Sinus imaging for diagnosis of chronic rhinosinusitis in children

Imaging technologies for the detection of sinus pathologies of odontogenic origin. A review

Sinus pathologies of odontogenic origin (SPO) are common in the clinical consultation; however, the dentist has some complications to detect them because their discovery is usually incidental and through imaging studies that, in most cases, are of low quality. The objective of this review is to describe the pertinent imaging resources that allow the detection of the most frequent SPO and, at the same time, carry out an updated review of the scientific literature in order to recognize the imaging of both the maxillary sinus and the dental organs. The scientific literature focused on this topic, published between 2014 and 2020, was consulted. The review showed two important results: the first is that Cone Beam Tomography (CBCT) represents the imaging modality with the best performance for the detection of SPO by what can be considered the gold standard for this purpose. The second is that the most frequent SPO is sinus mucositis, which is related to odontogenic conditions such as periapical lesions and periodontal affectations. Although Cone Beam Computed Tomography (CBCT) is the most appropriate tool to detect SPO compared to images obtained by 2D devices, there are also other alternatives such as magnetic resonance imaging and ultrasonography, which seem to have a promising future.

Pediatric Versus Adult Chronic Rhinosinusitis

PURPOSE OF REVIEW

Pediatric and adult chronic rhinosinusitis (CRS) have some similarities but a number of differences. This article reviews the similarities and differences between pediatric and adult CRS.

RECENT FINDINGS

Rhinosinusitis is an inflammatory disease of the nose and the paranasal sinuses. In adults, inflammation in CRS without polyps (CRSsNP) mainly manifests with T-helper 1 lymphocytes while in CRS with polyps (CRSwNP) manifests with T-helper 2 lymphocytes and eosinophilic inflammation. In children, CRS inflammation manifests with neutrophils, macrophages, and lymphocytes. The associations between the ostiomeatal complex occlusion and CRS are revealed in adults but are not so evident in children. Although the relationship between the CRS and allergic rhinitis is still controversial, recent findings have shown an association between allergen sensitization and a specific group of adults with rhinosinusitis. Intranasal corticosteroids and saline constitute the first-line of medical treatment for both pediatric and adult rhinosinusitis. Low-dose macrolides are used for immunomodulatory activities and beneficial effects to adult patients with CRSsNP were demonstrated by recent meta-analyses. For surgical treatment, adenoidectomy is a key strategy to eradicate mature biofilms in pediatric CRS and effective in treating children with CRS regardless of the adenoid size. Although endoscopic sinus surgery has been proven to improve quality of life outcomes in adult CRS, it should be only considered in the pediatric CRS after failure of adenoidectomy. Pediatric and adult CRS are different in many aspects, including immunopathogenesis and management. Investigations should be considered in specific cases. After failure of medical treatments, endoscopic sinus surgery is recommended for adults, while adenoidectomy is primarily considered for children.

Imaging of Paranasal Sinus Infections in Children: A Review

Paranasal sinuses (PNS) infections are common in children. They may cause common and well-known complications, but also, unusual and potentially devastating complications. Diagnosing PNS infections and complications in children requires knowledge of the unique anatomy of the nasal cavity and the PNS. In fetal life, nasal mucosa evaginations into the lateral nasal walls initiate the development of the PNS. The PNS continue to develop after birth and complete their maturation and pneumatization at different ages during childhood which makes the pattern of PNS infections determined by patient age. Complications are caused by direct spread of the infection to the orbit, face, intracranial or osseous structures or hematogenous spread of the infection to the intracranial structures. Emergent imaging studies are often necessary in the evaluation of the complications in pediatric patients when the symptoms persist for 10 days and/or if there is evidence of intracranial or orbital complications. In addition, immunocompromised children are especially vulnerable to developing unusual complications. Computed tomography (CT) is excellent for determining whether there is intraorbital extension of PNS disease. However, when the infection approaches the orbital apex, a magnetic resonance imaging (MRI) study with contrast is necessary to assess spread into the cavernous sinus and the intracranial compartment. The goal of this manuscript is to review and characterize imaging findings of PNS infections using CT and MRI allowing determination of the extent of PNS infections and their common and unusual complications in children. In addition, a summary of the development of the normal PNS is provided.

Chronic Rhinosinusitis in Children: Pathophysiology, Evaluation, and Medical Management

PURPOSE OF REVIEW

Pediatric chronic rhinosinusitis (CRS) is a common disorder that carries significant morbidity. The diagnosis requires sinus symptoms that persist despite standard medical therapy greater than 3 months. Viral infections, allergies, and anatomic differences in children lead to chronic obstruction of the osteomeatal complex.

RECENT FINDINGS

Chronic rhinosinusitis as a diagnosis is a conglomeration of multiple phenotypes and endotypes. As such, the diagnosis and management are complex. New survey studies provide some consensus on prevalence and management of this disease in children. In this review, we highlight the differential diagnosis of pediatric CRS, including non-eosinophilic/infectious variants, eosinophilic variants with and without nasal polyps, allergic fungal sinusitis, aspirin-exacerbated respiratory disease, primary immunodeficiency, and disorders of mucociliary clearance. Further, we detail treatment options that should be considered. Finally, we feature emerging potential treatment options of CRS, including anti-immunoglobulin E, interleukin-5, and interleukin-4 receptor alpha subunit.

A new ultrasound sign in the diagnosis of pediatric maxillary sinusitis

Background: Computed tomography scans (CT scan) and X-rays are used to diagnose paediatric maxillary sinusitis. This study aimed at exploring the diagnostic value of the conventional and colour Doppler ultrasounds and their specific findings in cases of paediatric sinusitis. Methods: A total of 60 children diagnosed with sinusitis were included in this study. The conventional and colour Doppler ultrasounds of the sinus were performed on each of them. The symptoms that suggested increased blood flow to the sinuses were interpreted as positive findings on the colour Doppler ultrasound and were named "Ghasemi signs" for the purpose of this study. Such symptoms included unilateral artery bumps on the front artery, reduction of arterial resistive index (RI) to less than 0.5, and diameter of 2 mm or above for maxillary arteries. Sensitivity, specificity, and positive and negative predictive values, and accuracy of the conventional and colour Doppler ultrasounds were also calculated. Results: Compared to CT scan, the conventional ultrasound showed sensitivity and specificity of 73.4% and 100%, respectively. Sensitivity and specificity for the colour Doppler ultrasound were 89.36% and 100%, respectively. The maxillary artery diameter in normal and affected maxillary sinuses were, respectively, 2.4 mm (2.1-2.6, 95% CI) and 1.7 mm (1.6-1.9, 95% CI), with p<0.001. The RI of the affected sinuses were 0.47 (0.45-0.49, 95% CI), and those of the normal sinuses were 0.58 (0.54-0.61, 95% CI), with p<0.001. Conclusion: The findings of this study revealed that the conventional ultrasound agrees with the CT scans in the diagnosis of paediatric maxillary sinusitis. This diagnostic modality becomes even more valuable when the colour Doppler is used, particularly when considering the specific symptoms (Ghasemi signs) suggested by this study.

May chronic rhinosinusitis in children be diagnosed by clinical symptoms?

OBJECTIVES

Chronic rhinosinusitis (CRS) is a common disease in childhood but is often underdiagnosed because the symptoms are subtle and similar to other nasal pathologies. No clinical symptom is pathognomonic, and consensus documents suggest nasal fibroendoscopy (NF) or imaging criteria (computed tomography, magnetic resonance imaging) as the gold standards for diagnosis of CRS. However, considering the frequent unavailability of such tools to physicians, we designed this study to evaluate whether combinations of symptoms may achieve a clinical diagnosis of CRS in children as confirmed by NF.

METHODS

The study population consisted of 275 children with a clinical diagnosis of CRS, in 228 of whom diagnosis of CRS was confirmed by NF, while in 47 diagnosis was not confirmed by NF and they served as the control group. The symptoms considered were nasal obstruction, nasal discharge, cough, facial pain, and halitosis, using for statistical analysis multivariate logistic regression, Wald tests, and receiver operating characteristic (ROC) curve.

RESULTS

The multivariate logistic regression for CRS symptoms indicated rhinorrea as the strongest predictor of CRS. With three symptoms the probability of CRS was from 60% to 75% without rhinorrea and 77-91% in the presence of this symptom, with four symptoms the probability was over 93%, and with all the five symptoms the probability of having CRS was virtually 100%.

CONCLUSIONS

These findings suggest that an initial symptoms assessment may help to recognize children with a high probability of CRS, thus reducing the need of NF or imaging techniques.

Pediatric chronic rhinosinusitis

Pediatric chronic rhinosinusitis is a multifactorial inflammatory and infectious disorder. It likely reflects a dysfunction at the site of the interaction between host and environmental factors in the nose and sinuses. Our limited understanding of this common childhood disease makes it difficult to diagnose and to treat effectively. This review focuses on the scope of manifestations particular to the pediatric form of the disease, diagnostic challenges, and epidemiologic data. The normal development of sinuses in children, the role of inflammation, and biofilm and immune responses in the pathophysiology of chronic rhinosinusitis in pediatric patients are discussed. Predisposing and comorbid factors contributing to this disorder or associated with it are described. The current investigational and therapeutic approaches are presented, including recommendations for imaging and medical and surgical therapy. Various aspects of the disease that are still subject of controversy are underscored. Advice for what constitutes a reason to involve a multidisciplinary collaboration in the care of a child with chronic rhinosinusitis is provided.

Orbital complications in children: differential diagnosis of a challenging disease

Orbital swelling in children presents diagnostic and therapeutic challenges. Most are associated with acute sinusitis with complicating factors possibly including: amaurosis, meningitis, intracranial abscess or even cavernous sinus thrombosis. However not all acute orbital swelling is associated with acute sinusitis. A careful evaluation is critical prior to initiating therapy. Clinical records of 49 children (27 girls, 22 boys, with an average age of 11.8 years) were retrospectively reviewed. Historical data evaluated included all available information from parents and previous treating physicians. All patients underwent intensive pediatric, ophthalmologic, and otorhinolaryngologic examinations. Computed tomography (CT scans) were additionally performed in 40 % of children. The results of any examinations were also evaluated. Eighteen of the 49 patients had an orbital complication due to acute sinusitis. All 18 had elevated body temperature, C-Reactive Protein (CRP) values and white blood cell counts. Endoscopy of the nose revealed pus in the middle meatus in each case. According to Chandlers' classification, ten children presented with a preseptal, and eight children had a postseptal orbital cellulitis. All patients were admitted to the hospital and treated with intravenous antibiotics. CT scans further demonstrated signs of subperiostal abscess in four children. Functional endoscopic sinus surgery (FESS) was required in six children, including all patients with subperiostal abscess. Twenty children experienced orbital swelling unrelated to acute sinusitis, i.e. atheroma, inflammed insect stings, dental related abscess, conjunctivitis, and Herpes simplex associated superinfection. In three children, acute orbital swelling was caused by an orbital tumor. Orbital complications of an acute sinusitis occur often in the pediatric patient group, and most of these patients can be treated conservative with intravenous antibiotics. Indications for FESS include failure to improve or worsening of clinical symptoms during 24 h of therapy, signs for subperiostal abscess in CT scan, and/or vision loss. Patients with infectous orbital complications had fever, elevated CRP and white blood cell counts. This symptom complex is key in making the correct diagnosis. Interestingly, 61 % of patients in this study demonstrated non-sinusitis related diseases leading to acute orbital swelling, which also required prompt recognition and appropriate therapy.

Chronic rhinosinusitis in children

Chronic rhinosinusitis (CRS) affects nearly 37 million people in the United States each year and accounts for approximately $6 billion in direct and indirect health care costs. Despite its prevalence and significant impact, little is known about its exact cause and pathophysiology, and significant controversy remains regarding appropriate treatment options. Basic science research, however, has shown recent promise toward improving understanding of the innate and environmental factors underlying the pathophysiology of CRS. The hope is that this will also lead to advances in treatment for children adversely affected by this common yet complicated disease.

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.

Diagnosis of acute rhinosinusitis

Rhinosinusitis is almost always a complication of a viral infection involving the upper respiratory tract. A common cold is the first symptom of rhinosinusitis, but infectious processes involving the nose inevitably affect the paranasal sinuses because of their anatomical contiguity. The symptoms remain those of a common cold as long as nasal phlogosis is moderate and the ostia between the nose and sinuses are patent. If the inflammation is intense, edema may obliterate the ostia and isolate the sinuses, thus stopping the removal of the exudates. The duration of symptoms makes it possible to distinguish acute (10-30 days) from subacute (30-90 days) and chronic rhinosinusitis (>90 days). The diagnosis of rhinosinusitis should only be based on anamnestic and clinical criteria in children with serious or persistent symptoms of upper respiratory tract infection, or which appear within a short time of an apparent recovery. Computed tomography and magnetic resonance images of the paranasal sinuses should be reserved for children reasonably considered to be candidates for surgery. Antibiotics are recommended in cases of mild acute bacterial rhinosinusitis as a means of accelerating the resolution of symptoms. The use of antibiotics is mandatory in severe acute bacterial rhinosinusitis to cure the disease and avoid the possible onset of severe complications.

Diagnosis of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a rather common disease in children, but its symptoms are often subtle and non-specific and this may result in overlooking a correct diagnosis. In turn, a missed diagnosis of CRS prevents a correct management to be performed and is associated with uneffective investigations and improper treatments. Actually, when CRS symptoms, which are mainly nasal congestion and obstruction, nasal discharge, facial pain, cough, and halitosis, are correctly assessed, the clinical diagnosis of CRS may be achieved, and confirmation may be obtained by imaging criteria or nasal fibroendoscopy. In imaging, computed tomography (CT) is the first choice technique for the evaluation of CRS and is able to provide an anatomic road map when surgery is required. Magnetic resonance imaging (MRI) of the sinuses, orbits, and brain should be performed whenever extensive or multiple complications of sinusitis are suspected. Also for middle ear disorders, CT is the first choice because it detects opacification of the middle ear cavity and mastoid cells, presence of fluids or debris, and allows the ossicular chain and the cortical bone of the mastoid to be evaluated. Another important diagnostic issue is the need to look for disorders that are frequently associated with CRS, such as obstructive sleep apnea syndrome (OSAS), that has some recognized risk factors in adenotonsillar hypertrophy, craniofacial anomalies, obesity, and neuromuscular disorders. Other associated disorders requiring investigation are recurrent or persistent otitis media and difficult asthma.

Management of chronic rhinosinusitis

: Chronic rhinosinusitis (CRS) in children is difficult to treat, with resultant frequent recurrences and failures. There are controversies in the treatment, mirroring the debate over the exact etiology of this disorder. The available medical treatments are antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions; though, there is no general agreement on the efficacy of the latter. The new technique of balloon sinuplasty allows ventilation to the sinuses to be restored with minimal risk and trauma to the tissues, and initial outcome seems promising, being successful in most treated children. Concerning the surgical approach, adenoidectomy is among the most frequent surgical procedures performed on children, but its therapeutic effect is controversial, because randomized studies have failed to prove that adenoidectomy alone is sufficient in curing CRS. Instead, functional endoscopic sinus surgery is a minimally invasive technique which restores the sinus ostia patency and can re-establish ventilation and drainage through the natural pathways. It is important that the effectiveness of any treatment is also evaluated by patient-reported outcomes (PROs) that refer to all health-related reports coming from the patients, without any involvement or interpretations by physician or others. Among PROs, health-related quality of life (HRQL) is the one most widely known and used. HRQL can be measured by means of validated questionnaires, which provide scores proportional to the degree of well-being perceived by patients. Concerning diseases of the upper airway including RS, there are numerous instruments specifically designed for children and caregivers, which allow to assess the effects of treatments in a more extensive and complete manner.

Sinusitis and chronic cough in children

Background:

Chronic cough in children is a common problem, and sinusitis is a common etiology. The diagnosis of sinusitis is often clinical, but confirmation is thought to require a CT scan due to the difficulty of interpreting a Water’s view sinus X-ray.

Objectives:

The purposes of the study were (1) to examine the frequency of an abnormal sinus X-ray in children with a chronic cough of more than 4 weeks duration; (2) to compare the interpretation of the sinus film between allergy/pulmonary clinicians and radiologists; and (3) to correlate symptoms with X-ray results.

Methods:

A chart review of 2- to 18-year-old patients with coughing exceeding 4 weeks was performed. Data was collected for patients who had received a Water’s view sinus film as part of their evaluation. Exam, X-ray results, and clinical outcomes were categorized and statistical analyses performed.

Results:

A total of 86 patients were included. Clinicians found that 65% of the children had positive Water’s view films, compared with the radiologist’s reading of 62% (non significant). Significant associations between post-tussive emesis (P = 0.01) and purulence (P = 0.03) were noted with a positive film. Positive sinus X-ray was highly associated with all findings except wheeze when present together (P < 0.001).

Conclusion:

Sinus abnormalities on X-ray are associated with prolonged cough in 65% of children. The Water’s view sinus film is a clinically useful screening tool for clinicians in the workup of chronic cough. Certain physical findings and clinical complaints, when present concurrently, correlate with the X-ray results.