Medical management of sinusitis in pediatric patients

A randomized controlled trial of azithromycin and amoxycillin/clavulanate in the management of subacute childhood rhinosinusitis

OBJECTIVE

Subacute childhood rhinosinusitis is a disorder commonly seen in children with allergic rhinitis. Antibiotics have been recommended as a major component of the treatment regime. The objective of the present study was to compare the effectiveness of a 3-day course of azithromycin and a 2-week course of amoxycillin/clavulanate in the treatment of subacute childhood rhinosinusitis.

METHODOLOGY

A randomized single-blinded control study of subacute rhinosinusitis was conducted, comparing a 3-day course of azithromycin and a 2-week course of amoxycillin/clavulanate. Inclusion criteria were children aged between 5 and 16 years, duration of nasal blockage or discharge between 30 and 120 days, and abnormal sinus radiographs. All enrolled children were prescribed budesonide nasal spray (Rhinocort Aqua Nasal Spray, Astra Pharmaceuticals, Sodertalje, Sweden) as adjuvant treatment.

RESULTS

Forty-two children were recruited into the study and one defaulted on follow-up. Failure occurred in 6 of 20 for the azithromycin group and 5 of 21 for the amoxycillin/clavulanate group. The odds ratio was 1.46 (95%CI 0.37-5. 80, P = 0.73). No relapse occurred in azithromycin group and 5 of 21 in amoxycillin/clavulanate group. The odds ratio was 0.16 (95%CI 0. 017-1.51, P = 0.18). Both antibiotics were well tolerated, however, two children, one from each group, complained of mild transient epigastric discomfort.

CONCLUSIONS

This small study did not provide evidence of a difference between 14 days of amoxycillin/clavulanate and 3 days of azithromycin. Larger studies will be needed to determine which, if any, antibiotic regimen should be used in treating subacute childhood rhinosinusitis.

Current concepts in the management of paediatric rhinosinusitis

It is well recognized that adenoid hypertrophy and allergic rhinitis are common in children and that recurrent upper respiratory tract infections are a fact of life. The main causes of symptoms associated with rhinosinusitis in children are rhinorrhoea, nasal obstruction, mouth breathing, hyponasal speech and snoring. Most children grow out of adenoid hypertrophy and recurrent colds by the age of eight to 10 and this means that the main treatment strategy should therefore be conservative and not surgical. An explanation to anxious parents, simple non-invasive measures such as teaching nose-blowing, the use of saline sprays or a trial of allergen avoidance and age-appropriate topical nasal anti-inflammatory sprays should be tried before surgery is even contemplated. Because repeated infections are so common, antibiotics given for chronic nasal discharge often have only short-lived effects. Rhinosinusitis in children is not a surgical disease and 'watchful waiting' is advised. Any treatment should first of all be safe, as even without any intervention the problem usually resolves with time. It is likely that growth and maturation of the immunological response to pathogens play a major role in resolution of the disease. There are few exceptions to this principle: nasal polyps (indicating possible cystic fibrosis), and periorbital cellulitis where an assessment of vision, parenteral antibiotics, and if there is concern about the possibility of a subperiosteal abscess, computerized tomography (CT) and drainage of any pus is indicated.