Scott Iwashyna, MD

Creating relationships with families by offering personalized care that is honest, open and respectful.

I Hate Sinusitis & It Hates Me

I hate sinusitis in a totally different way than all of the adults out there with a stuffy nose, pain when they lean over and achy teeth.  I hate it in a “Seriously? You expect me to diagnose this is someone?”-kind of way.  I secretly long for the days before Internal Review Boards told people that doing sticking a needle through someone’s face to drain the sinuses seemed too cruel to justify the information they might yield.  Let me explain:

Sinusitis is the 5th most commonly used pediatric diagnosis.  It accounts for 5-10% of most pediatric practice patient visits.  If treated, it is recommended to treat for 10-14 days with antibiotics (= a lot of antibiotics).   But there is NO GOOD WAY of diagnosing it.   The only difference between most cases of sinusitis and a common viral upper respiratory infection is that on day 10 of symptoms, most colds are getting better and most sinus infections are not.  (http://www.cdc.gov/getsmart/campaign-materials/info-sheets/child-rhin-vs-sinus.pdf)  That’s it.  The color of the drainage doesn’t help either.  Let me repeat.  Green or yellow boogers does not mean it is or isn’t a sinus infection.  

From the Cincinnati Children’s Hospital Evidence Based Medicine Guidelines
     It is recommended that the character of the nasal discharge not be used to make a diagnosis or as an indication for antibiotic treatment. The quantity, quality, and color of nasal discharge are not helpful in differentiating ABS from other upper respiratory illnesses (e.g. common cold, allergic rhinitis) (Wald 1981 [B], Aitken 1998 [C], McLean 1970 [D], Gungor 1997 [S], Wald 1994 [S]). Note: Physical exam is likely to reveal purulent nasal discharge and/or posterior oropharyngeal drainage. These findings, however, are non-specific and of little diagnostic usefulness (Wald 1981 [B], McLean 1970 [D], Williams 1993 [S], Fireman 1992 [S]).
(http://www.cincinnatichildrens.org/assets/0/78/1067/2709/2777/2793/9199/b0f1d374-b4fd-444c-8422-8041f8863f1d.pdf)

“Well, Scott,” you say. “That doesn’t seem too bad, just treat the kids who have had symptoms for over 10 days and quit your whining.”   But wait, there’s more – From the Cochrane Library a review of 59 randomized controlled studies showed:

There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, 80% of participants treated without antibiotics improved within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population level.

So do I wait until 14 days and treat the 20% not better?  Or will you have already gone to Patient First to get your antibiotics?

*This post is supposed to teach people about the difficulty of diagnosing and treating Sinusitis.  Please know that I understand how difficult it to care for a sick child (Read: not sleeping) for 10-14 days just waiting for symptoms to get better .   I also know how stressful a 10 day illness can be on your job; as a doctor with patients scheduled in advance it is VERY HARD to “just take a sick day” when my kids can’t go to school.

3 Comments

  1. As an adult who struggles (a lot) with sinus issues and a mother of four children I can sympathize with this topic. For myself things like neti pot, “natural decongestants” (herbal), saline, warm compresses to the face, etc. help. How many of these “other” treatments would work/are safe for children? (assuming, of course, they let you try them) Do humidifiers really help?

    • Scott

      April 1, 2011 at 1:52 pm

      While the neti pot or high volume saline flushes make sense, there isn’t a lot of evidence (from studies) that they help prevent sinusitis. There are a lot of chronic sinusitis patients who swear by them. The low volume nasal saline sprays are very unlikely to make much difference at all. Humidifiers in general dont seem to make much of a difference either – in fact, one of the best pediatric allergist in towns often argues that all humidifiers do is increase mold counts in houses and should therefore be avoided.
      I do believe that treating underlying issues that can lead to sinusitis is very important. Patients with deviated septum should be seen by an otolaryngologist and patients with underlying allergies should be sure to treat them. Mechanically, I think nasal steroids make a lot of sense in the prevention of sinusitis in children with nasal allergies. Decreasing inflammation with the steroid should allow the sinus openings to drain as designed.
      Just to muddy the picture – I also had a pediatric infectious disease doctor who would argue that blowing your nose is one the worst things you can do because it leads to backpressure and bacteria landing in your previously sterile sinuses.

  2. I agree that antibiotics quite frequently handed out like candy when you walk in with a stuffy head. I did, however, have to succumb to the antibiotics after a two month battle of sinus pressure. I’m not sure, but have been told I am contagious to my 8-month-old. Is this true?

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