Pediatric Sinusitis: Complications and Management in the Emergency Department

Table of Contents

 

About This Issue

Acute bacterial sinusitis (ABS) is a clinical entity that affects many children and may be further complicated by the development of orbital, intracranial, and osseous complications. Differentiating between viral upper respiratory infections and ABS and identifying cases of ABS that require antibiotics can pose a challenge for emergency clinicians. This issue describes evidence-based diagnostic criteria for the appropriate identification and treatment of pediatric ABS and its complications. In this issue, you will learn:

Sinus anatomy and general patterns of sinus development

The pathophysiology of sinusitis

Factors that increase susceptibility to sinusitis

The prevalence of ABS complications and the Chandler classification system of orbital complications

Common viral, bacterial, and fungal species associated with sinusitis

The regional differential diagnosis for ABS

Diagnostic criteria for uncomplicated ABS and red flag symptoms for complicated ABS

When diagnostic studies are indicated, and which studies should be ordered

Evidence-based recommendations for management of uncomplicated ABS and complicated ABS

Special considerations for high-risk patients, infants and young children, patients with recurrent ABS, and those with fungal sinusitis

plications

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Sinus Development
   2. Sinus Anatomy
   3. Sinus Physiology
   4. Pathophysiology of Sinusitis
   5. Microbiology of Sinusitis
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
11. Treatment
    1. Management of Uncomplicated Acute Bacterial Sinusitis
    2. Management of Complicated Acute Bacterial Sinusitis
    3. Ancillary Treatments
12. Special Populations
    1. High-Risk Patients
    2. Infants and Younger Children
    3. Patients With Recurrent Acute Bacterial Sinusitis
    4. Patients With Fungal Sinusitis
13. Controversies and Cutting Edge
    1. When to Prescribe Antibiotics
    2. Amoxicillin Versus Amoxicillin-Clavulanate and Duration of Treatment
    3. Doxycycline and Teeth Staining
    4. Antibiotic Versus Surgical Management for Subperiosteal Abscess
    5. Anticoagulation for Cerebral Vein Thrombosis
14. Disposition
15. Risk Management Pitfalls for Pediatric Patients With Acute Bacterial Sinusitis
16. 5 Things That Will Change Your Practice
17. Summary
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Management of Pediatric Patients With Sinusitis in the Emergency Department
21. Tables and Figures
22. References

Abstract

Upper respiratory infections are some of the most common reasons for pediatric patients to present to the emergency department. A small percentage of these viral infections can evolve into acute bacterial sinusitis (ABS), which can be further complicated by the development of orbital, intracranial, and osseous complications. Differentiating between viral upper respiratory infections and ABS and identifying cases of ABS that require antibiotics can pose a challenge. This issue highlights the patterns of illness that are most consistent with ABS, based on the most current clinical practice guidelines. Additionally, this issue reviews clinical features that should raise suspicion for complicated disease and provides associated diagnostic and management pearls.

Case Presentations

A 5-year-old girl is brought into the ED by her father for persistent fevers and runny nose over the past 3 days...

• The father tells you he is worried that her fevers recur after 5 to 6 hours, despite oral antipyretics.
• On examination, the girl is playful and interactive. Her tympanic membranes are nonerythematous, but she is noted to have yellow nasal discharge. Her father asks for a prescription for antibiotics, since he had a similar illness last week and that was “the only thing that helped.”
• How should you approach counseling with this father regarding antibiotic use for his child?

A 4-year-old boy presents to the ED with a 1-week history of runny nose, nasal congestion, and low-grade fevers...

• His mother became concerned due to increased fevers up to 39.4°C and copious nasal discharge over the last day.
• The boy is running around and is interactive. He has thick green nasal discharge. His tympanic membranes are nonerythematous, and he has full range of motion of his neck.
• What treatment plan would be most appropriate for this patient?

A 13-year-old boy with severe headache and forehead swelling is brought in by EMS...

• The boy has a 1-week history of headache and nasal congestion, with new-onset forehead swelling and worsening pain over the past 24 hours. He is febrile with a temperature of 38.5°C and has notable swelling and tenderness of the forehead. He has difficulty with bilateral lateral gaze but is moving all extremities. He does not have nuchal rigidity or photophobia.
• What studies should you obtain for this patient? What is your diagnosis?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Management of Pediatric Patients With Sinusitis in the Emergency Department

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

4. * Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280. (AAP clinical practice guideline) DOI: 10.1542/peds.2013-1071

5. * Chow AW, Benninger MS, Brook I, et al. Executive summary: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):1041-1045. (IDSA clinical practice guideline) DOI: 10.1093/cid/cir1043

29. * Sawada S, Matsubara S. Microbiology of acute maxillary sinusitis in children. Laryngoscope. 2021;131(10):E2705-E2711. (Prospective; 31 patients) DOI: 10.1002/lary.29564

46. * Tekes A, Palasis S, Durand DJ, et al. ACR Appropriateness Criteria^® sinusitis-child. J Am Coll Radiol. 2018;15(11):S403-S412. (ACR clinical practice guideline) DOI: 10.1016/j.jacr.2018.09.029

66. * Savage TJ, Kronman MP, Sreedhara SK, et al. Treatment failure and adverse events after amoxicillin-clavulanate vs amoxicillin for pediatric acute sinusitis. JAMA. 2023;330(11):1064-1073. (Retrospective cohort; 198,942 patients) DOI: 10.1001/jama.2023.15503

69. * Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology. 2000;107(8):1454-1456. (Prospective; 40 patients) DOI: 10.1016/s0161-6420(00)00242-6

76. * Saposnik G, Bushnell C, Coutinho JM, et al. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association. Stroke. 2024;55(3):e77-e90. (AHA clinical practice guideline) DOI: 10.1161/str.0000000000000456

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Keywords: pediatric sinusitis, bacterial sinusitis, viral sinusitis, allergic sinusitis, fungal sinusitis, sinusitis complications, sinusitis treatment, cerebral sinus thrombosis, anticoagulation, rhinosinusitis, pansinusitis, upper respiratory infection, sinus development, sinus anatomy, Chandler classification system, orbital cellulitis, forehead swelling, periorbital swelling, pediatric facial swelling, osteolysis, osteomyelitis, cerebral vein thrombosis, subperiosteal abscess, runny nose, nasal congestion, pediatric nasal discharge, Pott puffy tumor