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Rhinosinusitis is the term used for infections that involve both the nose and sinuses. Bacterial sinusitis may be an acute, subacute, or chronic infection. Acute bacterial sinusitis is a bacterial infection of the paranasal sinuses with complete resolution in <30 days. Subacute bacterial sinusitis is defined by resolution between 30 and 90 days, and chronic sinusitis lasts >90 days.1 The most common predisposing factor for bacterial sinusitis is a viral upper respiratory infection (URI). The incidence of viral URIs in children ages 6 months to 35 months is approximately six episodes per patient-year, with approximately 8% of those becoming complicated by acute bacterial sinusitis. Bacterial sinusitis in children is most common in the 12 to 23 months age group, probably because these children are most likely to be in day care, predisposing them to URIs.2 In 1996, health care costs in the U.S. incurred from treating sinusitis in children <12 years of age had been estimated at $1.8 billion a year.3

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Pathophysiology

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The sinuses are air cavities lined with ciliated columnar epithelium that helps mucus clearance by pushing mucus and debris out of the sinus ostia into the nasal cavity. Blockage of the ostia by mucus and inflammation predisposes to bacterial sinusitis. The ethmoid and maxillary sinuses are present at birth and are most commonly involved in sinusitis in children. The sphenoid sinuses form at 3 to 5 years of age. The frontal sinuses do not appear until 7 to 8 years of age and remain incompletely pneumatized until late adolescence. The most common predisposing factors for acute bacterial sinusitis are diffuse mucositis secondary to viral rhinosinusitis in 80% of cases and allergic inflammation in 20% of cases.4 Less common predisposing factors include nonallergic rhinitis, cystic fibrosis, dysfunctional or insufficient immunoglobulins (Igs), ciliary dyskinesia, and anatomic abnormalities.5

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The most common pathogen of acute bacterial sinusitis is Streptococcus pneumoniae, recovered in 30% of children with acute sinusitis. Nontypeable Haemophilus influenzae and Moraxella catarrhalis are recovered in 20% of children each.5,6 In addition to the more common pathogens, chronic sinusitis may also be caused by Staphylococcus aureus, anaerobes, and, rarely in children, fungus, including Aspergillus, Fusarium, Bipolaris, Curvularia lunata, and Pseudallescheriaboydii.7

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Clinical Features

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Children with acute bacterial sinusitis typically present with high fever and purulent nasal discharge. Headache, particularly behind the eye, is a variable presenting symptom, whereas complaints of facial pain in children are rare.1 The physical examination findings of acute bacterial sinusitis are often similar to those of uncomplicated viral sinusitis, with swollen and erythematous turbinates and mucopurulent discharge. However, reproducible unilateral tenderness to percussion or direct pressure of the frontal or maxillary sinus may indicate acute bacterial infection, and periorbital edema might indicate ethmoid sinusitis.1 Transillumination of the maxillary sinuses is unreliable in children <10 years of age.8

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Diagnosis

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Although the gold standard for diagnosis of acute bacterial sinusitis is the recovery of ≥104 colony-forming units/mL of bacteria from the paranasal sinus,5 sinus ...

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