What are the diagnostic criteria and treatment options for pediatric sinusitis (inflammation of the paranasal sinuses)?

From the Guidelines

Pediatric sinusitis should be treated with amoxicillin 45-90 mg/kg/day divided twice daily for 10-14 days as the first-line treatment for uncomplicated acute bacterial sinusitis in children. This recommendation is based on the most recent and highest quality study available, which prioritizes morbidity, mortality, and quality of life as the outcome 1. The diagnosis of acute bacterial sinusitis is made when a child presents with persistent illness, worsening course, or severe onset, and clinicians should not obtain imaging studies to distinguish acute bacterial sinusitis from viral URI, unless there are concerns for orbital or central nervous system complications 1.

Key Considerations

• For patients with risk factors for resistant organisms, amoxicillin-clavulanate 90 mg/kg/day of the amoxicillin component divided twice daily is recommended 1.
• In penicillin-allergic patients, alternatives include cefdinir, cefuroxime, or, for non-type I allergies, cefpodoxime 1.
• Symptoms should improve within 48-72 hours of starting antibiotics, and supportive care includes adequate hydration, saline nasal irrigation, and analgesics for pain 1.
• Decongestants and antihistamines are generally not recommended as they have limited evidence of benefit 1.

Imaging Studies

• Imaging studies are not recommended for uncomplicated acute sinusitis, but CT or MRI of the head and paranasal sinuses with IV contrast may be recommended for cases with suspected orbital or intracranial complications, or for suspected invasive fungal sinusitis 1.
• CT of the paranasal sinuses without IV contrast may be recommended for persistent sinusitis, recurrent sinusitis, or chronic sinusitis, or to define paranasal sinus anatomy before functional endoscopic sinus surgery 1.

Treatment Approach

• Antibiotic therapy should be prescribed for acute bacterial sinusitis in children with severe onset or worsening course, and either prescribed or offered with additional observation for 3 days to children with persistent illness 1.
• Clinicians should reassess initial management if there is either a caregiver report of worsening or failure to improve within 72 hours of initial management, and may change the antibiotic therapy or initiate antibiotic treatment as needed 1.

From the Research

Definition and Diagnosis of Pediatric Sinusitis

• Pediatric sinusitis is defined as an inflammation of the mucosal lining of the paranasal sinuses, with acute sinusitis lasting less than 4 weeks 2.
• The diagnosis of acute sinusitis is mainly clinical and based on stringent criteria, including persistent symptoms and signs of a URI beyond 10 days, without appreciable improvement; a URI with high fever and purulent nasal discharge at onset lasting for at least 3 consecutive days; and biphasic or worsening symptoms 3.
• Diagnostic criteria utilized by providers include persistent nasal congestion/cough lasting >10 days, worsening of classic viral URI symptoms at days 5-7, and severe onset and purulent nasal discharge for at least 3 consecutive days 4.

Treatment of Pediatric Sinusitis

• The present consensus is that amoxicillin-clavulanate, at a standard dose of 45 mg/kg/day orally, is the drug of choice for most cases of uncomplicated ABS in children in whom antibacterial resistance is not suspected 3.
• Alternatively, oral amoxicillin 90 mg/kg/day can be administered, and for those with severe ABS or uncomplicated acute sinusitis who are at risk for severe disease or antibiotic resistance, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) is the drug of choice 3.
• Other antibiotics used by providers include cefdinir, azithromycin, clarithromycin, and Bactrim, with the typical length of antibiotic therapy being 10 days 4.
• There is limited evidence on the use of ancillary measures and nasal corticosteroids, with one randomized, placebo-controlled trial showing some transient symptomatic improvement with the use of nasal corticosteroids 5.

Pathogens and Resistance

• Haemophilus influenzae (non-typeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the major pathogens in uncomplicated ABS in otherwise healthy children 3.
• In complicated ABS, polymicrobial infections are common, and the current rates of antimicrobial resistance among commonly implicated pathogens should be considered in therapeutic decisions 3, 5.
• The inaccuracy of clinical signs and symptoms in documenting the diagnosis further complicates therapeutic decisions, and radiographic assessment does not meaningfully improve the accuracy of the diagnosis for uncomplicated cases 5.