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Dr. Todd Otteson from pediatric ENT joins us to discuss sinusitis, another common issue for children with Down syndrome.
Dr. Vellody: Hello everyone and welcome to our next Down Syndrome Center of Western Pennsylvania podcast. I am Dr. Kishore Vellody, medical director of the Down Syndrome Center, and your host for this podcast. It’s been really exciting to learn that episodes from this podcast have been downloaded in almost 20 countries across the world! So, welcome to our local Pittsburgh families and a special welcome also to those of you across the world who happened to find this podcast through other means. Well, today, we are going to continue our discussion Dr. Todd Otteson who is a pediatric ear, nose, and throat specialist. Last time, Dr. Otteson gave us his thoughts on ear infections and today we are going to tackle another common issue we see in Down syndrome and that’s sinusitis. Dr. Otteson, thanks for joining us again!
Dr. Otteson: Thank you, it’s good to be back.
Dr. Vellody: It’s great to have you back. Could you start us off with a definition for sinusitis?
Dr. Otteson: Sure. First, it requires a little bit of an explanation about the symptoms that occur with sinusitis. It’s typically fever. It’s nasal drainage. The color doesn’t often matter. It’s usually yellowish to greenish drainage and pretty significant nasal congestion. The definitions of sinusitis depend on the length of time for symptoms. An acute sinusitis is basically anything shorter than four weeks. A subacute sinusitis would be from four weeks to twelve weeks. Anything more than 12 weeks is considered a chronic sinusitis. Those definitions are sometimes important because it can different bacteria that grow for acute versus chronic. It can also be a different treatment pattern based on whether it’s acute or chronic.
Dr. Vellody: Ok, so now that we know about the different types of sinusitis, can you tell us how, say, maybe acute sinusitis diagnosed?
Dr. Otteson: For the acute sinusitis, it’s really similar to how we would diagnose an ear infection as we talked about. It’s taking a good history, especially quantifying really how long the symptoms have been going on. And then it’s the nasal exam and really getting an idea about the lining of the nose – how inflamed is it and any drainage? Often, we’ll send a culture from what’s called the middle meatus which is really where the sinuses sort of really all drain to that area. That sometimes can be helpful to direct any antibiotics, if needed.
Dr. Vellody: Great, I’ll be asking you some questions about antibiotic treatment in a little bit. Before I do, could you tell us why kids with Down syndrome seem to get more sinusitis infections that other kids?
Dr. Otteson: So again, sort of similar to ear infections, I think it’s two pronged. It’s the anatomy, especially the size of the sinuses, the midface. I think children with Down syndrome also have the immune problems that we talked about that go along with ear infections. The same goes for sinus infections. I think that adenoids are more common a problem in children with Down syndrome. Certainly, they can predispose to sinus infections as well. I think taking all of that into account is helpful.
Dr. Vellody: Todd, you mentioned adenoids just now. This is a term that a lot of our listeners have probably heard before. Could you tell us what exactly they are?
Dr. Otteson: So the adenoids are basically tonsil tissue but just in a different location. They are basically straight to the back of the nose just above the roof of the mouth. They’re important both for sinus infections but also for ear infections. If they harbor infection, then the infection basically can be seeded by the adenoids and out then into the sinuses. They can be a problem with ear issues because, if they’re large, they can prevent the ear from draining well and can cause Eustachian tube troubles.
Dr. Vellody: Given that they are such a potential source for problems for kids with Down syndrome, and they are in a location that is hard to see on a regular exam, how do you know if the adenoids are enlarged or not?
Dr. Otteson: There’s a couple of ways to do that. One is to get an adenoid x-ray. That we can tell the adenoid size but may or may not be able to tell if they look infected. The other way is to do a flexible scope to the back of the nose where the adenoids are and see if they’re look infected but also we can assess their size. Now, not every child is going to be cooperative for a scope so often an x-ray is done in that scenario.
Dr. Vellody: Let’s shift gears a little bit now. Let’s say that you diagnose sinusitis. Is there any way to tell if the sinusitis symptoms are due to a bacteria or a virus? A bacterial infection could be treated with antibiotics but antibiotics would not be helpful in a viral infection. So I think it’s important to know which one you have.
Dr. Otteson: You know, that’s a great question. I think often people try and quantify how much mucous there might be or what the color is to try and say it’s bacterial or viral. Really, there’s not one set for this is what is viral, this is what is bacterial. A lot of it is history and how long the symptoms have been going on. That’s why usually if we’ve had symptoms longer than ten days or so, I would treat with an antibiotic. The best way, really tried and true, is the middle meatus culture that we talked about because that will tell us definitively if it’s bacterial or viral.
Dr. Vellody: So, Todd, besides these clinical and microbiological clues, are there any other radiologic studies that can be helpful in diagnosing sinusitis?
Dr. Otteson: I mentioned that an adenoid x-ray can sometimes be helpful. Sometimes we would consider doing plain films of the sinuses although really we only get the maxillary (cheek) sinuses. The rest are very difficult to assess on a plain film x-ray. The utility of a CT scan is also one of the questions that we often get. If it is just for an acute sinusitis, as long as it’s not spread beyond the borders of the nose, then rarely, if ever, would we need to get a CT scan. Children who, as we mentioned, have recurrent sinus infections, or really chronic like meaning beyond the 12 weeks of symptoms, a CT scan after a course of antibiotics can often be helpful assessing if there are any anatomic abnormalities of the sinuses themselves. It can give us an idea if there’s other issues beyond just the sinuses or the adenoids and can help direct therapy as well.
Dr. Vellody: So, it seems as if the most useful and most common way to diagnose sinusitis is by the clinical findings. So if you suspect bacterial sinusitis due to let’s say more than 10 days of symptoms, how long would you treat with antibiotics for?
Dr. Otteson: Usually, in the ENT community, we would treat for 14 days for a sinus infection. We probably start to get better at about 7-10 days, but I think to prevent a pretty quick recurrence we like to treat with 14 days.
Dr. Vellody: Ok, so the treatment course is a long one and I agree that it does help to prevent recurrences. Well, Todd, for our listeners, I’m just going to run quickly through some antibiotics that are used for sinusitis. As it turns out, the typical antibiotics used for sinusitis are the same as those used for ear infections. We usually start with amoxicillin. If there is no improvement with amoxicillin, other more broad spectrum antibiotics like amoxicillin with clavulonic acid or cephalosporins could be used. Well, Todd, could you now take us through other treatments that you could use maybe along with antibiotics for the management of sinusitis?
Dr. Otteson: I would group this into three groups – prevention, medications (sometimes over the counter, sometimes antibiotic), and then possible surgical options. First, the usual common sense things like good handwashing, making sure that there’s a clean environment. Especially if it’s an allergy type of child, making sure that everything that we can control in the environment is as we like it. The second is medications. Obviously, we talked about antibiotic courses. Usually, beyond 10 days is when I would treat with an antibiotic but there are some other medications that can sometimes be helpful. I like a recipe of Afrin followed 5 minutes later with a nasal steroid spray like Nasonex or Flonase. I think you get the decongestion of the Afrin and then the benefit of the anti-inflammatory steroid. That can sometimes be helpful at cutting down on a lot of the nasal swelling. In turn, that cuts down on the number of sinus infections. So its something we can do, which is topically that doesn’t involve the whole body. I also like Mucinex, just anectdotally. I think it helps kind of break up the secretions. I usually wouldn’t do that in children younger than 2. It serves a dual purpose of breaking up the mucous and then it helps with any cough or post-nasal drip, that kind of thing. There have been a lot of studies about what over the counter preparations are most effective. I mentioned that Mucinex is more anectdotal – that’s my own experience. That one is probably hit or miss on if the studies show that it’s effective, but in my practice I like to use it a lot. And then surgically . . . I mentioned the adenoids. If we are having recurrent sinus infections, an investigation of the adenoid size and whether or not the adenoids appear infected can be helpful. Sometimes we’ll do a sinus tap or an aspiration of the sinus to get any fluid that’s there, especially that we can get a good culture sample so that we can direct any longer term antibiotic therapy if need be.
Dr. Vellody: That’s a great overview. Well, here we are at the end of our podcast again today, Todd. Thanks a lot for sharing your expertise with us today.
Dr. Otteson: Perfect, thanks for having me.
Dr. Vellody: Well I can’t thank you enough for joining us for these 2 podcasts. I hope to have you back again for one more podcast before you leave us here at CHP – maybe on a very common issue we deal with like sleep apnea. We’ll look forward to hearing your thoughts on that issue next time. Until then, thanks as always to our listeners. We’ll talk with you soon.
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