Pediatric Annals

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from the guest editor 

Sinusitis Overview

Ellen R Wald, MD

Abstract

This issue of Pediatrie Annais deals with a very common problem in clinical practice - the child with the acute onset of upper respiratory symptoms. The major difficulty for the practitioner is differentiating, on the one hand, the child with a selflimited viral upper respiratory infection (causing a viral rhinos inusitis) or allergic inflammation, from, on the other hand, the child with a secondary bacterial infection of the paranasal sinuses. Only in the latter case is it appropriate to prescribe antimicrobial agents. Both viral upper respiratory infection and allergic inflammation are far more common than secondary bacterial infections of the paranasal sinuses. To prevent the abuse of antibiotics, the empiric prescription of antimicrobial agents for children with nonspecific acute upper respiratory symptoms must be avoided.

DIAGNOSIS

The distinction between patients with viral rhinosinusitis and those with acute bacterial sinusitis is based primarily on a carefully obtained history. Dr. Turner's article on the common cold provides an elegant review of this problem. Attention to the duration of symptoms and their severity is the key to the diagnosis. The course of most uncomplicated viral upper respiratory infections is between 5 and 7 days. Importantly, although the patient may not be completely free of symptoms by the tenth day, almost always their symptoms have peaked in intensity and have begun to improve by that time. The spontaneous improvement of symptoms provides evidence that the episode is self-limited. Unfortunately, the physical examination is of limited value in distinguishing viral rhinosinusitis from bacterial sinusitis. In both cases there may be mucosal edema and erythema with mucotd or even pumlent nasal discharge. Occasionally, the examiner may see pus coming from the middle meatus or there may be periorbital swelling that provides a clue to the diagnosis of acute bacterial sinusitis.

Distinguishing children with allergic rhinitis from those with viral rhinosinusitis or acute bacterial sinusitis may sometimes be difficult. However, there are often clinical clues on the physical examination that help establish a diagnosis of allergic rhinitis. The photographs provided by Dr. Nash demonstrate the distinctive findings of atopic disease. The allergic salute, the nasal crease, Dennie-Morgan lines, and facial pruritis (manifest by grimacing) will often direct the diagnosis. In addition, a family history of atopy - either eczema, asthma, or allergic rhinitis (seasonal or perennial) - or a personal history of eczema or asthma may help confirm the diagnosis of allergic rhinitis as the explanation for the presence of acute respiratory symptoms.

TREATMENT ISSUES

Current concerns about the inappropriate use of antibiotics have been underscored in the lay press and in nearly every medical journal. These concerns are created by the current escalation of the rate of antibiotic resistance among bacterial agents. Although in the past antibiotic resistance was primarily the purview of the physician caring for immunosuppressed patients with nosocomial Gram-negative infections, this phenomenon is now a part of everyday practice. Common infections such as acute otitis media, acute bacterial sinusitis, and acute conjunctivitis are often caused by antibiotic-resistant organisms. Specifically, the community practitioner must be aware of the problems of penicillin-resistant Streptococcus pneumoniae and beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis.

Although avoidance of inappropriate use of antibiotics is essential, the practitioner must also recognize those situations in which antibiotics are indicated and must treat with potent antibiotics for the appropriate length of time. I am particularly concerned about those investigators who raise the issue of whether antibiotics should be used at all for children with acute otitis media or sinusitis and others who are advocating short courses of antibiotics in place of the traditional duration of at least 10 days.1'2 The motivation for treating…

This issue of Pediatrie Annais deals with a very common problem in clinical practice - the child with the acute onset of upper respiratory symptoms. The major difficulty for the practitioner is differentiating, on the one hand, the child with a selflimited viral upper respiratory infection (causing a viral rhinos inusitis) or allergic inflammation, from, on the other hand, the child with a secondary bacterial infection of the paranasal sinuses. Only in the latter case is it appropriate to prescribe antimicrobial agents. Both viral upper respiratory infection and allergic inflammation are far more common than secondary bacterial infections of the paranasal sinuses. To prevent the abuse of antibiotics, the empiric prescription of antimicrobial agents for children with nonspecific acute upper respiratory symptoms must be avoided.

DIAGNOSIS

The distinction between patients with viral rhinosinusitis and those with acute bacterial sinusitis is based primarily on a carefully obtained history. Dr. Turner's article on the common cold provides an elegant review of this problem. Attention to the duration of symptoms and their severity is the key to the diagnosis. The course of most uncomplicated viral upper respiratory infections is between 5 and 7 days. Importantly, although the patient may not be completely free of symptoms by the tenth day, almost always their symptoms have peaked in intensity and have begun to improve by that time. The spontaneous improvement of symptoms provides evidence that the episode is self-limited. Unfortunately, the physical examination is of limited value in distinguishing viral rhinosinusitis from bacterial sinusitis. In both cases there may be mucosal edema and erythema with mucotd or even pumlent nasal discharge. Occasionally, the examiner may see pus coming from the middle meatus or there may be periorbital swelling that provides a clue to the diagnosis of acute bacterial sinusitis.

Distinguishing children with allergic rhinitis from those with viral rhinosinusitis or acute bacterial sinusitis may sometimes be difficult. However, there are often clinical clues on the physical examination that help establish a diagnosis of allergic rhinitis. The photographs provided by Dr. Nash demonstrate the distinctive findings of atopic disease. The allergic salute, the nasal crease, Dennie-Morgan lines, and facial pruritis (manifest by grimacing) will often direct the diagnosis. In addition, a family history of atopy - either eczema, asthma, or allergic rhinitis (seasonal or perennial) - or a personal history of eczema or asthma may help confirm the diagnosis of allergic rhinitis as the explanation for the presence of acute respiratory symptoms.

TREATMENT ISSUES

Current concerns about the inappropriate use of antibiotics have been underscored in the lay press and in nearly every medical journal. These concerns are created by the current escalation of the rate of antibiotic resistance among bacterial agents. Although in the past antibiotic resistance was primarily the purview of the physician caring for immunosuppressed patients with nosocomial Gram-negative infections, this phenomenon is now a part of everyday practice. Common infections such as acute otitis media, acute bacterial sinusitis, and acute conjunctivitis are often caused by antibiotic-resistant organisms. Specifically, the community practitioner must be aware of the problems of penicillin-resistant Streptococcus pneumoniae and beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis.

Although avoidance of inappropriate use of antibiotics is essential, the practitioner must also recognize those situations in which antibiotics are indicated and must treat with potent antibiotics for the appropriate length of time. I am particularly concerned about those investigators who raise the issue of whether antibiotics should be used at all for children with acute otitis media or sinusitis and others who are advocating short courses of antibiotics in place of the traditional duration of at least 10 days.1'2 The motivation for treating both acute otitis media and acute bacterial sinusitis with antibiotics is twofold: to shorten the duration of the acute illness and to prevent the development of serious suppurative complications. Although middle ear effusion may be a benign condition, acute otitis media is a potentially serious infection. The most common and important complications of acute otitis media are perforation of the tympanic membrane and acute mastoiditis. The important suppurative complications of acute bacterial sinusitis are subperiosteal abscess and intracranial abscess. Although neither H. influenzas nor M. catanhaks are likely to cause these suppurative complications, infection caused by S. pneumonias may progress to produce serious local pyogenic complications. In this era of resistance to antibiotics, failure to treat or inadequate treatment of acute bacterial sinusitis and otitis media may lead to the development of serious suppurative complications. Of note, several studies have already shown that short courses of antibiotics are a disadvantage for young children (< 2 years of age) with acute otitis media.3,4

Another issue that has become a concern as an outgrowth of the problem of antibiotic resistance is the strategy of antimicrobial prophylaxis for the management of patients with recurrent infections. A common definition for recurrent acute otitis media or recurrent acute bacterial sinusitis is the occurrence of three episodes in 6 months or four episodes in a year. In the past, this history of infection would prompt an evaluation of the patient for a possible underlying immunodeficiency (by assessing quantitative tmmunoglobulins) and a trial of antibiotic prophylaxis as a strategy to control the morbidity of recurrent infections before resorting to surgery. Currently, there is great reluctance to initiate antibiotic prophylaxis. However, in selected cases, in which the diagnoses of acute otitis media and sinusitis have been appropriately substantiated, this strategy may still be appropriate. The key element is the accurate diagnosis of acute otitis media or acute bacterial sinusitis in the first place. Three episodes of bona fide acute otitis media (not simply persistent middle ear effusion) manifest by stringent criteria (a red, white, or yellow bulging and immobile tympanic membrane) is a signal for action.. Likewise, three or four well-documented, closely spaced episodes of acute bacterial sinusitis (not viral upper respiratory infections) is a call for action. The usual choices for antibiotic prophylaxis are amoxicillin or sulfisoxazole. In the current era, many investigators prefer sulfisoxazole to reserve the beta-lactams in the event that resistance to the antibiotic used for prophylaxis does emerge. The appropriate patient may be started on antimicrobial prophylaxis. If there are recurrences despite prophylactic strategies, surgical therapy may be indicated. This is the subject of Dr. Lusk's article on the surgical management of patients with recurrent or chronic sinusitis.

REFERENCES

1. VariBuchem FL, Knottnems JA, Schnjnemackers V], Peelers MJ. Pnmary-caiebased randomized placebo-controlled trial of antibiotic treatment m acute maxillary sinusitis. Lancet. 1 99 7;3 49:683 -687.

2. VanBuchem FL. Dunk JH, Van Hot' MA. Therapy of acute otitis media: myringotomy. antibiotics, or neither? A double-blind study in children. Lancet. 1981;Z:

3. Paradise JL. Short-course antimicrobial treatment lor acute otitis media: not best for infants and young children. JAMA 1997:278:1640-1642.

4. Hoberman A, Paradise JL. Burch DJ. et al. Equivalen! efficacv and teduced occurrence of diarrhea from a new formulation of amoxicillin/clavulanate (Augmenlin) for treatment of acute otitis media in children. Peduur Infect Du J. 1997; 16:463 -4 70.

10.3928/0090-4481-19981201-05

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