in children and adolescents
What is paediatric rhinosinusitis?
You may hear and read different terms in relation to your child’s nasal symptoms. “Paediatric” refers to healthcare issues in childhood. “Rhinitis” is inflammation of the lining of the nose and can be caused in the short term by common infections, or over a longer period by an allergy. “Rhinosinusitis” is inflammation that affects not only the nose but also the sinuses. This can be chronic (lasting more than 12 weeks) or acute (less than 12 weeks).
What is the difference between acute and chronic rhinosinusitis?
Acute rhinosinusitis (ARS) is the sudden onset of two or more of the following symptoms;
Or discoloured nasal discharge
Or cough (daytime and night-time)
Strictly speaking, acute rhinosinusitis includes episodes of these symptoms that last up to 12 weeks; in reality, most infections last only a few weeks and the majority settle down spontaneously.
Chronic rhinosinusitis (CRS) causes similar symptoms (listed below) but is present for 12 weeks or more:
Two or more of the below symptoms, one of which should be either
Nasal blockage / obstruction / congestion
or nasal discharge (anterior/posterior nasal drip)
+/- facial pain/pressure;
It can be more challenging to diagnose CRS in children, partly because they find it difficult to describe and communicate their symptoms. In addition, it can be hard to tell the difference between CRS and other common reasons for a blocked nose in children (such as allergic conditions, and enlarged adenoids). Your doctor will therefore take more information and examine your child to try to understand which condition your child has.
Chronic rhinosinusitis (CRS)
How common is it?
It is difficult to say exactly how common chronic rhinosinusitis is in children but studies have shown between 2.1 to 4% of children may have symptoms associated with sinus disease. This makes it a less common problem than in adults, but there is undoubtedly a significant impact on the quality of life for children who suffer from CRS. The impact on overall health is greater than that of diseases such as asthma, attention deficit hyperactivity disorder, juvenile rheumatoid arthritis, and epilepsy.
What causes this?
The factors that lead to chronic rhinosinusitis in children are not fully understood. Overall, it seems most likely that rather than one single cause, it is due to a combination of several different factors that result in inflammation.
These factors are not equally present in all children, and your child may only have some of the factors described below:
Cigarette smoking (Passive smoking)
This is one thing that we do know contributes. One study showed that 68% of children with symptoms of acute rhinosinusitis were exposed to passive smoking, compared to 1.2% among children without exposure
Studies have also demonstrated worse outcomes in children with CRS exposed to cigarette smoke. These include the need for more operations.
Adenoids (a mound of immune tissue, similar to a tonsil that lies at the back of the nose) can contribute to CRS in children by harbouring bacteria and by causing blockage of the nasal airway.
Although more clear evidence is needed there appear to be linked to allergy, asthma and reflux disease.
Rarely there are some conditions that can affect the nose and sinuses as well as the lungs such as cystic fibrosis that will require further investigation and treatment.
What tests for CRS might a doctor offer for my child? Depending on the information your doctor has as well as the examination findings there may be some further tests required.
These may include:
Allergy testing (skin prick or blood tests)
Scans of the nose and sinuses
Assessment of the breathing/lungs
What treatments for CRS might a doctor offer for my child? The treatment of chronic rhinosinusitis in children is largely based on the therapies that have been found to be effective in adults. There is no good evidence in the literature to support the use of antibiotics for chronic rhinosinusitis in children.
The main medical treatments are:
Nasal steroid medication
If nasal steroids are to be used, then your doctor will choose one which has as few side effects as possible and generally this is a very safe way to use medication. Often, they will ask to measure your child’s height and weight regularly to make sure that the medication is not causing any problems.
Surgery can also be used to improve the control of symptoms in children, but usually, this tends to be reserved for only the very few cases that do not respond to medications. A surgeon will usually choose the least invasive possible type of surgery for your child in order to balance the risks of surgery against improving the symptoms of the disease.
It is rare for children to develop nasal polyps.
Some children with allergic rhinitis may develop swollen turbinates (part of the internal lining of the nose) that may be mistaken for polyps. If your child does have nasal polyps these may just be caused by inflammation but it is likely that your doctor will request further tests to look for a cause. Cystic fibrosis, a relatively rare inherited disorder that affects the respiratory system is commonly associated with chronic rhinosinusitis with nasal polyps.
Acute rhinosinusitis (ARS) as defined at the beginning of this leaflet covers a range of conditions from the common cold to bacterial rhinosinusitis with associated complications. What is important to understand is how rare symptoms of a blocked, runny nose will turn into anything other than the common cold.
It is believed that school children suffer from around 7-10 episodes of the common cold every year. Similarly to CRS, there is little in the way of scientific evidence to tell us who is more likely to get ARS. We do know that smoking and passive smoking increase the chances of developing ARS.
There are many different viruses that can cause the common cold some of these include:
Respiratory syncytial virus
The diagram below shows how the severity of the symptoms and the length of time assist us in making the diagnosis.
The common cold lasts typically 5-10 days but after 48 hours your child should experience a gradual improvement in symptoms. Post viral ARS either has symptoms lasting longer than 10 days or an increase in symptoms after 5 days.
Bacterial rhinosinusitis is rare but it is defined by the measures set out in the diagram such as a high temperature, severe pain, one-sided symptoms, getting better than getting worse (double sickening) and abnormal blood tests.
Can ARS make my child very unwell?
Complications of ARS are uncommon but vital to identify and if you suspect any of these you should speak to a medical professional immediately.
They most often occur early in the course of the illness, and some of the signs and symptoms to watch out for are:
Swelling or redness around the eye
Lethargy and confusion
Severe headache or swelling over the forehead
Rash, difficulty in bright lights or neck stiffness
Current evidence suggests that antibiotic treatment of ARS in general practice does not prevent complications.
Hopkins C, Surda P, Walker A, Wolf A, Speth M, Jacques T, et al. EPOS 4 patients. Rhinology. 2021 Suppl. 30: 1-57.