Учебники / Pediatric Sinusitis and Sinus Surgery Younis 2006

intracranial infection and heart disease is stronger in groups of cyanotic patients where bacterial vegetations are more commonly seen and cause changes in hematological flow (22). Sinus disease is also associated with sub-acute bacterial endocarditis (23). The proliferation and distension of the venous channels and marrow spaces in patients with congenital cyanotic heart disease may alter the bacteriology of the nasal cavity and paranasal sinuses and facilitate the spread of disease (24).

Cleft Palate

Children with a cleft palate are at a higher risk of rhinosinusitis. In a study of 47 patients with cleft lip and alveolus, with and without cleft palate, coexisting rhinosinusitis was observed in 15 patients (32%), a much higher percentage than that seen in the general population. The paranasal sinus cavities are known to be significantly smaller in patients with cleft palate. Whether this contributes to the higher prevalence of rhinosinusitis is unknown.

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is increasingly recognized as a factor in many otolaryngologic disorders. Several studies have shown a correlation between frequency and severity of rhinosinusitis and the degree of reflux (25–27).

Disorders of Inflammation and of the Immune System

Immunoglobulin deficiency: A history of recurrent upper respiratory tract infection (URI) should prompt suspicion of an underlying immune disorder. Children in developed countries normally experience six to eight viral upper respiratory infections each year. About 10% of these URIs are complicated by a secondary bacterial rhinosinusitis. An increase in the frequency of URIs above the normal threshold should prompt further investigation (28).

Chronic sinus conditions are now more appropriately characterized as derangements of the local or systemic immune system rather than unremitting bacterial colonization. Close associations between asthma, allergy, and sinus disease are now clear, largely due to identifiable and treatable humoral and cellular immune dysfunction. Immunoglobulin deficiency or dysfunction may be the most common cause of pediatric rhinosinusitis and may involve any of the four typical families of immunoglobulins. Consideration of immune defects in the patient history is important for several reasons. Prophylactic antibiotic therapy can reduce or resolve symptoms in patients with mild immune deficits, and intravenous immunoglobulin therapy (IVIG) can be added in more refractory disease with beneficial results (29). Realistic expectations regarding surgery efficacy can be established. Finally, patients and family members may express relief to have a treatable and understandable diagnosis.

Immunodeficiency, T-cell dysfunction, and HIV: T-cell dysfunction may be the most common immune disorder contributing to chronic rhinosinusitis. DiGeorge syndrome, discussed previously, is the most common identifiable T-cell disorder. Unlike the conditions of immunoglobulin deficiency, systemic T-cell dysfunction usually manifests early with severe systemic illness that may overshadow sinonasal complaints.

The population of pediatric patients with HIV continues to grow (30). Generally, a diagnosis has been established prior to subspecialty referral. Often, sinonasal complaints will involve atypical pathogens such as fungus, or neoplastic disorders. An increased incidence of atopic disease has also been found in HIV patients (31). The otolaryngologist should maintain a high suspicion for these disorders, as routine sinonasal pathologies will present in an even greater frequency in these patients.

Tuberculosis and mycobacterium infection: The prevalence of tuberculosis in children in the United States may be rising (32), and the problem of drug resistance has made treatment of this disease difficult. The possibility of tuberculosis infection should be considered when chronic rhinosinusitis is diagnosed in a child with a family member with tuberculosis or with recent travel to places where tuberculosis is endemic.

Mucormycosis: This condition is almost always seen in diabetic children. Unfortunately, children commonly present without antecedent URI complaints and with a rapidly progressing sinonasal complaint. Predisposing factors in addition to diabetes include acquired or induced immunodeficiency of a genetic, infectious, or chemotherapeutic nature. A history of type-I diabetes or systemic immune disease with rapidly progressive sinus symptoms, including proptosis, diminishing vision, headaches, or mental status changes, should prompt suspicion of this condition.

Additional Behavioral and Social Assessment

There is a higher prevalence of rhinosinusitis in females than males (33,34). Breast-feeding provides protection against rhinosinusitis in young patients. Inner city living (35), low income (36), tobacco use (37), day care (38), and swimming impart increased risk.

REVIEW OF SYSTEMS

Recent health problems merit specific inquiry. These include:

URIs

ocular complaints

pharyngitis

otitis media

asthma

GERD

PHYSICAL EXAMINATION

The components of a thorough physical exam include:

vital signs

general appearance

scalp and skin examination

cranial nerve exam including ocular motility and gross visual acuity

otologic examination, including pneumotoscopy

nasal cavity examination—symmetry of nares, drainage, and mucosal appearance

endoscopic examination of the nasal cavities with or without cultures

oral cavity and oropharyngeal examination

palpation of the face

neck examination

chest, cardiovascular, and abdominal examination

Fever and other vital signs are of value in identifying the child at risk for sepsis or intracranial complications. A tachycardic or hypotensive child may be dehydrated. General appearance and systemic evaluation may elicit syndromic conditions predisposing to sinus disease. The physical exam can provide information concerning sinus-related conditions such as atopy. A lethargic or disoriented child, particularly with cranial nerve deficits, should prompt investigation for intracranial complications. Reproducible unilateral pain, present on percussion or direct pressure over the body of the frontal and maxillary sinuses, may indicate a diagnosis of acute bacterial sinusitis (39).

Otologic examination may reveal a coincident otitis media. An endoscopic culture of the middle meatus is considered by many to be the gold standard for the diagnosis of rhinosinusitis (40). The intranasal examination may demonstrate several features that may predispose to rhinosinusitis including a septal deformity, a concha bullosa, or abnormalities of the uncinate process (41). Allergic mucosa may be seen in the nasal cavity, manifesting as boggy, bluish changes with clear drainage. The general facial examination may identify several features of atopy including allergic shiner (periorbital edema), a supratip ‘‘allergic’’ nasal crease (chronic upward rubbing of the nasal tip), and Denny’s lines (small lower eyelid creases from chronic mild edema of this region).

The oral cavity and pharynx should be assessed for adenotonsillar hypertrophy, palatal clefting, and asymmetry. The neck should be assessed for lymphadenopathy suggestive of systemic disease. Pulmonary examination may reveal generalized wheezing indicative of asthma. The remainder of the

examination may elucidate occult systemic conditions with rare sinonasal manifestations, as discussed above.

OTHER CLINICAL AND LABORATORY INVESTIGATIONS

Laboratory investigations that are relevant to pediatric rhinosinusitis may include:

nasal aspirate

chloride sweat testing

exhaled nitrate testing

mucosal biopsy

complete blood count (CBC) with differential

immunoglobulin assays

erythrocyte sedimentation rate (ESR)

Sweat testing is employed for identification of cystic fibrosis. Exhaled nitrate testing has been proposed both for the identification of KS as well as a general screening tool for rhinosinusitis (42). Nitrate levels are well below normal in children with KS and in children with infection (43). Mucosal biopsy may also be helpful in identifying primary ciliary disorders.

Three other techniques have been employed for the measurement of in vivo ciliary clearance. These include the saccharin test, the methylene blue dye test, and the radioisotope test. Each involves placing a droplet of test substance into the front of the nose and assessing time to detection by patient sensation, by visual detection in the oropharynx, or by radioisotope scanner.

A raised white cell count suggests acute infection. More detailed hematology and serology workup may be necessary in a suspected case of HIV. Immune dysfunction can be screened using immunoglobulin assays. Generally, all subclasses are assayed, with particular attention to IgA and IgG. The diagnosis of IgA deficiency cannot be made before the age of two years. Patients with IgA deficiency associated with selective IgG subclass deficiency appear to be more susceptible to respiratory tract infections than those who do not have IgG deficiency (44). ESR may be of benefit in screening for chronic disorders that contribute to rhinosinusitis.

RADIOGRAPHIC EVALUATION

Radiographic imaging is generally reserved for children with refractory rhinosinusitis who are candidates for operative management. Less frequently, it is used to exclude complications of rhinosinusitis or in looking for suspected neoplastic or fungal disease. Concern persists regarding unnecessary radiation exposure. A typical plain film of the pediatric skull exposes a child’s orbit to

to CT in assessing the status of the anterior skull base and orbit in neoplastic disease. Contrast-enhanced MRI may be used to distinguish inflamed meninges from tumor invasion and is invaluable in preoperative planning for a potentially disfiguring and debilitating operation. MRI also has a role in the diagnosis and surgical planning for fungal rhinosinusitis.

Ultrasound

In Europe, ultrasound has been used to screen for rhinosinusitis and to monitor treatment progress, but it has not been used widely in the United States (54,55).

OTHER TESTS

These may include allergy workup, investigations for GERD, workup for ciliary dysfunction, and genetic testing and counseling.

OTHER DIAGNOSTIC CONSIDERATIONS

Pediatric sinusitis is often more a disease of a family rather than a child. The health status of the child will often impact the whole family, particularly parental ability to work. Several quality of life instruments have been developed and validated to quantify the impact of the disease on the child and family (56,57). Monitoring diagnosis and treatment as it impacts the family is an important part of the clinical management of rhinosinusitis.

NATURAL HISTORY OF DISEASE

Uncomplicated rhinosinusitis spontaneously resolves in 40% of patients. A placebo study of 188 randomized patients in a group of community-based clinics demonstrated no outcome difference between comparable groups of children treated with amoxicillin, amoxicillin-clavulanate, or placebo (58).

SUMMARY

The current management of pediatric rhinosinusitis stresses prevention, evidence-based treatment, and continuing quality of life assessment. The risk to the individual from incomplete or improper workup and treatment may be low in most cases, but the cost to society and the inconvenience to the child’s family and other social infrastructures are substantial. As a rule, medical treatment should be exhausted before surgery is considered as therapy for pediatric rhinosinusitis (59).

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