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Sinusitis
Sinusitis is a common illness of childhood and adolescence. There are 2 common types of acute sinusitis—viral and bacterial—with significant acute and chronic morbidity as well as the potential for serious complications. Fungal sinusitis is rare in immunocompetent patients but can also occur. The common cold produces a viral, self-limited rhinosinusitis (see Chapter 407 ). Approximately 0.5–2% of viral upper respiratory tract infections in children and adolescents are complicated by acute symptomatic bacterial sinusitis. Some children with underlying predisposing conditions have chronic sinus disease that does not appear to be infectious. The means for appropriate diagnosis and optimal treatment of sinusitis remain controversial.
Typically, the ethmoidal and maxillary sinuses are present at birth, but only the ethmoidal sinuses are pneumatized. The maxillary sinuses are not pneumatized until 4 yr of age. The sphenoidal sinuses are present by 5 yr of age, whereas the frontal sinuses begin development at age 7-8 yr and are not completely developed until adolescence. The ostia draining the sinuses are narrow (1-3 mm) and drain into the ostiomeatal complex in the middle meatus. The paranasal sinuses are normally sterile, maintained by the mucociliary clearance system.
Etiology
The bacterial pathogens causing acute bacterial sinusitis in children and adolescents include Streptococcus pneumoniae (~30%; see Chapter 209 ), nontypeable Haemophilus influenzae (~30%; see Chapter 221 ), and Moraxella catarrhalis (~10%; see Chapter 223 ). Approximately 50% of H. influenzae and 100% of M. catarrhalis are β-lactamase positive. Approximately 25% of S. pneumoniae may be penicillin resistant. Staphylococcus aureus, other streptococci, and anaerobes are uncommon causes of acute bacterial sinusitis in children. Although S. aureus (see Chapter 208.1 ) is an uncommon pathogen for acute sinusitis in children, the increasing prevalence of methicillin-resistant S. aureus is a significant concern. H. influenzae , α- and β-hemolytic streptococci, M. catarrhalis , S. pneumoniae , and coagulase-negative staphylococci are commonly recovered from children with chronic sinus disease.
Epidemiology
Acute bacterial sinusitis can occur at any age. Predisposing conditions include viral upper respiratory tract infections (associated with out-of-home daycare or a school-age sibling), allergic rhinitis, and tobacco smoke exposure. Children with immune deficiencies, particularly of antibody production (immunoglobulin (Ig)G, IgG subclasses, IgA; see Chapter 150 ), cystic fibrosis (see Chapter 432 ), ciliary dysfunction (see Chapter 433 ), abnormalities of phagocyte function, gastroesophageal reflux, anatomic defects (cleft palate), nasal polyps, cocaine abuse, and nasal foreign bodies (including nasogastric tubes), can develop chronic or recurrent sinus disease. Immunosuppression for bone marrow transplantation or malignancy with profound neutropenia and lymphopenia predisposes to severe fungal (aspergillus, mucor) sinusitis, often with intracranial extension. Patients with nasotracheal intubation or nasogastric tubes may have obstruction of the sinus ostia and develop sinusitis with the multiple-drug resistant organisms of the intensive care unit.
Acute sinusitis is defined by a duration of <30 days, subacute by a duration of 1-3 mo, and chronic by a duration of longer than 3 mo.
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