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JohannaNokso-Koivisto

Sinusitis in Children

During a common cold a child usually has secretions in the nasal meatuses and in the maxillary sinuses, in which case the term rhinosinusitis is used, and the condition does not require treatment.
The structure of the sinuses in children prevent the secretions from accumulating in the sinuses and an acute bacterial sinusitis rarely occurs.
There is no clear definition of a sinusitis in children. It is most important to understand when the child's symptoms and findings deviate from those of a normal common cold.
Acute bacterial sinusitis can be suspected if a child still has purulent rhinitis and a cough 10 days after the onset of a common cold, without signs of improvement, or if the symptoms worsen after an initial phase of recovery.
Imaging should not be carried out for children.
The antimicrobial drug of choice is amoxicillin.
Bacterial sinusitis leads to complications more often in children than in adults. Swelling of the eyelids (picture 1) is a warning sign.

The maxillary sinuses are bean-sized at birth and widely open to the nasal meatus.
After the permanent teeth have developed the sinuses expand downwards in the direction of the palate, and the maxillary sinuses reach their final size during teenage years.
As the child grows, the ostium of the maxillary sinus becomes narrower in relation to the size of the sinus.

Inflammation of the sinus mucosa is nearly always due to a viral respiratory infection.
In bacterial infections, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the most common causative agents.

Sinusitis in a child is diagnosed based on the patient history and clinical picture.
Due to the structure of the sinuses acute bacterial sinusitis rarely occurs in small children.
Bacterial rhinosinusitis can be suspected if the course of a child's upper respiratory infection significantly deviates from a regular common cold.
- Symptoms such as purulent rhinitis and daytime cough persist unchanged for more than 10 days without signs of improvement.
- Symptoms initially become milder but then become worse again (double sickening).
- Symptoms are severe (fever ≥ 39°C, purulent rhinitis, worsened general condition) from the beginning and continue for at least 3 consecutive days.
A purulent discharge in the nasopharynx and a trickle of purulent exudate from below the middle concha in the nasal meatus may be visible.
Other possible reasons for the symptoms should also be considered (allergy, new viral infection)
In children, imaging of sinuses should not be performed.

Viral rhinosinusitis will resolve without antimicrobial treatment.
Antimicrobial medication should be considered if a bacterial sinusitis is suspected based on the clinical picture, symptoms and signs (see above Symptoms and diagnosis).
The choice of antimicrobial agent can be based on bacterial culture and sensitivity testing of a sample taken from the area of the middle concha.
The first-choice antimicrobial treatment is amoxicillin, 40-80 mg/kg/day, divided into 2 or 3 doses, for 7 days.
The second-choice antimicrobial treatments are amoxicillin-clavulanic acid (40-80 mg/kg/day, divided into 2 doses) and, for children over 8 years, doxycycline.
For patients allergic to penicillin or doxycycline, sulpha-trimethoprim, second generation cephalosporins or macrolides may be considered.
There is little evidence on the benefits of supportive measures. Symptomatic treatment (e.g. nasal decongestants) may be used. Saline irrigation of the nose may alleviate the symptoms and is well tolerated even by small children.

The examination of recurrent or persistent sinusitis should be carried out by an ENT specialist.
Recurrent disease may be due to recurrent respiratory infections, allergies or factors irritating the nasal mucosa. If factors maintaining inflammation can be eliminated, the prognosis of sinusitis is good in children.
If sinusitis recurs or persists despite conservative treatment and follow-up, adenoidectomy and maxillary irrigation should be considered as the primary measure.
Endoscopic maxillary surgery is rarely indicated in children.

Severe complications are rare but they may develop rapidly and require immediate hospital treatment. If a complication is suspected, the patient should be referred as an emergency case to specialized care.
Symptoms suggesting a complication in a child with rhinitis include unilateral eyelid swelling, severe headache, swelling and tenderness in the forehead, impairment of colour vision or vision, diplopia, and impaired general condition.
Preseptal cellulitis Facial Cellulitis in a Child and orbital cellulitis or orbital abscess are among the most common complications. The inflammation may spread to cause an intracranial complication (e.g. epidural or subdural abscess).

DeMuri GP, Wald ER. Clinical practice. Acute bacterial sinusitis in children. N Engl J Med 2012;367(12):1128-34. [PubMed]