CASE REPORT

ACUTE RHINOSINUSITIS IN PEDIATRIC

Presentator : dr. Yosephine Nina Widyarini

Moderator : Dr. dr. Sagung Rai Indrasari, M.Kes., Sp.T.H.T.K.L (K), FICS

Otorhinolaryngology Head and Neck Surgery Departement

Faculty of Medicine, Public Health and Nursing
Gadjah Mada University
Dr. Sardjito Hospital Yogyakarta
2019
Introduction following symptoms like nasal discharge,
stuffiness or congestion, facial pain or
Acute rhinosinusitis is one of the
pressure, and anosmia or hyposmia. There
most common and serious pediatric
may be associated fever, malaise,
infections. It has been demonstrated that
irritability, headache, toothache, or cough.
children have upper respiratory tract
When symptoms are present for 4–12
infections 6-8 times per year of which 5-
weeks, it is subacute rhinosinusitis. When
10% are associated with sinusitis. While
they persist for more than 12 weeks, it is
acute rhinosinusitis is usually diagnosed in
termed as chronic rhinosinusitis. Recurrent
children between 4 to 7 years, it has been
rhinosinusitis is 4 or more episodes of acute
demonstrated that it specifically affects
sinus infection in one year with each
children between 1 and 5.1
episode lasting for about a week.4

Sinus infections can occur as a result

Based on the etiology, rhinosinusitis
of reccurent upper respiratory tract
could be viral, bacterial, fungal, parasitic, or
infections. For this reason, pediatric
mixed. Common pathogens involved in
rhinosinusitis cases are the most frequent
acute bacterial rhinosinusitis are
and important problems of Family
Streptococcus pneumonia, Haemophilus
Medicine, Pediatrics and
influenza, and Moraxellacatarrhalis. 3 Up to
Otorhinolaryngology practices. Moreover,
5-10 % of viral upper respiratory tract
chronic rhinosinusitis can develop when the
infections in children, progress to bacterial
underlying cause cannot be successfully
acute rhinosinusitis with a number of them
treated with conventional treatment
developing into chronic rhinosinusitis. The
methods, and may seriously effect the
presentation of viral rhinosinusitis is similar
children’s quality of life. A detailed
to ABRS and it is difficult to differentiate
understanding of the pathophysiology and
between them since they both have the same
microbiology and knowledge about medical
clinical and radiological findings.4
and surgical principles are important for the
treatment of pediatric rhinosinusitis. 2
Rhinosinusitis should be considered
rather than acute viral upper respiratory tract
Based on the duration,
infection, and antibiotic therapy should be
rhinosinusitis signs are divided into acute,
recommended if body temperature is
subacute, or chronic (more than three
rapidly increasing and or above 39°C and
months). Acute rhinosinusitis implies
purulent nasal discharge lasting longer than
sudden onset of two or more of the
three days is present. Similarly, antibiotic

1
therapy is recommended if symptoms do not
improve or persist or worsen after the third
day. 5
About 90% recover without
antibiotics in a week. Antibiotics are
reserved for children with severe acute
sinusitis, toxic features, suspected
complications, or persistence of symptoms.
Choice of antibiotics should be guided by
local susceptibility studies, safety profile,
and child's age. Usual preferred are
amoxicillin, coamoxiclav, oral
cephalosporins, and macrolide group of
antibiotics. Associated conditions should be
simultaneously and individually addressed
as follows.5
The American Academy of
Pediatrics states that some children with
persistent sinusitis symptoms may
overcome the disease through their immune
systems and that the risk of suppurative
complications is low in such patients.
Therefore they recommend short term
followup in selected patients or antibiotic
therapy. Persistent acute bacterial sinusitis
can affect the quality of life of patients
mildly (cough-nasal discharge) or seriously
(sleep disturbance, school failure). Decision
of follow-up is evaluated based on the
severity of the symptoms, how they affect
the quality of life of the patient, recent
history of antibiotic use, current experience
relating to acute sinusitis, the cost and
availability of the antibiotic, the concerns of
the parents about the possible side effects,
or development of complications. 5
Case Report
A 6 years old boy came on to ENT
clinic RSUP Dr. Sardjito with chief
complain greenish nasal discharge since 7
days ago. Patient felt difficult to breathing
because of nasal congestion, cough and
fever since 7 days ago. Patient also felt
facial pain especially in cheek area. Patient
never had similar complain before. But
patient often felt fever and nasal congestion
since 2 months before and missing out.
Sleep apnea, halitosis, and snooring was
denied. Ear and nose complaints are denied.
Patient claims, there is no history of allergy
and asthma.
From physical examination it was
found that the patient’s general condition
was moderate, compos mentis, pulse
frequency 98 times/minute, breathing 22
times/minute, with the temperature 38,5 OC,
pain threshold with VAS 2-3, and weight 25
kgs.
On the ENT examination, auricular
dextra and sinistra within normal limits,
examination of otoscopy dextra and sinistra,
external acoustic canal within normal limit,
tympanic membrane looks intact and
positive light reflex. On anterior rhinoscopy
2
nasal discharge (+) and oedem of inferior
concha. On dental examination is not found
abnormality, no caries dentis. On
oropharynx examination tonsil T1-T1, with
no hyperemic mucosa and detritus (-). On
indirect laryngoscopy examination is not
found abnormality. Neck examination is not
found abnormality.
The patient was diagnosed with acute
rhinosinusitis. The patient was treated with
Amoxicillin 250 mg three times a day for 5
days and Paracetamol 250 mg three times a
day.
The problem with this case is the
therapy.
Discussion
Rhinosinusitis is the inflammation of
the mucous membranes of nose and
paranasal sinus(es). 5–13% of upper
respiratory tract infections in children
complicate into acute rhinosinusitis.1 It has
been demonstrated that children have upper
respiratory tract infections 6-8 times per
year of which 5-10% are associated with
sinusitis.5 While acute sinusitis is usually
diagnosed in children aged between 4 to 7
years, and in this case, patient is 6 years old.
The diagnosis of rhinosinusitis in
children and adults usually start with
clinical diagnosis. Diagnosis
rhinosinusitis is based on a medical history
to find out whether rhinosinusitis is
recurrent and a physical exam of the nose.
This can give clue whether the cause is
bacterial or viral or other. 2
From the anamnesis, patient came with
chief complain greenish nasal discharge
since 7 days ago. Patient felt difficult to
breathing because of nasal congestion,
cough and fever since 7 days ago. Patient
also felt facial pain especially in cheek area.
The normal function of the sinuses
requires normal ostium, proper mucociliary
function and systemic and local immune
response. When all these systems work
well, the sinuses are generally sterile.
Lowintensity bacterial contamination is
transient6. Sinusitis often begins with
inflammation and occlusion of the sinus
ostium.7 Impaired mucociliary clearance,
blocked sinus drainage or anatomical
structures near the sinuses that contain
different potential microorganisms may
play a role, individually or in combination,
in the development of sinusitis. 5 This leads
to accumulation of secretions and reduction
of sinus ventilation. In this patient, he felt
difficult to breath because of nasal
congestion and facial pain. It caused by
impaired mucocilliary clearance.5
From the anamnesis patient said that he
never had similar complain before. But
of
3
patient often felt fever and nasal congestion
since 2 months before and missing out. Viral
upper respiratory tract infections are the
most common predisposing factor for
bacterial sinusitis. It has been demonstrated
that the prevalence of upper respiratory tract
infections is increasing the prevalence of
rhinosinusitis. Viral sinusitis leads to nasal
congestion and abnormal mucosal activity.
Bacteria or fungi increase the risk of
secondary infections.6
In physical examination, patient
temperature is 38.5 and form anterior
rhinoscopy, we can see purulent discharge,
and oedema of inferior concha.
Vasodilation associated with mediators,
increased mucosal secretion, plasma
extravasation, neurogenic inflammation and
mast cell-nerve interactions can be seen.
Inflammation leads to local changes that
contribute to the development of
infection.6
Rhinosinusitis should be considered
rather than acute viral upper respiratory
tract infection, and antibiotic therapy should
be recommended if body temperature is
rapidly increasing and/ or above 39°C and
purulent nasal discharge lasting longer than
three days is present. Similiarly, antibiotic
therapy is recommended if symptoms do not
improve or persist or worsen after the third
day. 7
The American Academy of Pediatrics
states that some children with persistent
sinusitis symptoms may overcome the
disease through their immune systems and
that the risk of suppurative complications is
low in such patients. Therefore they
recommend short term followup in selected
patients or antibiotic therapy. 7
Persistent acute bacterial sinusitis can
affect the quality of life of patients mildly
(cough-nasal discharge) or seriously (sleep
disturbance, school failure). Decision of
follow-up or antibiotherapy is evaluated
based on the severity of the symptoms, how
they affect the quality of life of the patient,
recent history of antibiotic use, current
experience relating to acute sinusitis, the
cost and availability of the antibiotic, the
concerns of the parents about the possible
side effects, or development of
complications.8
Antibiotic therapy is recommended if
the patient received antibiotic therapy
within the last four weeks but have
concurrent bacterial infection (pneumonia,
suppurative lymphadenitis, group A
betahemolytic streptococcal pharyngitis or
acute otitis media), has complications or
suspected complications, has asthma, cystic
fibrosis, immunodeficiency or a history of
sinus surgery, has an anatomical
abnormality in the upper respiratory tract.9
4
 Penicillin should be preferred for the
first-line treatment. It is recommended
because of its efficacy, safety, affordability,
pleasant flavor and narrow microbiological
spectrum. 45mg/kg/day as two doses is
recommended in children with acute
bacterial sinusitis who are followed-up
without complications and who have not
received antibiotics for the last 4 weeks
while 80-90 mg/kg/day as two doses (max 2
g/day) is recommended in populations with
high resistance to pneumococci. 8
Penicillin still the treatment of choice
for this case, and amplified aminopenicillins
have grown usefulness in performance with
the growing incidence of beta-lactamase
producing bacteria. The penicillin,
especially in children and adolescents,
display the highest advantage for it being
lowest cost. Treatment with high dose (80-
90 mg/kg/day) is recommended in sinusitis
patients aged < 2 years who present with
moderate or severe clinical symptoms.
Parenteral single dose 50 mg/kg ceftriaxone
may be administered to patients who vomit
or cannot tolerate oral therapy.
Ceftriaxone is an agent which has been
demonstrated to be effective against the
identified microorganisms in acute bacterial
sinusitis in 95-100% of the cases. If
improvement is observed within 24 hours
after administration of ceftriaxone,
treatment may be continued with an oral
antibiotic. An additional dose of ceftriaxone
may be administered before switching to
oral antibiotic in symptomatic children
whose fever persists despite the treatment. 9
Studies have demonstrated that the risk of
allergic reactions that may develop with the
use of 2nd or 3rd generation
cephalosphorins in patients who are allergic
to penicillin or amoxicillin is almost the
same as in those who are nonallergic to
these agents. Therefore cefdinir, cefuroxime
and cefpodoxime can be safely used in
patients with allergies of non-type 1
hypersensitivity reaction9 S. pneumoniae
and H. influenzae are sensitive to cefdinir,
cefuroxime and cefpodoxime at rates of 60-
75% and 85-100%, respectively.10
Cefixime and clindamycin (or
linezolid) combination may be preferred to
be attentive to the resistance of S.
pneumoniae and H.influenza in children of
< 2 years of age with moderate/severe
bacterial sinusitis who have serious allergic
reaction to penicillin. Linezolid is an
antibiotic that is highly sensitive even
against penicillin-resistant S.pneumoniae
but poorly effective against H.influenzae
and M.catarrhalis. No oral preparation of
linezolid is available in our country. In areas
with high resistance to penicillin, it has been
demonstrated that using TMPSMX and
azithromycin is not useful since
pneumococci strains are resistant to these
agents 10
5
 No optimal duration of antibiotic
therapy has been specified; however it is
stated that the duration of therapy will vary
between 10 and 28 days. Another
recommendation is to continue the
antibiotic therapy for 7 days after resolution
of the signs and symptoms. 10
As a general rule, prevention of risk
factors can help avoid development of
rhinosinusitis. These include environmental
pollutants, upper airway infections, daycare
centre attendance, nasal allergies, and
anatomical aberrations. These should be
managed on a war footing in order to avoid
their development into rhinosinusitis. Acute
attacks of rhinosinusitis should be optimally
managed to prevent progress to chronicity.
Influenza and pneumococcal vaccines could
also lead to fall in upper airway infections
2
and hence rhinosinusitis.
Swimming in pools with high chlorine
content may also worsen mucosal swelling
and lining. Hence care should be taken at
such places. Frequent plane flyers may also
see worsening of symptoms with flights and
precautions during such flights may help.3
Summary
Patient 6 years old boy came on to ENT
clinic RSUP Dr. Sardjito with chief
complain greenish nasal discharge since 7
days ago. The patient felt difficult to
breathing because of nasal congestion,
cough and fever since 7 days ago. The
patient also felt facial pain especially n
cheek area. Before chief complain, patient
never had similar complain before. But the
patient often felt fever and nasal congestion
since 2 months before and missing out.
Sleep apnea, halitosis, and snooring was
denied. Ear and nose complaints are denied.
Patient claims, there is no history of Allergy
and Asthma.
From physical examination from on
rhinoscopy anterior examination anterior
rhinoscopy nasal discharge (+) and oedem
of inferior concha.
The patient was diagnosed with acute
rhinosinusitis. In this patient, have been
treated by antipiretic and antibiotic.
References
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2012
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Microbiological Aspects of Acute
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10.3390/jcm8020149 4. Dana T.
Badr, MD, Jonathan M. Gaffin, MD,
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Acute bacterial rhinosinusitis in
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