Sinus infection in Children

Sinus infection in children is a common problem. It results from infections of any one of the sinuses.

The maxillary sinus is the most commonly involved sinus. Sinus infection in children may be caused by bacteria or viruses.

Uncomplicated infections caused by viruses usually resolve with symptomatic therapy within 7 to 10 days.

Most children have sinus inflammation or sinus congestion caused by allergic rhinitis or viral upper respiratory tract infections.

However, inflammation of any cause may predispose the child to bacterial infections.

Supportive care may not be sufficient at this point. Acute bacterial sinusitis must be treated with antibiotics.

Visible manifestations of Sinus infection in Children:

Sinus infection in children usually manifests as one or more of the following signs and symptoms:

  • Fever in sinus infections:

    • Fever is not a chief complaint in most children with a sinus infection.
    • 19 - 30 % of the children with sinus infection have a fever.
    • The fever may be low grade initially but becomes high-grade (101 - 103 F).
    • It may occur throughout the day but is usually noticed in the evening and night.
  • Stuffy nose and clogged ears:

    • Children with a sinus infection develop flu and nasal discharge at the start of the illness.
    • 10% of the children with sinus infection have primarily nasal symptoms.
    • The child may develop sneezing followed by a stuffy nose. Severe sinus congestion may result in clogged ears.
    • Symptoms of nasal blockage and runny nose may alternate.
    • Nasal discharge in sinus infection is usually mucoid but may become purulent in children with bacterial sinusitis.
  • Headache behind eyes and nose:

    • Headache may be the presenting complaint in 8 - 10 % of children with sinus infections.
    • The child may not localize the headache, however, the headache behind eyes and nose is the frequent complaint.
    • Older children may notice worsening of the headache with bending forward or after sneezing. This is mostly seen in frontal and maxillary sinusitis.
    • Some children may characterize the headache as sinus pressure that gets worse when the nasal passages are blocked or after excessive sneezing
  • Postnasal drip

    • Postnasal drip is the irritation caused by the mucus in the throat when it falls back.
    • In sinus infection and stuffy nose, there is an excessive mucous secretion that can not be drained because of the blocked nasal passages. The excessive mucus flows backward resulting in throat irritation.
    • Children may start coughing as a result of foreign body sensation or repeatedly try to clear the throat.
  • Facial pain and swelling:

    • Maxillary sinus infections may result in unilateral or bilateral facial swelling as a result of inflammation of the sinuses.
    • Facial swelling is prominent in the cheeks and around the nose.
    • Frontal sinusitis may cause facial swelling over the forehead and around the eyes.
  • Sore throat and chest congestion:

    • The child might complain of throat irritation, discomfort, pain, and difficulty swallowing.
    • Sore throat and chest congestion is an occasional chief complaint of sinusitis in children.
    • This is usually accompanied by chest congestion primarily manifesting as cough and abnormal conducting sounds with each breath.
    • The cough is usually worse at night.
  • Bad breath:

    • Halitosis or bad breath is present in about 20% of the children.
    • This is usually noticed by family members.
    • It may be associated with distaste as well.

How to differentiate viral from a bacterial sinus infection?

It may be very difficult to differentiate viral from bacterial sinus infections based on the patients' symptoms and signs.

However, the following features suggest a bacterial sinus infection rather than a viral one and warrants the use of antibiotics:

  1. High-grade fever (fever of greater than a 102 F) is usually a sign of bacterial sinus infection.
  2. Bacterial sinus infections have a purulent nasal discharge that may be green or deep yellow. Viral sinusitis usually has a white mucoid nasal discharge.
  3. Viral and allergic sinusitis usually resolves by itself within 7 - 10 days while bacterial sinus infections last longer and seldom resolve by itself.

How to treat sinus infection in children?

  • Most sinus infections are caused by viruses or allergies. Therefore, supportive treatment suffices.
  • Supportive treatment is also helpful in relieving the symptoms of sinus congestion, throat irritation, clogged ears, and nasal discharge.

Nasal irrigation (sinus flush) and sinus rinse:

  • Nasal irrigation or sinus flush is a simple method that can be performed at home.
  • A homemade salt solution is used to gently flush the nasal passages after blowing and cleaning the nose.
  • Saline solutions for the nose are available over the counter, however, frequent irrigation with a homemade saline solution is the preferred and commonly used method.

Decongestants and antihistamines for sinus infections:

  • Decongestants are not generally recommended for sinus infections.
  • Decongestants may result in decreasing the blood flow to the infected area impeding the passage of antibiotics to the infected area.
  • Decongestants may also cause the secretions to dry, making them thicker and difficult to clear.
  • However, patients with severe inflammation, decongestants may improve the mucous drainage, improve nasal airflow, and provide symptomatic relief.
  • Pseudoephedrine and xylometazoline are commonly used decongestants.
  • Antihistamines also reduce the mucosal and sinus congestion and are most helpful in relieving allergic symptoms such as sneezing, flu, nasal discharge, and postnasal drip.
  • Commonly used antihistamines in children for the allergic component of sinus infections are chlorpheniramine (Avil), diphenhydramine (Benadryl), and cetirizine (Baydal, Zyrtec)

Intranasal corticosteroids:

  • Steroids and decongestants have the same mechanisms in relieving the symptoms of sinus infections with an allergic component.
  • Intranasal corticosteroids may relieve the inflammation, clearing the blocked nasal passages in severe cases.
  • However, in bacterial sinus infections in children, the use of intranasal corticosteroids should be limited.

Acetaminophen (Tylenol) and Ibuprofen (Advil for sinus headache):

  • Acetaminophen relieves fever and pain in children with sinus infections. However, ibuprofen (Advil) may be preferred because of its anti-inflammatory properties.
  • Both these medicines may be given every six to eight hourly for the first two to three days. The doses may be reduced when the patients improve.

Antibiotics for Acute Sinusitis (Bacterial):

Antibiotics should be ideally guided by culture and sensitivity. However, antibiotics therapy is often initiated empirically.

The following groups of antibiotics can be used to treat acute bacterial sinusitis:

  1. Penicillins ( Amoxicillin is the preferred antibiotic for bacterial sinusitis in most cases. Amoxicillin combined with clavulanic acid is considered superior to amoxicillin alone).
  2. Second generation antibiotics like cefuroxime axetil (Zinacef) and third-generation cephalosporins like cefixime.
  3. Macrolides ( clarithromycin and azithromycin)
  4. Trimethoprim-sulfamethoxazole
  5. Tetracyclines (Doxycyclin). Tetracyclines may be used in patients allergic to penicillins
  6. Quinolones especially respiratory quinolones. These drugs can be used as an alternative to penicillins

Duration of antibiotics therapy in children with bacterial sinus infection:

  • The infectious disease society of America advises treating bacterial sinusitis for a total of five to seven days.
  • Immunocompromised, malnourished, and children with recurrent diseases including those with an anatomical defect may be given the treatment for a longer duration.
  • Other patients who require a longer duration of therapy include those who develop complications.

Alarming signs - Indications for urgent referral:

Children who develop the following signs and symptoms must be evaluated by an expert.

  1. Vision problems like double vision and  reduced vision
  2. Eye swelling, redness, and pain, and
  3. Altered mental status and worsening headache

Children who do not respond to the treatment and those who have recurrent episodes may also be reviewed by an expert.

Sore throat treatment

Fever of no apparent cause


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