Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT
--Otitis Media:
Classification, Rx and Complications
--Pediatric ENT:
1. When to Refer for Tubes
2. Laryngeal Abnormalities
--The Treatment of Otorrhea
--Eye Problems of Children
--Allergic Rhinitis

Sinusitis vs. Purulent Rhinitis vs. URI

Age of Clinical Significance of sinuses: (not necessarily the same as age of development)
- maxillary: birth; ethmoid: 6-8 months of age; sphenoid: 3-5 ys; frontal: 10-12 ys of age

Etiology:

1. Viruses: Rhinovirus the most common (over 100 different types), Influenza, RSV, parainfluenza, adenovirus; many others
2. Bacteria: Pneumococcus, H. Flu, Moraxella Catarrhalis
3. Chronic Infection: Staphylococci and anaerobes are common; also can find Enterobacteriae, fungi, mycobacteria and protozoa

Symptoms: fever, night-time cough associated with a day-time cough, periorbital edema, allergies, sinus tenderness, sinus pressure, postnasal drip, congestion for over 1,5 or 10 days (see below), green nasal drainage---green color is caused by polys not bacteria.

Physical Findings: swollen area over maxillary sinus, purulent drainage down the back of the throat, pain on palpation over affected sinus, toothache, headache, and cellulitis. Dec transillumin

Indications for X-Rays: A commonly used test for diagnosing sinusitis, but usually not necessary.  Major indications for doing X-Rays (CT better than plain films): Consider surgical referral or chronic disease that recurs or doesn’t respond to adequate treatment

When is an antibiotic indicated?  Most physicians overprescribe.  The worst are those who have been in practice longer; non-pediatricians more than ped: the 5-11 year age group most common:

1. Schwartz: 70% of practitioners treat purulent rhinorrhea after one day of symptoms

2. Placebo group: 60% resolve with no antibiotic treatment: Gwaltney: NEJM: followed CT proven sinusitis, did not treat; all “infections” went away.

3. When pediatricians’ offices monitored, over 80% of patients get antibiotic Rx   

Parental Expectations: Less educated think antibiotic helps clear nasal discharge, more educated believe that the child is improved with antibiotics once the color of the nasal d/c changes.

Algorithim: AAP Clinical Practice Guideline: Pediatrics 2001;108:798-807

1. low or high dose Amoxicillin
2. Augmentin
3. Ceftin
4. Vantin
5. Omnicef

Non-antibiotic treatment for the purulent nasal discharge?

A. Nose Drops: Very useful in the infant. Saline or Neo-Synephrine: short courses.

B. Oral Decongestants: Never use these before 6 months of age!  Use rarely before 12 months of age; few studies indicate their effectiveness.

C. Avoidance of Environmental Causes of Nasal Congestion:

1. Cigarette Smoke: passive smoking causes severe nasal congestion in infants

2. Wood stove: similar effects on children

3. Kerosene and other forms of drying heat can be very congesting to infants. 

D. Humidifiers: Cool Mist may be preferable.

Reviewed 2/02

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004