Decongestants, antihistamines and nasal irrigation for acute sinusitis in children

Bacterial contamination of saline nasal irrigations in children: An original research

Microbiologic analysis of nasal saline irrigations (NSIs) used in hospitalized children was performed. Of 253 collected samples, 24.9% were positive, and the number of positive samples significantly increased over time (P < .001). Staphylococcus aureus was the most frequently detected bacterium (28.6%). None of the 118 patients who received NSIs developed a nasosinusal infection. Colonization by cutaneous and environmental germs is frequent and develops early. Hygienic measures should be advocated to reduce contamination.

Diseases of the nose and paranasal sinuses in child

Diseases of the pediatric nose and nasal sinuses as well as neighboring anatomical structures encompass a variety of pathologies, especially of inflammatory nature. Congenital disease, such as malformations and structural deviations of the nasal septum, as well as systemic metabolic pathologies affecting the nose and sinuses, rarely require medical therapy from an Otolaryngologist. The immunological function of the mucosa and genetic factors play a role in the development of disease in the pediatric upper airway tract, especially due to the constantly changing anatomy in this growth phase. Disease description of the nose and nasal sinuses due to mid-facial growth must also take developmental age differences (infant, toddler, preschool, and school age) into account. Epidemiological examinations and evidence based studies are often lacking in the pediatric population. The wide range of inflammatory diseases of the nose and paranasal sinuses, such as the acute and chronic rhinosinusitis, the allergic rhinitis, and adenoid disease, play a role in the susceptibility of a child to infection. The susceptibility to infection depends on the pediatric age structure (infant, young child) and has yet to be well defined. The acute rhinosinusitis in children develops after a viral infection of the upper airways, also referred to as the "common cold" in the literature. It usually spontaneously heals within ten days without any medical therapy. Antibiotic therapy is prudent in complicated episodes of ARS. The antibiotic therapy is reserved for children with complications or associated disease, such as bronchial asthma and/or chronic bronchitis. A chronic rhinosinusitis is defined as the inflammatory change in the nasal mucosa and nasal sinus mucosa, in which the corresponding symptoms persist for over 12 weeks. The indication for CT-imaging of the nasal sinuses is reserved for cases of chronic rhinosinusitis that have been successfully treated with medication. A staged therapeutic concept is followed in CRS based on conservative and surgical methods. Nasal sinus surgery is considered nowadays as effective and safe in children. Based on the assumption that adenoids are a reservoir for bacteria, from which recurrent infections of the nose and nasal sinus originate, the adenoidectomy is still defined as a cleansing procedure in rhinosinusitis. 69.3% of the children had benefit from adenoidectomy. Comorbidities, such as pediatric bronchial asthma, presently play an even more important role in the therapy of rhinosinusitis; therefore, it is often wise to have the support of pediatricians. In western European countries 40% of children presently suffer from allergic rhinitis, in which pronounced nasal obstruction can cause disturbed growth in facial bones. An early therapy with SIT may prevent the development of bronchial asthma and secondary sensitization to other allergens. Therefore, SIT is recommended in treatment of allergic rhinitis whenever, if possible. The assessment of diagnostic tools is for the examiner not often possible due to the lack of evidence. Rhinosurgical approaches are often described in study reports; however, they lack the standard prospective randomized long-term study design required nowadays and can only be evaluated with caution in the literature.

Decongestants, antihistamines and nasal irrigation for acute sinusitis in children

BACKGROUND

The efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis has not been systematically evaluated.

OBJECTIVES

To determine the efficacy of decongestants, antihistamines or nasal irrigation in improving symptoms of acute sinusitis in children.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (1950 to June week 1, 2014) and EMBASE (1950 to June 2014).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs, which evaluated children younger than 18 years of age with acute sinusitis, defined as 10 to 30 days of rhinorrhea, congestion or daytime cough. We excluded trials of children with chronic sinusitis and allergic rhinitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed each study for inclusion.

MAIN RESULTS

Of the 662 studies identified through the electronic searches and handsearching, none met all the inclusion criteria.

AUTHORS' CONCLUSIONS

There is no evidence to determine whether the use of antihistamines, decongestants or nasal irrigation is efficacious in children with acute sinusitis. Further research is needed to determine whether these interventions are beneficial in the treatment of children with acute sinusitis.

Acute rhinosinusitis in children

Acute rhinosinusitis in children is a common disorder that is characterized by some or all of the following symptoms: fever, rhinorrhea, nasal congestion, cough, postnasal drainage, and facial pain/headache. It often starts as an upper respiratory tract infection that is complicated by a bacterial infection in which the symptoms worsen, persist, or are particularly severe. The accurate diagnosis of acute rhinosinusitis is challenging because of the overlap of symptoms with other common diseases, heavy reliance on subjective reporting of symptoms by the parents, and difficulties related to the physical examination of the child. Antibiotics are the mainstay of treatment. There is no strong evidence for the use of ancillary therapy. Orbital and intracranial complications may occur and are best treated early and aggressively. This article reviews the diagnosis, pathophysiology, bacteriology, treatment, and complications of acute rhinosinusitis in children.

Rhinosinusitis in children

Rhinosinusitis is the inflammation of the mucous membranes of nose and paranasal sinus(es). 5-13% of upper respiratory tract infections in children complicate into acute rhinosinusitis. Though not life threatening, it profoundly affects child's school performance and sleep pattern. If untreated, it could progress to chronic rhinosinusitis (CRS). The pathogens involved in perpetuation of CRS consist of multidrug-resistant mixed microflora. CRS is challenging to manage and could further extend to cause eye or intracranial complications. In children, CRS diagnosis is often either missed or incomprehensive. Due to this, morbidity and strain on healthcare budget are tremendous. Flexible fiberoptic endoscopy has revolutionized management of CRS. Its utility in children is being increasingly recognized. Optimal management entails specific appropriate antimicrobials as well as treatment of underlying causes. The aim is to normalize sinus anatomy and physiology and regain normal mucociliary function and clearance.

Decongestants, antihistamines and nasal irrigation for acute sinusitis in children

BACKGROUND

The efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis has not been systematically evaluated.

OBJECTIVES

To systematically review the efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis. We considered the following four interventions: 1) decongestants versus placebo or no medication, 2) antihistamines versus placebo or no medication, 3) decongestant and antihistamine combination versus placebo or no medication, 4) nasal irrigation versus no irrigation. The primary outcomes of the review were symptom resolution (improvement in symptom score from enrolment to day five and overall symptom burden (as measured by average symptom scores while on therapy).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 1), which includes the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1950 to January week 3, 2012) and EMBASE (1950 to January 2012).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs which evaluated children less than 18 years of age with acute sinusitis, defined as 10 to 30 days of rhinorrhea, congestion or daytime cough. We excluded trials of children with chronic sinusitis and allergic rhinitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed each study for inclusion.

MAIN RESULTS

Of the 526 studies found through the electronic searches and handsearching, none met all the inclusion criteria.

AUTHORS' CONCLUSIONS

There is no evidence to determine whether the use of antihistamines, decongestants or nasal irrigation is efficacious in children with acute sinusitis. Further research is needed to determine whether these interventions are beneficial in the treatment of children with acute sinusitis.

Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis

PURPOSE

Acute sinusitis is a common condition in ambulatory care, where it is frequently treated with antibiotics, despite little evidence of their benefit. Intranasal corticosteroids might relieve symptoms; however, evidence for this benefit is currently unclear. We performed a systematic review and meta-analysis of the effects of intranasal corticosteroids on the symptoms of acute sinusitis.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central register of Controlled Trials (CENTRAL), and Centre for Reviews and Dissemination databases until February 2011 for studies comparing intranasal corticosteroids with placebo in children or adults having clinical symptoms and signs of acute sinusitis or rhinosinusitis in ambulatory settings. We excluded chronic/allergic sinusitis. Two authors independently extracted data and assessed the studies' methodologic quality.

RESULTS

We included 6 studies having a total of 2,495 patients. In 5 studies, antibiotics were prescribed in addition to corticosteroids or placebo. Intranasal corticosteroids resulted in a significant, small increase in resolution of or improvement in symptoms at days 14 to 21 (risk difference [RD] = 0.08; 95% CI, 0.03-0.13). Analysis of individual symptom scores revealed most consistently significant benefits for facial pain and congestion. Subgroup analysis by time of reported outcomes showed a significant beneficial effect at 21 days (RD = 0.11; 95% CI, 0.06-0.17), but not at 14 to 15 days (RD = 0.05; 95% CI, -0.01 to 0.11). Meta-regression analysis of trials using different doses of mometasone furoate showed a significant dose-response relationship (P=.02).

CONCLUSIONS

Intranasal corticosteroids offer a small therapeutic benefit in acute sinusitis, which may be greater with high doses and with courses of 21 days' duration. Further trials are needed in antibiotic-naïve patients.

Intranasal steroids for acute sinusitis

BACKGROUND

Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school.

OBJECTIVES

We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2008, issue 4) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1966 to October 2008), EMBASE (1990 to October 2008) and bibliographies of included studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) were considered eligible if they compared INCS treatment to placebo treatment of a control group for acute sinusitis; acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop-outs before the end of the study, rates of relapse, complications and return to school or work.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data, assessed trial quality and resolved discrepancies by consensus.

MAIN RESULTS

Four studies with 1943 participants met the inclusion criteria. The trials were well designed, double-blind, placebo controlled in which the included participants had acute sinusitis. The treatment assigned was INCS versus control treatment for 15 or 21 days. The rates of loss to follow up in the studies were 7%, 11%, 41% and 10%. When the results from the three trials included in the meta-analysis were combined, participants receiving INCS were more likely to have resolution or improvement of symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% CI 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement or complete relief of symptoms: for mometasone furoate (MFNS) 400 mcg versus 200 mcg, (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop-out and recurrence rate for the two treatment groups and for groups receiving higher doses of INCS.

AUTHORS' CONCLUSIONS

For acute sinusitis confirmed by radiology or nasal endoscopy, current evidence is limited, but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy.