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PEDIATRICS Vol. 108 No. 3 September 2001, pp. 798-808
This clinical practice guideline formulates
recommendations for health care providers regarding the diagnosis,
evaluation, and treatment of children, ages 1 to 21 years, with
uncomplicated acute, subacute, and recurrent acute bacterial sinusitis.
It was developed through a comprehensive search and analysis of the
medical literature. Expert consensus opinion was used to enhance or
formulate recommendations where data were insufficient.
A subcommittee, composed of pediatricians with expertise in infectious
disease, allergy, epidemiology, family practice, and pediatric
practice, supplemented with an otolaryngologist and radiologist, were
selected to formulate the practice parameter. Several other groups
(including members of the American College of Emergency Physicians,
American Academy of Otolaryngology-Head and Neck Surgery, American
Academy of Asthma, Allergy and Immunology, as well as numerous national
committees and sections of the American Academy of Pediatrics) have
reviewed and revised the guideline. Three specific issues were
considered: 1) evidence for the efficacy of various antibiotics in
children; 2) evidence for the efficacy of various ancillary,
nonantibiotic regimens; and 3) the diagnostic accuracy and concordance
of clinical symptoms, radiography (and other imaging methods), and
sinus aspiration.
It is recommended that the diagnosis of acute bacterial sinusitis be
based on clinical criteria in children There were only 5 controlled randomized trials and 8 case series on
antimicrobial therapy for acute bacterial sinusitis in children.
However, these data, plus data derived from the study of adults with
acute bacterial sinusitis, support the recommendation that acute
bacterial sinusitis be treated with antimicrobial therapy to achieve a
more rapid clinical cure. Children with complications or suspected
complications of acute bacterial sinusitis should be treated promptly
and aggressively with antibiotics and, when appropriate, drainage.
Based on controversial and limited data, no recommendations are made
about the use of prophylactic antimicrobials, ancillary therapies, or
complementary/alternative medicine for prevention and treatment of
acute bacterial sinusitis.
This clinical practice guideline is not intended as a sole source of
guidance in the diagnosis and management of acute bacterial sinusitis
in children. It is designed to assist pediatricians by providing an
analytic framework for evaluation and treatment. It is not intended to
replace clinical judgment or establish a protocol for all patients with
this condition.
ABSTRACT
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Abstract
Background
Methods
Recommendation
Conclusion
References
6 years of age who present
with upper respiratory symptoms that are either persistent or severe.
Although controversial, imaging studies may be necessary to confirm a
diagnosis of acute bacterial sinusitis in children >6 years of age.
Computed tomography scans of the paranasal sinuses should be reserved
for children who present with complications of acute bacterial
sinusitis or who have very persistent or recurrent infections and are
not responsive to medical management.
The ethmoid and the maxillary sinuses form in the third to
fourth gestational month and, accordingly, are present at birth. The
sphenoid sinuses are generally pneumatized by 5 years of age; the
frontal sinuses appear at age 7 to 8 years but are not completely developed until late adolescence. The paranasal sinuses are a common
site of infection in children and adolescents.1 These
infections are important as a cause of frequent morbidity and rarely
may result in life-threatening complications. It may be difficult to
distinguish children with uncomplicated viral upper respiratory
infections or adenoiditis from those with an episode of acute bacterial
sinusitis.2 Most viral infections of the upper respiratory
tract involve the nose and the paranasal sinuses (viral
rhinosinusitis).3 However, bacterial infections of the
paranasal sinuses do not usually involve the nose. When the patient
with bacterial infection of the paranasal sinuses has purulent (thick,
colored, and opaque) nasal drainage, the site of infection is the
paranasal sinuses; the nose is simply acting as a conduit for
secretions produced in the sinuses.
The common predisposing events that set the stage for acute bacterial
sinusitis are acute viral upper respiratory infections that result in a
viral rhinosinusitis (a diffuse mucositis that predisposes to
approximately 80% of bacterial sinus infections) and allergic
inflammation (that predisposes to 20% of bacterial sinus
infections).4 Children have 6 to 8 viral upper respiratory
infections each year; it is estimated that between 5% to 13% of these
infections may be complicated by a secondary bacterial infection of the
paranasal sinuses.5-7 Acute bacterial otitis media and
acute bacterial sinusitis are the most common complications of viral
upper respiratory infections and are probably the most common
indications for the prescription of antimicrobial agents.8
The middle ear cavity connects to the nasopharynx via the eustachian
tube. In a sense then, the middle ear cavity is also a paranasal
sinus.9 The pathogenesis and microbiology of acute otitis
media and acute bacterial sinusitis are similar.9 This
similarity allows us to extrapolate information known about the
treatment of acute otitis media and apply it to the treatment of acute
bacterial sinusitis. This is especially helpful when considering
antimicrobials and antibacterial resistance. Data on antimicrobial
efficacy and antibacterial resistance also may be derived from the
study of adult patients with acute sinusitis, in whom there have been
more recent systematic inquiry.10,11
This practice guideline focuses on the diagnosis, evaluation, and
treatment of children, ages 1 to 21 years, with uncomplicated acute,
subacute, and recurrent acute bacterial sinusitis. Neonates and
children younger than 1 year of age are not considered. Although bacterial sinusitis does occur rarely in children less than 1 year of
age, their exclusion reflects, in part, the difficulty in conducting
clinical investigation in this age group. This is a consequence of the
small size of the paranasal sinuses and the difficulty in safely
performing sinus aspiration.12 This practice parameter
does not apply to children with previously recognized anatomic
abnormalities of their paranasal sinuses (facial dysmorphisms or
trauma), immunodeficiencies, cystic fibrosis, or immotile cilia
syndrome.
A discussion of chronic sinusitis (defined by the presence of symptoms
for 90 days) and acute exacerbations of chronic sinusitis are not
included in this guideline. The role of bacterial infection as a
primary cause of chronic sinusitis is controversial.11,13 Chronic inflammation of the paranasal sinuses may be a consequence of
noninfectious conditions such as allergy, environmental pollutants, cystic fibrosis, or gastroesophageal reflux.
This guideline is intended for use by clinicians who treat children and
adolescents in a variety of clinical settings including the office and
emergency department. The purpose of the guideline is to encourage
accurate diagnosis of bacterial sinusitis, appropriate use of imaging
procedures, and judicious use of antibiotics.
To develop the clinical practice guideline on the management of
acute bacterial sinusitis, the American Academy of Pediatrics subcommittee partnered with the Agency for Healthcare Research and
Quality and colleague organizations from family practice and otolaryngology. The Agency for Healthcare Research and Quality worked with the New England Medical Center Evidence-based Practice Center, as one of several centers that focus on conducting systematic reviews of the literature. A full report was produced by the New England Medical Center on the diagnosis and management of acute sinusitis.15 However, because there were only 5 randomized studies in children, a supplemental analysis was conducted that included nonrandomized pediatric trials. The subcommittee used both
reports to form the practice guideline recommendations but relied
heavily on the pediatric supplement.16
For the pediatric supplement, the major research questions to be
analyzed through the literature on acute bacterial sinusitis in
childhood were 1) evidence for the efficacy of various antibiotics in
children; 2) evidence for the efficacy of various ancillary, nonantibiotic regimens; and 3) the diagnostic accuracy and concordance of clinical symptoms, radiography (and other imaging methods), and
sinus aspiration.
The literature was searched in Medline, complemented by Excerpta
Medica, from 1966 through March 1999, using the word "sinusitis." Search criteria were limited to human studies and English language and
appropriate pediatric terms. More than 1800 citations were reviewed.
One hundred thirty-eight articles were fully examined, resulting in 21 qualifying studies. These studies included 5 controlled randomized
trials and 8 case series on antimicrobial therapy, 3 controlled
randomized trials on ancillary treatments, and 8 studies with
information on diagnostic tests. The heterogeneity and paucity of the
data did not allow for formal meta-analysis. When possible, rates were
pooled across different studies and heterogeneity assessed.
The draft clinical practice guideline underwent extensive peer review
by committees and sections within the American Academy of
Pediatrics and by numerous outside organizations. Liaisons to
the committee also distributed the draft within their organizations. Comments were compiled and reviewed by the subcommittee and relevant changes incorporated into the guideline.
The recommendations contained in this practice guideline are based on
the best available data. Where data are lacking, a combination of
evidence and expert opinion was used. Strong recommendations were based
on high-quality scientific evidence or, when such was unavailable,
strong expert consensus. Fair and weak recommendations are based on
lesser-quality or limited data and expert consensus. Clinical options
are identified as interventions for which the subcommittee could not
find compelling positive or negative evidence. These clinical options
are interventions that a reasonable health care professional may or may
not wish to consider.
Methods of Diagnosis
Under normal circumstances the paranasal sinuses are assumed to be
sterile.17-19 However, the paranasal sinuses are in
continuity with surface areas, such as the nasal mucosa and
nasopharynx, which are heavily colonized with bacteria. Although it is reasonable to assume that the paranasal sinuses are
frequently and transiently contaminated by bacteria from neighboring surfaces, these bacteria, which are present in low density, are probably removed by the normal function of the mucociliary apparatus. Accordingly, the gold standard for the diagnosis of acute bacterial sinusitis is the recovery of bacteria in high density
( Recommendation 1
The diagnosis of acute bacterial sinusitis is based on
clinical criteria in children who present with upper respiratory symptoms that are either persistent or severe (strong recommendation based on limited scientific evidence and strong consensus of the panel).
BACKGROUND
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Abstract
Background
Methods
Recommendation
Conclusion
References
DEFINITIONS
Bacterial infection of the
paranasal sinuses lasting less than 30 days in which symptoms resolve completely.
Bacterial infection of the
paranasal sinuses lasting between 30 and 90 days in which symptoms resolve completely.
Episodes of bacterial
infection of the paranasal sinuses, each lasting less than 30 days and
separated by intervals of at least 10 days during which the patient is
asymptomatic.
Episodes of inflammation of the
paranasal sinuses lasting more than 90 days. Patients have persistent
residual respiratory symptoms such as cough, rhinorrhea, or nasal
obstruction.
Patients with residual respiratory symptoms develop
new respiratory symptoms. When treated with antimicrobials, these new
symptoms resolve, but the underlying residual symptoms do
not.14
METHODS
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Abstract
Background
Methods
Recommendation
Conclusion
References
RECOMMENDATIONS
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Abstract
Background
Methods
Recommendation
Conclusion
References
104 colony-forming units/mL) from the cavity
of a paranasal sinus.20 Although sinus aspiration is the
gold standard for the diagnosis of acute bacterial
sinusitis,11 it is an invasive, time-consuming, and
potentially painful procedure that should only be performed by a
specialist (otolaryngologist). It is not a feasible method of diagnosis
for the primary care practitioner and is not recommended for the
routine diagnosis of bacterial sinus infections in children. However,
the results of sinus aspiration have been correlated with clinical and
radiographic findings in children with acute respiratory
symptoms.21,22
Recommendation 2a
Imaging studies are not necessary to confirm a diagnosis of
clinical sinusitis in children 6 years of age
(strong recommendation based on limited scientific evidence and strong
consensus of the panel).
104 colony-forming units/mL) were
recovered in 70% to 75% of the children. This proportion of positive
cultures (75%) is similar to the likelihood that a tympanocentesis
will yield middle ear fluid with a positive culture for bacteria in
children with otoscopic evidence of acute otitis media.30
In children with persistent symptoms, the history of protracted
respiratory symptoms (>10 but <30 days without evidence of improvement) predicted significantly abnormal radiographs (complete opacification, mucosal thickening of at least 4 mm, or an air-fluid level) in 80% of children.31 For children 6 years of age
or younger, the history predicted abnormal sinus radiographs in 88% of
children. For children older than 6 years, the history of persistent
symptoms predicted abnormal sinus radiographs in 70%. The peak age for
acute bacterial sinusitis is in children 6 years of age or younger.
Accordingly, in this age group, because a positive history predicts the
finding of abnormal sinus radiographs so frequently (and because
history plus abnormal radiographs results in a positive sinus aspirate
in 75% of cases), radiographs can be safely omitted and a diagnosis of
acute bacterial sinusitis can be made on clinical criteria alone.
Approximately 60% of children with symptoms of sinusitis (persistent
or severe) will have bacteria recovered from an aspirate of the
maxillary sinus.
In contrast to the general agreement that radiographs are not necessary
in children 6 years of age or younger with persistent symptoms, the
need for radiographs as a confirmatory test of acute sinusitis in
children older than 6 years with persistent symptoms and for all
children (regardless of age) with severe symptoms is
controversial.32,33 Some practitioners may elect to
perform sinus radiographs with the expectation or suspicion that the
study may be normal. A normal radiograph is powerful evidence that
bacterial sinusitis is not the cause of the clinical
syndrome.34 However, the American College of Radiology has
taken the position that the diagnosis of acute uncomplicated sinusitis
should be made on clinical grounds alone.35 They support
this position by noting that plain radiographs of the paranasal sinuses
are technically difficult to perform, particularly in very young
children. Correct positioning may be difficult to achieve and therefore
the radiographic images may overestimate and underestimate the presence
of abnormalities within the paranasal sinuses.36,37 The
college would reserve the use of images for situations in which the
patient does not recover or worsens during the course of appropriate
antimicrobial therapy. Similarly, a recent set of guidelines generated
by the Sinus and Allergy Health Partnership (representing numerous
constituencies) does not recommend either radiographs or computed
tomography (CT) or magnetic resonance imaging scans to diagnose
uncomplicated cases of acute bacterial sinusitis in any age
group.1
It is essential to recognize that abnormal images of the sinuses
(either radiographs, CT, or magnetic resonance imaging) cannot stand alone as diagnostic evidence of acute bacterial sinusitis under
any circumstances. Images can serve only as confirmatory measures of
sinus disease in patients whose clinical histories are supportive of
the diagnosis. Numerous investigations have demonstrated the high
frequency of abnormal images in the paranasal sinuses of children
undergoing imaging for indications other than suspected
sinusitis.38-40 In a study by Glasier et
al,39 almost 100% of young children who were undergoing
CT examination for reasons other than sinus disease and who had an
upper respiratory tract infection in the previous 2 weeks demonstrated
soft tissue changes in their sinuses. A study by Gwaltney et al in
19943 found that abnormalities of the paranasal sinuses on
CT scan are extremely common in young adults with acute (<72 hours)
uncomplicated viral upper respiratory infections. This study and others
serve to underscore that when abnormalities of the mucosa are present
on images they indicate the presence of inflammation but do not
disclose whether the inflammatory process is caused by viral infection,
bacterial infection, allergy, or chemical irritation (eg, chlorine
exposure in the swimmer).
Recommendation 2b CT scans of the paranasal sinuses should be reserved for patients in whom surgery is being considered as a management strategy (strong recommendation based on good evidence and strong panel consensus).
Despite the limitations of CT scans,338-40 they offer a detailed image of sinus anatomy and, when taken in conjunction with clinical findings, remain a useful adjunct to guide surgical treatment. Computed tomography scans are indicated in children who present with complications of acute bacterial sinus infection or those who have very persistent or recurrent infections that are not responsive to medical management.33 In these instances, the image, preferably a complete CT scan of the paranasal sinuses, is essential to provide precise anatomic information to the clinician. These are instances in which the physician may be contemplating surgical intervention, including aspiration of the paranasal sinuses.Recommendation 3 Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical cure (strong recommendation based on good evidence and strong panel consensus).
To promote the judicious use of antibiotics, it is essential that children diagnosed as having acute bacterial sinusitis meet the defining clinical presentations of "persistent" or "severe" disease as described previously.41 This will minimize the number of children with uncomplicated viral upper respiratory tract infections who are treated with antimicrobials. In a study comparing antimicrobial therapy with placebo in the treatment of children with the clinical and radiographic diagnosis of acute bacterial sinusitis, children receiving antimicrobial therapy recovered more quickly and more often than those receiving placebo.31 On the third day of treatment, 83% of children receiving an antimicrobial were cured or improved compared with 51% of the children in the placebo group. (Forty-five percent of children receiving antimicrobial therapy were cured [complete resolution of respiratory symptoms] compared with 11% receiving placebo.) On the 10th day of treatment, 79% of children receiving an antimicrobial were cured or improved compared with 60% of children receiving placebo. Approximately 50% to 60% of children will improve gradually without the use of antimicrobials; however, the recovery of an additional 20% to 30% is delayed substantially compared with children who receive appropriate antibiotics. A recent study by Garbutt et al42 has challenged the notion that children identified as having acute sinusitis on clinical grounds alone (without the performance of images) will benefit from antimicrobial therapy. When children randomized to low-dose antibiotic therapy were compared with those receiving placebo there were no differences observed in outcome, either in the timing or frequency of recovery. The discrepancy in results between this investigation and the Wald31 study may be attributable to the inclusion in this study of a larger cohort of older children (who may not have had sinusitis) and the exclusion of more seriously ill children with a temperature >39°C or facial pain. Current recommendations for antibiotic management of uncomplicated sinusitis vary depending on a previous history of antibiotic exposure (in the previous 1-3 months), attendance at day care, and age. Some of the children in the Garbutt study might have qualified for high-dose amoxicillin-clavulanate to overcome antimicrobial resistant pathogens. Comparative bacteriologic cure rates in studies of adults with acute sinusitis indicate the efficacy of antimicrobial treatment.11,43 The findings of these studies indicate that antimicrobials in adequate doses with appropriate antibacterial spectra are highly effective in eradicating or substantially reducing bacteria in the sinus cavity, whereas those with inadequate spectrum or given in inadequate doses are not (Table 1).
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-lactamase positive
nationwide.44,45 Upper respiratory tract isolates of
S pneumoniae are not susceptible to penicillin in 15% to
38% (average 25%) of children; approximately 50% are highly
resistant to penicillin and the remaining half are intermediate in
resistance.1,46,47 The mechanism of penicillin resistance
in S pneumoniae is an alteration of penicillin binding
proteins. This phenomenon, which varies considerably according to
geographic location, results in resistance to penicillin and
cephalosporin. Table 2 shows the
calculation for the likelihood that a child with acute bacterial
sinusitis will harbor a resistant pathogen and not respond to treatment with amoxicillin. The following should be considered: the
prevalence of each bacterial species as a cause of acute bacterial
sinusitis, the prevalence of resistance among each bacterial species,
and the rate of spontaneous improvement. Extrapolating from data
derived from patients with acute otitis media, 15% of children with
acute bacterial sinusitis caused by S pneumoniae will
recover spontaneously, half of the children with acute bacterial
sinusitis caused by H influenzae and half to three-quarters
of the children infected with M catarrhalis also will
recover spontaneously.48 Furthermore, only S
pneumoniae that are highly resistant to penicillin will not
respond to conventional doses of amoxicillin. Accordingly, in the absence of any risk factors, approximately 80% of children with
acute bacterial sinusitis will respond to treatment with amoxicillin. Risk factors for the presence of bacterial
species that are likely to be resistant to amoxicillin
include 1) attendance at day care, 2) recent receipt (<90 days) of
antimicrobial treatment, and 3) age less than 2 years.49,50
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-lactamase producing H influenzae and M
catarrhalis. Alternative therapies include cefdinir,
cefuroxime, or cefpodoxime. A single dose of ceftriaxone
(at 50 mg/kg/d), given either intravenously or intramuscularly, can be
used in children with vomiting that precludes administration of oral
antibiotics. Twenty-four hours later, when the child is clinically
improved, an oral antibiotic is substituted to complete the therapy.
Although trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole
have traditionally been useful in the past as first- and second-line
therapy for patients with acute bacterial sinusitis, recent
pneumococcal surveillance studies indicate that resistance to these 2 combination agents is substantial.51,52 Therefore, when
patients fail to improve while receiving amoxicillin, neither trimethoprim-sulfamethoxazole nor erythromycin-sulfisoxazole are appropriate choices for antimicrobial therapy. For patients who do
not improve with a second course of antibiotics or who are acutely ill,
there are 2 options. It is appropriate to consult an otolaryngologist
for consideration of maxillary sinus aspiration to obtain a sample of
sinus secretions for culture and sensitivity so that therapy can be
adjusted precisely. Alternatively, the physician may prescribe
intravenous cefotaxime or ceftriaxone (either in hospital or at home)
and refer to an otolaryngologist only if the patient does not improve
on intravenous antibiotics. Some authorities recommend performing
cultures of the middle meatus instead of aspiration of the
maxillary sinus to determine the cause of acute bacterial
sinusitis.53 However, there are no data in children that
have correlated cultures of the middle meatus with cultures of the
maxillary sinus aspirate.54
The optimal duration of therapy for patients with acute bacterial
sinusitis has not received systematic study. Often empiric recommendations are made for 10, 14, 21, or 28 days of therapy. An
alternative suggestion has been made that antibiotic therapy be
continued until the patient becomes free of symptoms and then for an
additional 7 days.23 This strategy, which individualizes treatment for each patient, results in a minimum course of 10 days and
avoids prolonged courses of antibiotics in patients who are
asymptomatic and thereby unlikely to be compliant.
Adjuvant Therapies No recommendations are made based on controversial and limited data.
Adjuvant therapies used to supplement the effect of antimicrobials have received relatively little systematic investigation.55 Available agents include saline nasal irrigation (hypertonic or normal saline), antihistamines, decongestants (topical or systemic), mucolytic agents, and topical intranasal steroids. Currently there are no data to recommend the use of H1 antihistamines in nonallergic children with acute bacterial sinusitis. There is a single prospective study in which children with presumed acute bacterial sinusitis were randomized to receive either decongestant-antihistamine or placebo in addition to amoxicillin. The active treatment group received topical oxymetazoline and oral decongestant-antihistamine syrup (brompheniramine and phenylpropanolamine). No difference in clinical or radiographic resolution was noted between groups.56 There has been a single study of intranasal steroids as an adjunct to antibiotics in young children with presumed acute bacterial sinusitis. Intranasal budesonide spray had a modest effect on symptoms only during the second week of therapy.57 A multicenter, double-blind, randomized, parallel trial evaluating flunisolide spray as an adjunct to oral antibiotic therapy was reported in patients at least 14 years of age.58 The benefit of flunisolide was marginal and of minimal clinical importance. There is little reason to expect a substantial benefit from intranasal steroids in patients with acute bacterial sinusitis when antibiotics work effectively in the first 3 to 4 days of treatment. No clinical trials of mucolytics have been reported in nonatopic children or adults with acute bacterial sinusitis.59 Neither saline nose drops nor nasal spray have been studied in patients with acute bacterial sinusitis. However, by preventing crust formation and liquefying secretions, they may be helpful. In addition, saline also may act as a mild vasoconstrictor of nasal blood flow.59 A method for performing a nasal saline flush was reported anecdotally by Schwartz.60Antibiotic Prophylaxis No recommendations are made based on limited and controversial data.
Antibiotic prophylaxis as a strategy to prevent infection in patients who experience recurrent episodes of acute bacterial sinusitis has not been systematically evaluated and is controversial.59 Although previously successful in children who experience recurrent episodes of acute otitis media,61,62 there is little enthusiasm for this approach in light of current concerns regarding the increasing prevalence of antibiotic-resistant organisms. Nonetheless, it may be used in a few highly selected patients whose infections have been defined meticulously (always fulfilling criteria for persistent or severe presentation) and are very frequent (at least 3 infections in 6 months or 4 infections in 12 months). Amoxicillin (20 mg/kg/d given at night) and sulfisoxazole (75 mg/kg/d in 2 divided doses) have been used successfully to prevent episodes of acute otitis media. Usually prophylaxis is maintained until the end of the respiratory season. It is appropriate to initiate an evaluation for factors that commonly predispose to episodes of recurrent acute bacterial sinusitis such as atopy, immunodeficiency, cystic fibrosis, and dysmotile cilia syndrome. Children with craniofacial abnormalities also are at risk to develop acute bacterial sinusitis.Complementary/Alternative Medicine for Prevention and Treatment of Rhinosinusitis No recommendations are made based on limited and controversial data.
A substantial number of children, adolescents, and their parents use nonprescription cold medicines or simple home-based remedies such as soups, fruit juices, or teas as alternatives or complements to conventional therapy for the treatment of upper respiratory infections including rhinosinusitis.63,64 Others use herbal remedies and nutritional supplements or seek care from acupuncturists, chiropractors, homeopaths, naturopaths, aromatherapists, massage and therapeutic touch practitioners, and a variety of other healing modalities.64-67 Few of these therapies for upper respiratory tract infection or rhinosinusitis have been validated in randomized controlled trials. Claims that homeopathic medicines,68-70 vitamin C preparations,71 or zinc lozenges72 prevent upper respiratory infections or hasten their resolution are controversial. A recently published study provides evidence that zinc nasal gel is effective in shortening the duration of symptoms of the common cold when taken within 24 hours of their onset.73 Studies performed among adults indicating efficacy of Echinacea preparations in stimulating the immune system, thereby reducing the incidence, duration, or severity of respiratory infections, are debated74,75; however, a recent meta-analysis suggested a predominance of generally positive effects.76 Physicians treating children and young adults should be aware that many of their patients are using complementary therapies, often without informing them. Most of these remedies are harmless and, whether through pharmacologic or placebo effect, a perception of efficacy in providing relief from symptoms has stood the test of time. Nevertheless, many herbal medicines sold in the United States are of uncertain efficacy, content, and toxicity and carry a potential for serious adverse effects.77 Of particular concern is the ability of the botanicals, either by direct interaction or by altering excretion mechanisms, to magnify or oppose the effect of conventional medicines that patients may be using concurrently.78 Physicians should inquire about the use of complementary medicine for upper respiratory tract infections among their patients, particularly those on long-term medication for chronic conditions. Information on dietary supplements is available on a regularly updated Internet site.79Recommendation 4 Children with complications or suspected complications of acute bacterial sinusitis should be treated promptly and aggressively. This should include referral to an otolaryngologist usually with the consultation of an infectious disease specialist, ophthalmologist, and neurosurgeon (strong recommendation based on strong consensus of the panel).
The complications of acute bacterial sinusitis usually involve either the orbit, the central nervous system, or both. Although rare, complications can result in permanent blindness or death if not treated promptly and appropriately. Periorbital and intraorbital inflammation and infection are the most common complications of acute sinusitis and most often are caused by acute ethmoiditis. These disorders are commonly classified in relation to the orbital septum. The orbital septum is a sheet of connective tissue continuous with the periosteum of the orbital bones that separates tissues of the eyelid from those of the orbit. Preseptal inflammation involves only the eyelid, whereas postseptal inflammation involves structures of the orbit. Complications can be classified as 1) periorbital (or preseptal) cellulitis or sympathetic edema (periorbital cellulitis is not a true orbital complication. The periorbital swelling is attributable to passive venous congestion; infection is confined to the paranasal sinuses), 2) subperiosteal abscess, 3) orbital abscess, 4) orbital cellulitis, or 5) cavernous sinus thrombosis. Mild cases of periorbital cellulitis (eyelid <50% closed) may be treated with appropriate oral antibiotic therapy as an outpatient with daily patient encounters. However, if the patient has not improved in 24 to 48 hours or if the infection is progressing rapidly, it is appropriate to admit the patient to the hospital for antimicrobial therapy consisting of intravenous ceftriaxone (100 mg/kg/d in 2 divided doses) or ampicillin-sulbactam (200 mg/kg/d in 4 divided doses). Vancomycin (60 mg/kg/d in 4 divided doses) may be added in children in whom infection is either known or likely to be caused by S pneumoniae that are highly resistant to penicillin. If proptosis, impaired visual acuity, or impaired extraocular mobility are present on examination, a CT scan (preferably coronal thin cut with contrast) of the orbits/sinuses is essential to exclude a suppurative complication. In such cases, the patient should be evaluated by an otolaryngologist and an ophthalmologist. Suppurative complications generally require prompt surgical drainage. An exception to this is the patient with a small subperiosteal abscess and minimal ocular abnormalities for whom intravenous antibiotic treatment for 24 to 48 hours is recommended while performing frequent visual and mental status checks. Patients who have changes in visual acuity or mental status or who fail to improve within 24 to 48 hours require prompt surgical intervention and drainage of the abscess. Antibiotics can be altered, if inappropriate, when results of culture and sensitivity studies become available. In patients with altered mental status, neurosurgical consultation is indicated. Signs of increased intracranial pressure (headache and vomiting) or nuchal rigidity require immediate CT scanning (with contrast) of the brain, orbits, and sinuses to exclude intracranial complications such as cavernous sinus thrombosis, osteomyelitis of the frontal bone (Pott's puffy tumor), meningitis, subdural empyema, epidural abscess, and brain abscess. Central nervous system complications, such as meningitis and empyemas, should be treated either with intravenous cefotaxime or ceftriaxone and vancomycin pending the results of culture and susceptibility testing.| |
AREAS FOR FUTURE RESEARCH |
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The extensive Medline searches to review the literature for the diagnosis and treatment of acute bacterial sinusitis in children uncovered the fact that there are scant data on which to base recommendations. Accordingly, areas for future research include the following:
1.
Conduct more and larger studies correlating the clinical findings of acute bacterial sinusitis with findings of sinus aspiration, imaging, and treatment outcome.
2.
Develop noninvasive strategies to accurately diagnose acute bacterial sinusitis in children.
a.
Correlate cultures obtained from the middle meatus of the maxillary sinus of infected individuals with cultures obtained from the maxillary sinus by puncture of the antrum.
b.
Develop imaging technology that differentiates bacterial infection from viral infection or allergic inflammation.
c.
Develop rapid diagnostic methods to image the sinuses without radiation.
3.
Determine the optimal duration of antimicrobial therapy for children with acute bacterial sinusitis.
4.
Determine the causes and treatment of subacute and recurrent acute bacterial sinusitis.
5.
Determine the efficacy of prophylaxis with antimicrobials to prevent recurrent acute bacterial sinusitis.
6.
Determine the impact of bacterial resistance among S pneumoniae, H influenzae, and M catarrhalis on outcome of treatment with antibiotics by the performance of randomized, double-blind, placebo-controlled studies in well-defined populations of patients.
7.
Determine the role of adjuvant therapies (mucolytics, decongestants, antihistamines, etc) in patients with acute bacterial sinusitis by the performance of prospective, randomized, clinical trials.
8.
Determine the role of complementary and alternative medicine strategies in patients with acute bacterial sinusitis by performing systematic, prospective, randomized clinical trials.
9.
Assess the effect of the pneumococcal conjugate vaccine on the epidemiology of acute bacterial sinusitis.
10.
Develop new bacterial and viral vaccines to reduce the incidence of acute bacterial sinusitis.
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CONCLUSION |
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Top
Abstract
Background
Methods
Recommendation
Conclusion
References
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This clinical practice guideline provides evidence-based recommendations for the management of bacterial rhinosinusitis in children ages 1 to 21 years. The guideline emphasizes 1) appropriate diagnosis in children who present with persistent or severe upper respiratory symptoms; 2) the utility of imaging studies to confirm a diagnosis; 3) treatment therapies such as antibiotic use including prophylaxis, adjuvant treatment, and alternative interventions; and 4) management of complications. The guideline provides decision-making strategies for managing sinusitis to assist primary care providers in diagnosing and treating children with this common health problem.
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ACKNOWLEDGMENTS |
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The subcommittee wishes to acknowledge the Agency for Healthcare Research and Quality and the New England Medical Center Evidence-based Practice Center for their work in developing the evidence report. We especially thank John P. A. Ioannidis, MD, and Joseph Lau, MD, for their work on the technical report.
Subcommittee on Management of Sinusitis
Ellen R. Wald, MD, Chairperson
W. Clayton Bordley, MD, MPH
David H. Darrow, MD, DDS
Katherine Teets Grimm, MD
Jack M. Gwaltney, Jr, MD
S. Michael Marcy, MD
Melvin O. Senac, Jr, MD
Paul V. Williams, MD
Liaisons
Larry Culpepper, MD, MPH
American Academy of Family Physicians
David L. Walner, MD
American Academy of Otolaryngology-Head and Neck Surgery
Staff
Carla Herrerias, MPH
Committee on Quality Improvement, 2000-2001
Charles J. Homer, MD, MPH, Chairperson
Richard D. Baltz, MD
Michael J. Goldberg, MD
Gerald B. Hickson, MD
Paul V. Miles, MD
Thomas B. Newman, MD, MPH
Joan E. Shook, MD
William M. Zurhellen, MD
Liaisons
Charles H. Deitschel, Jr, MD
Committee on Medical Liability
Denise Dougherty, PhD
Agency for Healthcare Research and Quality Institutions
F. Lane France, MD
Committee on Practice and Ambulatory Medicine
Kelly J. Kelleher, MD, MPH
Section on Epidemiology
Betty A. Lowe, MD
National Association of Children's Hospitals and Related Institutions
Ellen Schwalenstocker, MBA
National Association of Children's Hospitals and Related Institutions
Richard N. Shiffman, MD
Section on Computers and Other Technology
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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CT, computed tomography.
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REFERENCES |
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Top
Abstract
Background
Methods
Recommendation
Conclusion
References
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a report from
the Drug-resistant Streptococcus pneumoniae Therapeutic
Working Group.
Pediatr Infect Dis J
1999;
18:1-9 [CrossRef][Medline]bacteriology of middle ear exudate during antimicrobial
therapy in otitis media.
Pediatrics
1969;
44:940-944 a
review of current evidence.
Scand J Infect Dis
1994;
26:1-6 [Medline]the risks of untested and
unregulated remedies.
N Engl J Med
1998;
339:839-841 This article has been cited by other articles:
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  C. J. Stille, S. L. Rifas-Shiman, K. Kleinman, J. B. Kotch, and J. A. Finkelstein Physician Responses to a Community-Level Trial Promoting Judicious Antibiotic Use Ann. Fam. Med, May 1, 2008; 6(3): 206 - 212. [Abstract] [Full Text] [PDF]
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 M. W. Weinberger Additional Evidence Antibiotics Are Not Helpful for Sinusitis AAP Grand Rounds, April 1, 2008; 19(4): 37 - 38. [Full Text] [PDF]
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 K. Revai, L. A. Dobbs, S. Nair, J. A. Patel, J. J. Grady, and T. Chonmaitree Incidence of Acute Otitis Media and Sinusitis Complicating Upper Respiratory Tract Infection: The Effect of Age Pediatrics, June 1, 2007; 119(6): e1408 - e1412. |
