Imaging studies unnecessary for children with uncomplicated acute sinusitis

AAP 2011 National Conference

BOSTON — Stringent criteria should be used to diagnose a child with acute bacterial sinusitis, according to a presenter during the American Academy of Pediatrics 2011 National Conference and Exhibition.

According to Infectious Diseases in Children Editorial Board member Ellen Wald, MD, the three common clinical presentations for acute bacterial sinusitis include: 1) onset with persistent symptoms; 2) onset with severe symptoms; and 3) onset with worsening symptoms.

Ellen Wald

“Onset with persistent symptoms is far and away the most common presentation,” Wald said during her presentation.

Acute sinusitis with persistent symptoms is defined as infection with respiratory symptoms of nasal discharge or daytime cough that persists for 10 to 30 days without improvement. Nasal discharge may be of any quality in these children, and the cough is also worse at night.

In children who present with persistent onset of acute sinusitis, fever, headache and facial pain are variable symptoms, according to Wald.

“These children come to you not because they are horribly ill but because they have persistent respiratory symptoms that simply do not go away,” Wald said.

Wald stressed that when these stringent criteria are applied to children with persistent symptoms who present to most office practices with respiratory symptoms, “only 6% to 7% of children will meet those criteria. It’s really not an abundance of children,” she said.

Onset with worsening symptoms is the second most common presentation of acute sinusitis, otherwise known as double sickening. This typically begins with children having a viral upper respiratory infection (URI) with nasal discharge with or without cough. Their symptoms improve slightly but then on day 6 to 8 of symptoms, the symptoms will worsen significantly with increased nasal discharge, severe headache or fever.

“This is a classic presentation of a secondary bacterial infection of a viral URI,” Wald said. “This is the way we see presentations of acute otitis media, acute bacterial sinusitis and acute bacterial pneumonia.”

The third most common presentation of acute bacterial sinusitis is onset with severe symptoms, defined as the presence of a high fever ( ≥39ºC) plus purulent nasal discharge for at least 3 to 4 consecutive days.

“These children who present with severe onset of acute sinusitis need to be distinguished from children with uncomplicated viral infections who have a moderate illness,” Wald said.

Wald said it is important to remember that most children with uncomplicated viral URIs do not have fever, or the fever presents early in the course of illness and then dissipates to let the respiratory symptoms flourish.

As for imaging studies to diagnose a child’s sinusitis, Wald recommends skipping the procedure because the literature does not support it. According to Wald, studies have shown that a URI causes inflammation in all the mucous membranes in the nose, sinus cavity, middle ear, nasopharynx and oropharynx.

Several studies of imaging of the paranasal sinuses reported abnormalities in 70% to 87% in children with URIs but not sinusitis. Therefore, Wald said that normal images definitely prove that a child does not have sinusitis, but abnormal images do not confirm sinusitis.

“We can make an emphatic recommendation now that images should not be used for children who present with uncomplicated sinusitis,” Wald concluded.

Disclosure: Dr. Wald reports no relevant financial disclosures.

Stan L. Block

I think that Dr. Wald' s approach to sinusitis in the child with a bad runny nose, cough, with or without fever has withstood the test of time. The gray zones for sinusitis recommendations seem to be the duration of symptoms. This is what really puts the practitioner in a bind. For example, when a parent and child present to the office with purulent rhinorrhea for 3 to 5 days, fever to 101°F, and a demand for antibiotics, we have to make a difficult and controversial, often times antagonistic, choice.

My approach to this case has now evolved into the following compromise discussion: "We are not going to prescribe antibiotics today, as most of the time this cold is a viral URI, which will spontaneously resolve in most of the children over the next several days. However, if the runny nose does not improve or worsens by day 9 or 10, we figure that most of the time this turned into a bacterial sinusitis and will likely respond well to antibiotics.

"You will not require a second office visit, since sinusitis is mostly a diagnosis by history and symptoms any way. You can just call us back later this week (after day 9 or 10) and we can phone in antibiotics for bacterial sinusitis."

Just be keenly aware to avoid the weekend day 9 or10, as you may have a very unhappy, unsuspecting partner on call. Thus, we have done our due diligence about Dr. Wald's duration of sinusitis symptoms. The parents know we are sympathetic, really working with them and sparing them a lot of inconvenience, a second co-pay, and an additional lost work day. They actually are quite accepting of this compromise. I rarely ever receive parental contentiousness with this approach. It also usually helps them avoid the urgent care's often looser pens over the next few days of rhinorrhea.

Stan L. Block, MD
Infectious Diseases in Children Editorial Board member

Disclosure: Dr. Block reports no relevant financial disclosures.

For more information:

• Wald E. #X2010. Sinusitis for the Pediatrician. Presented at: AAP 2011 National Conference and Exhibition. Oct. 15-18, 2011. Boston.

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