‘Sinusitis’?
Jason Kahn, MDJohn G. Frohna, MD, MPH
Departments of Internal Medicine and Pediatrics
University of Michigan Health System
Ann Arbor, MI 48109-0368
To the Editor.—
The guidelines on the management of sinusitis1 provide a valuable reference for the practicing clinician. The differentiation between subsets of children with sinusitis is critical to guide antibiotic choice. However, we feel the algorithm does not clearly differentiate between those patients with sinusitis and those with persistent upper respiratory infections (URIs).
The algorithm begins with patients "with persistent or severe upper respiratory tract infection." The patient with "severe" symptoms, defined as temperature of at least 102°F and purulent nasal discharge present concurrently for at least 3 to 4 consecutive days in a child who seems ill, certainly deserves immediate treatment with an appropriate antibacterial agent. As pointed out in the guidelines, the simultaneous presence of fever and nasal discharge strongly suggests a bacterial etiology. The patient with "persistent" symptoms, defined as lasting longer than 10 to 14 but <30 days including nasal or postnasal discharge of any quality or cough, may have sinusitis but may also have continued symptoms from a viral URI. Differentiating between these is the diagnostic challenge not addressed in the guidelines.
Short of radiographs, which as described in the guidelines are of limited additional value after a thorough history and physical, is there a way for the primary care physician to separate persistent URIs from acute sinusitis? The recent study by Garbutt et al2 may provide an alternative to treatment in every case. In this study, patients with symptoms matching the AAP definition of "persistent," were randomized to receive amoxicillin, amoxicillin-clavulanic acid, or placebo for 14 days. Patients in all groups improved over the next 14 days. Although the study may have been slightly underpowered, and the low-dose amoxicillin may have undertreated resistant organisms, the fact remains that patients in the placebo group showed symptomatic improvement while suffering no complications.
Based on present data, we feel that it is possible to withhold antibiotics in patients with persistent (10–14 days) symptoms of nasal discharge or cough, who have temperatures <39°, lack facial swelling or pain, do not look ill and who have reliable caregivers and known access for follow-up. The data of Garbutt et al suggest that the majority of these patients will improve. Follow-up for those with continued symptoms after 7 additional days or any who develop fevers, worsening symptoms, or signs of complications (which would have to be carefully described to the caregivers) would have to be ensured before attempting conservative treatment.
REFERENCES
- American Academy of Pediatrics, Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guideline: management of sinusitis.
Pediatrics.2001; 108
:798
–808
[Abstract/Free Full Text] - Garbutt JM, Goldstein M, Gellman E, Shannon W, Littenberg B. A randomized, placebo-controlled trial of antimicrobial treatment for children with clinically diagnosed acute sinusitis.
Pediatrics.2001; 107
:619
–625
[Abstract/Free Full Text]
Ellen R. Wald, MD AAP Subcommittee on Management of Sinusitis and Committee on Quality Improvement
Pediatrics and Otolaryngology
University of Pittsburgh School of Medicine
Division of Allergy, Immunology and Infectious Diseases
Children’s Hospital of Pittsburgh
Pittsburgh, PA 15213
In Reply.—
We appreciate the thoughtful comments of Drs Kahn and Frohna. We agree that the need to distinguish between acute sinusitis and uncomplicated viral upper respiratory infections (URIs) is a great challenge for the practicing clinician. However, there are 2 features of an URI that may help separate it from an episode of acute bacterial sinusitis: severity and duration. Most uncomplicated viral URIs peak in intensity by 7 days and begin to improve. The failure to show improvement by 10 days is a distinguishing characteristic. If the history is taken carefully, <10% of URIs will be characterized by protracted symptoms that have not begun to resolve.1,2
The AAP guidelines have endorsed making a clinical diagnosis of acute bacterial sinusitis in children 
6 years without the use of imaging procedures.3 This recommendation was based on 2 studies. The first, reported in 1981, showed that when children with respiratory symptoms (nasal discharge or cough or both for >10 but <30 days) plus significantly abnormal radiographs (complete opacification, mucosal swelling of >4 mm, or presence of an air-fluid level) underwent sinus aspiration, bacteria in high density were recovered in 75% of cases.4 The second, reported in 1986, showed that the history of persistent symptoms (nasal discharge or cough or both for >10 but <30 days) predicts significantly abnormal radiographs in 88% of children <6 years of age.5 Knowing that children with typical symptoms and abnormal radiographs have positive sinus aspirates in 75% of cases and that the history of persistent symptoms predicts abnormal radiographs nearly 90% of the time in children <6 years, the Committee was comfortable in recommending the omission of sinus radiographs in young children (<6 years).3 They were silent on the need for images in older children (>6 years). In this latter age group, the history of persistent symptoms predicts abnormal radiographs in only 70% of children.5 Accordingly, it may be necessary to perform confirmatory images in older children to more accurately diagnose acute sinusitis.
Wald et al showed that children with clinical and radiographic evidence of acute sinusitis recover more quickly and more often when treated with antibiotics than when receiving placebo.5 The most dramatic finding in their study was the very rapid recovery observed in almost 45% of children who received antibiotic (who were completely free of symptoms on the third day of treatment) compared with 11% in the placebo group. The overall difference in outcome between children receiving placebo and those receiving antibiotic at the end of therapy (10 days) was about 20%. The magnitude of difference in outcome between treated and untreated children with acute sinusitis was in the range of 20% to 30%.
There are several important differences between the studies reported by Wald et al and by Garbutt et al.5,6 In the Garbutt study the mean age of children was 8 years. The inclusion of a substantial number of children over 6 years of age without the performance of confirmatory radiographs may have resulted in the inclusion of children without sinusitis. The antibiotic doses that were used were low (by 2002 standards) and may have been inadequate for a subgroup of children infected with resistant organisms. These two factors alone could easily have obscured the 20% to 30% difference in outcome that is expected between treated and untreated children.
Garbutt and her colleagues have performed a very important study.6 It is essential that we continue to do systematic investigation of this issue so that we can determine which children with respiratory symptoms are most likely to benefit from antimicrobial therapy and whether imaging procedures can be omitted in all age groups.
REFERENCES
- Ueda D, Yoto Y. The ten-day mark as a practical diagnostic approach for acute paranasal sinusitis in children. Pediatr Infect Dis J.1996; 15 :576 –579[CrossRef][Web of Science][Medline]
- Aitken M, Taylor JA. Prevalence of clinical sinusitis in young children followed up by primary care pediatricians.
Arch Pediatr Adolesc Med.1998; 152
:244
–248
[Abstract/Free Full Text] - American Academy of Pediatrics, Subcommittee on Management of Sinusitis and Committee on Quality Improvement. Clinical practice guideline: management of sinusitis. Pediatrics.2001; 108 :798 –808
- Wald ER, Milmoe GJ, Bowen A, Ledesma-Medina J, Salamon N, Bluestone CD. Acute maxillary sinusitis in children. N Engl J Med.1981; 304 :749 –754[Abstract]
- Wald ER, Chiponis D, Ledesma-Medina J. Comparative effectiveness of amoxicillin and amoxicillin-clavulanate potassium in acute paranasal sinus infections in children: a double-blind, placebo controlled trial.
Pediatrics.1986; 77
:795
–800
[Abstract/Free Full Text] - Garbutt JM, Goldstein M, Gellman E, Shannon W, Littenberg B. A randomized, placebo-controlled trial of antimicrobial treatment for children with clinically diagnosed acute sinusitis. Pediatrics.2001; 107 :619 –625
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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