Introduction

Sinusitis is where the sinuses (small, empty spaces behind your cheekbones and forehead) become swollen, usually caused by an infection.¹

Sinusitis is the inflammation of the sinuses, the clear spaces found behind the forehead and cheekbones. Sinus inflammation can be due to bacterial, viral, or allergic reasons. Sinusitis in adults is typically characterised by pain behind the eyes, the cheeks, and across the forehead, which is reproduced by pressure such as by touching or bending one’s head. As well as nasal symptoms such as a runny or blocked nose, a loss of smell, nasal mucus, or postnasal drip. If it is bacterial or viral in nature, it can be associated with a fever, fatigue, and halitosis.^1,2

However, in infants and toddlers, sinusitis can appear differently than in adults. Paediatric sinusitis has symptoms which include a cough, halitosis, clinginess, fatigue, and swelling around the eyes which are slightly different. Furthermore, recognising symptoms in children as young as this can be problematic as children cannot verbally communicate what is wrong with them. Therefore, clinicians and health professionals must rely on non-verbal communication to decipher what is wrong with such patients and differentiate these from symptoms which can present similarly such as the common cold. Nevertheless, sinusitis in infants and toddlers must be recognized to prevent further complications and ensure appropriate management and care.³

What is sinusitis?

Sinusitis is inflammation of the sinus cavities due to either bacterial or viral infection or an allergic reaction. In adults, its presentation is well documented, however, in infants, it can appear differently and differs from a common viral cold in its presentation as well.

Usually, children are diagnosed with viral sinusitis because of a viral upper respiratory tract infection. This generally improves by itself and is managed by symptomatic relief. If sinusitis has a bacterial cause, then antibiotics are used. In allergic cases, symptoms in infants and toddlers will include an itchy rash, and watery eyes, and will occur once exposed to the offending allergic substance. In rare cases, if symptoms do not resolve and the patient does not respond to medication within primary care a referral can be made to the hospital via a referral to ENT.³

The reason why such young children respond differently to sinusitis is because their sinuses are not fully developed until the teenage years. Sinuses are there from birth, but both the maxillary and ethmoid sinuses are small.

^{Fig 1: Sinusitis in children} 

Symptoms of sinusitis in infants and toddlers

• Nasal discharge: Green or yellow-coloured nasal discharge lasting more than 10 days. This is different to a cold as this is a viral infection that has clear coloured discharge
• Ongoing cold-like symptoms: Symptoms such as nasal congestion, rhinorrhoea, and cough ongoing for up to 2 weeks are consistent with sinusitis
• Facial pain and swelling: Swelling around the eyes and cheeks can be seen especially in older toddlers causing discomfort. This is not usually seen in adults
• Persistent fever: A persistent or recurrent fever after the initial cold symptoms
• Crankiness: Toddlers and infants with sinusitis are generally irritable and clingy, they have difficulty sleeping and feeding, these can indicate discomfort due to sinus pressure
• Cough: A dry or productive cough commonly occurs in pediatric sinusitis that is typically worse at night due to postnasal drip. A cough which lasts more than 10 days can be seen in paediatric sinusitis
• Halitosis: Bad breath is not a symptom which is commonly seen in viral colds and can indicate sinusitis
• Nausea and vomiting: This is not seen in adults and is typically only seen in sinusitis in children. These symptoms are not exclusive to paediatric sinusitis but can be seen in viral respiratory infections. However, in conjunction with other typical symptoms of paediatric sinusitis can be used to diagnose this

How does sinusitis differ from the common cold or allergies?

Sinusitis can be confused with a common viral cold or allergies. However, there are certain differences between the conditions that can help health professionals diagnose sinusitis and rule out other causes.

• Symptom duration: A common cold typically resolves in 5-7 days, whereas symptoms of paediatric sinusitis take up to 14 days to resolve. Allergies also do not have symptoms persisting this long and symptoms usually resolve after treatment with an antihistamine or other symptomatic relief
• Ongoing fever: A fever may occur in a common cold and this is usually mild in nature. However, this is usually self-limiting and resolves after a few days. In paediatric sinusitis, fevers tend to come and go and can be both low and high grade. Allergies typically do not show a fever
• Nasal mucus: Thick green or yellow mucus is seen in paediatric sinusitis, while in allergies, it tends to be clear and watery. Mucus also tends to be clear-coloured or yellow in common colds
• Progressive symptoms: Sinusitis tends to show a worsening or ongoing pattern after the initial cold-like symptoms have appeared by developing pressure headaches and prolonged fevers. This is typically not seen in either a common cold or allergies

Causes of sinusitis in infants and toddlers

• Young children are susceptible to allergies and infections affecting the nose, sinuses and ears in the first few years of life⁴
• This is because their immune system is still developing and becoming stronger
• Bacteria, allergies and viruses all can cause sinusitis
• If acute sinusitis is viral in origin, they are typically ill for less than 10 days, acute bacterial sinusitis usually causes patients to be ill for more than 10 days
• In allergy cases, this typically occurs when the patient is exposed to the allergen, and its duration depends on how long the patient is exposed to it
• Chronic sinusitis is when it occurs for more than 3 weeks and usually is because of ongoing inflammation rather than an infection. Infection may be a cause, but it is usually not the main reason
• Recurrent sinusitis is when it keeps returning^4,5

Signs that require medical attention: diagnosis and treatment

Any infant or toddler if ill should be assessed by a health professional to rule out any other issue. This is because such young children are vulnerable to further complications such as dehydration particularly as they cannot articulate their condition properly.

Therefore, it is important that they are assessed by a professional via a thorough history and focused examination with their parent or guardian to confirm or rule out any other causes and if necessary, to decide if patients are to be transferred to secondary care.

Prompt assessment and management help to ensure timely intervention, preventing complications and the prevention of unnecessary treatment with antibiotics which can contribute to growing antibiotic resistance.

Like any health issue, there are signs which indicate that medical attention is needed as the child may be worsening. In toddlers and infants, there is the risk of worsening symptoms causing further complications. If an infant or toddler has symptoms lasting more than 10-14 days, high fever, swelling around the eyes, or increasing lethargy are all symptoms that indicate further medical attention is needed with likely transfer to hospital as the infection may be spreading. Therefore, parents and guardians must be counselled on when to attend A&E and what red flag signs they should look out for.

Complications of untreated paediatric sinusitis

If paediatric sinusitis is untreated then this can result in a range of complications as a result of the spread of the infection from the sinuses further into the bloodstream, the membranes and fluid around the brain and the spinal cord, resulting in potential neurological issues. As well as spreading to the bones and skin.

• Orbital cellulitis
• Osteomyelitis
• Empyemas
• Brain abscesses
• Meningitis
• Cavernous sinus thrombosis
• Seizures
• Eye issues such as visual loss, non-reactive pupils, and restricted eye movement⁶

Prevention of paediatric sinusitis

• Good hygiene: Regular handwashing, ensuring that common household items such as towels, flannels, hairbrushes, and food are not shared helps to prevent the spread of infections and allergens which can increase the risk of sinusitis.
• Saline washes: Use of nasal saline washes can be used in children as young as newborns to help flush away any allergens or pathogens that may be in the nasal passages that could aid in causing sinusitis.
• Humidifiers: These generate a warm mist with or without aromatic oil which evaporates in the atmosphere to help open up a child’s sinuses and aid them to breathe better.
• Monitoring the child: It is important that if any parent suspects sinusitis they are constantly monitoring the child and checking for any red flag symptoms that could indicate that the child is getting worse and understand when medical attention should be sought. This especially applies to sinusitis as its symptoms are non-specific and could indicate a more serious problem and is prone to complications.⁵

Summary

Paediatric sinusitis is a condition that affects infants and toddlers and although sinusitis is common in adults, it can also occur in young children. However, its symptom presentation is different from when it occurs in adults. Typical symptoms include prolonged cold-like symptoms, prolonged high- or low-grade fevers, thick green or yellow nasal discharge, irritability, dry or productive cough and swelling around the eyes.

In addition to this since such young children cannot communicate like adults, it is important that if such patients are ill, medical attention should be sought from a qualified medical practitioner to assess them via a history and examination from the parent and guardian with the appropriate treatment such as antibiotics. Paediatric sinusitis, if untreated, can lead to a range of complications which can be very serious, so it is important not only to diagnose and manage such patients appropriately but also to inform parents and guardians with safety netting advice on when the patient needs to return to see a healthcare practitioner and when emergency treatment is needed and when to attend. Early detection and the necessary medical treatment will help to ensure a healthy child.