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The Informed Parent

Sinusitis in Children: Often Times Things Aren’t Always As They Appear

by Louis P. Theriot, M.D., F.A.A.P.
Published on Apr. 23, 2007

Pat, a 20-year-old college student, was home for a week on Easter break. The family had planned a trip together. Mom made the appointment because she was afraid they might have to cancel since Pat was so sick.

He attended school back East. It seemed to him that since December most of the college students were sick with one thing or another. He had been doing quite well until two days before flying home. That was when he developed nasal congestion, fever and terrible pressure in his forehead and right cheekbone. The pressure intensified greatly throughout the flight. During takeoff, "I thought that my eye was going to explode right through the eye socket."

This was day five of his illness. His temperature was 101.5 degrees. He had an impressive cough and sounded significantly congested. He complained that, "Even my teeth hurt!" The result of his examination found his eardrums normal and his throat noticeably red. He presented with a thick yellowish post-nasal drip and was uncomfortably tender in the forehead and over the right cheekbone.

Twenty-eight-month-old baby Nikki came to the office with a chief complaint of bad breath. According to mom this foul breath had been going on for some time.

"I get her to brush her teeth at least three times a day. And, she is really good about letting me get in there to be sure that they are brushed properly. But in spite of that, the poor thing just has terrible breath." Nikki was even taken to the dentist to determine if a cavity or other dental problem might be causing the halitosis. The dentist gave her a clean bill of health concerning the teeth. He did comment that Nikki had particularly bad breath and recommended having it looked into.

There was little other history to report. She did not have a fever. A persistent cough was noted at night time and during naps, but it was neither better nor any worse. The only positive finding upon an examination was a thick purulent post-nasal drainage. Ears, lungs and nasal passages were clear and free of any evidence of a foreign body. It should be noted that a foreign body in the nose can cause a horrendously bad smell that can fill an entire room. A physician can literally walk into an examining room where there is a child with a foreign body up the nose, take one whiff, and make a diagnosis.

In two weeks Ty will be a year old. Mom is thoroughly frustrated because he is once again sick. He has goopy, yellow-green nasal discharge, hacking and productive cough, and no appetite.

Consulting his chart Ty was in the office two months ago with similar complaints. He was diagnosed as having a purulent rhinitis, meaning that he had an upper respiratory tract infection that started out viral but had become secondarily infected. At that visit both ears and lungs were essentially clear. It had been going on for a few weeks, and he was started on amoxicillin to treat the infection. According to mom he took the antibiotic for the full ten days; however he only improved but never got completely over it.

Mom then offered the information that after that visit the family took a trip to see the grandparents in another state. While there they took Ty to an urgent care center for the same symptoms. They wanted the baby to be checked out before boarding a plane to fly home, to be sure that he did not have an ear infection. They were told that his ears were clear. But because of the thick green nasal discharge and congestion he was put on seven days of another antibiotic, bactrim. 

Once again he took the medicine faithfully, but the improvement was marginal at best. In fact, just a few days after finishing the bactrim he awake in the middle of the night screaming in pain and grabbing his ear. He was rushed to an emergency room. Sure enough, he had a middle ear infection along with the green runny nose that had been going on for over a month. He was now put on cefzil. The E.R. doctor told mom to be sure and give it for the full ten days. And, have his ears checked when he finishes the antibiotic.

After the seventh or eighth day of the cefzil he got better and his nose actually cleared up. Mom figured he was home free and thought she'd see how he did. She never did come back in for the ear re-check. Literally two days after finishing the cefzil, his nose started to run a thick yellow-green color, his congestion returned and by the next day he was back to square one. In a semi-joking manner his mom said, "I've just about had it with this goopy nose and I am not leaving this office until I get this cleared up!"

Ty did not have a fever. His ears were NOT clear since he had fluid behind both ear drums which were dull in appearance. His throat was slightly inflamed and he had a copious amount of the now famous green nasal discharge. When checking his throat it was obvious that he had an equally copious discharge dripping down the back of his throat.

At first glance these three little vignettes represent three very different patients with very different ailments. In reality, however, they all have the same problem. They all have a sinusitis, or sinus infection.

Pat presented with the classic symptoms of sinusitis that most people would expect. In children the symptoms of a sinus infection may be more insidious and subtle. This is because of the anatomy and development of the sinuses. There are four pairs of sinuses. The frontal sinuses are located in the area of the forehead. The maxillary sinuses are in the cheekbones, and the ethmoid and sphenoid sinuses are positioned around the nose. At birth, the only sinuses that are present are the ethmoid and maxillary sinuses. They are small and do not fully develop until three years of age. While they are small in the toddler age, they have the potential of becoming infected, but the symptoms may be subtle as was the case in Nikki and Ty's infections. The sphenoid sinus starts to develop at approximately three years of age and completes its development by the age of 12. The frontal sinuses start to form around five-to-six years and are fully developed by 12. The frontal sinus is the one that most people associate with "sinus disease"...splitting headache, tremendous pressure in the forehead, the feeling that your teeth hurt, etc. These were the exact symptoms that Pat exhibited.

While it is not difficult to make a clinical diagnosis of sinusitis in an older patient like Pat, it is more of a challenge in the younger patient. The gold standard of diagnostic tests for sinusitis is the CT scan. Routine x-rays of the sinuses in children are not very helpful because they are forming and not yet fully developed. Thus, the x-ray is usually questionable. The CT scan is much more definitive. As for cost, an x-ray of the sinuses and a CT of the sinuses are about the same.

The treatment of sinusitis deserves special attention. Most experts agree that a true sinus infection must be treated with 14-21 days of antibiotics. This is where most people run into problems. The treatment of most ear infections, upper respiratory tract infections and pneumonias require a ten day course of antibiotics. This regimen will successfully treat most, if not all, of these infections...but not a sinus infection. This is precisely what happened in the case of little Ty. He was given various rounds of a ten day course of antibiotics (excellent choices) for what was thought to be routine infections. In each instance he improved, but did not clear. Or the infection came back shortly after he stopped the antibiotic. This was because he actually had the same infection for the entire two months that should have been treated for at least 14 days. This scenario happens all the time.

Sinus disease can present itself in many different ways, some quite obvious, and some much more subtle. It is the responsibility of the physician to have a very high index of suspicion when evaluating these patients in order to properly treat them, and not under treat. If the diagnosis is uncertain, a CT scan of the sinuses should be done to confirm the diagnosis.

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