What are sinuses?

The sinuses are air-filled spaces within the facial bones that surround the nose. The sinuses are connected to the nose through natural drainage passageways. The nose and sinuses share the same mucous membrane lining, which is also present throughout the body’s respiratory system. There are four different types of sinuses:

• Ethmoid sinus. Located between the eyes, this sinus is present at birth and continues to grow through childhood.
• Maxillary sinus. Located beneath the eyes and within the cheeks, this sinus is also present at birth, and grows further through childhood.
• Frontal sinus. Located within the bone of the forehead, this sinus does not form until around 7 years of age; it continues to grow into teenage years.
• Sphenoid sinus. Located in the center of the skull and at the base of the brain, this sinus forms in during childhood and grows further into adolescence.

What is sinusitis?

Sinusitis is symptomatic inflammation of the nose and sinuses. The symptoms are very common in children but they can arise from many different causes. Sinusitis is commonly defined by how long symptoms have been present:

• Acute sinusitis means that symptoms have been present for less than 30 days. It is usually due to an infectious process and often develops after a viral cold.
• Chronic sinusitis means that symptoms have been present for greater than 90 days, or 3 months. Unlike acute sinusitis, chronic sinusitis is usually not simply driven by infection but is better understood as an inflammatory syndrome. Because it can have many different causes, chronic sinusitis can be challenging to treat and requires care individualized to each patient.

What causes sinusitis?

Sometimes, a sinus infection happens after an upper respiratory infection (URI) or common cold. These URIs are caused by common viruses and create inflammation of the nasal passages that can block the openings of the paranasal sinuses and result in a sinus infection. Allergies can worsen sinusitis by adding inflammation that comes from reacting to environmental allergens. There are other conditions that can cause imbalance in the normal flow of mucous out of the sinuses or create inflammation that can lead to sinusitis including:

• Abnormalities in the structure of the nose
• Enlarged or chronically infected adenoids
• Infections from a tooth
• Nasal polyps
• Cystic fibrosis
• Primary ciliary dyskinesia
• Trauma to the nose
• Foreign objects stuck in the nose
• Gastroesophageal reflux disease (GERD)
• Secondhand smoke

When inflammatory processes block the flow of secretions from the sinuses, bacteria may begin to grow. In sinusitis, it is important to treat both infection and the underlying inflammation or blockage that allowed infection to occur.

What are the symptoms of sinusitis?

The symptoms of sinusitis depend greatly on the age of the child. The following are the most common symptoms of sinusitis. However, each child may experience symptoms differently. Symptoms may include:

Younger children

• Runny nose
  • Lasts longer than seven to 10 days
  • Discharge is usually thick green or yellow, but can be clear
• Cough
• Nasal congestion
• Fever

Older children and adults

• Runny nose or cold symptoms lasting longer than seven to 10 days
• Drip in the throat from the nose
• Headache or facial pain*
• Cough
• Fever (more common in younger children)

The symptoms of sinusitis may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

*Multiple studies have found that more than 90% of physician-diagnosed or self-described “sinus headaches” are actually migraine-related. The researchers found that the participants described the classic symptoms of pain in the front of the face and pressure under the eyes. However, the participants lacked other symptoms of a true sinus infection, nasal discharge, nasal congestion, or fever. In addition, migraines are often under-recognized in children as they often do not present with the classic symptoms of nausea, vomiting, or sensitivity to light. Always consult your child's primary care provider for a diagnosis.

How is sinusitis diagnosed?

Generally, your child's physician can diagnose sinusitis based on your child's symptoms and physical examination. In some cases additional tests may be performed to confirm the diagnosis. These may include:

• Computed tomography (also called CT or CAT scan). A diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.
• Nasal endoscopy. In some cases, it may be useful for your physician to examine your child’s nose using a small flexible fiberoptic scope. This simple test can be performed during an office visit without the need for anesthesia.
• Cultures from the sinuses. Laboratory tests that involve the growing of bacteria or other microorganisms to aid in diagnosis. Nasal endoscopy is often used to aid in capturing infectious mucus from areas where the sinuses drain into the nose.

What is the treatment for sinusitis in children?

Treatment for sinusitis depends on several factors, including:

• Your child's age, overall health, and medical history
• Extent of the infection
• Your child's tolerance for specific medications, procedures, or therapies
• Expectations for the course of the infection
• Your opinion or preference

Treatment of sinusitis depends on each patient’s individual history and symptoms and may include a combination of:

• Antibiotics, which are usually given for at least 14 days
• Anti-inflammatory nasal sprays
• Acetaminophen (for pain or fever)
• A mucus thinner, such as guaifenesin
• Antihistamines (if environmental allergies are present)
• Orally administered steroids, such as prednisone
• Medications to treat GERD
• Surgery to remove the adenoids
• Endoscopic sinus surgery

Antibiotics may be withheld for 10 to 14 days, unless severe symptoms develop, such as: fever, facial pain or tenderness, or swelling around the eye. Surgery should be considered only if other treatments have failed.

In challenging or persistent cases, collaboration with other pediatric specialists is often needed to address the underlying causes of inflammation that driving symptoms. These specialties include pulmonary medicine, immunology, allergy or infectious diseases. At CHOP, our aim is to facilitate communication among specialists to best coordinate our patients’ care.