JOSEPH R. ANTICAGLIA, MD
Medical Advisory Board
Nine year old little Billy has a runny nose, is coughing and complains that he can’t breathe through the nose. Is it a cold, his allergies, infected adenoids or sinusitis? How should it be treated?
The sinuses (paranasal sinuses) are four pairs of air-filled cavities in the bones around the eyes and nose. (1) For the sinuses to work normally, the openings (ostia) that connect the sinuses to the nasal cavity must remain open, the tiny hair cells (cilia) in the sinus cavities must be able to sweep the mucus out of the sinus into the nose and the secretions should be not be abnormal. When swelling or mucus blocks the openings of the sinuses, a cascade of events can unfold causing sinusitis.
Children sinuses are different from adult sinuses in several ways. First, not all the sinuses show up at birth and those that do are rudimentary. In other words, children do not have four pairs of sinuses at birth and the others are underdeveloped. For example, the frontal sinus doesn’t make its first appearance until the child is about six years of age and at birth the maxillary sinus is about the size of a pea.
It’s important to note that the age of children influences the size and shape of the sinuses. Under normal developmental conditions, the configuration and location of the sinus vary significantly compare to the adult. It’s not until the teenage years do the paranasal sinuses closely resemble the adult sinuses. Of course, there are exceptions.
Consider Jamal, an 8 year old youngster with a history of allergies and a recent cold that doesn’t want to go away. The “cold?” has lasted almost two weeks and during this time Jamal has been coughing every day, has had a stuffy nose with thick yellow-greenish nasal discharge. He has become irritable, trouble sleeping and there’s some puffiness around his eyes.
Acute sinus infections almost always start in the nose as an URI (cold) and spread to the paranasal sinuses. They may be aggravated by reflux disease, allergies, milk products and tobacco smoke. Isolated acute sinusitis is almost nonexistent.
The American Academy of Pediatrics published guidelines for children with acute bacterial sinusitis. (2) The guideline recommends the diagnosis of sinusitis in children be made if your child has an upper respiratory infection (colds) along with day time coughing and nasal discharge of any quality that lasts for 10 days without improvement. Jamal fits into this first category.
Second, children may initially improve but not completely and thereafter suffer a new onset of nasal discharge and daytime cough. In other instances, the child’s symptoms of nasal discharge and cough keep getting worse over 10 to 14 days.
Jeannine, a 14 year old teenager, enjoyed swimming in a lake while vacationing in Maine. After a few days of swimming, she complained of thick, discolored nasal discharge, stuffy nose and pain over the maxillary and ethmoid sinuses. These symptoms persisted for several days and were accompanied by an elevated temperature.
A third scenario the Academy writes about are those youngsters who present with a severe onset of a fever of 102F or greater for at least three consecutive days. This presentation is accompanied by pus-like nasal discharge and coughing. Jeannine most closely fits into the this third category of sinusitis
Antibiotic treatment should be prescribed in children with a diagnosis of sinusitis. A CT scan (computed tomography) is recommended whenever a child is suspected of having complications involving the orbit or central nervous system. Imaging studies are not indicated in uncomplicated acute sinusitis.
The management of childhood sinusitis can be challenging. When sinusitis is recurrent – i.e. four or more episodes of acute sinusitis within a twelve month period – other factors may predispose to sinusitis, such as allergies and infection of adenoid tissue. These last two can mimic a sinusitis with their symptoms of stuffy nose, nasal drainage, cough and headache.
An accurate diagnosis of sinusitis and an understanding of the development of the sinuses are essential in the management of sinusitis in children.
(1) Two of the sinuses are the maxillary (cheek) sinuses and frontal (forehead) sinuses. The other two are the ethmoid sinuses, between the eyes and nose and the sphenoid sinuses behind the upper-back part of the inside of the nose.
(2) Wald Ellen; Clinical Practice Guideline for the Diagnosis and Treatment of Acute Bacterial Sinusitis in Children 1 to 18 Years; American Academy of Pediatrics July, 2013.
