Symptoms and Signs of Sinusitis in Pediatric Patients
Distinguishing Bacterial Sinusitis from Viral Upper Respiratory Infections
The diagnosis of acute bacterial sinusitis in children relies on recognizing three distinct clinical patterns: persistent symptoms lasting >10 days without improvement, worsening symptoms after initial improvement, or severe onset with high fever and purulent discharge. 1
Persistent Pattern (Most Common)
- Nasal discharge of any quality (clear, mucoid, or purulent) or daytime cough (often worse at night) lasting ≥10 days without improvement 1
- This is the most common presentation and distinguishes bacterial sinusitis from uncomplicated viral URIs, which typically resolve by 7-10 days 1
- The key is lack of improvement, not the color or consistency of nasal discharge 1
Worsening Pattern
- Initial improvement from a viral URI followed by new onset or worsening of nasal discharge, cough, or fever (≥38°C/100.4°F) 1
- This "double-worsening" pattern suggests bacterial superinfection 1
Severe Onset Pattern
- Concurrent high fever (≥39°C/102.2°F) and purulent nasal discharge for ≥3 consecutive days at illness onset 1
- These children typically appear ill and require differentiation from severe viral infections 1
Additional Symptoms (Common but Non-Specific)
- Bad breath (halitosis) - particularly notable in preschool-age children (50% of cases) without pharyngitis or poor dental hygiene 1, 2
- Fatigue, headache, and decreased appetite - common but not specific indicators 1
- Facial pain or pressure - uncommon in children compared to adults 1, 2, 3
- Postnasal drainage - may be reported by parents 4
Physical Examination Findings
Physical examination findings are generally not helpful in distinguishing bacterial sinusitis from viral URIs. 1
- Erythema and swelling of nasal turbinates - nonspecific findings present in both viral and bacterial infections 1
- Sinus percussion - not useful in children 1
- Purulent nasal discharge on examination - can occur in both viral and bacterial infections 1
Critical Pitfalls to Avoid
The Purulent Discharge Misconception
Purulent (thick, colored, opaque) nasal discharge alone does NOT indicate bacterial sinusitis. 1 In uncomplicated viral URIs, nasal discharge typically transitions from clear to purulent and back to clear without antibiotics over 5-7 days 1. The concurrent presentation of high fever AND purulent discharge for 3-4 days at illness onset is what defines severe bacterial sinusitis 1.
Distinguishing from Allergic Rhinitis
- Family history of atopy, seasonal patterns, or allergen exposure suggest allergic rhinitis rather than infection 1
- Pruritic eyes and nasal mucosa, nasal crease, allergic shiners, pale nasal mucosa, or cobblestoning suggest allergic etiology 1
- Allergic rhinitis is a predisposing factor for bacterial sinusitis, so both conditions may coexist 1, 2
Imaging is NOT Recommended for Diagnosis
Imaging studies (plain films, CT, MRI, or ultrasound) should NOT be obtained to distinguish bacterial sinusitis from viral URI. 1 Sinus opacification is present in 68% of symptomatic children with viral URIs and 42% of healthy children, making imaging findings unreliable for diagnosis 1. Imaging should be reserved only for suspected orbital or intracranial complications 1, 5.
Age-Related Considerations
- Cough and purulent rhinorrhea are the most common presentations in children (80% and 75% respectively), unlike adults who more commonly report facial pain 1, 2, 3
- Headache and facial tenderness are uncommon in pediatric patients compared to adults 3, 6
- Symptoms in children are often difficult to distinguish from the common cold, requiring reliance on the three clinical patterns described above 1, 2