SOAP Pedi – Sinusitis, Bacterial

Source: Manual of Ambulatory Pediatrics 2010

SOAP Note – Sinusitis, Bacterial

An acute inflammatory process involving one or more of the paranasal sinuses.

I. Etiology

A. S. pneumoniae, H. influenzae, and M. catarrhalis are the most common bacteria responsible for acute bacterial sinusitis (ABS) (70%). Other organisms implicated are S. aureus, Streptococcus pyogenes, gramnegative bacilli, and respiratory viruses.
B. Acute sinusitis usually follows rhinitis, which may be viral, allergic, or vasomotor in origin. It also may result from abrupt pressure changes (air planes, diving) or from dental extractions or infections.

II. Incidence

A. The incidence of sinusitis closely parallels the incidence of upper respiratory tract infections because the paranasal sinuses are lined with epithelium, which is contiguous with the rest of the respiratory tract. Therefore, it is seen most often in winter.
B. If associated with allergic rhinitis, an increase in incidence is seen at times of high pollen counts.

III. Subjective data

A. History of upper respiratory infection (URI) or allergic rhinitis
B. History of pressure change (e.g., airplane flight, diving, scuba diving, bungee jumping)
C. Sensation of pressure over sinuses followed by local pain and tenderness
D. Pain increases in intensity 1 to 2 hours after arising, and subsides in late afternoon.
E. Malaise
F. Low-grade temperature
G. Persistent nasal discharge; of any quality, but often purulent
H. Postnasal drip
I. Cough, often worse at night
J. Mouth breathing
K. Snoring
L. Malodorous breath
M. Maxillary dental pain
N. History of previous episodes of sinusitis

IV. Objective data

A. Nasal mucosa: Edematous and hyperemic
B. Percussion or palpation tenderness over a sinus

1. Maxillary sinusitis: Over cheek and upper teeth
2. Frontal sinusitis: In forehead above the eyebrow
3. Sphenoid sinusitis: Headache in occipital area
4. Anterior ethmoidal sinusitis: In the temporal area
5. Posterior ethmoidal sinusitis: Over trigeminal nerve distribution

C. Nasal discharge of any quality in corresponding nasal meatus; may be thick or thin, serous, mucoid, or purulent
D. Postnasal discharge visualized in posterior pharynx
E. Periorbital swelling
F. Examine for other respiratory tract involvement.
G. History positive for URI of more than 7to 10-day duration
H. Transillumination is difficult to perform, and results are unreliable.
I. Laboratory studies

1. Culture of sinus puncture aspirates
a. Most reliable indicator other than sinus biopsy
b. Indicated if child is not responsive to therapy, in an immunocompromised child, or with life-threatening complications
2. X-ray: Not a reliable indicator because a majority of children with an uncomplicated URI will have abnormal X-rays, as will a substantial number of children without URIs. May be used to confirm diagnosis in a child over 6 years of age.
3. Computerized axial tomography (CAT) scan: Often abnormal in patients without clinical signs of sinusitis. Reserved for children who present with complications or who have persistent or recurrent infections.

V. Assessment

A. Diagnosis of acute bacterial sinusitis is based on clinical criteria in children.

1. Persistent upper respiratory symptoms
2. Nasal discharge of any quality and cough for more than 10 days
3. Symptoms that have not resolved in 10 days or worsen after 5 to 7 days

B. Differential diagnosis

1. Viral URI: Low-grade fever, pharyngitis, conjunctivitis; typically presents with 2 to 3 days of purulent nasal discharge, which then turns clear again
2. Allergic rhinitis: Nasal itching and sneezing, afebrile, no myalgia
3. Group A streptococcal infection: Nasopharyngeal or throat culture positive for group A streptococci (GAS)
4. Nasal foreign body: Unilateral, foul smelling discharge; often bloody

VI. Plan

A. Antimicrobials: Treat for 10 to 21 days based on presenting symptoms.

A. For children with uncomplicated ABS of mild to moderate severity, who do not attend day care, and have not been treated with an antimicrobial in the preceding 90 days

1. Amoxicillin, 45–90 mg/kg/d in 2 divided doses or
2. Augmentin, 45–90 mg/kg/d of the amoxicillin component in 2 divided doses. Do not use regular 250 or 500-mg tablets for a child less than 40 kg. Use chewables or suspension.

B. For children who have uncomplicated ABS of at least moderate severity, have received an antimicrobial agent in the preceding 90 days, or who attend day care:

1. Augmentin, 80–90 mg/kg/d of amoxicillin component and 6.4 mg/kg/d of clavulanate in two divided doses or
2. Cefdinir, 14 mg/kg/d in 1 or 2 doses or
3. Cefuroxime, 30 mg/kg/d or
4. Cefpodoxime, 10 mg/kg/d once daily

C. Continue antibiotic therapy for 7 days after resolution of symptoms.

D. Avoid nasal decongestants, antihistamines and nasal corticosteroids unless required prior to illness.

VII. Education

A. Moist heat over affected sinus may ease discomfort.
B. Prolonged shower—“for as long as hot water lasts”—helps promote drainage.
C. Avoid deep diving or jumping into deep water with an upper respiratory infection.
D. Sinus inflammation occurs as a normal part of a cold. Antibiotics may not always be indicated.
E. Saline nasal spray may be used.
F. Children average six to eight colds a year of about 5to 7-day duration.

1. Nasal secretions are clear initially, then purulent for 3 to 4 days, then clear again before resolving.
2. Fever is often present for the first day or so.
3. Symptoms generally resolve or greatly improve by day 7.