Paeds · ent-hearing-and-oral-health
Acute and chronic rhinosinusitis
Also known as Acute bacterial sinusitis · Acute viral rhinosinusitis · Paediatric sinusitis · Ethmoiditis · Chronic rhinosinusitis · Orbital cellulitis of sinus origin · Subperiosteal abscess · Pott puffy tumour · Cavernous sinus thrombosis · Sinogenic intracranial complication
Fellowship topic on acute and chronic rhinosinusitis in children: the term rhinosinusitis because the nasal and sinus mucosa are one continuous lining; the distinction of acute viral from acute bacterial rhinosinusitis by the AAP criteria of persistence beyond ten days, double worsening, and severe onset; the chronic form lasting twelve weeks or more with impaired mucociliary clearance; the Streptococcus pneumoniae, nontypeable Haemophilus influenzae and Moraxella catarrhalis microbiology; the ostial-obstruction pathophysiology and spread through the lamina papyracea to the orbit by the Chandler stages and through the valveless diploic veins to the brain; the orbital complications of preseptal and orbital cellulitis, subperiosteal and orbital abscess and cavernous sinus thrombosis; the intracranial complications of meningitis, epidural and subdural empyema, brain abscess and Pott puffy tumour; the clinical diagnosis, the contrast CT indication, high-dose amoxicillin-clavulanate, saline irrigation and intranasal corticosteroid, and the medical versus surgical threshold for the medial subperiosteal abscess; and ANZ, UK and North American guidance.
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Target exams
Red flags
- A child with a cold whose nasal discharge and cough persist beyond ten days without improvement, or who worsens after initial improvement — acute bacterial rhinosinusitis; treat with high-dose amoxicillin-clavulanate
- Periorbital or eyelid swelling, redness, eye pain, proptosis, restricted eye movement, diplopia or reduced vision in a child with sinus symptoms — an orbital complication; admit for intravenous antibiotics, contrast CT and urgent ENT and ophthalmology review
- Severe headache, vomiting, photophobia, neck stiffness, focal neurology, seizures or a fluctuating or depressed conscious state in a child with sinus disease — intracranial extension: meningitis, epidural or subdural empyema, brain abscess or cavernous sinus thrombosis
- A boggy swelling of the forehead or scalp with a frontal headache and fever in an older child — Pott puffy tumour, osteomyelitis of the frontal bone needing urgent imaging and combined ENT and neurosurgical drainage
- Bilateral eye signs, cranial nerve palsies, a toxic appearance and rapid deterioration — cavernous sinus thrombosis, a life-threatening emergency
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and ENT: distinguishing viral from bacterial rhinosinusitis using the AAP criteria, and the high-dose amoxicillin-clavulanate regimen
- Infectious diseases: the causative organisms and the recognition of orbital and intracranial complications
- Renewed curriculum — Infectious diseases and emergency care: rhinosinusitis as a sight- and life-threatening emergency when the orbit or brain is involved
- ENT and neurology: the Chandler classification, cavernous sinus thrombosis, Pott puffy tumour and the surgical threshold
- General Paediatrics: distinguishing bacterial from viral rhinosinusitis, when to prescribe antibiotics, and the red flags for orbital and intracranial spread
- Emergency care: recognition and resuscitation of the child with an orbital or intracranial complication and escalation to ENT, ophthalmology and neurosurgery
- Long Case / Structured discussion: a child with chronic rhinosinusitis and underlying disease, or a complication of acute disease — diagnosis, imaging, medical versus surgical management
- Communication station: explaining the diagnosis, the antibiotic decision and the safety-net to a family
- Level 2 / 3 — Infection and ENT: acute bacterial rhinosinusitis and the AAP criteria, antimicrobial stewardship and the surgical threshold
- Emergency and acute care: the child with a swollen eye — recognition of the orbital complication of sinusitis
- Foundation of Practice (FOP): the paranasal sinus anatomy, the Chandler classification, the causative organisms and the antibiotic choice
- Applied Knowledge in Practice (AKP): the orbital and intracranial complications, the contrast CT indication and the medical-versus-surgical decision
- History-taking and management: the child with persistent nasal discharge and cough and the recognition of acute bacterial rhinosinusitis
- Communication: explaining the antibiotic decision and the safety-net for orbital and intracranial spread to a family
- General Pediatrics Content Outline — acute and chronic rhinosinusitis: diagnosis, treatment and complications
- Infectious Diseases and ENT: S. pneumoniae, H. influenzae and M. catarrhalis sinusitis, the Chandler orbital classification and intracranial extension
- Patient Care: recognition and stepwise management of rhinosinusitis and its complications across severity, with timely imaging and multidisciplinary referral
- Systems-Based Practice: coordinated care with ENT, ophthalmology, neurosurgery and infectious diseases, and safe disposition and follow-up
- Medical Expert: acute and chronic rhinosinusitis diagnosis, imaging, treatment and complications
- Collaborator: multidisciplinary management with ENT, ophthalmology and neurosurgery for the orbital and intracranial complications
The ten-day line — viral cold versus acute bacterial rhinosinusitis
Acute viral rhinosinusitis (the common cold)
Acute bacterial rhinosinusitis
Overview & Definition
Picture a four-year-old brought in with what sounds like an ordinary cold — a runny nose and a cough for the last twelve days. The family expected it to have settled by now, but the nasal discharge has stayed thick and the cough has not gone, and in the last two days the child has become more miserable with a fever returning. The temptation is to call it "just a cold that is dragging on" and to reach for an antibiotic; the skill is to recognise that the persistent, unremitting course and the late worsening mark the transition from a viral rhinosinusitis, which needs no antibiotic, to an acute bacterial rhinosinusitis, which does. [1]
The term rhinosinusitis is deliberate. The mucosa lining the nasal cavity and that lining the paranasal sinuses are one continuous sheet, and an inflammation that affects one almost always affects the other — which is why nearly every viral upper-respiratory infection briefly involves the sinuses. Rhinosinusitis is therefore defined as symptomatic inflammation of both the nose and the paranasal sinuses: a combination of nasal blockage, discharge, facial pressure or hyposmia. The paranasal sinuses — the maxillary, ethmoid, frontal and sphenoid — are paired, air-filled mucosal outpouchings that drain through narrow ostia into the nasal cavity, all converging at the ostiomeatal complex. [6]
The classification that examiners expect is by duration. Acute rhinosinusitis lasts under twelve weeks and is further split into acute viral (the common cold, by far the commonest) and acute bacterial. Chronic rhinosinusitis lasts twelve weeks or more and reflects persistently impaired mucociliary clearance rather than simple infection; it overlaps heavily with adenoidal hypertrophy, allergic rhinitis and, in a minority, with cystic fibrosis, primary ciliary dyskinesia and immunodeficiency. Recurrent acute rhinosinusitis describes separate acute episodes separated by symptom-free intervals. [6] [7]
Most rhinosinusitis is viral and self-limiting, and the modern challenge is stewardship — reserving antibiotics for the bacterial patterns and reserving imaging for the complication. The danger lies in the orbital and intracranial spread that can follow when an obstructed sinus infects and erodes: a swollen eye in a febrile child, or a severe headache with meningism, turns a routine upper-airway problem into a sight- and life-threatening emergency. The task is layered — make the bacterial diagnosis on clinical grounds, give the right antibiotic, and watch for the red flags that demand imaging and a multidisciplinary response. [4] [11]
References12ShowHide
- [1]Wald ER; Applegate KE; Bordley C; et al Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics, 2013.PMID 23796742
- [2]Chow AW; Benninger MS; Brook I; et al IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis, 2012.PMID 22438350
- [3]Chandler JR; Langenbrunner DJ; Stevens ER The pathogenesis of orbital complications in acute sinusitis. Laryngoscope, 1970.PMID 5470225
- [4]Jones NS; Walker JL; Bassi S; et al The intracranial complications of rhinosinusitis: can they be prevented? Laryngoscope, 2002.PMID 11802039
- [5]Giannoni C; Sulek M; Friedman EM Intracranial complications of sinusitis: a pediatric series. Am J Rhinol, 1998.PMID 9653474
- [6]Fokkens WJ; Lund VJ; Hopkins C; et al European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology, 2020.PMID 32077450
- [7]Ramadan HH Pediatric chronic rhinosinusitis. Eur Arch Otorhinolaryngol, 2024.PMID 37899371
- [8]Brietzke SE; Shin JJ; Choi S; et al Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg, 2014.PMID 25274375
- [9]Bedwell J; Bauman NM Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg, 2011.PMID 22001661
- [10]Lu NE; Gardiner LA; McCoy JL; et al Characteristics and management of pediatric medial subperiosteal orbital abscesses. Int J Pediatr Otorhinolaryngol, 2024.PMID 38852548
- [11]Oxford LE; McClay J Complications of acute sinusitis in children. Otolaryngol Head Neck Surg, 2005.PMID 16025049
- [12]Moreddu E; Rossi ME; Bellal D; et al Prognostic Factors of Pediatric Acute Ethmoidal Rhinosinusitis With Orbital Subperiosteal Abscess: A Retrospective Cohort Study. J Otolaryngol Head Neck Surg, 2025.PMID 40652356