Chronic Sinusitis in Children
What is chronic sinusitis in children?
Chronic sinusitis presentation in children is very different from that in adults. Chronic sinusitis is sinusitis persisting for more than 12 weeks, i.e. three months. These patients should be under the care of an ENT surgeon. They get temporary relief from using prescribed medicines or complete relief, but symptoms recur once the medication is stopped.
The sinuses are air pockets in the skull around the nose and eyes. There are five pairs of sinuses – Maxillary (behind cheeks), Frontal (behind the forehead), Anterior and posterior ethmoids (between eyes in the front and back), Sphenoids (back part of the head just above the pharynx). The sinuses below the eyes (Maxillary sinuses) and the sinuses between the eyes (ethmoid sinuses) develop as early as birth. They slowly enlarge and reach the adult size by mid to late teens.
These sinuses produce a thin slimy fluid called mucus 24×7, and this keeps getting cleared to the back of the nose. Mucus can get trapped within the sinuses because of various reasons we will discuss a little later. This trapped mucus that cannot drain out of the sinuses forms a suitable nutritional medium for the bacteria to grow in. Once the bacteria starts growing in the mucus, the mucus turns into pus, producing chronic sinusitis symptoms.
What Causes Chronic Sinusitis in Children?
Chronic sinusitis in child, in general, are susceptible to common cold and sinusitis. The most common causes of sinusitis are infections with bacteria, viruses and allergies. The infections and allergies cause inflammation and swelling of the mucosal skin lining of the nose and sinuses. This mucosal lining swelling blocks the sinus drainage openings and sinus drainage pathways, causing accumulation of mucus, a thin slimy fluid produced 24×7 inside the sinuses. This accumulated mucus forms a suitable nutritional medium for the bacteria to grow in. Once bacteria grow, the mucus turns into pus producing chronic sinusitis symptoms. This mechanism of chronic sinusitis occurs similar to that in adults, but the symptom presentation is different in children.
What are the symptoms of chronic sinusitis in children?
The children having chronic sinusitis present with the following symptoms
- Severe nasal congestion and nose block
- Mouth breathing and dry mouth, dry, chapped lips
- Bad breath from the mouth
- Thick yellowish to greenish coloured discharge from the front of the nose
- Postnasal discharge of similar colour
- Throat pain, throat irritation, cough
- Clogged ears and sometimes ear pain
- Pain on pressing on the forehead or the cheeks
- Children above six years can complain of headache and facial pain
- Fever of high or low grade
- Fatigue and irritability
- Reduced appetite from loss or reduced sense of smell and taste
How do I know if my child has a sinus Infection?
You, as a parent, can quickly identify chronic sinusitis in child by looking for its symptoms. Your child will complain of nose block and start talking with his nose (no nasal tone in his voice). He will open his mouth at night while sleeping, and he will snore. He will have thick yellowish to greenish nasal discharge from the front and back of the nose. Your child will repeatedly be clearing his throat, and he will have a dry cough. He can have a fever, fatigue and his appetite will drop. He can sometimes experience clogged ears or ear pain.
Why does my child keep getting sinus infections?
Children, in general, are more susceptible to upper respiratory tract infections. Viruses or bacteria are the common microbes causing chronic sinusitis in child. Acute infections do not last more than ten days. Chronic sinusitis symptoms last more than twelve weeks and do not resolve entirely with medicines or recur once medications are stopped. The common bacteria causing sinusitis in children are streptococcus pneumonia and haemophilus influenza.
Allergies are the next common cause of chronic sinusitis in children. Allergic rhinitis is the hyper-responsiveness the child’s nose exhibits on exposure to a substance he is allergic to.
Some children are at increased risk of developing chronic sinusitis.
- Children having structural problems such as a bend in the nose, aka. Deviated nasal septum or large turbinates. These structural abnormalities narrow down the nasal cavity space into which the sinuses drain, causing clogging in the sinuses
- Children who have an injury to the nose causing a bend in the nasal septum, which again narrows the nasal cavity
- Children having large adenoids: in children with grade 3 and 4 adenoids, the back of the nose is completely blocked. Large adenoids cause a blockage to sinus mucus drainage into the throat and lead to accumulation of mucus in the nose and sinuses.
- Children who put foreign bodies in the nose – I have seen foreign bodies several months after being placed in the nose. These children have single-sided thick nasal discharge along with chronic sinusitis symptoms.
- Children having congenital abnormalities like cleft palate are more susceptible to chronic sinusitis because of food contents entering into the nasal cavity, causing infections
- Children who have cystic fibrosis or other immunodeficiency diseases also have chronic sinusitis. In cystic fibrosis, the nose and sinuses lose their natural ability to push the mucus produced within them to the back of the nose, causing a build-up of mucus within the sinuses. Children with immunodeficiency get easily infected with bacteria and viruses and suffer with recurrent upper respiratory tract infections.
- Children having gastro-oesophageal reflux disease also suffer from chronic sinusitis because of reflux acids reaching the nose, causing inflammation
How is chronic sinusitis diagnosed in children, and what is the treatment?
If your child has had the above symptoms for more than a week and the symptoms are not being relieved with home remedies, you have to take your child for ENT consultation.
Your ENT doctor will take a detailed history of all the symptoms your child is facing, their severity, duration and enquire about similar episodes in the past. He will try to identify the root cause for your child’s symptoms. He will examine your child’s ear, nose and throat under the headlight.
Once the diagnosis is confirmed, your ENT doctor will usually prescribe the following medicines to help with your child’s sinusitis.
- Antibiotics – Antibiotics are prescribed for 7-10 days. After 3-4 days of prescribed usage, the yellowish to greenish thick nasal discharge from the front and back of the nose starts becoming thinner, and your child’s symptoms will improve. It is advised to use antibiotics for the suggested duration by your doctor and not stop them in between once your child starts feeling a little better. After that, the infection will come back.
- Decongestants – Oral and nasal decongestants prescribed will help reduce the swelling of the nose and sinuses mucosal lining, aiding in sinus drainage. In addition, nasal saline sprays and drops work wonders in relieving the nose block your child has.
- Painkillers – Painkillers like ibuprofen can help reduce the headache, facial pain and earache your child may be experiencing and keep him comfortable. Warm presses over areas of facial pain can be soothing
Apart from warm compresses, certain other home remedies can be helpful.
- Increased fluid intake – increased water intake by the child can help thin the thick mucopus in the nose and sinuses, allowing for easier clearance.
- Reducing milk intake – evidence suggests that milk and milk products intake can increase mucus formation. So reducing milk product intake for a few days can give the benefit
- Humidifier – Using a humidifier, especially in dry seasons, can help soothe the nasal mucosal lining and reduce its inflammation
- Keep your child away from irritants like smoke, strong smells. These will irritate the nose and sinuses and further the inflammation and swelling of the already inflamed nose and sinuses.
If your child is not recovering entirely after ten days with medication or the symptoms are recurring once the medication is stopped, your child may be advised to do investigations like nasal endoscopy, CT scan of nose and sinuses, X-ray nasopharynx for adenoids, nasal discharge culture. Investigations are done to identify the problem and also the probable microorganism causing the symptoms.
- Nasal endoscopy – a 2mm – 4mm endoscope is gently advanced into the nose to look for structural abnormalities, foreign bodies etc.
- CT scan nose and sinuses – can help in identifying the status of sinuses, structural abnormalities and also adenoids
- Xray nasopharynx can help in the identification of enlarged adenoids and how much of the back of the nose they are blocking
- Nasal discharge culture and sensitivity – The nasal discharge from the nose and sinus is collected and sent for microbiological examination and culture sensitivity to identify the bacteria and what antibiotics the infecting bacteria are susceptible to. Culture and sensitivity test allows targeted antibiotic usage rather than an empirical one.
Surgery is advised for very few children. Adenoids, if enlarged and are not resolving with medication or causing recurrent cold, can be removed by adenoidectomy. In children of a higher age group, FESS, short for functional endoscopic sinus surgery, can widen the sinus drainage openings and sinus drainage pathways, allowing normal drainage and avoiding re-infection.
Deviated septum, enlarged turbinates can also be corrected if they are found to be causing sinus drainage pathway blockages.
When to seek medical attention for chronic sinusitis in children?
When your child has a nose block, thick nasal discharge, headache and facial heaviness for more than a week and the symptoms are not improving with a saline nasal wash, steam inhalation etc., parents must take him for an ENT doctor’s consultation.
What are the complications of chronic sinusitis treatment?
The medical treatment of chronic sinusitis does not carry any risks other than the occasional side effects from the medicines used. The surgical treatment is also very safe with a low complication rate. An incidence of 1-2% of these complications is seen. The following are the complications you can see during endoscopic sinus surgery
- Septum surgery complications
- Change in the voice
- Bruising around eye
- Reduced sense of smell
- CSF leak
- Vision problems
Precautions to be taken to avoid chronic sinusitis in children
You can take the following precautions to prevent the occurrence of sinusitis in your child
- Vaccinate your child as per the vaccination schedule. Flu shots can be helpful. Every year flu shots are manufactured based on that year’s strains. So, always select the current year’s flu shots
- Avoid your child from going near or playing with children or adults suffering from upper respiratory tract infections
- Avoid exposing your child to irritants like cigarette smoke. Some children are easily irritated by fumes from incense sticks commonly used during prayers. If your child is one of them, avoid exposure
- If your child has allergies, i.e. there is repeated sneezing, itching and watering from the nose, try to identify the causative allergens and keep him away from them. If these symptoms are present all through a year or if you are unable to determine the allergen, seek an ENT doctors help
5. Use saline nasal washes and sprays to keep your child’s nose moist all the time
6. Using a humidifier during the dry season can help in reducing the inflammation in the nose
7. Teach your child good hand hygiene
8. Avoid chlorinated swimming pools. If your child loves swimming, advise him not to jump into the swimming pool as water gushes into the nose and sinuses, causing inflammation