SINUSITIS

Paranasal sinuses are air-filled cavities within the facial bones, lined by ciliated, mucus secreting epithelium. The frontal, maxillary and anterior ethmoidal sinuses drain in middle meatus, while posterior ethmoidal cells and sphenoidal sinus drains into superior meatus.

Paranasal sinuses are not well developed at birth. While small ethmoidal and maxillary sinuses are present at birth, sphenoidal and frontal sinuses are not pneumatized till 9-10 months and 7-8 years of age respectively.

Sinusitis, i.e. inflammation of sinuses, frequently coexists with rhinitis (Rhinosinusitis) and may be acute or chronic (gt;30 days) with intermittent exacerbations.

Etiopathogenesis: Anatomical position of sinus ostia and mucociliary clearance are main defence mechanisms against sinus infection. Chronic sinusitis is more common in cases with:

• Blocked sinus ostia due to septal deviation, foreign body, polyps, adenoid hypertrophy etc.

• Impaired mucociliary clearance due to viral or allergic rhinitis, environmental pollution, immotile cilia syndrome, cystic fibrosis, etc.

• Increased risk of infection, e.g. gastroesophageal reflux, immunodeficiency states, etc.

Microbially, acute sinusitis is usually caused by S. pneumoniae, H. influenza, Moraxella and Staph. aureus, while polymicrobial and anaerobic infections are common in chronic disease. Fungal sinusitis is rare in immunocompetent children.

Clinical manifestations include: (a) persistent cough and nasal discharge that worsens in supine position,

(b) headache, specially on forward bending of head,

(c) periorbital puffiness, specially in morning, and

(d) secondary anosmia/parosmia.

Examination may reveal: (a) sinus tenderness, (b) postnasal drip, and (c) inflamed nasal mucosa, and (d) co-existing otitis media.

Complications include: (a) recurrent respiratory infections, (b) orbital infections, e.g.

Diagnosis is supported by presence of opacification, mucosal thickening or air-fluid levels on sinus X-rays

Fig. 16.5: Sinusitis.

Note mucosal edema and fluid collection in right maxillary sinus

with special views, e.g. Water's or Caldwell's view (Fig. 16.5), which may be confirmed on CT scan. Etiological diagnosis needs examination of nasal fluid for eosinophils to exclude allergic etiology and sinus aspiration/ culture, though rarely needed in immunocompetent children.

Management aims to: (a) control the infection by antibiotics, and (b) facilitate sinus-fluid drainage by decongestants, steam inhalation and positioning.

Oral amoxicillin with/without clavulanate is the drug of choice for acute sinusitis, though cephalosporins or levofloxacin (in older children) are equally effective. Treatment should continue for 14-21 days or at least 7 days after resolution of symptoms.

Chronic sinusitis for gt;12 weeks may be due to staphylococcal, anaerobic or fungal infections and must be treated with broad-spectrum antibiotics for 3-6 weeks, along with oral decongestants, nasal steroid sprays and saline irrigations, before considering surgical drainage of sinus.

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