Rhinosinusitis%20-%20acute,%20bacterial%20(pediatric) Diagnosis

• Presumptive diagnosis and identification of bacterial versus viral rhinosinusitis may be made when the child has an acute upper respiratory tract infection (URTI) and with any of the following:
  • Persistent illness, eg, symptoms of nasal discharge (of any quality) or daytime cough or both lasting ≥10 days with no improvement
  • Severe onset, eg, concurrent fever (temperature ≥39°C/102.2°F) and purulent nasal discharge or facial pain for at least 3-4 consecutive days at the beginning of illness
  • At least 3 of the following: Discolored nasal discharge, severe local pain, fever, elevated erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP), and/or double sickening 
  • Worsening course, eg worsening or new onset of nasal discharge, daytime cough, headache or fever that lasted 5-6 days after initial improvement of a viral upper respiratory tract infection

Severity of Acute Bacterial Rhinosinusitis (ABRS)

• The terms mild and moderate reflect the degree of patient discomfort (symptom complex and time course of disease) and the likelihood of spontaneous resolution of symptoms
• Evaluation of disease severity is based on total severity visual analogue scale (VAS) score
  • Mild: VAS 0-3
  • Moderate: VAS >3-7
  • Severe: VAS >7-10
• Differences in disease severity do not necessarily imply antimicrobial resistance

• Document all relevant signs and symptoms including severity and time course
• Most common presenting symptoms in children are cough, nasal discharge, and fever

• Nose should be examined for deviated septum, nasal polyps and foreign bodies
• Examination of the ears for concomitant otitis media
• Perform anterior rhinoscopy to look for erythematous nasal mucosa and to examine nasal turbinates for edema and purulent drainage
  • Change in the color, quantity and quality of the nasal discharge are not specific signs of bacterial infection
• Fiberoptic endoscopy is done to visualize the middle meatus
  • May show nasal polyps, mucopurulent discharge, and/or edema or mucosal obstruction 
  • Culture of purulence in this area may be parallel with cultures from sinus aspirates
• Local tenderness on percussion or direct pressure over the body of the frontal and maxillary sinuses with unilateral predominance may be present
• Periorbital edema may indicate ethmoidal sinusitis
• Tympanic membrane, pharynx and neck exam for lymph nodes may not support the diagnosis of acute bacterial rhinosinusitis (ABRS)

Sinus Aspiration and Culture

• Considered the gold standard for the diagnosis of acute bacterial rhinosinusitis (ABRS)
  • Bacterial recovery of ≥10⁴ colony-forming units/mL is considered positive
  • Not recommended for routine diagnosis due to its invasiveness and technical skills it requires
• Indications: Lack of response to conventional therapy, toxic-looking patient or presence of severe illness, suppurative or intracranial complications, and suspected rhinosinusitis in immunocompromised patient

Transillumination

• May be useful in adolescents for assessing maxillary and frontal sinus disease, however shown to be unreliable in patients <10 years of age

Other Lab Tests

• C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) may be used as a marker of bacterial infection, with correlation with CT scan results
• Procalcitonin is also considered a potential biomarker for more serious bacterial infection

• Imaging studies [eg plain radiographs or computed tomography (CT) scan] are nonspecific and do not distinguish bacterial from viral rhinosinusitis, thus it is discouraged to used these studies
  • CT studies may show mucosal changes within the ostiomeatal complex and/or sinuses
• Radiologic studies should not be routinely done as part of initial management of uncomplicated acute bacterial rhinosinusitis (ABRS) and as confirmatory test in patients ≤6 years of age
  • Some support the use of radiographs in patients >6 years of age with persistent symptoms and in all patients with severe disease regardless of age
• CT scan is indicated in the following patients with:
  • Recurrent or persistent rhinosinusitis
  • Signs of ABRS complications
  • Refractory rhinosinusitis in which surgery is being contemplated
• Magnetic resonance imaging (MRI) scan is indicated in extra sinus local spread or intracranial complications, although this is uncommon
• More data are needed to know the usefulness of ultrasound in diagnosing ABRS