Pediatric Sinusitis Surgery Workup

Updated: Oct 31, 2018
  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Workup

Laboratory Studies

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  • The only laboratory evaluation to consider in children with signs and symptoms of chronic sinusitis are the following:

    • Radioallergosorbent testing (RAST) for food and inhalant allergens

    • Sweat test or serological testing for cystic fibrosis (CF)

    • Immunologic evaluation, including immunoglobulins

  • A culture and sensitivity can be taken from purulent drainage near the OMC to ensure proper antibiotic choice.

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Imaging Studies

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  • CT scanning: CT scanning in the axial and especially coronal plane is the criterion standard for evaluation of chronic sinusitis in children and adults to look for chronic mucosal disease, anatomic abnormalities, and chronic stasis of secretions.

    • Scanning intervals of 3 mm in the coronal plane are adequate to define the anatomy and disease.

    • For endoscopic sinus surgery (ESS) to correct skull base defects or to further identify abnormalities observed on coronal scans of 3-mm intervals, 1- to 2-mm overlapping intervals can be obtained.

    • A screening CT scan that contains a scout radiograph of the lateral skull and neck and 11 other cuts through various key anatomic areas can provide information on the amount of disease in the paranasal sinuses and nasal cavity at a cost similar to plain radiography of the sinuses.

    • Anatomic abnormalities observed on CT scan (eg, concha bullosa, agger nasi cell, Haller cell, deviated septum) have a similar incidence in patients with or without chronic sinusitis symptoms. These abnormalities, however, combined with chronic inflamed mucosa, could contribute to the perpetuation of chronic sinusitis. If these abnormalities are observed in conjunction with CT scan evidence of chronic sinusitis and impinge upon the natural outflow tract of the sinuses, they should be corrected or removed. Isolated anatomic abnormalities without chronic sinusitis may have no bearing on the disease process.

  • Plain radiography

    • The role for plain radiography of the paranasal sinuses in children in preparation for endoscopic sinus surgery (ESS) is limited.

    • When evaluating plain radiographs and CT scans, a 75-80% disagreement can occur. In 2 independent studies, roughly 35% of the time plain radiographs of the sinuses showed sinusitis when CT scans were clear. Forty percent of the time, plain radiographs were negative when CT scans showed disease.

    • In younger children, incomplete pneumatization of a sinus can be confused with an opacified sinus, and overlapping structures make determining mucosal thickening in the sinuses, a common finding in chronic sinusitis requiring surgical therapy, difficult.

    • Plain radiography is occasionally helpful in diagnosing acute sinusitis but still falls short in diagnosing disease in the ethmoid cavity because it is a labyrinth of 5-15 small cells that can overlap, clouding true disease.

    • Air-fluid levels and opacification can be identified more accurately in the single chamber cavity of the frontal, maxillary, and sphenoid sinus. A lateral plain radiograph of the neck is helpful, however, to evaluate for adenoid hypertrophy, which can mimic sinusitis.

  • MRI

    • MRI is helpful if further soft tissue delineation is needed to differentiate polyps, tumors, or allergic fungal sinusitis.

    • It also is helpful if intracranial extension is suspected on CT scanning or clinical examination.

  • Clinical significance: Significance of the findings on any radiographic examination of the sinuses can only be determined in conjunction with the current treatment and clinical picture. A CT scan (if taken at the time of maximum symptoms) of an acute viral respiratory illness lasting 24 hours can look exactly like chronic opacification of all of the sinuses. Therefore, the optimum time to obtain a CT scan of the sinuses is following maximum medical therapy. [21]

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Other Tests

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  • Routine maxillary sinus aspirates to obtain diagnostic information are not performed in healthy children with chronic sinusitis because of the pain associated with the procedure.

  • In a sedated child, when culture of the fluid is paramount, an aspirate can be considered.

  • Normally, children should have maximum medical therapy based on normal causative agents for acute or chronic sinusitis. CT scan evaluation of the sinuses is then performed prior to or following adenoidectomy if adenoid hypertrophy exists or chronic adenoid infection is suspected.

  • If gastroesophageal reflux (GER) is suspected, a barium swallow or pH probe should be considered, as GER can cause or contribute to chronic sinusitis in children.

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Diagnostic Procedures

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  • Rigid or flexible rhinoscopy in a clinical setting for a child with sinusitis symptoms may be beneficial to define the presence of adenoidal hypertrophy, a lesion in the nasal cavity, or polyps in the nasal cavity or middle meatus (where the anterior sinuses drain).

  • If the child has had a CT scan, it may define these conditions, making rigid or flexible rhinoscopy unnecessary. Occasionally, the middle meatus can be observed with anterior rhinoscopy, and the adenoids can be evaluated by plain radiography. These tests help with these diagnoses, avoiding a procedure that may cause anxiety or discomfort to patients. However, rigid or flexible rhinoscopy can be performed safely and comfortably when necessary when the diagnosis is unclear.

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