What Is Rhinosinusitis?
The inflammation of the mucous membranes in the nasal and paranasal sinuses is called rhinosinusitis. In children, chronic rhinosinusitis (CRS) is a prevalent issue that poses challenges for diagnosis and treatment due to the similarity of symptoms with adenoid hypertrophy and allergic rhinitis. Although less common than acute rhinosinusitis, CRS is on the rise and can significantly impact a child's quality of life, impairing their daily functioning. Various factors contribute to the development of CRS, including viral infections, bacterial infections, mucosal inflammation, and predisposition to allergies.
What Causes Rhinosinusitis in Pediatrics?
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Genetic Predisposition - According to research, CRS has a strong genetic predisposition, as demonstrated by familial association studies. The risk of developing CRS is 57.5 times higher for relatives of CRS patients, 9 times higher for first cousins, and 2.9 times higher for second cousins. This genetic predisposition may be related to genes encoding potassium channels on the airway epithelium.
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Allergy - Allergic rhinitis (AR) is a significant contributing factor and a comorbid condition with pediatric CRS. It is more prevalent than other comorbidities combined in children with CRS, but the prevalence of AR in CRS patients is similar to that in the general pediatric population. Indoor aeroallergen sensitivity is more common than outdoor aeroallergen sensitivity in children with CRS. The most common indoor aeroallergen is dust mites, while the most common outdoor aeroallergen is tree pollen. Inflammation of the sinuses can be evaluated by histopathological examination, detection of molecular components of the immune system, and expression of pro and anti-inflammatory cytokines. Mast cells and eosinophils are found in the nasal and bronchial mucosa of individuals with allergic rhinitis and asthma. Medical and surgical management of CRS has been shown to improve asthma symptoms and lung function. Children with CRS and asthma show increased levels of inflammatory cytokines in their sinus tissue compared to non-asthmatic children with CRS.
How to Diagnose Rhinosinusitis in Pediatrics?
The diagnosis of acute and chronic rhinosinusitis in children is typically based on clinical evaluation alone. However, in some instances, it may be necessary to obtain sinus imaging or a specimen of sinus secretions for microbiological assessment.
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Imaging Studies - Imaging is not essential for diagnosing rhinosinusitis in children. Transillumination of the sinuses is unreliable, and the value of ultrasound is controversial. Plain radiographs can assess maxillary or frontal sinuses if CT scans are unavailable. CT scans are necessary if sinus surgery is being considered or in the presence of severe illness, toxicity, immunodeficiency, or suppurative complications.
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Microbiological Assessment - This is generally not required in children with uncomplicated acute or chronic rhinosinusitis. Exceptions to this include children who are severely ill, toxic, immunocompromised or have suppurative complications. There is no consensus on whether middle meatal cultures can replace sinus punctures, but they may be more likely to yield positive results.
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Sinus Aspiration - Sinus aspiration is indicated for cases of sinusitis that do not respond to multiple courses of antibiotics, severe facial pain, and suspected sinusitis in an immunocompromised child in whom unusual pathogens such as fungi may be present. Although it can be performed on an outpatient basis, it is generally not well-tolerated in children without anesthesia.
CRS is prevalent in individuals with CVID, and selective IgG3 subclass deficiency weakens the host's defense against Moraxella catarrhalis and the M component of Streptococcus pyogenes.
Allergy testing, such as skin prick testing or specific allergen IgE levels, a sweat chloride test and genetic testing for cystic fibrosis, and nasal and preferably bronchial biopsies and genetic testing for primary ciliary dyskinesia, may also be necessary.
In cases of recalcitrant rhinosinusitis, underlying conditions such as immunodeficiency, allergy, cystic fibrosis, gastroesophageal reflux, and ciliary immotility disorders should be considered. Respiratory allergy is a common underlying condition, and an allergic assessment should be performed in children with chronic or recurrent acute rhinosinusitis who continue to have clinical difficulties despite avoidance and simple pharmacological measures. An immunologic assessment is also recommended.
How Is Rhinosinusitis Treated in Pediatrics?
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Acute Rhinosinusitis - Antimicrobial therapy for acute rhinosinusitis is indicated in severe illness, toxic conditions, or non-severe cases with protracted symptoms and other conditions like asthma or chronic bronchitis. The duration of treatment should be at least 10 to 14 days and can be prolonged to 1 month if symptoms have not entirely resolved.
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Chronic Rhinosinusitis - An initial course of two weeks of oral antimicrobial treatment is advised for chronic rhinosinusitis, with changes in antibiotics or obtaining a specimen of sinus secretions for culture if there is no response.
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Intranasal Steroids - They are recommended for chronic, nonpurulent rhinosinusitis in children with an established diagnosis or suspicion of allergic rhinitis.
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Adenoidectomy - Adenoidectomy is recommended in the presence of moderate-to-severe nasal obstruction secondary to adenoid hyperplasia, and antral aspiration and lavage are indicated in severe, unresponsive, or complicated conditions.
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Endoscopic Sinus Surgery - It is a reasonable alternative to continuous medical treatment for chronic rhinosinusitis that persists despite optimal medical management. Still, it should be considered only after excluding any systemic disease. Children who are eligible for sinus surgery represent only a small fraction of all children suffering from chronic rhinosinusitis.
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Antral Lavage - The indications for antral lavage are similar to those for sinus puncture. However, according to research, antral lavage may not be effective for younger children with chronic rhinosinusitis.
The standard treatment for pediatric rhinosinusitis is nasal irrigation and antibiotic use. For pediatric CRS, medical treatment includes avoiding allergens (such as environmental or food allergens), therapy with nasal irrigation, nasal corticosteroid sprays, nasal decongestants, and antibiotics aimed at the most common sinonasal organisms, including Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.
Surgical intervention is rarely necessary following appropriate medical treatment. If medical treatment fails, referral to an otolaryngologist and allergy specialist is recommended.
Conclusion:
Rhinosinusitis in children is a complex condition involving multiple contributing factors that vary in significance as children grow older. Depending on the duration of symptoms, pediatric rhinosinusitis can be classified as acute or chronic, each requiring distinct diagnostic and therapeutic approaches. Chronic rhinosinusitis (CRS) is often associated with comorbidities such as allergic diseases, and treating these underlying conditions is a crucial part of the medical and surgical management of the disease.
