Chronic rhinosinusitis in pediatric patients is not as common as many people think. Children, however, are more prone to developing recurrent acute rhinosinusitis (aka, a “runny nose”). This is due to their immature and developing immune system. But how many infections is considered too many, and how aggressive do physicians need to be in treating children with a recurrent “runny nose?”
The immune system develops over the first few years of a child’s life, when they are exposed to various “bugs” (viruses and bacteria). This response causes the child to be sick multiple times during the first few years of life. Many studies note that normal and healthy children will get up to 8-10 upper respiratory tract infections (rhinosinusitis, pharyngitis-tonsillitis, and bronchitis) per year. If a child develops more than 8-10 infections per year, then further evaluation for processes such as Cystic Fibrosis is indicated.
Physicians believe that roughly 80% of these infections are due to viruses and do not need treated with antibiotics. However, there has been no good and consistant test to identify whether an infection is due to a virus or bacteria, thus, often difficult to decide if the child needs an antibiotic. Otolaryngologists have found that if the symptoms get worse after the fifth day of the infection, or the symptoms persist more than 7-10 days, then antibiotics are indicated as there is a higher chance it is bacterial.
So for children that have recurrent runny nose, are there other factors besides viral and bacterial infections that may be involved? Current research shows in a minority of cases, other factors can be the etiology of the runny nose.
The most common other factor is allergic rhinitis. Allergies are classified as either seasonal (tree and grass and weed pollen) and perennial (dust and mold and animal dander), and many patients are affected by both types. In some children, formal allergy testing and treatments will significantly reduce the number of infections and the severity of the runny nose. Another factor with less evidence of playing a critical role in recurrent runny nose in children is gastric reflux. Although some patients will improve with anti-reflux measures and medicine, studies clearly show that this is in a minority of these patients.
When does a clear runny nose need medical treatment? If it is clear and not causing problems such as nasal obstruction or snoring-sleep problems, then observation is a reasonable choice. Another option would be to use saline nasal drops in the AM and PM as needed to help clear the thick mucous. If this drainage is causing symptoms of nasal obstruction or snoring-sleep problems, then starting an anti-Histamine or anti-reflux medication (if there is a history or significant reflux) can be utilized.
What about a yellow-green runny nose? When the mucous is discolored, then we often think of infectious causes. Again the vast majority of these infections are due to viruses and a good rule of thumb to start antibiotic therapy is the duration of symptoms: progressive symptoms after 5 days or symptoms lasting more than a week warrant antibiotic therapy. In the meantime, saline drops in the AM and PM are also recommended.
When the discolored runny nose occurs more than 6 times a year, or becomes chronic and occurring on a daily basis, then further treatments are indicated. These children have often developed chronic adenoiditis. The adenoids are tonsil-like tissue in the back of the nose, just above the palatine tonsils, and they can become chronically inflamed-infected. Symptoms of chronic adenoiditis are: chronic and thick nasal drainage, nasal congestion and obstruction with mouth-breathing, halitosis (bad-smelling breath), dry cough, sore throat, and snoring. These patients will often need a prolonged course of a broad-spectrum antibiotic, but likely will need surgery in the form of an adenoidectomy.
Adenoidectomy surgery requires general anesthesia, utilizing an IV line and endotracheal tube. The surgery often takes 40-45 minutes overall, and is done routinely on an outpatient basis. Afterwards, there is mild pain that is treated with Tylenol or Ibuprofen and typically resolves in 2-3 days. Children can return to normal activity the following day, as there is less than 1% risk of postoperative bleeding. It is a very safe and effective procedure.
Adenoidectomy surgery improves the chronic and recurrent runny nose in approximately 75% of these patients. In patients who still have problems, then treating allergies and reflux can be started. However, if symptoms persist, then further evaluation is needed using a CT scan of the sinuses. The sinus CT scan can determine if the patient has other pathology such as nasal or sinus polyps, and whether sinus surgery is indicated.
Endoscopic sinus surgery in children is very uncommonly needed today. The most common procedure done for these patients who are found to have chronic sinusitis is a maxillary sinus washout. Done with general anesthesia, this procedure often utilizes the newer balloon sinus dilation instruments to dilate and open the sinus cavities. It typically takes 1 hour of anesthesia and done on an outpatient basis.
Although a recurrent runny nose is common in many children, the management continues to be evaluated through research. Currently, saline nasal drops-sprays have been shown to be beneficial in all causes, and that other directed management (such as allergy and reflux treatments) be started on a clinical patient by patient basis. If this becomes a chronic problem then a surgical evaluation by an ENT is warranted. Adenoidectomy is a very safe procedure that works in a majority of patients. Very rarely is an endoscopic sinus procedure needed in children.
For further information or questions, please contact your local ENT specialist.
Robert Wilson, MD.