Sinusitis Microbial etiology,risk factor,newest treatment

  Sinusitis

Microbial etiology

l       Viruses are the most frequent cause of rhinosinusitis

l       viruses are known to predispose to subsequent bacterial infection via such mechanisms as viral-induced impairment of the mucociliary apparatus.

 

Bacterial causes of sinusitis

50% of H. Influenzae  and 100% M. catarrhalis are B- lactamase positive Sign and symptoms

2%

l         In pediatric patients, most URIs last 5-7 days.

l       By 10 days, the URI almost always improves.

l       Most rhinoviral infections improve within 7-10 days so the complaint of persistent or worsening symptoms may indicate a developing bacterial sinusitis.

l       Pediatric patients may complain of a daytime cough and persistent nasal discharge.

l       Complaints of facial pain and headache are rare in children.

l         The clinical diagnosis of Bacterial sinusitis is based solely on history.

l          Persistent of symptoms of URI , including nasal discharge and cough, for >10-14 days,

l         or temp 39 C and purulent discharge for 3-4 days

Chronic sinusitis

l       Cough

l       Nasal discharge or nasal congestion lasting more than 90 days

Physical examination
pan>- Facial tenderness to palpation is present

- Nasal mucosa is inflammation, redness and swelling

- Purulent secretions in the middle meatus (highly predictive of maxillary sinusitis)

- Complete opacification of sinus on transillumination is present.

Antibiotics for siuusitis

l       Amoxicillin remains as efficacious drug : 80-90 mg/kg/day divided bid for 10-14 days (maximum dose 2-3 g/day)

l       High dose of amoxicillin-clavulanate ( 80-90 mg/kg/day and 6.4  mg/kg/day) should be given if

     there are  risk factors:

1.   antibiotics treatment in the preceding1-3 mo,
2.    day care attendance, age ≤2 yr )
3.    resistant bacterial species
4.    failure to respond to initial amoxicillin within 72 hr
   
   
5. 
   
   
   

Other treatment alternatives

1. Most patients with penicillin allergy will tolerate Cephalosporins. If allergy manifests as anaphylaxis macrolides should be given instead of Cephalosporins:

•          Cefdinir 14 mg/kg/day in 2 divided doses

•               Cefuroxime: 30mg/kg/day in 2 divided doses

•          Cefpodoxime 10mg/kg/day once daily

•          Azithromycin 10 mg/kg on day 1; 5mg/kg x 4 days once daily.

•          Clarithromycin 15mg/kg/day in 2 divided doses

l       Frontal sinusitis can rapidly progress to intracranial complication -parenteral ceftriaxone until improvement then oral antibiotic therapy.

l       The use of decongestants, antihistamines, mucolytics and intranasal steroids have not adequately studied in children