Учебники / Pediatric Sinusitis and Sinus Surgery Younis 2006

antibiotic use in children aged 1 to 12 years (48). Complete or near-complete resolution of symptoms was reported in 58% of the children, some improvement in 21%, and minimal or no improvement in 21%. Other studies support the role of adenoidectomy as beneficial in the treatment of rhinosinusitis in the pediatric population (49–52).

Environmental Factors

Environmental factors, including pollutants, irritants, toxicants, and passive cigarette smoke, may cause local irritation or inflammation. Resultant cellular damage may initiate an inflammatory cascade including the release of mediators, attraction of inflammatory cells to the area, and local edema. This could lead to mucosal swelling, decreased airflow, and possible OMC obstruction with subsequent development of rhinosinusitis. Preexisting conditions such as allergic or vasomotor rhinitis may exacerbate the effects of environmental factors.

Environmental factors may also lead to ciliary dysfunction. Aguis et al. found that after in vitro exposure of nasal ciliated cells from nonsmokers to cotinine, a major metabolite of nicotine, there was a significant drop in ciliary beat frequency compared with non-exposed ciliated cells (53). They concluded that cotinine has a marked effect on ciliary function in vitro. Secondhand smoke exposure may thus lead to diminished mucociliary clearance in children and subsequently to rhinosinusitis.

Dubin et al. examined the effect of passive tobacco smoke exposure on eustachian tube function in rats (54). There was a significant alteration in ciliary function and mucociliary clearance time within the eustachian tube. Bascom et al. reported similar results (55). In summary, environmental factors have been shown to affect ciliary function and mucociliary clearance and are likely to be etiologically important in pediatric rhinosinusitis.

CONCLUSION

The management of pediatric rhinosinusitis relies on a clear understanding of the pathophysiology and etiology of the underlying disease process. Any condition that affects the patency of the ostia, the mucociliary clearance mechanism, or the consistency and makeup of the secretions predisposes to rhinosinusitis. Our understanding of the role of comorbidities such as allergic disease, immune deficiencies, and GERD in contributing to pediatric rhinosinusitis continues to increase. Finally, the role of environmental pollutants and particularly of secondhand smoke exposure is increasingly recognized as a cause of rhinosinusitis in children.

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common diagnosis resulting in an antibiotic prescription. The direct medical cost to treat rhinosinusitis in children exceeds $2.4 billion annually in the United States (2).

Definitions

Acute bacterial rhinosinusitis has been defined as an infection of the sinuses lasting not more than 30 days and concluding in complete resolution (3). Subacute disease persists for 30 to 90 days with complete resolution. Recurrent acute disease consists of multiple acute episodes separated by symptomfree intervals of at least 10 days, or alternatively three acute episodes in six months or four acute episodes in one year. Chronic bacterial rhinosinusitis persists for more than 90 days. Acute rhinosinusitis superimposed on chronic disease occurs when patients with chronic rhinosinusitis acquire new symptoms that resolve within 30 days of treatment. The underlying residual symptoms attributed to chronic rhinosinusitis persist in these patients.

DEVELOPMENTAL ANATOMY AS RELEVANT TO

DISEASE WORKUP

The embryologic development of the sinuses is summarized in Table 1. Certain key points regarding sinus cavity growth are germane to clinical, radiologic, and laboratory workup. The clinician must identify the child’s status along the continuum of sinus development in order to adequately assess and treat the disease. The ostiomeatal complex (OMC) is present in nearly full

Table 1 Paranasal Sinus Development

Several other factors related to the development of the sinuses are relevant to disease workup. These include the status of the foramen cecum; the status of the palate, lip, and alveolus; and the completion of closure of the nasal roof. Defects in any of these areas may result in conditions masquerading as, or contributing to, sinus disease. The presence of any of these defects should initiate a multidisciplinary workup rather than symptomatic management of sinonasal complaints. Evaluation of the intactness of the anterior skull base is best performed with computed tomography (CT) scan. Many of the midline nasal masses contribute to obstruction, inflammation, and chronic sinonasal complaints. These are often best evaluated by magnetic resonance imaging (MRI).

DISEASE HISTORY

A comprehensive medical history is essential for the diagnosis of sinus disease in children. This medical history serves a number of purposes. First, a diagnosis is obtained. Second, a reference point for monitoring treatment progress is established. Finally, a document is created that summarizes all relevant data for fellow healthcare providers in a standardized format. Children are often unable to articulate the symptoms of rhinosinusitis. Caregivers must provide information about congenital, genetic, and environmental factors that may influence treatment and outcome.

In fact, family circumstances may assume more importance than many aspects of disease pathology. For instance, time off from work, eligibility for day care while ill, and frequency of physician visits may prompt treatment decisions more than a change in symptoms. Ideally, treatment should address quality of life for all family members. Many providers rely on standardized questionnaires to avoid overlooking important details in this regard (7).

Chief Complaint

The chief presenting complaint of a child or caregiver may include:

frequent anterior or posterior nasal drainage

daytime cough

nasal congestion

low-grade fever

ear pain or fullness

irritability

headache

halitosis

behavior problems

learning problems

poor growth or failure to thrive

snoring

frequent snorting

cyclic vomiting (8)

anorexia nervosa (9)

chronic fatigue (10)

More severe cases of sinus disease may present as purulent rhinorrhea, a high fever, or periorbital edema. Nighttime cough is more prevalent in chronic than acute rhinosinusitis. A systematic approach to the documentation of presenting complaints will help to guide treatment, but more importantly, to provide a means for monitoring treatment and maintaining patient/caregiver rapport. This should include the following:

1.age at onset

2.severity

3.associated symptoms

4.alleviating factors

5.aggravating factors

6.any variation in the degree of severity or pattern of the complaint

7.a description of the nature of the complaint, for instance, burning, sharp or dull pain

History of Illness, Past Medical History, and Risk

Factor Assessment

The past medical history should focus on those factors that are treatable or may require otolaryngologic intervention. Occult genetic disorders, correctable lifestyle factors, systemic disease, and risk prevention are all requisite elements of the workup.

Important elements of the past medical history address patient quality of life. Quality of life factors such as time lost from school due to illness, sleep disturbance, interference with daily activity, lack of attention at school or home, and medication side effects are important elements to include in the evaluation of sinus disease. Equally important to document are the previous treatment regimens and response to treatment, including:

1.antihistamines, noting which were effective and any side effects

2.decongestants and route of delivery

3.other nasal sprays—saline, corticosteroids, or anticholinergics

4.asthma medications—oral or inhaled

5.antibiotics, type including length and number of courses

6.previous emergency room/hospital treatment

Inquiry into ear infections is important. About 50% of children with otitis media will ultimately be diagnosed with allergic or infectious sinonasal disease (11). Food sensitivities, drug hypersensitivity, insect sting allergy, eczema, asthma, urticaria or angioedema, and contact sensitivity or

dermatitis are all conditions that indicate systemic atopy and tendency toward sinonasal disease (12). Sinonasal disease is often familial, manifesting in one or both parents, or a sibling. This is particularly true with chronic rhinosinusitis (13). More importantly, high-density occurrence of sinus disease in a family may be the initial indicator of a more serious inherited disorder, as discussed below.

Inhalant allergies are becoming better understood as a major contributor to pediatric rhinosinusitis (14). Atopic conditions are perhaps the most common cause of mucosal edema in the sinonasal spaces and are largely influenced by the child’s family and social environment. About 80% of children undergoing sinus surgery have a positive skin test response to inhalant allergens (12). Many children will not have classic allergy symptoms but may have enough disease manifestation to alter normal nasal function (15). Investigation into an allergic environment should include:

1.type of family dwelling: single or multiple, apartment or home

2.type of heating system: forced air, baseboard, or wood stove

3.type of cooling system: air conditioning, evaporative cooling

4.bedroom: frequency of cleaning, bedding changes, other issues related to hygiene, presence of stuffed animals or dolls (a child spends up to 12 hours daily there)

5.flooring: linoleum, carpeting, or hard wood

6.bedding: conventional mattress or waterbed, hollow-fiber-filled or feather pillow

7.pets: outdoor or indoor and access into bedroom areas

8.other: presence of molds or dampness; use of a humidifier, electrostatic or HEPA filters; and exposure to secondhand smoking

Related Disorder Assessment

Several disease conditions are relevant to both the history and the subsequent laboratory investigation of pediatric rhinosinusitis patients. These are discussed individually.

Cystic Fibrosis and Genetic Disorders

Cystic fibrosis is a disorder in which a transmembrane conductance regulator is defective. Related symptoms and disease states include congenital bilateral absence of the vas deferens, allergic bronchopulmonary aspergillosis, chronic pulmonary infection, and isolated chronic pancreatitis (16). Most patients with cystic fibrosis present to the otolaryngologist for focused workup and treatment often to include surgery for nasal polyposis. Chronic rhinosinusitis in the very young, especially when associated with multiple infections of the ear, nose, and throat, should prompt concern about undiagnosed cystic fibrosis (16).