Note to me: When I review any of Dr. Fox’s excellent posts, I follow all the links in the post which takes me deep into a review of all the associated topics. The extra time it takes me is very much worth it.
In this post I link to and excerpt from Pediatric EM Morsels‘ Pediatric Sinus Complications by Dr. SEAN M. FOX, JULY 9, 2021.
All that follows is from Dr. Fox’s post [I excerpt from medical ed review because it helps me remember the material].
Naturally, we all know that in the Emergency Department we need to consider “Lions, Tigers, and Bears” (ie, things that will kill or maim our patients); however, it is challenging to continue to remain ever-vigilant in the face of so many relatively benign horses (ie, the common and uncomplicated). We have discussed previously, that on rare occasions, zebras will show up and they can inflict a lot of damage (ex, Gradenigo’sSyndrome, Osteosarcoma, Acute Cerebellar Ataxia, andOgilvie’s Syndrome). Often, these zebras may show up following the horses (ie, complications of a common, typically benign issues) – like parapneumonic effusions. Let us now consider another zebra – Pediatric Sinusitis Complications:
Pediatric Sinusitis Complications: Basics
Acute Bacterial Sinusitis Diagnosis (2013) [Wald, 2013 – PMID 23796742]
- Acute Bacterial Sinusitis is a clinical diagnosis.
- It requires a child having an acute upper respiratory tract infection (URI) to also have:
- PERSISTENT illness – any nasal drainage, or DAYtime cough, or both lasting > 10 days WITHOUT IMPROVEMENT; or
- WORSENING course – worsening or new onset of nasal discharge, DAYtime cough, or new fever; or
- SEVERE onset AND PURULENT Nasal drainage – concurrent fever > 102.1F (>38.9C) AND purulent rhinorrhea for at least 3 consecutive days.
- While it is a concern, it is also concerning that “sinusitis” is often the diagnosis used to give children inappropriate antibiotics — every snotty nose is NOT sinusitis.
Age Matters: [Wiersma, 2018 – PMID 28614102]
- Children < 5 years of age
- Ethmoid sinusitis and orbital involvement are most common
- Older school aged children and Adolescents
- Frontal sinus become a more common site of involvement and complications
- Frontal sinuses begin being to develop between 2 – 10 years of age.
- Frontal sinuses don’t reach the orbital ridges until ~ 6 years of age.
- Frontal sinus completes its development during pre-teen ages.
- Complications from frontal sinusitis are typically more severe.
It can become complicated.
- It is rare that complications develop – ~3% of pediatric patients hospitalized with sinusitis.
- Typical bacteria involved: [Adil, 2020 – PMID 32065412; Wiersma, 2018 – PMID 28614102]
- Streptococcus pneumoniae
- Nontypable Haemophilus influenzae
- Moraxella catarrhalis
- Streptococcus anginosus
- Responsible for more severe complications.
- Likely related to enzymes that cause tissue destruction.
- Anaerobic species
- May be polymicrobial.
- Sinusitis can become complicated via:
- Direct extension to adjacent structures
- Dissemination through the valveless diploic veins*that drain the regions
*Pott’s Puffy Tumor. Pediatric EM Morsels, by Dr. Sean Fox, April 24, 2020.
- Location: [Wiersma, 2018 – PMID 28614102; Sharma, 2014 – PMID 24998502]
- Orbital Complications of sinusitis:
- Most common – ~80% of all Orbito-Cranial complications
- Intraorbital cellulitis and/or abscess
- Subperiosteal phlegmon or abscess
- Can cause compression on globe as well or extraocular muscles.
- Intracranial Complications of sinusitis:
- Seen less commonly
- Epidural abscess
- Subdural empyema
- Intracranial abscess
- Frontal Bone Osteomyelitis (Pott’s Puffy Tumor)
- Cavernous Sinus Thrombosis
Pediatric Sinusitis Complications: Management
Diagnosis requires high-index of suspicion
- Pediatric sinusitis complications are often associated with delays in diagnosis. [Sharma, 2014 – PMID 24998502]
- Several encounters for persistent symptoms may be seen.
- It may take time for more obviously findings to become evident.
Look for obvious “Red Flags” for pediatric sinusitis complications:
- Ocular chemosis
- Eye pain
- Cranial nerve palsy
- Focal neurological deficit
Consider more subtle clues for pediatric sinusitis complications:
- Persistent headache – especially progressive or prolonged
- Vomiting (particularly that has developed after several days from the onset of the URI symptoms)
- Worsening symptoms despite appropriate treatment
- Change in personality
- This can be subtle and easily missed… especially in the hormone infused adolescent!
- Involvement of the frontal region of the brain may be “neurologically silent.”
- Intracranial complications can be present WITHOUT signs of meningismus, focal neurologic deficits, or severely altered mental status.
Kill all of the bugs!
- While surgical drainage is often required, antibiotics should always be started upon initial diagnosis of pediatric sinusitis complications. [Adil, 2020 – PMID 32065412]
- Some will not require surgery.
- Ensure broad spectrum coverage is started.
- Typical treatment options: [Adil, 2020 – PMID 32065412; Wiersma, 2018 – PMID 28614102]
- A penicillin, a 3rd-Gen cephalosporin, and Metronidazole.
- Vancomycin should be considered in MRSA is prevalent in your community.
Moral of the Morsel
- Not every snotty nose is sinusitis. Please don’t call every call a URI “sinusitis” just so you can throw antibiotics at the kid.
- Common things can become complicated. Look for clues in the history and exam – is this the normal course of events, or is the headache now with vomiting unusual after having sinusitis 2 weeks ago.
- Kill all of the bugs… then call a surgeon. Based on the size, characteristics, and location of the infection, surgery may be needed, but some will be medically managed successfully.