Sinusitis in Children: IAP Guidelines
Acute sinusitis is an illness that results from infection of one or more of the paranasal sinuses.
By the duration of clinical symptoms, sinusitis is called acute, when symptoms completely resolve in <30 days.
The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Sinusitis. The lead author for these guidelines on Sinusitis is Dr Indu Khosla along with co-author Dr Hema Mittal and Dr Sarika Gupta. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.
Following are the major recommendations of guidelines:
Difference Between Acute Bacterial Sinusitis and Acute Viral Sinusitis:
| Clinical characteristics | Acute bacterial sinusitis | Acute viral sinusitis |
| Fever | Fever may develop or recur on day 6 to 7 of illness after initial improvement, high grade since start | Fever is present in earlier part of illness (initial 1–2 days), mild grade |
| Nasal discharge | Fails to improve substantially or worsens over time | Peaks on Days 3 to 6, then steadily improves |
| Cough | Fails to improve substantially or worsens over time | Peaks on Days 3 to 6, then steadily improves |
| Ill appearance | Present with severe disease | Absent |
| Headache | Present with severe disease | Absent |
| Clinical course | Symptoms are present for ≥10 days without improvement | Symptoms peak in severity on Days 3 to 6 and then improve |
Microbiology:
H. influenzae (non-typeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the major pathogens in uncomplicated ABS in otherwise healthy children.
In complicated ABS polymicrobial infections are common with dominance of Streptococcus species (e.g., Streptococcus anginosus group), other anaerobes, and Staphylococcus species.
Clinical Manifestations:
ABS has three characteristic presentations.
| Clinical presentation | Description |
| Persistent symptoms | Nasal discharge or cough or both for >10 days without improvement |
| Severe symptoms | Onset with temperature of ≥39°C (102.2°F) and purulent nasal discharge for ≥3 consecutive days |
| Worsening symptoms | Respiratory symptoms (nasal discharge or cough, or both) that worsen after initial improvement, or onset of new fever or severe headache |
Diagnosis:
History and based on stringent clinical criteria, including persistent clinical features of an upper respiratory infection beyond 10 days, without much improvement; an upper respiratory infection with high fever and purulent nasal discharge at onset lasting for at least three consecutive days; and biphasic or worsening symptoms (double sickening).
Clinical Severity Score for Acute Bacterial Sinusitis:
A total score<8 indicates mild/moderate disease. A total score ≥8 indicates severe disease
| Symptom or sign | Points |
| Abnormal nasal or postnasal discharge: | |
| Minimal | 1 |
| Severe | 2 |
| Nasal congestion | 1 |
| Cough | 2 |
| Malodorous breath | 1 |
| Facial tenderness | 3 |
| Erythematous nasal mucosa | 1 |
| Fever: | |
| <38.5°C | 1 |
| ≥38.5°C | 2 |
| Headache (retro-orbital)/irritability: | |
| Severe | 3 |
| Mild | 1 |
Treatment:
Source:Indian Academy of Pediatrics Guidelines
Chronic Sinusitis in Children:
Chronic sinusitis is characterized by persistent inflammation of the mucosa of paranasal sinuses. Pediatric chronic rhinosinusitis (CRS) is more prevalent than acute rhinosinusitis and similar to allergic rhinitis. Prevalence is most common among 2–6 year and gradually decline thereafter.
Definition:
American Academy of Otolaryngology—Head and Neck Surgery defined pediatric CRS as at least 90 continuous days of 2 or more symptoms of purulent rhinorrhea, nasal obstruction, facial pressure/pain, or cough and either endoscopic signs of mucosal edema, purulent drainage, or nasal polyposis, and/or CT scan showing mucosal changes within the ostiomeatal complex and/or sinuses. It is classified into 2 main groups of with or without nasal polyposis. Patients with nasal polyposis have different pathophysiology and management, and have increased risk of underlying conditions such as cystic fibrosis, allergic fungal sinusitis and antrochoanal polyps. Etiopathogenesis remains unclear and may be an inappropriate or excessive immune response to an external stimulus inhaled through nasal airway. Viral or bacterial infection along with comorbid conditions and environmental triggers leads a cascade of process leading to chronic sinusitis.
Conditions Associated with Chronic Sinusitis:
Source:Indian Academy of Pediatrics Guidelines
Anatomical defects | Chronic inflammation |
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*controversial role
| Common microbiological pathogens: Generally polymicrobial infections are suggested. |
| Alpha-hemolytic Strep, Staph. aureus, coagulase negative Staph. aureus, Streptococcus pneumonia, non- typeable H. influenza, Moraxella catarrhalis, anaerobes |
| P. aeruginosa and other aerobic gram-negative rods: More common nosocomial origin or immuno- compromised or those with CF |
| Fungi pathogens: Bipolaris, Curvularia, Aspergillus, and Drechslera species. Children with nasal polyposis are predisposed to allergic fungal sinusitis (AFS) whereas immunocompromised children may have invasive fungal disease |
Evaluation of Children with Chronic Sinusitis:
History: Nonspecific and difficult to distinguish from recurrent viral upper respiratory infections, chronic allergic rhinitis, or chronic nasal congestion due to adenoid hypertrophy.
Symptoms: Chronic nasal congestion, purulent rhinorrhea, facial pain and pressure, and cough. Mouth breathing and otitis media are also common. Hyposmia and headache are less common.
Complications: Bony erosion and expansion due to polyps or mucoceles, sclerosis due to chronic osteitis, and recurrent pulmonary exacerbations in the setting of asthma or cystic fibrosis.
Investigations: Plain radiographic studies: Not recommended for either diagnosis or follow-up.
Computed tomography (CT): Imaging of choice though not routinely recommended.
Contrast CT scan/MRI: Reserved for suspected abscess formation in orbit/ brain. Nasal endoscopy: Flexible or rigid for visualization of purulent discharge, adenoid hyperplasia or infection, nasal polyps, mucosal edema, and septal deviation. Cultures: Only if no response to empiric therapy within 72 hours, significant comorbidities, or severe illness. Maxillary sinus aspirations or endoscopically-guided middle meatal cultures are preferred over blind paranasal swabs.
Medical Treatment: Aim: Eradicate bacterial infection and reduce underlying sinonasal inflammation. Mainstay: ; Oral antibiotics (Amoxicillin, amoxicillin/clavulanate (45 mg/kg per day divided every 12 hours), or cephalosporin are 1st line.; Clindamycin (20–40 mg/kg per day orally divided every 6–8 hours) for anaerobes and in penicillin allergic, dual therapy with 3rd generation cephalosporin and clindamycin or levofloxacin is recommended. Duration of therapy: No consensus, upto 10–20 days) ; Daily nasal saline irrigation/spray and nasal steroids along with antibiotics are 1st line treatment.
Adjunctive Treatment: Oral steroids (short course: 2 weeks 1–2 mg/kg prednisolone or equivalent) in children with severe symptoms, polyps, allergic fungal sinusitis)
Antifungals: Allergic fungal disease. Most preferred Itraconazole (5–10mg/kg)
Antihistamines (second generation), and anti-leukotrienes (aspirin sensitivity/ allergic/asthma with nasal polyps)
In allergic rhinitis: Allergen avoidance, anti-histamines (second generation), nasal steroids and allergen immunotherapy.
Controversial: Role of empiric anti-reflux medication, topical antibiotics, and antral irrigation ENT surgeon should be consulted in patients with suspected underlying anatomic abnormalities polyps, recurrent disease, failure of medical treatment.
Surgical Treatment: In cases failure of maximal medical therapy, comorbidities like underlying anatomical defects, polyps, orbital or intracranial complications, underlying diseases such as immunodeficiencies, cystic fibrosis, ciliary dyskinesia, uncontrolled asthma, etc. Aim: Eradicate potential bacterial reservoirs and enhance sinonasal aeration and drainage. Secondary: Reserved for those failing maximum medical management. Most effective: Adenoidectomy. Other techniques: Endoscopic sinus surgery, sinus puncture and lavage, balloon sinuplasty, open surgical approaches and turbinate reduction.
Stepwise Approach to Pediatric Chronic Sinusitis:
Source:Indian Academy of Pediatrics Guidelines
Reference:
Badr DT, Gaffin JM, Phipatanakul W. Curr Treat Options Allergy. 2016;3(3): 268–81.
Brietzke SE, Shin JJ, Choi S, Lee JT, Parikh SR, Pena M, et al. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014;151(4):542–53.
Chandy Z, Ference E, Lee JT. Clinical Guidelines on Chronic Rhinosinusitis in Children. Current Allergy and Asthma Reports. 2019;19:14.
Chow AW, Benninger MS, Brook I, et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012;54:e72.
Dieck LQ, Lam DJ. Curr Treat Options Pediatr. 2018;4(4):413-424. ; Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. EPOS 2012: European Position Paper on Rhinosinusitis and Nasal Polyps 2012: a summary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12.
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The guidelines can be accessed on the official site of IAP :https ://iapindia.org/standard-treatment-guidelines/
