Transcript Chronic Rhinosinusitis in Children

Chronic Rhinosinusitis in Children
Clinical Presentation
Hector Stone-Aguilar, M.D.
Pediatric Allergy & Immunology
Hospital San Jose de Hermosillo
Universidad del Valle de Mexico
Clinical presentation of CRS in Children
The problem:
• To fully define chronic sinusitis has been
difficult
• There is a wide variation in clinical
expression of the disease
• Discordance between patient symptoms
and objective findings
• No one set of diagnostic criteria has been
agreed on by all specialty groups
Clinical presentation of CRS in Children
The problem:
• Clinical criteria to diagnose CRS, as well as the
predictive value of these criteria, are not well
defined, specially in children
• Historically, the diagnosis of CRS was based on
several clinical symptoms, similar to acute RS,
but usually less severe
• However, none of these symptoms are specific
to sinusitis
Definition of Sinusitis
• Inflammation of 1 or more of the paranasal
sinuses
• Acute Sinusitis: less than 4 weeks/duration
• Subacute Sinusitis: 4 to 12 weeks/duration
• Chronic Sinusitis: longer than 12 weeks
Some guidelines also requiring :
– Failure to respond to treatment
– One positive imaging study
Dykewicz M, JACI Feb 03
Definition of Rhinosinusitis
• Inflammation of the nose and paranasal
sinuses characterized by two or more
symptoms, one of which should be either
nasal blockage/obstruction/congestion or
nasal discharge (anterior/posterior nasal
drip)
± facial pain/pressure
± reduction or lost of smell
EPOS Guidelines, Rhinology 2007
Rhinosinusitis
OHNS , 1997
Definition of Chronic Rhinosinusitis
• More than 12 weeks of symptoms without
complete resolution
• Can be subdivided in:
– Chronic Rhinosinusitis with Nasal Polyps
– Chronic Rhinosinusitis without Nasal Polyps
• CRS also may be susceptible to exacerbations
EPOS Guidelines, Rhinology 2007
CRS: Symptom-based Diagnosis
• 73.15% of the nonallergic patients
with symptom based diagnosed CRS
• 65.34% of the allergic patients with
symptom-based diagnosed CRS
Had No CT and endoscopic pathology
(Endoscopic score 0 + CT score 0)
Tahamiler R, Allergy 2007
Chronic Rhinosinusitis in Children
In general :
The main symptoms associated with
rhinosinusitis in children are rhinorrhea,
nasal obstruction, mouth breathing,
hyponasal speech, and snoring
but…
Diagnosing CRS in Children: Special issues
Infants and Pre-school children
• Signs/symptoms difficult to evaluate:
• Congestion (very subjective/indirect/parent’s biass)
• Only anterior rhinorrhea is reported
• Symptoms impossible to evaluate:
• Posterior discharge
• Sense of smell
• Headache / toothache / facial pain
• Symptoms very unspecific :
• Cough, irritability, fever, fatigue/decreased activity, etc.
Diagnosing CRS in Children: Special issues
Infants and Pre-school children
• Anterior Rhinoscopy : Limited data
– Anterior third of nasal cavity
– Osteomeatal zone difficult to reach, even w/use of
topical decongestant
• Nasal Endoscopy: Ideal but impossible to
perform without sedation or anesthesia
• CT scan: Also requieres sedation or
anesthesia
• Sedation/anesthesia: increases costs and risks
• Increased value of plain X-Rays at this age ??
Severity of Sinusitis
• Disease severity can be divided into:
– Mild
– Moderate
– Severe
(0-3 points)
(4-7 points)
(8-10 points)
• Using a 10-point scoring system or
Visual Analogue Scale (VAS)
EPOS Guidelines, Rhinology 2007
Clinical presentation of CRS in Children
Diagnosis must be based in a combination of:
– Clinical symptoms and evolution
• Age-group related
• Previous treatments (type and duration)
• Likelihood of allergy involvement: Family history,
allergy stigmata, personal history of other allergic
diseases (AD or Asthma)
– Clinical Signs
• Anterior rhinoscopy and/or Nasal endoscopy
– Imaging support
• Plain X-Rays
• CT scans
• MRI
Chronic Rhinosinusitis in Children
• By definition, needs to be at least 12 weeks old (3
m.o.)
• Ethmoid and maxillary sinuses present at birth
• Clinical presentation strongly related to the specific
pediatric age group:
– Infants: Persistent or recurrent rhinorrhea after an acute
febrile URIs ( ± AOM, Rhinopharyngitis, Bronchitis)
– Pre-schoolars: Persistent rhinorrhea and nasal congestion
w/adenoid and tonsil hypertrophy, serous OM, allergies
and asthma.
– Scholars and adolescents : Nasal obstruction, headaches,
sore throath, hyposmia, irritability, sleep disturbances, etc.
(PAR or PNAR)
Clinical presentation of CRS in Children
• In infants and preschool childrens, most
cases of CRS are a chronologic extension of
acute infectious sinusitis (viral bacterial)
• In contrast, in older children or adolescents
most CRS cases are not an infectious disease
but an inflammatory disease, much akin to
asthma.
Jones NS, Curr Opinion Pulm Med, 2000
Clinical evolution of Viral URI’s
When to suspect CRS in INFANTS
• Continuous or intermittent RHINORRHEA
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Anterior, posterior or both
Usually clear initially (days or weeks)
Colored (greenish or yellowish) more dense secretions
It can alternate clear and colored secretions
• Nasal CONGESTION
– Mild at the beginning
– Worsening in an intermittent pattern in absence of
appropriate treatment
– Not as bad as other age groups
– Objective findings: mouth breathing, snoring
When to suspect CRS in INFANTS
• COUGH :
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A prominent feature of sinusitis at this age
Starts as “Dry” cough usually for several days
Can continue with “wet” cough all the way
Intermittent along the day, not very intense
Can start or worse at night or bedtime
Usually associated with posterior rhinorrhea
Also associated with coarse and audible ronchi
Maybe a better predictor than rhinorrhea about
the outcome
When to suspect CRS in INFANTS
• FEVER:
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Usually present at the beginning of the clinical picture
Low or mid grade
Fades away after few days (with or without treatment)
Can not be present at all
Can relapse in the course of the disease (worsening)
Its absence doesn’t rule out the possibility of chronic
infection
When to suspect CRS in INFANTS
• Other possible symptoms:
– Irritability
– Bad appetite
– Sleep disturbances:
• Trouble to got sleep
• Restless sleeping
• Nocturnal awakenings
– Halitosis
– Reduced general activity
When to suspect CRS in INFANTS
• Physical signs, NASAL :
– Rhinorrhea (anterior)
– Pale and enlarged turbinates
– Mucosal edema
– Hyperemic mucosa
– Middle meatus colored discharge
Rhinoscopy
Muco-purulent discharge in the
Sinus Ostium zone
Middle turbinate
Lateral nasal wall
Purulent mucus
Septum
When to suspect CRS in INFANTS
• Physical signs, GENERAL :
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Posterior rhinorrhea
Mouth breathing
Pallor
Dark infra-orbital shiners
Halitosis
Tympanic opacity, retraction or hyperemia
Enlarged tonsils
Granular (cobblestone) adenoid tissue in
the pharynx
– “rude” breathing
– Coarse rhonchi on chest examination
Serous Otitis Media
Enlarged Adenoids:
Cause or consequence ?
Chronic Rhinosinusitis in PRE-SCHOLARS
• Not necessarily associated to respiratory
infection
• Mostly related to allergies and asthma
• Difficult to distinguish from PAR. Same sort of
signs and symptoms
• Usually considered a “complication” of allergic
rhinitis
• Nasal or sinusal polyps not frequent at this age
Chronic Rhinosinusitis in PRE-SCHOLARS
Differences with CRS in Infants
• Congestion more prominent than
rhinorrhea
• Cough frequently related to asthma or BHR
• Headaches, frequently mild or intermittent
• Hyposmia rarely reported
• Halitosis
• Clear or thick mucoid rhinorrhea
• Paler and more enlarged turbinates
• Intense edema of nasal mucosa
Chronic Rhinosinusitis in
School children and adolescents
• Moderate to severe nasal congestion/obstruction:
– Snoring
– Sleeping problems
– Dry mouth and sore throat at mornings
• Headaches:
– Mild to severe
– Frequent or intermittent
– Frontal, maxillary or occipital
• Rhinorrhea:
– Posterior > anterior
• Halitosis
Chronic Rhinosinusitis in
School children and adolescents
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Daytime somnolence
Tiredness
Poor concentration: altered school performance
Hyposmia
Dysgeusia
Middle ear:
– Hypoacusia, Popping, Buzzing
• Polyps: More frequent than the other pediatric
groups
Consequences of chronic nasal congestion
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Snoring
Oral breathing
Hyponasal speech
Sleep disturbances
Obstructive Sleep Apneas (OSA)
Dry mouth
Sore throath
Headaches
Daytime somnolence
Poor concentration
Tiredness
Facial and dental changes
CRS Diagnosis:
Plain X Rays: Useful?
Plain X-rays vs. CT scan in Sinusitis
• The sensitivity of Plain X-Ray compared to CT was:
– 77% (30/39)
• The specificity of the radiograph to CT was 81%
(25/31).
• The positive likelihood ratio is 4.05 and
• The negative likelihood ratio is 0.28.
• Conclusions - The difference between radiographs
and CT for diagnosing sinus disease in this
population is relatively small but favors CT exam.
Garcia, DP Radiographic imaging studies in pediatric chronic sinusitis
J Allergy Clin Immunol, 94:523-530, 1994.
CRS Diagnosis:
CT scan: Gold standard ?
‘Limited’ CT Scan
Garcia D, JACI sept 1994
Sinusitis severity Index (grading):
(Glicklich)
• Grade 0: mucosal thickening of ≤ 2 mm in any
sinusal wall
• Grade 1: Any unilateral disease or abnormality
• Grade 2: Bilateral disease limited to ethmoid
or maxillary sinuses
• Grade 3: Bilateral disease with frontal or
sphenoidal involvement (any)
• Grade 4: Pansinusitis.
Emmanuel IA, Otolaryngology Head Neck Surg 2000
CRS Diagnosis:
CT scan: Gold standard ?
HWANG et al, OHNS april, 2003
CRS Diagnosis:
CT scan: Gold standard ?
Unilateral involvement of the right maxillary sinus and structural abnormalities:
MT concha bullosa and paradoxical curvature of middle turbinate, stretching
the OMC
Nasal Endoscopy
Clasification of the severity of polyposis
by endoscopy
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0 - No visible polyps
1 - Polyps confined to the middle meatus
2 - Polyps beyond middle meatus but did
not occlude the nasal cavity
3 - Polyps obstructing completely the nasal
cavity
Mackay IS y Lund VJ, 1997
Nasal / Sinusal Polyposis in Children
• If nasal polyps are present in young children,
MUST rule out:
1. Aspirin Exacerbated Respiratory Disease (AERD)
2. Cystic Fibrosis (CF)
3. Genetic involvement
• But still most probably related to Perennial or
Persistent Allergic Rhinitis
• Polyps related to Perennial Non-Allergic Rhinitis
are rare at this age
Etiology of CRS in Children
• Infection:
– Viral/Bacterial
– Biofilms
– Fungal?
• Allergy
– Allergic Rhinitis: Persistent >
Intermittent
• Gastroesophageal Reflux
• Obstruction /Structural
– Adenoid > Tonsils Hypertrophy
– Septal deviation
– Other: concha bullosa, Haller cells,
agger nasi cells
Etiology of CRS in Children
• Immunodeficiency
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IgA deficiency
Transient Hipogammaglobulinemia
IgG sub-class deficiency ( IgG2 + IgG4)
Selective (polysaccaride) IgG deficiencies
CVI
Cystic Fibrosis
Ciliary Dyskinesia
Aspirin Exacerbated Respiratory Disease
Other: very uncommon
Hamilos D, JACI oct 2011
Conclusions:
• CRS is frequent in children
• No one set of diagnostic criteria has been agreed on by all
specialty groups
• CRS in children have special features that are different of
CRS in adult population
• There are differences also in the clinical presentation of the
different pediatric age groups
• The diagnosis of CRS in children is based almost exclusively
in clinical data. Use CT or endoscopy in selected cases.
• There are very few controlled clinical studies of CRS in
children. All Guidelines based in adult studies and
transpolated to children.
• The most common causes are bacterial infections and/or
allergies. Other causes are really not frecuent or rare, but
still have to rule out them if not responsive