© Borgis - New Medicine 4/2010, s. 122-126
Chronic and subacute recurring sinusitis in children
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head of Department: prof. Mieczysław Chmielik, MD, PhD
Introduction. Inflammation within the upper respiratory tract (nasal catarrh) in children is one of the most frequently observed medical illnesses. Because of the specific characteristics of the younger child?s immune system, nasal catarrh in many cases transfers to other organs and not infrequently also becomes a disease of the subacute and recurrent type. Chronic sinusitis is recognized when symptoms of illness definitively end when the level of adult immunity is attained, which usually occurs at the age of 12-14 years recurrent subacute sinusitis is recognized.
Aim. To present the observations and experience acquired at our Department of Paediatric Otolaryngology of WUM and review the current clinical and scientific literature concerning diseases of the upper respiratory tract in children aged up to 12 years.
Material and method. Children aged up to 12 years treated in the Department of Paediatric Otolaryngology of WUM. The data are based on clinical interview and clinical examinations of patients treated in our Department and also on the experience of the author.
Discussion. Chronic and subacute recurrent sinusitis in children have similar symptoms. They differ only in how and for how long they are treated. There are problems in defining chronic and subacute recurrent sinusitis, dividing the condition into permanent and frequently occurring. Chronic or subacute recurrent sinusitis in children can be recognized when symptoms defined as permanent persist for over 6 weeks and are not seasonal.
Inflammation within the upper respiratory tract (nasal catarrh) in children is one of the most frequently observed medical illnesses (1). Because of the specific characteristics of the younger child?s immune system, nasal catarrh in many cases transfers to other organs and not infrequently also becomes a disease of subacute and recurrent type (2, 3). For this reason the course of a child?s nasal and sinus infection is decidedly different when compared to adults (4). As a result, it is impractical to use the supposedly analogous model in adult patients to reflect the many variants of sinusitis seen in children (5, 6, 7).
In those children with impaired nasal patency of the upper respiratory tract resulting from a permanent defect (e.g. a deviation in the nasal septum, a narrowing of the paranasal sinuses, pathological adenoid hypertrophy or nasal polyps), the symptoms of illness are constantly occurring and a lasting improvement happens only after the obstacle is surgically removed. This is recognised as being chronic sinusitis (inflammation of the paranasal sinuses) (8, 9). Also included, but constituting a separate group of children, are those with permanently damaged local defence mechanisms in such cases as primary ciliary dyskinesia, cystic fibrosis or gastroesophageal reflux disease (10, 11).
In these children one can also see both chronic sinusitis and an improvement during the course of the disease afforded by appropriate management of the underlying condition through medical centres of excellence specialising in this field (12, 13). Likewise, but in a different manner, one should treat those children in whom chronic sinusitis is linked with various forms of allergy (14). The most numerous group of patients aged 6-12 years suffering from inflammatory disease of the upper respiratory tract is, however, made up of children with developing defence mechanisms; thus infection at specific ages may still persist in a recurring form from autumn to spring (15). The symptoms of inflammation retreat in the summer and the illness definitively ends when the level of adult immunity is attained, which usually occurs at the age of 12-14 years (16). This form of illness can be defined as recurrent subacute sinusitis.
The symptoms of chronic or subacute recurrent sinusitis are in principle similar, but the causes which lead to developing the illness are important. They can to a certain degree influence the appearance and exacerbation of particular symptoms.
The aim is to render a critical account of personal observations together with several decades of experience acquired at our Department of Paediatric Otolaryngology (WUM), where this area has been one of the main subjects for departmental research. Also included is a critical review of the current clinical and scientific literature concerning diseases of the upper respiratory tract in children aged up to 12 years as well as ways of treating subacute recurrent sinusitis in children (17 -23).
Chronic and subacute recurrent sinusitis in children have similar symptoms. They differ only in how and for how long they are treated, and thus also the prognosis. At the present time a definition of chronic sinusitis in children in regard to clinical criteria and physiopathology does not exist. The disease lasts for different periods in younger children than older ones, with a large variation in the individual forms of the illness. This makes any systematic documentation of clinical observations difficult. There are likewise problems in defining subacute recurrent sinusitis during the development of the child. A generally accepted definition and classification of this disease is the one used for adults (24), which is not applicable to developing child patients (25). This is even admitted by the authors of this classification (24).
Applying the experiences and the disease definition/
/classification from adult patients to the developing child does not therefore lead to good clinical outcomes.
Under current conditions of world civilisation, the European region has a moderate climate, with over 80% of nursery and primary school children demonstrating, in different degrees, symptoms of upper respiratory tract infection throughout the autumn, winter and spring.
The symptoms are different to those observed for the analogous disease in adults (26). At first the symptoms appearing are of a general nature: fatigue, nervousness, perspiration, lowered levels of concentration, anxiety and night-time bed wetting. Local symptoms vary ? nearly always there is difficulty in breathing through the nose, speech becomes nasal, and nasal mucus of various types is exuded. Both nasal cavities produce a secretion. Sometimes this only occurs in the caudal regions of the nasal cavity, thus allowing the child to breathe through the nose despite the exuding secretions. The swollen mucous membranes depend on the form and phase of the illness. In those children with an allergic component or angioedema, the swelling may be significant and may completely block the nasal cavity (27).
While in adults one of the main disease symptoms is headache, in children this is not so constant an observation (28). As a reliable part of the diagnosis the parents? unprompted comments (not obtained by formal questioning) on their child?s illness are important because where headaches are concerned many parents may give false answers, claiming that they have confused this symptom with general fatigue or a lack of concentration. Also symptom complaints made by children on these subjects are frequently just an attempt to mimic their parents. An important symptom confirming a headache in small children is a pained expression. In this case then, in addition to laryngological diagnostics, a paediatric consultation with a neurologist and ophthalmologist is needed.
To the frequently observed symptoms of chronic or subacute recurrent sinusitis a cough, which occurs at night-time or is exercise induced, may be added. These attacks of coughing usually occur before actually going to sleep or early in the morning or upon intense physical effort. The cough is wet and the coughed up mucus resembles that from the nose. The paediatrician treating such a child does not also observe changes in auscultation in the lower respiratory tract and lungs and x-ray imaging of the thorax does not reveal any changes or even small changes in the form of an increased bronchial figure.
Therefore on the basis of my own and my institute?s experience together with a review of the literature, a list of permanent symptoms is proposed as well as a list of symptoms frequently seen in children with chronic or subacute recurrent sinusitis. These are as follows:
Permanent symptoms seen in chronic or subacute recurrent sinusitis in children:
1. Permanent or frequent recurrent discharge of mucous, purulent, from both nostrils.
2. Impaired nasal patency (breathing through the mouth during night-time).
3. Paroxysmal cough most frequently occurring at daybreak, the evening before sleep and after exercise.
4. General symptoms ? nervousness, fatigue, perspiration, disturbances in concentrating, hyperactivity.
Symptoms frequently seen in children with chronic or subacute recurrent sinusitis:
1. Recurrent bronchitis and pneumonia.
2. Pain in the joints.
3. Appetite loss, morning nausea and vomiting, stomach ache.
6. Nose bleeding (epistaxis).
7. Twitching of facial muscles.
8. Rhinolalia clausa.
9. Bruises under the eyes.
10. Gnashing of teeth during sleep.
11. Tonsil exudates.
Chronic or subacute recurrent sinusitis in children can be recognised when the symptoms defined above as permanent persist for over 6 weeks and are not seasonal.
As mentioned above, chronic sinusitis often develops as a result of mechanical damage to the nasal septum or deformation of the nasal passages (29, 30). In these cases it is necessary to perform a surgical operation appropriate to the cause of the nose breathing disorder, i.e. adenoidectomy, adenotonsillectomy, nasal septum surgery, and others (31-33). If however there is no nasal obstruction one should consider the general causes of the illness. These may be patients with atypical changes (34) which should in principle be treated by an allergologist. The task of the laryngologist here however would be to rectify the skeletal defect previously mentioned ? if it exists (35).
Children with localised immunodeficiency will require separate specialist treatment; this is especially relevant to children with immotile cilia syndrome, cystic fibrosis, coeliac disease or other immunodeficiencies (36). Fortunately these are rare diseases. The role of the laryngologist here is to correct the primary or recurrent disorders of nasal patency. However, treatment of the underlying disease, which is vital, should be performed by a team of specialists. This also applies to children in whom gastroesophageal reflux disease has been identified.
Subacute recurrent sinusitis
This is a disease in which chronic symptoms of sinusitis occur in varying degrees of intensity only at colder times of the year. This form of sinusitis nearly always occurs in children aged 6-12 years and is associated with a given particular immunity status which occurs in children of this age (37). As already mentioned, the disease is aggravated in cold parts of the year ? from October to May; in summer it is rare. During this exacerbation, the child exhibits most of the disorders listed under the ?symptoms? sections. The illness usually abates when the child acquires adult mechanisms of immunity, which normally occurs around 12-14 years. Nevertheless, there are a few cases where older patients still show the juvenile forms of the reaction to the disease (37). Diagnostic procedures must depend on establishing characteristics defined for chronic sinusitis excluding permanent structural and immunological causes.
Results of blood morphology may be of great importance when assessing the child?s overall state of health as well as immunity capabilities. The identification of anaemia, markers of rickets or immunodeficiency drives the diagnosis and patient treatment in the right direction. A valuable indicator may be the levels of inflammatory markers such as ESR (erythrocyte sedimentation rate) or CRP (C-reactive protein). In those children suspected with cystic fibrosis a sweat test should be performed by measuring chloride. It is extremely important in planning surgical procedures to have precise results assessing the patient?s blood clotting system, APPT (kaolin-activated partial thromboplastin time), prothrombin time, and levels of fibrinogen. The amounts of IgA, IgE, IgG and IgM should also be determined (38).
The value of taking diagnostic-therapeutic nasal cultures is limited because the bacteria commonly found therein are not responsible for the actual aetiology of the inflammation (39). Treatment according to the obtained antibiogram does not therefore provide the expected results. The ones most clinically reliable are observed to be those cultures obtained during sinus puncture and sinusoscopy. Cultures taken from under the middle nasal concha, that is in places located directly by the nasal orifice, give results similarly reliable as those taken from the nasal cavity (40).
Because obtaining such reliable material usually exceeds the abilities of the GP (general practitioner), paediatrician or even a laryngologist in outpatient clinics (who is suitably prepared), a determination is required of what the microorganisms are, what drugs are effective against them, which microorganism most frequently causes (in a given time and defined area) the chronic or subacute recurrent sinusitis in children. This information can allow the outpatient doctors to use preliminary antibiotic therapy on an empirical basis. The most commonly observed pathogenic bacteria may be Haemophilus influenza, Streptococcus pneumoniae and Moraxella catarrhalis. However, this picture varies significantly, especially in children treated previously with antibiotics.
Currently radiological diagnostics are indispensable for making a correct diagnosis. Typical X-ray pictures of sinuses however, as can be inferred, lie beyond the capabilities of clinical practice. The optimal test is CT (computed tomography) of the sinuses made in the frontal plane. The radiographer should then provide answers to the following (41, 42);
1. What is the location of the VIC hamate orbital ethmoid labyrinth lamella ? is removal possible without risking opening up the orbit?
2. Are the maxillary sinuses properly developed? (a less experienced radiographer may ascribe an underdeveloped sinus as an opacity)
3. Does the maxillary sinus have extra outlets (fontanelles)?
4. Are Haller?s cells visible?
5. Where is the frontal recess region located?
6. Are the frontal sinuses symmetrical?
7. Is the causeway nose pneumatised?
8. Does the image suggest any previous surgery around the sinus region?
9. What is the appearance of the ethmoid sinus bordering with the orbital apex?
10. Is the middle nasal concha pneumatised (concha bullosa)?
11. Is the ceiling/top layer of ethmoid sinus cells visible?
12. By how much is the olfactory fissure in relation to the ethmoid sinus?
13. What is the position of the basal lamina with respect to the middle nasal concha?
14. Is it possible to identify the anterior ethmoidal artery?
15. Is it possible to define how the internal carotid artery is positioned in relation to the optic nerve?
16. Is the bay wedge symmetrical?
Magnetic resonance in cases of inflammatory illnesses, within the bounds of the upper respiratory tract, is not such a useful test. Nevertheless, it does provide invaluable information in any oncological diagnoses made in this vicinity. At this time ultrasound techniques may only be useful as an aid for helping to provide a diagnosis.
This is an objective test which defines nasal permeability. This test is performed after shrinking the nasal mucous membranes, which reflects breathing resistance related to the skeletal structure of the nasal cavity (39, 43). If one undertakes tests without the shrinking, then the assessment covers not only the influence of skeletal structure but also the mucous membranes to give the total resistance to breathing through the nose. Because of the significant individual variability in patient?s perception when breathing through the nose, these tests may serve to provide an assessment of conservative treatment and surgical therapy. They cannot however form the basis for indicating whether or not surgery should be performed (44).
Cytology of the nasal mucosa
The test which can provide the doctor with valuable information concerning the mechanism of the development of inflammation in the upper respiratory tract is a cytological assessment of the nasal mucosal lagging. A preponderance of neutrophils may indicate changes due to bacteria in eosinophils for allergic forms of disease. An experienced doctor possessing such results can make further conclusions based on the types of epithelial cells found in the swab (45).
In children with long-term forms of nasal and paranasal sinus infection a valuable screening test can be ciliary clearance. This test defines the speed of translocation of the mucosal lagging from the frontal nasal cavity to the nasopharynx. The movement of this lagging is caused by the activity of nasal mucosal cilia. If the activity is insufficient, the time of translocating a coloured or flavoured substance that is present on the surface of the frontal nasal septum to the middle pharynx is either prolonged by over 30 minutes or does not happen at all. One can thereby suspect a group of immobile cilia (inherited or acquired), which should be confirmed by ultramicroscopic imaging of the nasal mucosal cilia or bronchi (46).
Treatment of chronic sinusitis
In those cases when the disease aetiology is impaired, then nasal or sinus patency surgical intervention is necessary and must be based on their unblocking. In patients with hypertrophy of the pharyngeal tonsil an adenoidectomy should be performed (47). In cases of deformed nasal septa plastic surgery is necessary.
Children with a narrowed nasal passage system require surgery to expand them. Patients with nasal polyps should undergo a polypectomy. Because of the specific features of immunity in young children inflammation is not solely confined to one sinus. Usually pansinusitis or hemipansinusitis occurs. Thus puncturing the jaw sinuses is of no medical value, only diagnostic. Jaw sinus puncture should be performed under general anaesthetic and should therefore be combined, when it is necessary and feasible, with sinuscopy, which significantly increases the diagnostic merit. Chronic subacute recurrent sinusitis in younger children is nearly always brought about or implicated with bacterial infection requiring antibiotic treatment. If possible the antibiotic should be chosen by a screening antibiogram. Such treatment should last at least 14 days. It is important that correct doses are given and that the duration of therapy is in accordance with the guidelines of the Polish Antibiotic Grouping in this country (48). Topical treatments with corticosteroids, antibacterial drugs or decongestants in these patients are less applicable. The number of reliable clinical reports on the efficacy and those on lack of efficacy of this type of therapy are comparable
(7, 36, 49) and hence it should only be adopted in justifiable circumstances.
Treatment of subacute recurrent sinusitis
As mentioned above, subacute recurrent sinusitis develops as a result of specific characteristics of the immune system in children aged 6-12 years. Surgical treatment, with the exception of patients with impaired nasal patency due to structural causes, is hence unnecessary. Conservative treatment should be multilayered, which becomes necessary during and at the height of the antibiotic therapy. Eradication of the bacteria usually brings about improvement because one of the aetiological causes has been removed. At the end of this treatment the symptoms, however, more often than not, return and so further treatment is required where immunomodulation becomes necessary using specific and polyvalent bacterial vaccines. Children suffering from these aforementioned illnesses should be vaccinated before autumn against flu, because a significant majority of the diseases of the upper respiratory tract start from viral infections whose antigens will be incorporated within the aforementioned vaccine. Of importance are Haemophilus influenza and pneumococcal vaccines, even though the large numbers and the variability of the bacterial strains may lessen the efficacy of given vaccines.
Polyvalent bacterial vaccines yield advantageous results because they not only raise immunity due to the disease-causing determinants contained within, but they also increase the general capabilities of the body?s defence system. Immunomodulation treatment, however, may be used only in those children whose immune systems are sufficiently developed to produce the required level of immunity. It is therefore necessary to measure the levels of IgA, IgG, IgE and IgM. Atopic children should be checked if they are not allergic to elements contained within the vaccine. Topical treatment of subacute recurrent sinusitis in children is less important because of the systemic characteristics and the immunological specificities at that age (10). The benefits of climatic treatment should also be mentioned together with a proper diet low in carbohydrates and hardening exercises. As in cases of chronic sinusitis, children with subacute recurrent inflammation of the upper respiratory tract who suffer from atopy, gastroesophageal reflux, immobile cilia or immunological disease should be treated by specialists at appropriate specialist centres.
Chronic sinusitis and subacute recurrent sinusitis in children are diseases with a not always clear aetiopathogenesis as well as a variable clinical courses. Because of their frequent occurrence they have the character of a social disease. Treatment should thus be tailored to the individual status of the patient (42, 50).
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