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SINUSITIS
Rhonda Lesniak
Primary Care II
Anatomy
• Paranasal Sinuses
Anatomy
• Lateral View of Sinuses
Where are the sinuses?
• Four pairs of paranasal sinuses
– Frontal-above eyes in forehead bone
– Maxillary-in cheekbones, under eyes
– Ethmoid-between eyes and nose
– Sphenoid-in center of skull, behind
nose and eyes
What are the sinuses?
• The sinuses are hollow air-filled
sacs lined by mucous membrane.
The ethmoid and maxillary
sinuses are present at birth. The
frontal sinus develops during the
2nd year and the sphenoid sinus
develops during the 3rd year.
What are the sinuses? (cont’d)
• Sinuses have small orifices (ostia)
which open into recesses (meati)
of the nasal cavities.
• Meati are covered by turbinates
(conchae).
• Turbinates consist of bony
shelves surrounded by erectile
soft tissue.
• There are 3 turbinates and 3 meati
in each nasal cavity (superior,
middle, and inferior).
Considerations for Pediatrics
• At birth, the ethmoid, sphenoid
and maxillary sinuses are tiny and
cause problems in infants and
toddlers.
• Frontal sinuses develop between
4-7 years of age, causing
problems in school aged children
and adolescents.
Sinusitis
• Inflammation of paranasal sinuses
What is sinusitis?
• An acute inflammatory process
involving one or more of the
paranasal sinuses.
• A complication of 5%-10% of URIs
in children.
• Persistence of URI symptoms >10
days without improvement.
• Maxillary and ethmoid sinuses are
most frequently involved.
How Does Sinusitis Develop?
• Usually follows rhinitis, which
may be viral or allergic.
• May also result from abrupt
pressure changes (air planes,
diving) or dental extractions or
infections.
• Inflammation and edema of
mucous membranes lining the
sinuses cause obstruction.
• This provides for an opportunistic
bacterial invasion.
Development (cont’d)
• With inflammation, the mucosal lining
of the sinuses produce mucoid
drainage. Bacteria invade and pus
accumulates inside the sinus cavities.
• Postnasal drainage causes obstruction
of nasal passages and an inflamed
throat.
• If the sinus orifices are blocked by
swollen mucosal lining, the pus cannot
enter the nose and builds up pressure
inside the sinus cavities.
Predisposing Factors
• Allergies, nasal deformities, cystic
fibrosis, nasal polyps, and HIV
infection.
• Cold weather
• High pollen counts
• Day care attendance
• Smoking in the home
• Reinfection from siblings
Acute or Chronic Sinusitis?
• Acute Sinusitis – respiratory
symptoms last longer than 10
days but less than 30 days.
• Subacute sinusitis – respiratory
symptoms persist longer than 30
days without improvement.
• Chronic sinusitis – respiratory
symptoms last longer than 120
days.
Etiology of Sinusitis
70% of bacterial sinusitis is caused
by:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
Other causative organisms are:
• Staphylococcus aureus
• Streptococcus pyogenes,
• Gram-negative bacilli
• Respiratory viruses
Complications of Sinusitis
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Orbital cellulitis or abscess
Meningitis
Brain abscess
Intractable wheezing in children
with asthma
• Cavernous sinus thrombosis
• Subdural empyema
Subjective Symptoms of Sinusitis
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History of URI or allergic rhinitis
History of pressure change
Pressure, pain, or tenderness over sinuses
Increased pain in the morning, subsiding in
the afternoon
Malaise
Low-grade temperature
Persistent nasal discharge, often purulent
Postnasal drip
Cough, worsens at night
Mouthing breathing, snoring
History of previous episodes of sinusitis
Sore throat, bad breath
Headache
Clinical Presentations of Sinusitis
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Periorbital edema
Cellulitis
Nasal mucosa is reddened or swollen
Percussion or palpation tenderness
over a sinus
Nasal discharge, thick, sometimes
yellow or green
Postnasal discharge in posterior
pharynx
Difficult transillumination
Swelling of turbinates
Boggy pale turbinates
Pale, Boggy Turbinates
Diagnostic Tests
• Imaging studies, such as sinus
radiographs, ultrasonograms, or
CT scanning – indicated if child is
unresponsive to 48 hours of
antibiotics and if the child has a
toxic appearance, chronic or
recurrent sinusitis, and chronic
asthma.
• Laboratory studies, such as
culture of sinus puncture
aspirates.
Differential Diagnoses
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Allergic rhinitis
Non-allergic rhinitis
Infectious rhinitis
Drug-induced rhinitis
Nasal polyps
Dental abscess
Carcinoma of sinus
Cluster headache
Structural defects (septum deviation)
Nasal foreign body
Pharmacological Plan of Care
Antimicrobials-treat for 10-14 days,
depending upon severity, with one
of the following:
• Amoxicillin:20-40mg/kg/d in 3
divided doses(>20kg, 250mg tid)
• Augmentin:25-45mg/kg/d in 2
divided doses(>20kg, 400mg q12)
Use chewable or suspension if
child is less than 40kg.
Pharmacological Plan of Care
• Biaxin:15mg/kg/d in 2 divided
doses(>30kg, 250mg q12)
• Cefzil:15mg/kg/d in 2 divided
doses (>35kg, 250mg bid)
• Lorabid: 30mg/kg/d in 2 divided
doses (>26kg, 400mg bid)
Other Relief Medications
• Codeine – for severe pain
• Rhinocort nasal spray – 2 sprays
in each nostril every 12 hours for
children over 6 years of age.
OTC Medications
• Acetaminophen or ibuprofen to
relieve pain
• Decongestants
• Antihistamines
• Nasal saline
Non-pharmacological treatment
• Humidifier to relieve the drying of
mucous membrances associated
with mouth breathing
• Increase oral fluid intake
• Saline irrigation of the nostrils
• Moist heat over affected sinus
• Prolonged shower to help
promote drainage
Patient Education
• Child should not dive.
• Child should not travel by
airplane.
• Urge parent to eliminate triggers
in the home (dust, smoking)
• Have all members of the family
treated, if indicated.
Follow Up Guidelines
• Instruct parent to call in 48 hours
if condition of child has not
improved.
• Instruct parent to bring child in for
a recheck in 2 weeks.
Guidelines for Referral
• Child with complications or signs
of invasive infection.
• Child needing control of allergic
rhinitis.
• Child with chills and fever.
• Child with persistent headache.
• Child with edema of forehead,
eyelids.
• Child with orbital cellulitis
Case Study
• Austin, 9 years old, was seen in the
clinic ten days ago, was diagnosed
with rhinitis and sent home with
instructions for increased fluids,
decongestants, and rest.
• Austin presents today with worsened
symptoms of malaise, low-grade
temperature, nasal discharge, night
time coughing, mouth breathing, early
morning pain over sinuses, and
congestion.
Case Study (cont’d)
Physical findings for Austin:
• Thick, yellow nasal discharge
• Edematous, reddened nasal
mucosa
• Postnasal discharge visible in
posterior pharynx
• Periorbital swelling
• Tenderness of sinuses upon
palpation
Case Study (cont’d)
Treatment: Austin weighs 90 lbs, or
40.8 kg
• Amoxicillin – 250 mg tid po
• Comfort measures –
acetaminophen for pain relief
• Moist heat applied to sinuses
• Increased oral fluids
• Rest
References
• Boynton, R., Dunn, E., Stephens,
G., & Pulcini, J. (2003) Manual of
ambulatory pediatrics (5th ed.).
Philadelphia: Lippincott Williams
& Wilkins.
• Burns, C., Dunn, A., Brady, M.,
Starr, N., & Blosser, C. (2004).
Pediatric primary care: A
handbook for nurse practitioners
(3rd ed.). St. Louis, Missouri:
Saunders.
References (cont’d)
• Colyar, M. (2003). Well-child
assessment for primary care
providers. Philadelphia: F. A.
Davis Company.
• Tierney, L., Saint, S., & Whooley,
M. (2005). Current essentials of
medicine (3rd ed.). New York:
Lange Medical Books/McGrawHill.