Patient Presentation
A 3-year-old male came to clinic with a history of runny nose for 5 days. He had had some mild fever up to 38.2°C for the first 36 hours but hadn’t been bothered by it. He was drinking, urinating and playing well. “He just had a lot of clear runny nose and he keeps waking up at night and coming into our bed,” complained the mother. “Since he started at preschool he always seems to have a cold, and my mother was just diagnosed with sinusitis, so we’re both worried now,” his mother went on. The review of systems was positive for an occasional cough, but no emesis, rash, muscle pain or other pain.
The pertinent physical exam showed a healthy appearing boy with normal vital signs, and he was tracking at the 50% for weight. HEENT showed mild clear rhinorrhea of the nares bilaterally, no facial pain, and some clear rhinorrhea in the back of his throat. Ears and lungs were normal.
The diagnosis of a preschooler with a viral upper respiratory infection was made. The pediatrician discussed that sinusitis required a longer period of time to diagnose, and that he needed to have more significant symptoms. She discussed recent respiratory illnesses and ways to help the patient. She also discussed sleep hygiene techniques to help the patient stay in his own bed at night.
Discussion
Sinusitis and rhinitis are not the same thing. “Sinusitis is swelling of the sinus mucous membrane and/or exudate into the sinuses. Rhinitis is inflammation, engorgement or excessive secretions from the nasal mucous membranes that line the interior of the nasal cavity.” Sinusitis requires radiological imaging to diagnose but unfortunately there is huge overlap of radiological sinus changes that are not due to sinusitis itself. “…[S]ymptoms attributed to sinusitis correlate poorly with radiological evidence of sinus inflammation and radiological evidence of sinus inflammation correlates poorly with symptoms attributed to rhinitis.”
Similarly, clinical symptoms often attributed to sinusitis also have huge overlap with other problems including colored nasal discharge (green/yellow), headache, and facial pain. An author points out in one study that “Green snot was somewhat more likely to be associated with sinusitis by X-ray, but almost 30% of those without radiologic evidence of sinusitis also had green snot.”
It can be very difficult for the outpatient primary care clinician to make the diagnosis of acute bacterial sinusitis. Parents and patients appropriately want relief from symptoms that are causing discomfort. Children in childcare settings and school often have overlapping upper respiratory infections and those symptoms are almost identical to acute bacterial sinusitis. In general most URIs will improve within 10 days and may have a more benign course. However that may not necessarily be true for all patients.
Learning Point
Acute bacterial sinusitis is considered for patients with symptoms 12 weeks of symptoms. Chronic bacterial sinusitis is not further discussed here.
The American Academy of Pediatrics (AAP) Clinical Practice Guidelines has the following recommendations for the diagnosis and treatment of acute bacterial sinusitis in children:
Diagnosis of acute bacterial sinusitis can be made if one of the following scenarios is present:
- Persistent illness of > 10 days without improvement
- Symptoms of nasal discharge of any quality or daytime cough
- Antibiotic treatment is recommended to be started or additional 3 day outpatient monitoring can be offered as some patients will continue to improve on their own during this time
- Worsening course after initial improvement
- Symptoms of worsening or new onset of nasal discharge, daytime cough or fever
- Antibiotic treatment is recommended to be started
- Severe onset
- Symptoms of concurrent fever > 39°C and purulent nasal discharge for at least 3 days
- Antibiotic treatment is recommended to be started
The usual bacteria cultured are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Initial antibiotic treatment is amoxicillin with or without clavulanic acid. Most patients will improve in 3 days. If not antibiotics can be changed to add clauvulanic acid or use other regimes.
The AAP also recommends that radiological imaging studies should not be obtained for the diagnosis of acute bacterial sinusitis but should be used for evaluation of potential complications.
Potential complications include:
- Orbital – 60-75% of complications
- Abscess – orbital or subperiosteal
- Cellulitis – orbital or preseptal
- Cavernous sinus thrombosis
- Central nervous system
- Abscess – brain, subdural or epidural
- Cerebritis/encephalitis
- Meningitis
- Bone
- Osteomyelitis
Questions for Further Discussion
1. How often do you treat acute bacterial sinusitis?
2. What are surgical treatment options for complications of acute bacterial sinusitis?
3. What radiological studies would you order for possible complications of acute bacterial sinusitis?
Related Cases
- Disease: Common Cold | Sinusitis
- Symptom/Presentation: Rhinitis
- Specialty: General Pediatrics | Infectious Diseases | Otolaryngology
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Sinusitis
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-280. doi:10.1542/peds.2013-1071
Ramadan HH, Chaiban R, Makary C. Pediatric Rhinosinusitis. Pediatric Clinics of North America. 2022;69(2):275-286. doi:10.1016/j.pcl.2022.01.002
Weinberger M. Whither Sinusitis? Clin Pediatr (Phila). 2018;57(9):1013-1019. doi:10.1177/0009922818764927
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa