Burns, C., Dunn, A., Brady, M., Starr, N.,
  Blosser, C. (2004). Pediatric primary care A
  handbook for nurse practitioners (3rd ed.). St.
  Louis, Missouri Saunders.

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References (contd)

• Colyar, M. (2003). Well-child assessment for
  primary care providers. Philadelphia F. A. Davis
  Company.
• Tierney, L., Saint, S., Whooley, M. (2005).
  Current essentials of medicine (3rd ed.). New
  York Lange Medical Books/McGraw-Hill.