© Borgis - New Medicine 4/2010, s. 122-126
*Mieczysław Chmielik
Chronic and subacute recurring sinusitis in children
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head of Department: prof. Mieczysław Chmielik, MD, PhD
Summary
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.
INTRODUCTION
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.
STUDY AIMS
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).
DISCUSSION
Disease definition
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.
Symptoms
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.
4. Halitosis.
5. Headache.
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.
Additional studies
Clinical biochemistry
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).
Bacteriology
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.
Imaging
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Piśmiennictwo
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