Contents
Introduction . . . 127
Diagnosis of Frontal Sinusitis . . . 128
Medical Management . . . 129
Surgical Management . . . 130
Complications of Pediatric Frontal Sinusitis . . . 130
Intracranial Complications . . . 130
Orbital Complications . . . 131
Conclusion . . . 131
References . . . 131
Introduction
Dr. Casiano has presented detailed anatomy and em- bryology of the frontal sinus in Chapter 3. It is howev- er, important to consider certain salient features when considering frontal sinusitis in the pediatric group. The reader is referred to the studies by Onodi [10] and Wolf et al. [13] for the development of the frontal sinus in Table 15.1. These developmental stud- ies are only guidelines, as the development of the frontal sinus is the most variable of all the paranasal sinuses, and the final size of the sinus can vastly dif- fer among patients of the same age group.
Certain information must to be considered when evaluating frontal sinusitis in children:
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Possible etiologic factors
쐽
The possibility of response to medical therapy
쐽
Findings of imaging studies before consider- ing more aggressive medical or surgical therapy
Pediatric Frontal Sinusitis
Charles W. Gross, Joseph K. Han
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Core Messages
쐽
Pediatric frontal sinusitis is not common.
Frontal recess disease is more common, which often needs to be addressed
쐽Frontal sinusitis in the pediatric popula-
tion does not usually occur until the later childhood years
쐽
Due to the infrequency of frontal sinusitis with or without complications, there may often be a delay in the diagnosis and treat- ment
쐽
If frontal sinusitis is present, it is often dif- ficult to diagnose secondary to vague com- plaints in children
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Medical treatment should be the first line of treatment for frontal sinusitis, and the etiology of frontal sinus disease should be determined before considering surgical intervention
쐽
If medical treatment fails, anterior ethmoi- dectomy with exposure of the frontal re- cess should be the initial surgical approach
쐽Extra-sinonasal extension of the infection,
though infrequent, will likely require
prompt surgical intervention
A classic study by Kasper [9] in which he dissected 100 pediatric cadavers remains applicable today as he noted: “Evidence is seen in the embryo at the end of the third or early part of the fourth month of a begin- ning extension forward and upward of the middle nasal meatus. This early extension is the forerunner of the frontal recess and, strictly speaking, is the first step in the formation of the frontal sinus and certain anterior group of ethmoidal cells.”
From this extension children develop frontal sinuses at varying ages:
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In children less than 5 years old, approximate- ly 3% of the children have frontal sinuses [2]
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Between ages 5 and 10 years, approximately 50% have frontal sinuses
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At the age of 11 years and older, 65%–75% have frontal sinuses
As previously noted, the frontal sinus development is not completed until late teenage years. However, the authors have personally seen children as young as four with a well developed frontal sinus (Fig. 15.1).
Sinusitis in children with cystic fibrosis (CF) is a frequent problem, which often poses unique and dif- ficult management issues. It is well known that gen-
eral CF patients have less well-developed sinuses. In the excellent study by Eggesbo et al. in which they an- alyzed 116 CF patients against controls, they found that 44% of the CF patients studied had bilateral aplasia of the frontal sinuses [3]. It should also be noted that 30% of those CF patients studied had a low ethmoid roof, which must alert the surgeon to this anatomical feature when considering surgery, as it may potentially lead to intracranial complications.
Diagnosis of Frontal Sinusitis
The diagnosis of frontal sinusitis in children is more difficult than in adults, since the symptoms are often less specific. Viral upper respiratory infection is one of the most common medical illnesses in children. It is estimated that 5%–10% of the children with these viral infections will develop acute sinusitis. Thank- fully, pediatric acute sinusitis does not usually re- quire aggressive medical or surgical therapy, since frequently it will resolve spontaneously. However, se-
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Table 15.1.The dimensions of the frontal sinus in the pediatric population from two studies by Onodi [10] and Wolf et al. [13]
Investigator Age Frontal sinus development Length Height Width (mm) (mm) (mm)
Onodi [10] Newborn 3 4.5 2
Wolf [13] Cellular ethmoidales (frontal cell)
Onodi [10] 1–4 4.8 6.9 4.7
Wolf [13] 6.5 6 5
Onodi [10] 4–8 6–10 15–16 8–10
Wolf [13] 4–11 14–17 7–9
8–12 Period of near-completion of pneumatization
Fig. 15.1.CT scan of the frontal sinus in a coronal view of a four-year-old
vere cases of pediatric sinusitis require aggressive medical or surgical treatment, especially those not resolving to routine medical and supportive manage- ment.
The key elements for normal physiology of all the paranasal sinuses are:
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Patency of the sinus ostia
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Proper function of the mucociliary apparatus
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Proper quality and quantity of sinus secre- tions
Any impairment of these factors may lead to serious clinical consequences.
Children with recurrent sinusitis may have comorbid conditions leading to the sinusitis. These children should be evaluated for:
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Allergies
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Cystic fibrosis
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Immunodeficiency
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Impaired ciliary function
The clinical features indicating significant sinusitis in children are:
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Rhinorrhea
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Cough
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Otitis media
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Bronchitis
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Elevated temperature greater than 101° F
Children with multiple recurrent or persistent infec- tions and unexplained continued nasal mucosal in- flammation may require mucosal biopsy to evaluate for ciliary defects. If a ciliary biopsy is to be per- formed, it should take place at least 6 weeks from an upper respiratory infection, since viral respiratory infections have been shown to cause nasal ciliary damage that may require 6 weeks to resolve.
Appropriate treatment of acute sinusitis in chil- dren will usually lead to resolution of frontal sinus- itis when present. However, when there are threaten- ing or existing complications related to the frontal si- nus, prompt (if not emergent) treatment directed to the frontal sinus is required. Evaluation of frontal si- nusitis in children may be difficult because of the vagueness of symptoms and the difficulty of per- forming a good examination. Even though children with sinusitis may present only with persistent cough or rhinorrhea, the otolaryngologist should still per- form the best examination possible. With patience (and occasionally mild sedation), most children aged 4 years and older will tolerate at least an abbreviated endoscopic examination. The endoscopic examina- tion in the office setting can prove to be most benefi- cial since the quality, quantity, and often the site of origin for the secretions can be determined. If an en- doscopic examination is possible, a middle meatus culture can be very valuable in the antibiotic selec- tion process.
Imaging studies are increasingly more practical, even in young children. Newer CT scanners allow very rapid and less traumatic examination of chil- dren than those previously available. When neces- sary, as in severe cases, sedation or even general anes- thesia may be employed. When reviewing sinus CT studies, otolaryngologists should remember that children younger than 2 years of age frequently have varying degrees of opacification even in the normal state. In a study by Hill et al., 31% of children had an incidental finding of opacification of the sinuses on a routine CT scan [8].
Medical Management
When antibiotic therapy is necessary, it should be di-
rected toward the offending organism. Ideally, antibi-
otic therapy should be culture-directed, particularly
after failure of prior antibiotic use. The most com-
mon pathogens for acute sinusitis are Streptococcus
pneumonia, Haemophilus influenzae, and Moraxella
catarrhalis [12]. In chronic sinusitis, involved organ-
isms include anaerobes, Staphylococcus aureus, and
Streptococcus viridans. When comorbid conditions
such as allergic rhinitis, cystic fibrosis, and immune
deficiency are present, they should be treated to facil-
itate resolution of the sinus infection. Additional supportive therapy should include hydration and moisturizing agents such as nasal saline spray. More severe nonresponding cases may require hospital ad- mission and intravenous antibiotics, particularly when threatening complications are present.
Surgical Management
When surgery for chronic sinusitis in children is nec- essary, functional endoscopic sinus surgery (FESS) has proved to be very efficacious [8]. Even though surgery is effective, this should only be undertaken in recalcitrant cases. Recalcitrant cases (recurrent and chronic sinusitis) were well defined in the original thesis of Van Alyea, which has stood the test of time [11]. In his manuscript, originally published in 1946, Van Alyea stated that prolonged cases of acute frontal sinusitis imply faulty drainage with a likelihood of recurrence and progression to a chronic state. In these cases, correction of structural defects and es- tablishment of adequate drainage channels assist in the resolution of the condition. Van Alyea also wrote that most patients with long-standing suppuration of the frontal sinus might also improve by correction of structural defects and removal of barriers to drain- age.
Attention and exposure of the frontal recess is suf- ficient for most cases of frontal sinusitis in children requiring surgery. However, frontal sinusotomy may be required in those few cases not responding to an anterior ethmoidectomy with exposure of the frontal recess or in cases where complications are impend- ing or present. We have not found the mini-trephina- tion procedure in young children, other than in those with well-developed sinuses, to be a worthwhile pro- cedure [4]. In young children who cannot tolerate of- fice procedures, a return to the operating room for debridement and evaluation of the frontal recess as a second stage procedure is often beneficial. This is or- dinarily done about 2 weeks following primary sur- gery. In the older patient who will allow endoscopic debridement in the office, this may not be necessary.
Complications of Pediatric Frontal Sinusitis
It is important to remember that although not fre- quent, frontal sinusitis in children may be a focus of spread for infection to the orbit or central nervous system.
Intracranial Complications
Despite improvements in the medical management of recurrent or chronic sinusitis, complications do continue to occur. Frontal sinusitis can often spread to the cranium due to the intimate relationship between the frontal sinus and the anterior skull base.
When this occurs neurologic manifestations may be the initial presentation rather than symptoms from the frontal sinusitis.
The common intracranial complications of frontal si- nusitis are:
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Meningitis
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Epidural abscess
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Subdural empyema
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Brain abscess
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Venous sinus thrombosis
When the bony confines of the sinuses are not com- promised, infection can still spread to the intracrani- al cavity through the complex venous network that traverses this area.
In a study at the University of Virginia in which 176 cases of intracranial suppuration over a 5-year period were reviewed, 15 patients had 22 suppurative intracranial complications from sinusitis [4]. Four of the 15 patients were children. In another study by Giannoni et al., there were 18 cases of intracranial complications secondary to sinusitis over a 10-year period [5]. The same study also reports that 12% of the cerebral and 16% of the extra-axial abscesses were due to sinogenic origin. When intracranial
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complications are present, these patients should be managed in conjunction with a pediatric neurosur- geon. While sinusitis and intracranial complications may be initially managed medically, if a neurosurgi- cal procedure under general is necessary, an involved frontal sinus can be drained in the same setting. Due to the resilience of children, the outcome of neuro- logical complications is generally more favorable than in adults. Early and aggressive medical and sur- gical management in children often results in little or no permanent morbidity.
Orbital Complications
Pediatric frontal sinus infection can also extend into the orbit and cause periorbital cellulitis or subperios- teal abscess [1]. When an orbital subperiosteal ab- scess originates from the frontal sinus, the location of the abscess is generally in the lateral superior portion of the orbit. In contrast, when the subperiosteal ab- scess originates from the ethmoid sinuses, the ab- scess is usually located in the medial area of the orbit along the lamina papyracea. A specific organism in the head and neck region that has a high rate of ex- tension and involvement of the surrounding struc- tures in the pediatric population is Streptococcus mil- leri [7]. In their study, Han and Kerschner showed that the local extension rate of this organism with in- volvement of the surrounding structures was 56%
[7]. Intracranial involvement was seen when S. mille- ri was cultured from infected frontal sinuses, while orbital involvement was seen when S. milleri was cul- tured from infected ethmoid sinuses.
Once periorbital extension occurs, very aggressive management is compulsory. This is most often man- aged in an inpatient hospital environment. Intrave- nous antibiotic therapy may be successful in younger patients. However, if subperiosteal abscess is present and there is no improvement with intravenous anti- biotics, surgical drainage is indicated. This can often be done intranasally, but in certain circumstances ex- ternal drainage may be required.
Conclusion
The majority of cases of pediatric frontal sinusitis will likely resolve with medical management and not develop complications. When complication signs become apparent, early and aggressive medi- cal management with surgical intervention when necessary will most often result in complete recov- ery without permanent sequelae.
References
1. Brook I, Friedman EM (1982) Intracranial complications of sinusitis in children: a sequela of periapical abscess. Ann Otol 91 : 41–43
2. Cannon CR, McCay B, Halton JR (1995) Paranasal sinus de- velopment in children and its relationship to sinusitis. J Miss State Med Assoc 36 : 40–43
3. Eggesbo HB, Sovik S, Dolvik S et al (2001) CT characteriza- tion of developmental variations of the paranasal sinuses in cystic fibrosis. Acta Radiologica 42 : 482–493
4. Gallagher RM, Gross CW, Phillips CD (1998) Suppurative intracranial complications of sinusitis. Laryngoscope 108 : 1635–1642
5. Giannoni C, Sulek M, Friedman EM (1998) Intracranial complications of sinusitis: A pediatric series. Am Jour Rhinol 12 : 173–178
6. Gross CW, Gurucharri MJ, Lazar RH et al (1989) Function- al endonasal sinus surgery (FESS) in the pediatric age group. Laryngoscope 99 : 272–275
7. Han JK, Kerschner JE (2001) Streptococcus milleri: An or- ganism for head and neck infections and abscess. Arch Otolaryngol Head Neck Surg 127 : 650–654
8. Hill M, Bhattacharyya N, Hall TA, Lufkin R et al (2004) In- cidental paranasal sinus imaging abnormalities and the normal Lund score in children. Otolaryngol Head Neck Surg 130 : 171–175
9. Kasper KA (1953) Nasofrontal connections. Arch Otola- ryngol 322–345
10. Onodi A (1911) Die Nebenhohlen der nase beim kinde.
Wurzburg: Verlag Kabitzach
11. Van Alyea OE (1946) Frontal Sinus Drainage. Ann Otol Rhinol Laryngol 55 : 267–277
12. Wald ER (1994) Sinusitis in children. Israel J Med Sci 30 : 403–407
13. Wolf G, Anderhuber W, Kuhn F (1993) Development of the paranasal sinuses in children: Implications for paranasal sinus surgery. Ann Otol Rhinol and Laryngol 102 : 705–711
