Pediatric Sinus Disorders
Pediatric Sinusitis and Sinus Infections
Sinusitis is the inflammation of one or more of the sinuses that drain into the nose. In children, a common cold or viral infection is the most common event that may lead to a sinus infection. Also, foreign bodies such as a peanut, a raisin or a bead pushed into the nose may cause a nasal infection. When an infection begins, the lining of the sinuses may become swollen, blocking the passage where normal sinus mucus drains. This results in a back up of mucus, which cannot get out. When this mucus remains in the sinus too long it can become infected. Many of the signs of childhood sinusitis are the same as the common cold. When the symptoms of a cold last longer than 7 to 10 days it is time to consider a sinus infection. Common pediatric sinusitis symptoms include:
- yellow or green nasal discharge
- headache (in older children)
- facial pain or facial pressure
- swelling around the eyes
Fungus is present in all our surroundings and the air we inhale. Most healthy people do not react to the presence of fungus due to a functioning immune system. However, in rare instances, fungus may cause inflammation in the nose and the sinuses. Fungal sinusitis can come in many forms, differing in pathology, symptoms, course, severity, and the treatment required. Treatment involves surgery in combination with medical therapy using anti-fungal agents.
Sinusitis and Asthma
Allergic rhinitis and asthma are both conditions in which there is inflammation of the affected airway. The symptoms of rhinitis are runny nose, stuffy nose, nose itching, sneezing, and mucus dripping down the back of the nose. Asthma usually causes episodes of breathlessness, chest tightness, and wheezing. The severity of both conditions can vary by season. Adding medications for allergic rhinitis to the treatment for asthmatic patients can improve control of asthma. Endoscopic sinus surgery for the treatment of rhinosinusitis and nasal polyps in patients with asthma also appears to improve asthma control.
When the back of the nose is not open or not communicating with the rest of the airway this is called choanal atresia. It is a congenital condition (meaning a person is born with it) that occurs in about 1 in 6,000 to 8,000 live births. It has been reported in association with maternal use of methimazole. Patients may have noisy breathing, turn blue while sleeping or feeding, and aspirate milk. When the patient awakens, coughs or cries the mouth will open again, allowing air to move through to the lungs, and symptoms will often temporarily resolve. Feeding slowly can allow the baby to breathe between swallows. However, a feeding tube is often placed from the oral cavity into the stomach to make sure that the patient safely receives adequate feeds.
The choanal atresia can be repaired or opened with a surgical procedure. There are multiple techniques that can be used during surgery, but most often an endoscopic approach is used. With an endoscopic approach, there are no incisions on the face or the roof of the mouth. The procedure is done through the nostrils. The bone and soft tissue that is blocking the opening is taken down until it is open to the area where it connects with the pharynx. More than one surgery is often necessary to try to keep the nasal airway open. A medication called mitomycin may be used during surgery to reduce postoperative scarring. However, a suitable airway is attainable in the vast majority of patients.
Cystic Fibrosis (CF) is a disease that affects multiple systems in the body including the lungs, the digestive tract, and the sinuses. CF is the most common lethal inherited disease in the Caucasian population, with an incidence of 1 in 20 newborns. The earliest sign of CF is meconium ileus and is seen at birth in approximately 20% of infants with CF. Pancreatic insufficiency is also very common and causes stunted growth and development. The most common presenting symptom is respiratory manifestations including a chronic cough, wheezing, and recurrent upper or lower airway infections. Patients with upper respiratory manifestations commonly have severe nasal polyposis and thick tenacious mucus. Undiagnosed children may have nasal polyposis as their presenting finding. Other symptoms of sinus disease include post nasal drip, headaches, constant need to clear one’s throat, nasal obstruction, loss of taste or smell and severe bad breath.
Currently there is no cure for CF. However, patients benefit from a CF team consisting of multiple medical specialists, including pulmonologists and otolaryngologists. Medical therapies like hypertonic saline, intravenous and topical/nebulized antibiotics and pancreatic enzymes have somewhat alleviated the symptoms of this disease and have helped extend expected life spans of CF patients. Nasal irrigations are particularly helpful in the sinuses to help clear thick sticky mucus.
Medical treatment of the sinuses, although individually assigned to each patient, commonly consists of saline irrigations, oral or topical antibiotics, and nasal steroids. Surgical treatment of sinus disease could be considered for frequent recurring pulmonary exacerbations, pre- or post-lung transplant, and/or persistent symptoms such as headaches or nasal obstruction. Endoscopic sinus surgery removes the obstructing nasal polyps and opens the sinuses, which facilitates mucus clearance and allows access for mechanical irrigations.