Pediatric Examination and Board Review (100 page)

15.
Which of the following can predispose an individual to develop sinusitis?

(A) viral upper respiratory tract syndrome

(B) dental infections

(C) allergic rhinitis

(D) cystic fibrosis

(E) all of the above

16.
What should your next course of action be with the patient just described?

(A) radiographs of the sinuses

(B) intranasal steroid spray

(C) oral antibiotics

(D) CT of sinuses

(E) prescription antihistamine not associated with drowsiness

17.
How long should this patient receive antibiotics if clinical improvement is apparent?

(A) 7 days

(B) 10-14 days

(C) 21 days

(D) 30 days

(E) 45 days

18.
Under which condition would a maxillary sinus aspiration not be indicated?

(A) failure to respond to multiple courses of antibiotics

(B) severe facial pain

(C) an orbital or intracranial complication

(D) symptoms for 30 days

(E) evaluation of sinusitis in an immunocompromised patient

ANSWERS

1.
(B)
The vignette is a typical story for the common cold, most often caused by rhinovirus.

2.
(E)
Most healthy children have 6-8 upper respiratory tract infections per year.

3.
(D)
The definition of acute bacterial sinusitis is persistent symptoms lasting more than 10 and less than 30 days. Nasal discharge of
any
quality, cough that is present daytime and nighttime (although usually worse at night), foul breath, and facial pain and/or headache are the most common presenting symptoms. On examination, preseptal swelling, facial pain or tenderness over the sinuses, and findings of an upper respiratory tract infection are often present. Immotile cilia syndrome, or primary ciliary dyskinesia, is an inherited disease affecting the respiratory cilia. Most patients with this disease have chronic respiratory illnesses (including URIs, chronic sinusitis, chronic otitis media) throughout their childhood.

4.
(E)

5.
(D)
Subacute sinusitis is defined as persistent symptoms from 30 to 90 days. Chronic sinusitis lasts longer than 90 days.

6.
(E)
The frontal sinuses develop from the anterior ethmoid cells and move into their position by 5-6 years old. The maxillary and ethmoid sinuses form in utero and are present at birth.

7.
(D)
This is another, less common, presentation of acute bacterial sinusitis in children: high fever (>102°F [38.8°C]) and purulent nasal discharge for at least 3-4 consecutive days. Viral upper respiratory tract infections can also present with fever and thick nasal discharge, although the timing is different. With a viral URI, the quality of the nasal discharge may change several times throughout the course of the illness, from clear to thick and back to clear. Fever is usually present at the outset and resolves after several days; other constitutional symptoms are usually present.

8.
(C)
When children meet the criteria for acute bacterial sinusitis, whether in the case above or the case from question 3, antibiotic therapy is warranted. See the next question and answer for a discussion on antibiotic choices. Although amoxicillin is still considered the first choice, penicillin resistance to
S pneumoniae
should be considered. The rates of resistance vary by location. Routine radiographic examination of uncomplicated acute bacterial sinusitis is not helpful. A CT scan of a patient with suspected sinuitis may be helpful, but changes consistent with mild sinusitis are often found during uncomplicated upper respiratory tract infections (ie, mucosal changes within the sinuses that are indistinguishable from acute bacterial sinusitis). Recent studies investigating the use of intranasal steroids in patients with acute bacterial sinusitis are promising but not conclusive.

9.
(B)
Despite penicillin resistance of
S pneumoniae
(approximately half of the isolates obtained by sinus aspiration are intermediately resistant to penicillin and a small proportion of these will be fully resistant), amoxicillin is still the first choice for uncomplicated acute bacterial sinusitis, although at the higher dose of 90 mg/kg per day. Both azithromycin and trimethoprim-sulfamethoxazole have less efficacy against the primary agents of sinusitis and should not be used as first line therapy.

10.
(B)
Most patients should be treated for 10-14 days. Some require longer courses if symptoms persist. An alternative treatment approach is to treat for 7 days beyond resolution of symptoms. Treatment beyond a few weeks is not recommended or supported by clinical studies.

11.
(B)
Most patients who are treated with an appropriate antibiotic respond promptly, within 48-72 hours.

12.
(E)
Recent amoxicillin therapy and the presence of frontal or sphenoid sinusitis are situations in which an alternative to amoxicillin may be appropriate. Symptomatology for more than 30 days is another indicator. Reasons include the higher likelihood of a resistant organism and the need for higher drug levels than oral amoxicillin can provide. Clinically important frontal or sphenoid sinusitis may require parenteral therapy.

13.
(B)
This is likely to be an orbital process, either cellulitis or abscess, which are both complications of acute bacterial sinusitis. They require parenteral antibiotics and inpatient observation. Other complications of sinusitis include subperiosteal intraorbital abscess, sinus-associated osteomyelitis (frontal bone osteomyelitis, also known as Pott puffy tumor), epidural abscess, meningitis, and brain abscess.

14.
(D)
This is consistent with subacute bacterial sinusitis, with protracted respiratory symptoms (congestion and cough are most common). At this point it is important to consider other possibilities with your examination such as CF (poor growth, clubbing, barrel chest, nasal polyps, respiratory findings), allergic rhinitis (dark circles under the eyes, horizontal crease across the nose, Morgan-Dennie lines characterized by skin folds under the lower eyelid), adenoidal hypertrophy, or immunodeficiency.

15.
(E)
All of the other illnesses or situations listed predispose patients to sinusitis, acute and bacterial. Immune disorders, immotile cilia syndrome, facial trauma, choanal atresia, and foreign bodies have also been implicated.

16.
(C)
Because the microbial etiologies of subacute sinusitis are somewhat different from that of acute bacterial sinusitis, the treatment also is different, although antibiotics remain the first step in therapy. In addition to
S pneumoniae, H influenzae
,
S aureus
, and
M catarrhalis
, anaerobes may play a role. Therapy should be directed against all of these. One reasonable choice is amoxicillin-clavulanate except in areas where MRSA isolates are prevalent. If oral antibiotic therapy is not successful, surgical drainage and parenteral antibiotics are often required.

17.
(C)

18.
(D)
Maxillary sinus aspiration can be performed by an otolaryngologist on an outpatient basis, but this should be reserved for the other situations previously listed. Sinus symptoms for 30 days are still considered subacute, and an initial trial of oral antibiotics is appropriate.

S
UGGESTED
R
EADING

Brook I. Microbiology and antimicrobial management of sinusitis.
Otolaryngol Clin North Am.
2004;37(2):253-266.

Clinical practice guideline: management of sinusitis. American Academy of Pediatrics Web site.
http://aappolicy.aappublications.org/
. Accessed June 2010.

Nash D, Wald E. Sinusitis.
Pediatr Rev.
2001;22(4):111-116.

CASE 62: AN 8-YEAR-OLD GIRL WITH SORE THROAT

An 8-year-old girl comes to your office during winter complaining of worsening throat pain for 2 days, tactile temperatures at home, and abdominal pain. She has not vomited, has no diarrhea, and she has noticed no rashes. She was barely able to eat food this morning because of the pain. No one else is ill at home, but several of her friends at school have the “same thing.”

On examination you note a temperature of 101.5°F (38.6°C), clear nares, white conjunctivae, oropharynx with palatal petechiae, a swollen and erythematous uvula, enlarged erythematous tonsils, and no tonsillar exudates. She has tender anterior cervical lymphadenopathy, left greater than right, all smaller than 1 cm in diameter. Her lungs are clear bilaterally; she has mild periumbilical tenderness, no hepatosplenomegaly, and no rash.

SELECT THE ONE BEST ANSWER

1.
What is the most likely diagnosis?

(A) viral pharyngitis

(B) mononucleosis

(C) group A streptococcal pharyngitis

(D) Coxsackie virus

(E) group B streptococcal pharyngitis

2.
What is the most appropriate next step?

(A) in-office monospot test

(B) CBC and EBV titers

(C) rapid latex test for group A streptococcus

(D) reassurance

(E) start antibiotics

3.
Which of these is
not
a complication of this illness?