Clinical Practice Guidelines

Persistent nasal discharge rhinosinusitis

  • Rhinosinusitis is inflammation of the epithelial lining in the paranasal sinuses. It is common in children and is probably under-diagnosed, however it resolves spontaneously in the majority of cases.

    There are a number of causes;

    Infection Viral  
    Bacterial Streptococcal Pneumoniae
    Haemophilus Influenzae (non typeable)
    Moraxella Catarrhalis
    Allergic Seasonal  
    Perennial  
    Chemical  
     
    Obstructive Adenoidal Hypertrophy  
    Foreign Body  

    If recurrent or severe, consider rarer causes:

    Anatomical anomalies
    Immunodeficiency
    Ciliary dysfunction
    (Cystic Fibrosis)

    Acute bacterial sinusitis

    This usually follows a viral infection. Mucosal inflammation and thick secretions block the normal sinus drainage resulting in secondary bacterial infection.

    Symptoms Signs
    Nasal discharge (purulence is of little significance) Inflamed nasal mucosa
    Nasal obstruction Pus exuding from the middle meatus
    Maxillary toothache Maxillary transillumination (over 9yo)
    Unilateral facial pain Associated middle ear changes
    Headache  
    Fever  

    Diagnosis in younger children is more difficult as the signs and symptoms are non specific. Persistent nasal discharge (beyond 10 days) is usually the predominant symptom. There are a number of causes of this presentation including sequential URTI's, allergic rhinitis and adenoidal hypertrophy.

    Complications

    • Orbital Complications:
      Periorbital cellulitis , orbital cellulitis
      (see  Orbital Cellulitis Guideline)

    • Intracranial Complications:
      Cerebral abscess, cavernous sinus thrombosis, meningitis, encephalitis, subdural / epidural empyema

    Investigations

    CT is the imaging modality of choice. Air-fluid levels, opacification and mucosal thickening may be seen, however, these findings are non-specific.

    CT is not used routinely but may be indicated in the following situations:

    • failed medical management
    • possible orbital / intracranial complication
    • if surgery is being contemplated

    Culturing nasal secretions is not indicative of sinus flora and is therefore not helpful. The 'Gold Standard' would be sinus puncture for culture. This is invasive and painful and should only be done in an ENT setting.

    Treatment

    1st line amoxycillin (15mg/kg/dose tds) for 10days
    (Cephalexin if penicillin allergic)
    2nd line amoxycillin/clavulanic acid (if pt has had amoxycillin in the last month)
    If orbital / intracranial signs IV flucoxacillin (50mg/kg/dose 6 hourly) and IV Ceftriaxone 50 mg/kg/dose (2g) iv 12H and refer to ophthalmolgy/neurosurgery

    The addition of steroid sprays, decongestants, or antihistamines to antibiotic treatment has been shown to have no benefit in sinusitis.

    Surgery is very rarely needed.