Acute Rhinosinusitis in Children

Background

• Acute rhinosinusitis is defined as an inflammation of the mucosal lining of the nasal passage and paranasal sinuses < 4 weeks in duration.
• Acute bacterial sinusitis is rhinosinusitis complicated by a bacterial infection, usually Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and/or Moraxella catarrhalis.
• The risk of rhinosinusitis may be increased by exposure to tobacco smoke or other irritants and underlying conditions such as anatomic abnormalities of the nasal passages and sinuses, immunodeficiencies, cystic fibrosis, or primary ciliary dyskinesia.
• There can be significant complications from bacterial spread into the surrounding bone, and orbital and intracranial spaces, such as the meninges and central venous sinus.

Evaluation

• Symptoms of acute sinusitis
  • Major symptoms include nasal congestion or obstruction, facial congestion or fullness, facial pain or pressure, purulent anterior nasal discharge, purulent or discolored posterior nasal discharge, hyposmia or anosmia, or fever.
  • Minor symptoms include headache, ear pain, pressure, or fullness, halitosis, dental pain, cough, or fatigue.
• Acute bacterial sinusitis can be presumed with any of (Strong recommendation):
  • signs or symptoms lasting ≥ 10 days without clinical improvement
  • worsening signs or symptoms following initial improvement ("double sickening")
  • severe symptoms including fever ≥ 39 degrees C (102.2 degrees F) and purulent nasal discharge lasting ≥ 3 consecutive days
• Percussion of the sinuses is not useful to distinguish the causes of rhinosinusitis.
• Blood tests and imaging studies are not indicated to confirm uncomplicated acute bacterial sinusitis or distinguish it from viral causes of rhinosinusitis.

Management

• Initial antibiotic therapy or 3 additional days of observation may be offered for uncomplicated acute bacterial sinusitis.
• Antibiotic therapy should be given if there are severe symptoms, worsening symptoms after initial improvement, or infectious complications (Strong recommendation).
  • The antibiotics of choice are (Weak recommendation):
    • amoxicillin 45 mg/kg/day orally in 2 divided doses for uncomplicated cases
    • amoxicillin 80-90 mg/kg/day plus clavulanate 6.4 mg/kg/day orally in 2 divided doses for < 2 years old, moderate-to-severe illness, children attending day care, or antibiotic exposure within the prior 4 weeks
  • Options in penicillin-allergic children include (Weak recommendation):
    • cefdinir 14 mg/kg/day orally once daily or in 2 divided doses (maximum 600 mg/day)
    • cefuroxime suspension 30 mg/kg/day orally in 2 divided doses (maximum 500 mg/dose) or tablets 250 mg orally twice daily
    • cefpodoxime 10 mg/kg/day orally in 2 divided doses (maximum 200 mg/dose) plus clindamycin 30-40 mg/kg/day orally in 3 divided doses (maximum 600 mg/dose)
    • cefixime 8 mg/kg/day orally in 2 divided doses (maximum 400 mg/day) plus clindamycin 30-40 mg/kg/day orally in 3 divided doses (maximum 600 mg/dose)
    • levofloxacin 10-20 mg/kg/day orally once daily or in 2 divided doses
  • If unable to use oral medication due to vomiting or gastrointestinal intolerance, ceftriaxone 50 mg/kg intramuscularly or IV in single dose, followed in 24 hours by oral antibiotic therapy upon clinical improvement.
  • If symptoms worsen or fail to improve within 72 hours, and upon re-evaluation bacterial sinusitis is still the likely diagnosis, then the therapy can be changed from (Weak recommendation):
    • observation to amoxicillin
    • amoxicillin to high-dose amoxicillin-clavulanate
    • high-dose amoxicillin-clavulanate to levofloxacin or to cefixime plus either clindamycin or linezolid
  • The optimal duration of antibiotic therapy is unclear, generally 10-14 days or 7 days after the resolution of symptoms (Weak recommendation).
• Symptomatic treatment may be considered with intranasal corticosteroids (especially in children with allergic rhinitis) and normal saline nasal irrigation (Weak recommendation).
• Neither topical nor oral decongestants and/or antihistamines are recommended as adjunctive therapy for acute bacterial rhinosinusitis (Weak recommendation).