Subcommittee on Management of Sinusitis and Committee on Quality Improvement 108 (3): 798 PEDIATRICS Vol. 108 No. 3 September 2001, pp. 798-808 AMERICAN ACADEMY OF PEDIATRICS: Clinical Practice Guideline: Management of Sinusitis Subcommittee on Management of Sinusitis and Committee on Quality Improvement September 2001 AMERICAN ACADEMY OF PEDIATRICSMedical Speciality Society Subcommittee on Management of Sinusitis and Committee on Quality ImprovementA subcommittee, composed of pediatricians with expertise in infectious disease, allergy, epidemiology, family practice, and pediatric practice, supplemented with an otolaryngologist and radiologist, were selected to formulate the practice parameter. Ellen R. Wald, MDChairperson W. Clayton Bordley, MD, MPHDavid H. Darrow, MD, DDSKatherine Teets Grimm, MDJack M. Gwaltney, Jr, MDS. Michael Marcy, MDMelvin O. Senac, Jr, MDPaul V. Williams, MDLarry Culpepper, MD, MPHAmerican Academy of Family PhysiciansDavid L. Walner, MDAmerican Academy of Otolaryngology-Head and Neck SurgeryCarla Herrerias, MPHCharles J. Homer, MD, MPH, Chairperson Richard D. Baltz, MD Michael J. Goldberg, MD Gerald B. Hickson, MD Paul V. Miles, MD Thomas B. Newman, MD, MPH Joan E. Shook, MD William M. Zurhellen, MDCommittee on Quality Improvement,Charles H. Deitschel, Jr, MD Committee on Medical Liability Denise Dougherty, PhD Agency for Healthcare Research and Quality Institutions F. Lane France, MD Committee on Practice and Ambulatory Medicine Kelly J. Kelleher, MD, MPH Section on Epidemiology Betty A. Lowe, MD National Association of Children's Hospitals and Related Institutions Ellen Schwalenstocker, MBA National Association of Children's Hospitals and Related Institutions Richard N. Shiffman, MD Section on Computers and Other TechnologyLiaisons diagnosis, evaluation, and treatment of children, ages 1 to 21 years, with uncomplicated acute, subacute, and recurrent acute bacterial sinusitis Management to encourage accurate diagnosis of bacterial sinusitis appropriate use of imaging proceduresjudicious use of antibioticsThe objective of treatment of acute bacterial sinusitis is to foster rapid recovery, prevent suppurative complications, and minimize exacerbations of asthma (reactive airways diseases). clinicians who treat children and adolescents a variety of clinical settings including the office and emergency department. The literature was searched in Medline, complemented by Excerpta Medica, from 1966 through March 1999, using the word "sinusitis." Search criteria were limited to human studies and English language and appropriate pediatric terms.Searches of Electronic Databases More than 1800 citations were reviewed. One hundred thirty-eight articles were fully examined, resulting in 21 qualifying studies. These studies included 5 controlled randomized trials and 8 case series on antimicrobial therapy, 3 controlled randomized trials on ancillary treatments, and 8 studies with information on diagnostic tests. Weighting According to a Scheme(Scheme Given)Where data are lacking, a combination of evidence and expert opinion was used. Strong recommendations were based on high-quality scientific evidence or, when such was unavailable, strong expert consensus. Fair and weak recommendations are based on lesser-quality or limited data and expert consensus. Clinical options are identified as interventions for which the subcommittee could not find compelling positive or negative evidence. These clinical options are interventions that a reasonable health care professional may or may not wish to consider. The heterogeneity and paucity of the data did not allow for formal meta-analysis. When possible, rates were pooled across different studies and heterogeneity assessed.Systematic Review This clinical practice guideline is not intended as a sole source of guidance in the diagnosis and management of acute bacterial sinusitis in children. It is designed to assist pediatricians by providing an analytic framework for evaluation and treatment. It is not intended to replace clinical judgment or establish a protocol for all patients with this condition. Test textages 1 to 21 years uncomplicated acute, subacute, and recurrent acute bacterial sinusitisNeonates and children younger than 1 year children with previously recognized anatomic abnormalities of their paranasal sinuses (facial dysmorphisms or trauma), immunodeficiencies, cystic fibrosis, or immotile cilia syndromeThe child who seems toxic should be hospitalized and is not considered in this algorithm. Recommendation 1it is the concurrent presentation with high fever and purulent nasal discharge for at least 3 to 4 consecutive days that helps to define the severe presentation of acute bacterial sinusitis. Children with severe onset of acute bacterial sinusitis may have an intense headache that is above or behind the eye; in general, they seem to be moderately ill.high fever nasal dischargepurulent{duration}at least 3 to 4 consecutive daysintense headache (that is above or behind the eye)in general, they seem to be moderately ill.{conclude} the severe presentation of acute bacterial sinusitis The diagnosis of acute bacterial sinusitis is based on clinical criteria in children who present with upper respiratory symptoms that are either persistent or severe strong recommendation based on limited scientific evidence and strong consensus of the panel Recommendation 2aImaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children less than or equal to 6 years of age (ageless than or equal to 6 {years}Imaging studies are not necessary to confirm a diagnosis of clinical sinusitisIn children with persistent symptoms, the history of protracted respiratory symptoms (>10 but <30 days without evidence of improvement) predicted significantly abnormal radiographs (complete opacification, mucosal thickening of at least 4 mm, or an air-fluid level) in 80% of children.31 For children 6 years of age or younger, the history predicted abnormal sinus radiographs in 88% of children. Accordingly, in this age group, because a positive history predicts the finding of abnormal sinus radiographs so frequently (and because history plus abnormal radiographs results in a positive sinus aspirate in 75% of cases), radiographs can be safely omitted and a diagnosis of acute bacterial sinusitis can be made on clinical criteria alone.limited scientific evidencestrong recommendation based on limited scientific evidence and strong consensus of the panel31In contrast to the general agreement that radiographs are not necessary in children 6 years of age or younger with persistent symptoms, the need for radiographs as a confirmatory test of acute sinusitis in children older than 6 years with persistent symptoms and for all children (regardless of age) with severe symptoms is controversial.ageolder than 6 yearspersistent symptomssevere symptomsthe need for radiographs as a confirmatory test of acute sinusitis is controversial.A normal radiograph is powerful evidence that bacterial sinusitis is not the cause of the clinical syndrome.34 However, the American College of Radiology has taken the position that the diagnosis of acute uncomplicated sinusitis should be made on clinical grounds alone.35 They support this position by noting that plain radiographs of the paranasal sinuses are technically difficult to perform, particularly in very young children. Correct positioning may be difficult to achieve and therefore the radiographic images may overestimate and underestimate the presence of abnormalities within the paranasal sinuses.36,37 The college would reserve the use of images for situations in which the patient does not recover or worsens during the course of appropriate antimicrobial therapy. Similarly, a recent set of guidelines generated by the Sinus and Allergy Health Partnership (representing numerous constituencies) does not recommend either radiographs or computed tomography (CT) or magnetic resonance imaging scans to diagnose uncomplicated cases of acute bacterial sinusitis in any age group.1t is essential to recognize that abnormal images of the sinuses (either radiographs, CT, or magnetic resonance imaging) cannot stand alone as diagnostic evidence of acute bacterial sinusitis under any circumstances. Images can serve only as confirmatory measures of sinus disease in patients whose clinical histories are supportive of the diagnosis.IF( dv7 < 6 yrs and dv8) OR DV9 THEN a335, 36,37Recommendation 2bCT scans of the paranasal sinuses should be reserved for patients in whom surgery is being considered as a management strategypatients in whom surgery is being considered as a management strategyCT scans of the paranasal sinuses should be reservedDespite the limitations of CT scans,338-40 they offer a detailed image of sinus anatomy and, when taken in conjunction with clinical findings, remain a useful adjunct to guide surgical treatment.good evidencestrong recommendation based on good evidence and strong panel consensus)33Recommendation 3Most patients with acute bacterial sinusitis who are treated with an appropriate antimicrobial agent respond promptly (within 48-72 hours) with a diminution of respiratory symptoms (reduction of nasal discharge and cough) and an improvement in general well-being.11,23,31 If a patient fails to improve, either the antimicrobial is ineffective or the diagnosis of sinusitis is not correct.diminution of respiratory symptoms (reduction of nasal discharge and cough)an improvement in general well-being.within 48-72 hours)either the antimicrobial is ineffective or the diagnosis of sinusitis is not correct.If patients do not improve while receiving the usual dose of amoxicillin (45 mg/kg/d), have recently been treated with an antimicrobial, have an illness that is moderate or more severe, or attend day care, therapy should be initiated with high-dose amoxicillin-clavulanate (80-90 mg/kg/d of amoxicillin component, with 6.4 mg/kg/d of clavulanate in 2 divided doses).do not improve while receiving the usual dose of amoxicillin (45 mg/kg/d),have recently been treated with an antimicrobialhave an illness that is moderate or more severeattend day care,therapy should be initiated with high-dose amoxicillin-clavulanate80-90 mg/kg/d of amoxicillin component, with 6.4 mg/kg/d of clavulanate in 2 divided doses)his dose of amoxicillin will yield sinus fluid levels that exceed the minimum inhibitory concentration of all S pneumoniae that are intermediate in resistance to penicillin and most, but not all, highly resistant S pneumoniae. There is sufficient potassium clavulanate to inhibit all -lactamase producing H influenzae and M catarrhalis. Alternative therapies include cefdinir, cefuroxime, or cefpodoxime. A single dose of ceftriaxone (at 50 mg/kg/d), given either intravenously or intramuscularly, can be used in children with vomiting that precludes administration of oral antibiotics. Twenty-four hours later, when the child is clinically improved, an oral antibiotic is substituted to complete the therapy. Although trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole have traditionally been useful in the past as first- and second-line therapy for patients with acute bacterial sinusitis, recent pneumococcal surveillance studies indicate that resistance to these 2 combination agents is substantial.51,52 Therefore, when patients fail to improve while receiving amoxicillin, neither trimethoprim-sulfamethoxazole nor erythromycin-sulfisoxazole are appropriate choices for antimicrobial therapy.For patients who do not improve with a second course of antibiotics or who are acutely ill, there are 2 options. It is appropriate to consult an otolaryngologist for consideration of maxillary sinus aspiration to obtain a sample of sinus secretions for culture and sensitivity so that therapy can be adjusted precisely. Alternatively, the physician may prescribe intravenous cefotaxime or ceftriaxone (either in hospital or at home) and refer to an otolaryngologist only if the patient does not improve on intravenous antibiotics.patients who do not improve with a second course of antibioticsare acutely illIt is appropriate to consult an otolaryngologist for consideration of maxillary sinus aspirationthe physician may prescribe intravenous cefotaxime or ceftriaxone (either in hospital or at home) and refer to an otolaryngologist only if the patient does not improve on intravenous antibiotics.obtain a sample of sinus secretions for culture and sensitivity so that therapy can be adjusted precisely.Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical cureAntibiotics are recommended for the management of acute bacterial sinusitis children receiving antimicrobial therapy recovered more quickly and more often than those receiving placeboThe desire to continue to use amoxicillin as first-line therapy in patients suspected of having acute bacterial sinusitis relates to its general effectiveness, safety, and tolerability; low cost; and narrow spectrum.antimicrobials in adequate doses with appropriate antibacterial spectra are highly effective in eradicating or substantially reducing bacteria in the sinus cavity, whereas those with inadequate spectrum or given in inadequate doses are notThe microbiology of acute, subacute, and recurrent acute bacterial sinusitis has been outlined in several studies.20-22 The principal bacterial pathogens are Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. S pneumoniae is recovered from approximately 30% of children with acute bacterial sinusitis, whereas H influenzae and M catarrhalis are each recovered from about 20%.23 In the remaining 30% of children, aspirates of the maxillary sinus are sterile. It is noteworthy that neither Streptococcus aureus nor respiratory anaerobes are likely to be recovered from children with acute bacterial sinusitis.22For children younger than 2 years of age with uncomplicated acute bacterial sinusitis that is mild to moderate in degree of severity, who do not attend day care, and have not recently been treated with an antimicrobial, amoxicillin is recommended at either a usual dose of 45 mg/kg/d in 2 divided doses or a high dose of 90 mg/kg/d in 2 divided doses (Fig 1). If the patient is allergic to amoxicillin, either cefdinir (14 mg/kg/d in 1 or 2 doses), cefuroxime (30 mg/kg/d in 2 divided doses), or cefpodoxime (10 mg/kg/d once daily) can be used (only if the allergic reaction was not a type 1 hypersensitivity reaction). In cases of serious allergic reactions, clarithromycin (15 mg/kg/d in 2 divided doses) or azithromycin (10 mg/kg/d on day 1, 5 mg/kg/d × 4 days as a single daily dose) can be used in an effort to select an antimicrobial of an entirely different class. The Food and Drug Administration has not approved azithromycin for use in patients with sinusitis. Alternative therapy in the penicillin-allergic patient who is known to be infected with a penicillin-resistant S pneumoniae is clindamycin at 30 to 40 mg/kg/d in 3 divided doses.The optimal duration of therapy for patients with acute bacterial sinusitis has not received systematic study. Often empiric recommendations are made for 10, 14, 21, or 28 days of therapy. An alternative suggestion has been made that antibiotic therapy be continued until the patient becomes free of symptoms and then for an additional 7 days.23 This strategy, which individualizes treatment for each patient, results in a minimum course of 10 days and avoids prolonged courses of antibiotics in patients who are asymptomatic and thereby unlikely to be compliant.to promote the judicious use of antibiotics, it is essential that children diagnosed as having acute bacterial sinusitis meet the defining clinical presentations of "persistent" or "severe" disease as described previously.41 This will minimize the number of children with uncomplicated viral upper respiratory tract infections who are treated with antimicrobials.good evidencestrong recommendation based on good evidence and strong panel consensus)Risk factors for the presence of bacterial species that are likely to be resistant to amoxicillin include 1) attendance at day care, 2) recent receipt (<90 days) of antimicrobial treatment, and 3) age less than 2 years.49,50Adjuvant Therapies No recommendations are made based on controversial and limited data.Antibiotic Prophylaxis No recommendations are made based on limited and controversial data.Complementary/Alternative Medicine for Prevention and Treatment of Rhinosinusitis No recommendations are made based on limited and controversial data.4Children with complications or suspected complications of acute bacterial sinusitis should be treated promptly and aggressively. This should include referral to an otolaryngologist usually with the consultation of an infectious disease specialist, ophthalmologist, and neurosurgeoncomplications or suspected complications of acute bacterial sinusitisbe treated promptly and aggressively. This should include referral to an otolaryngologist usually with the consultation of an infectious disease specialist, ophthalmologist, and neurosurgeonstrong recommendation based on strong consensus of the panel)Mild cases of periorbital cellulitis (eyelid <50% closed) may be treated with appropriate oral antibiotic therapy as an outpatient with daily patient encounters.Mild cases of periorbital cellulitis (eyelid <50% closed)may be treated with appropriate oral antibiotic therapy as an outpatient with daily patient encounters.if the patient {with mild periorbital cellulitis} has not improved in 24 to 48 hours or if the infection is progressing rapidly, it is appropriate to admit the patient to the hospital for antimicrobial therapy consisting of intravenous ceftriaxoneMild cases of periorbital cellulitis (eyelid <50% closed){clinical status}not improved in 24 to 48 hours or infection is progressing rapidlyadmit the patient to the hospital for antimicrobial therapy consisting of intravenous ceftriaxone (100 mg/kg/d in 2 divided doses) or ampicillin-sulbactam (200 mg/kg/d in 4 divided doses). Vancomycin (60 mg/kg/d in 4 divided doses) may be added in children in whom infection is either known or likely to be caused by S pneumoniae that are highly resistant to penicillin.If proptosis, impaired visual acuity, or impaired extraocular mobility are present on examination, a CT scan (preferably coronal thin cut with contrast) of the orbits/sinuses is essential to exclude a suppurative complication. In such cases, the patient should be evaluated by an otolaryngologist and an ophthalmologist.proptosisimpaired visual acuityimpaired extraocular mobilitya CT scan (preferably coronal thin cut with contrast) of the orbits/sinuses is essential to exclude a suppurative complication.the patient should be evaluated by an otolaryngologist and an ophthalmologist.Suppurative complications generally require prompt surgical drainage.In patients with altered mental status, neurosurgical consultation is indicated. Signs of increased intracranial pressure (headache and vomiting) or nuchal rigidity require immediate CT scanning (with contrast) of the brain, orbits, and sinuses to exclude intracranial complications such as cavernous sinus thrombosis, osteomyelitis of the frontal bone (Pott's puffy tumor), meningitis, subdural empyema, epidural abscess, and brain abscess.altered mental statusneurosurgical consultation is indicatedSigns of increased intracranial pressure (headache and vomiting) or nuchal rigidity require immediate CT scanning (with contrast) of the brain, orbits, and sinuses to exclude intracranial complications such as cavernous sinus thrombosis, osteomyelitis of the frontal bone (Pott's puffy tumor), meningitis, subdural empyema, epidural abscess, and brain abscess. Central nervous system complications, such as meningitis and empyemas, should be treated either with intravenous cefotaxime or ceftriaxone and vancomycin pending the results of culture and susceptibility testing.Signs of increased intracranial pressure (headache and vomiting) or nuchal rigidityimmediate CT scanning (with contrast) of the brain, orbits, and sinusesto exclude intracranial complications such as cavernous sinus thrombosis, osteomyelitis of the frontal bone (Pott's puffy tumor), meningitis, subdural empyema, epidural abscess, and brain abscess. acute bacterial sinusitisBacterial infection of the paranasal sinuses lasting less than 30 days in which symptoms resolve completely. subacute bacterial sinusitisymptoms resolve completely.recurrent acute bacterial sinusitis Episodes of bacterial infection of the paranasal sinuses, each lasting less than 30 days and separated by intervals of at least 10 days during which the patient is asymptomatic.chronic sinusitisEpisodes of inflammation of the paranasal sinuses lasting more than 90 days. Patients have persistent residual respiratory symptoms such as cough, rhinorrhea, or nasal obstruction.acute bacterial sinusitis superimposed on chronic sinusitisPatients with residual respiratory symptoms develop new respiratory symptoms. When treated with antimicrobials, these new symptoms resolve, but the underlying residual symptoms do not.Persistent symptomsthose that last longer than 10 to 14, but less than 30, days. Such symptoms include nasal or postnasal discharge (of any quality), daytime cough (which may be worse at night), or both.Severe symptomsa temperature of at least 102°F (39oC) and purulent nasal discharge present concurrently for at least 3 to 4 consecutive days in a child who seems ill. The draft clinical practice guideline underwent extensive peer review by committees and sections within the American Academy of Pediatrics and by numerous outside organizations. Liaisons to the committee also distributed the draft within their organizations.External Peer Review