Sinusitis – Refining the Diagnosis
Acute bacterial sinusitis is a complication of a viral upper respiratory infection and/or allergies (hay fever). Approximately 10% of pediatric patients presenting with upper respiratory symptoms have clinically defined sinusitis. The accuracy of the diagnosis and subsequent decision making regarding treatment, including antibiotics, continues to be a challenging and actively evaluated area of pediatric research. The AAP recently published updated guidelines to help clinicians best diagnose and treat this common problem.
The guidelines outline 3 different “presentations” that can assist in more accurately diagnosing sinusitis: 1) a persistent illness of nasal congestion/ discharge or cough lasting > 10 days, 2) a worsening course of upper respiratory and/or cough symptoms that fail to improve in a reasonable time (7-10 days), or 3) a severe onset associated with high fever, purulent (infected) nasal discharge and an ill acting or appearing child persisting for at least 3 days. These 3 presentations would not be typical of a common cold. Severe (seasonal) allergies could have these characteristics and would require a good history and physical to differentiate.
Other caveats from the guidelines include:
1) Various types of x-ray imaging may not help to improve the accuracy of the diagnosis since imaging cannot differentiate inflammation from infection and can therefore “over diagnose” infection.
2) Antibiotics are indicated for acute infection with a severe onset or worsening course. For persistent illness, observation or other non-antibiotic options can be continued for a short time period.
3) Amoxicillin or its enhanced variant, Augmentin, is the first line treatment for sinusitis (high dose Amoxicillin is now the standard and has been in use for several years).
4) Improvement should be seen within 3 days of treatment. Reassessment is warranted in those patients not improving within that time period.