Upper respiratory infections in children are the most common reason for visits to the pediatrician. Viruses are usually to blame for the few days of runny/stuffy nose, head fullness and irritability. When the yellow/green nasal drainage persists beyond the expected three to seven day course of a viral infection, bacterial sinusitis is often the culprit.

The sinuses are cavities in the skull surrounding the nose: a pair under the cheek bones, a pair above the eyebrows, a single one directly behind the nose, and several small ones along the bridge of the nose between the eyes. Sinusitis according to the medical dictionary means "inflammation of the sinus cavities". When a physician tells you that you have sinusitis they typically are referring to bacterial sinusitis. This means that the inflammation, or swelling, of the sinuses is due to a bacterial infection.

Sinusitis in children is much more common than originally thought. Research studies using CAT scans of the sinuses have helped to establish the high frequency of sinus infections, many times in cases where the doctor would have missed the diagnosis. Armed with an increased suspicion of sinusitis in children and a greater understanding of the characteristic symptoms, we are better able to diagnose and properly treat sinus disease.

Keys to diagnosis

There are basically two types of sinus infection, acute and chronic sinusitis. The distinction between the two is made according to the duration and type of symptoms. An acute infection develops over one-two days with fever, yellow/green nasal drainage, pain over the sinuses and occasionally pain referred into the teeth. On the other hand, a chronic infection can persist in a more subtle manner over weeks to months with nasal congestion, flares of yellow/green drainage with days of clear secretions in between, bad breath, and vague loss of energy. It is important to distinguish between the acute and chronic infection because treatment is vastly different (see below).

The principles of diagnosing chronic or recurrent sinusitis in children and adults are similar with a few distinctions to be made. In considering the source of infections in children the physician will inquire into such factors as the number of siblings, day care setting, smoking status of household members, allergies in the patient and family, immune status (frequency of other infections), and structural abnormalities including enlargement of the adenoids or foreign body obstruction.

Cough may be the only manifestation of sinus disease in both children and adults. Persistent daytime or nighttime cough - with or without a history of wheezing - in a child with a normal chest examination should alert the doctor to think of sinusitis. Adults will more often describe the concomitant classic symptoms of headache, postnatal drip and facial pressure.

The role of allergies

Nasal allergies, often called hay fever, predispose people to develop sinus congestion and eventually sinusitis. Under normal conditions the sinus cavities should be air-filled. The small amount of fluid made within the sinus is swept out through a small opening into the nose by movement of tiny hair-like extensions called cilia. Once the fluid is in the nose it is then swallowed as post-nasal drainage into the stomach.

When the nose becomes stuffy from breathing in dust, pollen or mold spores, two things happen: 1) mucous membranes in the sinuses also swell keeping the cilia from working properly, and 2) the opening into the nose where sinus fluid normally passes becomes blocked by the nasal swelling. Both of these events disrupt sinus drainage allowing fluid to accumulate causing pressure and/or pain. The mucus builds up, and bacteria and viruses multiply, causing sinus infections.

Allergies should be suspected in children with a family history of allergies, recurring sinus infections, a seasonal pattern of symptoms, worsening nasal symptoms when exposed to animals or dust, and other allergic conditions such as asthma, eczema or food allergy. Children as young as one year old can undergo simple allergy skin testing to determine whether they are allergic. Recognizing and treating the allergic reactions in the nose will prevent the first step of the development of a sinus infection.

Treatment

The goal of treating bacterial sinusitis is two-fold: to sterilize the sinuses (that is, kill the invading bacteria) and improve sinus drainage through the nasal passages. A frequent cause of treatment failures or for a recurrence of symptoms several weeks later is inadequate attention to one of these two areas.

1. The simple 10-day course of antibiotics is fine for an acute sinusitis, an infection having begun only a few days earlier. A chronic sinusitis, on the other hand, requires antibiotics for 4-6 weeks to resolve. The child who has received 10 days of various antibiotics every few months for recurring symptoms is probably suffering with a single infection that has never been completely cleared rather than several new sinus infections.
2. Ignoring a child’s stuffy nose is asking for sinus trouble. There are various ways to improve nasal function - prescription nose sprays (steroids such as Vancenase, Flonase, Beconase, Nasonex, Nasarel, and Rhinocort) are the best for kids old enough to use them, antihistamine/decongestant combinations are available for all ages, over the counter cromolyn sold as Nasalcrom, allergy shots for the allergic patient, "irrigating" the sinuses with salt water, and sinus surgery, in resistant cases, can effectively restore drainage.

As with most diseases, the best action you can take is prevention. Finding out whether allergies are causing your child’s problem can start you on your way to preventing further episodes of sinusitis. If allergies are not the problem, early detection of nasal congestion and immediate, appropriate treatment can help you fight sinusitis.