Sinusitis in children is an inflammatory disease affecting the mucosa of the paranasal sinuses. It is a relatively common condition in pediatric populations. Due to anatomical development, growth, and immune maturation processes, the causes, symptoms, diagnostic methods, and treatment approaches differ from those in adults. Depending on the duration of symptoms, sinusitis is classified as acute if symptoms last less than 12 weeks, and as chronic if they persist beyond 12 weeks.
Etiology
The development of the nasal cavity and paranasal sinuses in children occurs from birth and continues until around the age of 20 years. The following anatomical and physiological characteristics are relevant:
The nasal cavity in children is short and narrow, and the mucosa is rich in blood vessels. Infections are prone to causing edema and obstruction of the nasal cavity and sinuses.
The growth of the sinuses is asynchronous, the mucosa of the nasal cavity and sinuses is continuous, and sinus ostia are relatively large, increasing the risk of infection spreading to the sinuses.
The nasolacrimal duct and Eustachian tube are underdeveloped, which may lead to complications.
Infections in nearby structures such as the adenoids and tonsils can easily spread to the nasal cavity and paranasal sinuses.
Common causes include:
- Upper respiratory tract infections: Acute sinusitis often develops as a complication of upper respiratory tract infections and is commonly associated with bacterial or viral pathogens. Streptococcus pneumoniae, Streptococcus spp., and Staphylococcus spp. are frequent bacterial culprits, while rhinoviruses, adenoviruses, and respiratory syncytial viruses are common viral pathogens.
- Anatomical variations: Abnormalities such as a deviated nasal septum or concha bullosa may impair sinus ventilation and drainage.
- Adenoid hypertrophy: This condition can cause mechanical obstruction of the posterior nasal cavity, while bacterial colonization of the adenoid surface may impair mucociliary clearance of the nasal and sinus mucosa.
- Allergic rhinitis: Mucosal edema can disrupt ventilation and drainage of the sinuses. Inflammation of the mucosa may damage mucociliary clearance, contributing to sinusitis.
- Congenital disorders: Conditions such as choanal atresia and cleft palate can affect normal ventilation and drainage of the nasal cavity and sinuses.
- Systemic diseases: Conditions such as cystic fibrosis, primary or acquired ciliary dyskinesia, and asthma may increase the risk of sinus inflammation.
- Other factors: Foreign bodies or trauma to the nasal cavity in children may lead to secondary infections.
Pathology
Acute sinusitis is characterized by congestion, swelling, and inflammatory cell infiltration of the sinus mucosa. Secretions may be serous or mucoid, but bacterial superinfection following sinus ostium obstruction can lead to purulent discharge.
Chronic sinusitis may involve edematous, follicular, or hypertrophic changes in the sinus mucosa. Fibrotic changes are rare in children.
Clinical Manifestations
Acute Sinusitis
Symptoms include nasal congestion, thick mucopurulent nasal discharge, facial pain, and headache. Severe cases may present with systemic symptoms such as fever, dehydration, lethargy, irritability, rapid breathing, refusal to eat, and even seizures. Complications including acute otitis media and coughing may also occur. Systemic symptoms are more pronounced in young children.
Chronic Sinusitis
Symptoms often include intermittent or persistent nasal congestion and mucoid or mucopurulent nasal discharge. Chronic coughing may also be present. In contrast to adults, olfactory dysfunction may be less obvious in children. Chronic sinusitis may coexist with conditions such as adenoid hypertrophy, chronic otitis media, anemia, rheumatic disease, joint pain, frequent colds, asthma, gastrointestinal issues, or renal disorders. Prolonged nasal congestion and mouth breathing may result in developmental abnormalities involving the maxillofacial region, chest, and cognitive abilities.
Auxiliary Examinations
External Nasal and Facial Examination
Skin on the upper lip and nasal alae may show peeling or cracking due to irritation from purulent nasal discharge. In acute sinusitis, adjacent soft tissue swelling, redness, and tenderness, such as swelling around the inner canthus in ethmoid sinusitis, may be observed.
Anterior Rhinoscopy
The anterior nasal vestibule may show crusting. The nasal cavity often contains abundant purulent secretions. After mucosal decongestion and removal of purulent secretions, acute or chronic congestion and swelling of the nasal mucosa may become apparent. Mucopurulent secretions are often visible in the middle nasal meatus or olfactory cleft.
Endoscopy
Nasal endoscopy is suitable for pediatric patients of all ages. Endoscopic findings include congested and edematous mucosa, with mucoid or purulent discharge evident in the general nasal meatus, nasal floor, posterior nasal cavity, or surface of the inferior nasal turbinate. The discharge often originates from the middle nasal meatus or olfactory cleft. Enlarged adenoids may be noted in some cases. Purulent discharge from the middle meatus and nasal floor is the most common finding in children, with turbinate edema typically more pronounced than in adults.
Imaging Studies
Sinus development varies across pediatric age groups; thus, sinus CT scans may exhibit false positives and require careful correlation with the clinical history. Routine CT scanning is not recommended unless complications involving the intracranial or orbital regions are suspected or surgical intervention is planned. Sinus X-rays are generally not used in pediatric sinusitis due to overlapping craniofacial anatomy and high false-positive rates.
Diagnosis and Differential Diagnosis
Diagnosis is based on key symptoms and signs, combined with findings from nasal endoscopy. In pediatric acute sinusitis, the relatively short clinical history and the presence of purulent secretions in the middle nasal meatus observed through nasal endoscopy are sufficient for diagnosis and treatment, generally without the need for a sinus CT scan. Persistent chronic sinusitis may be accompanied by nasal polyps or complications involving the orbit, face, or other areas. Anomalies related to anatomical development are often present, and sinus CT imaging may help confirm the diagnosis and provide detailed information about nasal anatomy to guide further treatment planning.
Pediatric sinusitis is often not an isolated condition. Acute sinusitis frequently develops as a complication of upper respiratory infections, with symptoms and signs that are more severe and prolonged compared to the common cold. Chronic sinusitis is often associated with diseases of adjacent organs, such as otitis media, adenoid hypertrophy, asthma, or bronchitis. Sinusitis in preschool-aged children is not uncommon. In cases where colds persist for more than one week, with increased or unchanged purulent nasal discharge and worsening symptoms, an accompanying diagnosis of sinusitis should be considered.
Complications
Common complications include otitis media, orbital and periorbital complications, intracranial complications, and bone-related complications. The widespread use of antibiotics has greatly reduced the incidence of complications. However, due to the incomplete development of the pediatric immune system and lower resistance, the probability of complications in children is higher than in adults. In addition to detailed examinations of the nasal cavity and sinuses, attention should also be paid to the child's hearing, lungs, eyelids, ocular motility, vision, and central nervous system functioning in order to identify complications early and initiate treatment.
Prevention
Prevention involves timely management and correction of potential causative factors, promoting proper nutrition, engaging in physical exercise, and avoiding colds.
Treatment
The primary treatment approach is conservative, primarily involving pharmacological management. Acute cases require supportive and symptomatic therapy in addition to medications. Surgical intervention may be considered in cases of complications or when conservative treatment proves ineffective.
Antibiotics
Acute Sinusitis in Children
The primary pathogens are Streptococcus pneumoniae, followed by Haemophilus influenzae and Moraxella catarrhalis. Amoxicillin-clavulanate is the first-line antibiotic choice. Second-generation cephalosporins are the preferred cephalosporins, and macrolides may also be used. The use of multiple antibiotics concurrently is not recommended. Continued antibiotic therapy for one week after clinical symptoms resolve is advised.
Chronic Sinusitis in Children
Antibiotics are generally not indicated unless purulent secretions are present. If needed, β-lactam antibiotics are recommended and should be administered for at least two weeks. Antibiotic selection may also be guided by culture results.
Intranasal Corticosteroids
Intranasal corticosteroids are a first-line treatment for pediatric sinusitis due to their anti-inflammatory and anti-edematous effects. Formulations with low systemic bioavailability are recommended.
Mucolytic Agents
Mucolytic agents may help reduce mucus viscosity and improve mucociliary clearance.
Antihistamines
Oral or topical antihistamines may be used in children with concurrent allergic conditions.
Nasal Irrigation
Nasal saline or hypertonic saline irrigation can enhance mucociliary activity, improve the local nasal environment, and alleviate symptoms.
Decongestants
Low-concentration decongestants may be used locally for short periods (no longer than 7 days) in children with severe nasal congestion to help alleviate symptoms.
Surgical Treatment
Due to the developmental stage of the nasal cavity and sinuses in children, surgical treatment is generally avoided for pediatric sinusitis. Surgical indications include:
- Persistent disease despite standardized medical treatment or the presence of nasal polyps.
- Intracranial, orbital, or periorbital complications.
- Adenoid hypertrophy or tonsillar hypertrophy causing impaired nasal ventilation or drainage.
Functional endoscopic sinus surgery (FESS) is the preferred surgical approach. The scope of surgery should be minimized to preserve the nasal and sinus mucosa, periosteum, and bony structures as much as possible. Pathological changes in children are often located in the anterior ethmoid sinus and the ostiomeatal complex, with extension into the maxillary sinuses. Surgical intervention should be limited to the ostiomeatal complex region. Restoration of ventilation and drainage in the ostiomeatal complex may allow inflamed mucosa to gradually return to normal.