Dear Dr. Wald: How long to treat sinusitis?
I enjoyed the December 1998 issue of Pediatric Annals for which you were guest editor.
What has always bothered me about the therapy for acute sinusitis is the lack of good data for a 10-day cutoff for initiation of therapy. According to published data cited by you, 88% to 92.5% of those children with 10 days of respiratory symptoms who are not getting better will have maxillary sinusitis on xray. Undoubtedly, different practices will see different severities of upper respiratory infections. For practices that see more severe illness, it might make good sense to begin therapy at 7 days.
The data I would like to see are the percentages of children with persistent respiratory symptoms at 5 and at 7 days who have demonstrable maxillary sinusitis on x-ray. With that information, I feel that I could make a decision about when to start therapy, rather than relying on experts who really do not have sufficient information on which to make a valid recommendation.
Paul R. Joseph, MD
Associate Professor of Clinical Pediatrics
NYV School of Medicine
Syosset, New York
Dr. Wold's response:
I very much appreciate your question about when to initiate therapy in children with respiratory symptoms. Unfortunately, I do not know of any data that address the frequency of abnormal maxillary sinus radiographs in children with respiratory symptoms of 5 or 7 days' duration. However, I do not believe that the presence of abnormal sinus radiographs will answer the question of the need for treatment of such children.
As you know, most adults (87%) with a 2- to 3-day history of an uncomplicated viral upper respiratory infection will have significantly abnormal computed tomography scans of their paranasal sinuses.1 Viral upper respiratory infections usually cause a "rhinosinusitis" (ie, inflammation of both the nasal and the sinus mucosa). The history of the illness is the most powerful piece of information.
Many children, in fact, most children, with acute respiratory symptoms of 5 or 7 days' duration will improve spontaneously during the next few days and will not require antibiotics.2 The mean duration of uncomplicated upper respiratory infections varies from 6.6 to 8.9 days for children 3 years of age or younger.
1. Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N En4IJ Med. 1994;330:25-30.
2. WaId ER, Guerra N, Byers C Upper respiratory tract infections in young children: duration of and frequency of complications. Ptdiatrics. 1991;87:129-133.
Ellen R. Wold, MD
Professor of Pediatrics and Otolaryngology
Chief, Division of Allergy, Immunology,
and Infectious Diseases
University of Pittsburgh School of Medicine