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ENT Part 2: who nose?

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Here is the second part in our three part ENT series looking at recognition and management of common paediatric ENT conditions.This series is based on a presentation by Rahul Santram, adapted by Tessa Davis, and checked by our resident ENT surgeon, Sinéad Davis.

Part 1 was on – the ear. Today, we look at the nose. Part 3 is on – the throat.


Rhinitis

Rhinitis is an inflammation of the nasal mucosal lining (infective or allergic).

Most kids with nasal discharge have a viral URTI.

More than 100 viruses have been implicated including: rhinovirus; coronavirus; parainfluenza; and RSV. The colour and thickness of nasal discharge alone does not predict whether bacterial infection is present.

Symptoms

Patients usually get symptoms of a viral URTI – low grade temp, rhinorrhoea, cough, and a sore throat. Symptoms resolve within ten days.

If symptoms last longer than 10 days, with little improvement, then we need to suspect bacterial superinfection.

If there is a unilateral foul purulent nasal discharge – consider a foreign body

Treatment

Keep up hydration.

Aspirate nasal secretions.

Give analgesia and antipyretics for comfort.

What about allergic rhinitis?

  • Most prevalent in school age years and rare <2 years of age
  • May be classified as intermittent/persistent and as mild/moderate-severe

Symptoms include:

  • Rhinorrhoea, nasal obstruction, nasal puritis and sneezing
  • Epistaxis is commonly associated with allergic rhinitis

Diagnosis:

  • Nasal mucosa is moist and congested
  • Inferior turbinates might have a blue/violet hue, due to significant congestion
  • Mucopurulent discharge maybe present in children, making a distinction from rhinosinusitis difficult based on clinical findings alone

Management:

  • Antihistamine
  • Topical corticosteroid spray, if age appropriate.


Sinusitis

Acute sinusitis is an inflammation of the paranasal sinuses of less than three weeks duration. Chronic sinusitis results from an unresolved acute sinusitis, which has persisted >12 weeks.

Ethmoid and maxillary sinuses are present at birth. The sphenoid sinus develops between three and five years of age. The frontal sinus develops between seven to ten years of age

Diagnosis of sinusitis is based on clinical features – sinus transillumination is not reliable for diagnosis.

Sinusitis is rare in children but complicates 0.5-5% of URTIs.

Causes

The paranasal sinuses most commonly become obstructed following viral URTIs.

Bacteria causes include – Strep pneumoniae, moxarella and haemophilus. Dental infections are an important cause.

Fungus may also cause infection but these are extremely rare in children who are not immunocompromised.

Symptoms

Patients present with fever and facial pain. In bacterial cases the facial pain and sinus congestion persist beyond the viral syndrome of cough and fever, which has often been relatively mild.

Sphenoid sinusitis causes retro-orbital pain or vertex headache.

Diagnosis

Diagnosis is usually clinical.

There is often a purulent nasal discharge.

Facial swelling, of the cheek (maxilla) or periorbital regions, may be seen in more definitive cases.

Plain radiographs have no role.

CT of sinuses are reserved for those suspected of having complicated sinusitis and sphenoid sinusitis.

Management

Nasal decongestants for three to five days only.

Amoxycillin, augmentin, or a third generation cephalosporin.

Add anti-pseudomonal cover in HIV and CF patients.

Complications

Complications are due to extension of infection:

  • Facial cellulitis
  • Orbital cellulitis
  • Cavernous sinus thrombosis
  • Meningitis
  • Cerebral abscess
  • Pott’s puffy tumor

Beware of mucomycosis – this can invade sinuses, presents with a black eschar on the nasal mucosa. It is a fungal infection seen predominantly in HIV and diabetes mellitus.




About the authors

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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