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Rhinitis and sinusitis

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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 do not predict whether a bacterial infection is present.

What are the symptoms of rhinitis?

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

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

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

How do we treat rhinitis?

Keep up hydration.

Aspirate nasal secretions.

Give analgesia and antipyretics for comfort.

What about allergic rhinitis?

Most prevalent in school-age years and rare under two years of age

It may be classified as intermittent/persistent and as mild, moderate or severe

What are the symptoms of allergic rhinitis?

Rhinorrhoea, nasal obstruction, nasal pruritus and sneezing

Epistaxis is commonly associated with allergic rhinitis

How do we diagnose allergic rhinitis?

The nasal mucosa is moist and congested.

Inferior turbinates might have a blue/violet hue due to significant congestion.

Mucopurulent discharge may be present in children. This makes distinguishing it from rhinosinusitis difficult based on clinical findings alone.

What is the treatment for allergic rhinitis?

Antihistamine

Topical corticosteroid spray, if age-appropriate.

Sinusitis

Acute sinusitis is an inflammation of the paranasal sinuses of less than three weeks. Chronic sinusitis results from unresolved acute sinusitis, which has persisted for>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 and ten years of age.

Diagnosis of sinusitis is based on clinical features – sinus transillumination is unreliable for diagnosis.

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

What causes sinusitis?

The paranasal sinuses most commonly become obstructed following viral URTIs.

Bacteria causes include – Strep pneumoniae, Moraxella and Haemophilus. Dental infections are an important cause.

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

What are the symptoms of sinusitis?

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.

How do we diagnose sinusitis?

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.

Sinus CT is reserved for those suspected of having complicated sinusitis and sphenoid sinusitis.

How do we treat sinusitis in children?

Nasal decongestants for three to five days only.

Amoxycillin, augmentin, or a third-generation cephalosporin.

Add anti-pseudomonal cover in HIV and CF patients.

What are some of the complications of sinusitis?

Complications are due to extension of infection:

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

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

Author

  • 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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