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The role of computed tomography scans in evaluating sinus disease in pediatric patients
International Journal of Pediatric Otorhinolaryngology 50 (1999) 63 – 68 www.elsevier.com/locate/ijporl
The role of computed tomography scans in evaluating sinus disease in pediatric patients Cheryl S. Cotter a,*, Scott Stringer b, Kevin R. Rust c, Anthony Mancuso d b
a Di6ision of Pediatric Otolaryngology, Nemours Children’s Clinic, 807 Nira Street, Jackson6ille, FL 32207, USA Department of Otolaryngology, College of Medicine, Uni6ersity of Florida, P.O. Box 100264, Gaines6ille, FL 32610 -0264, USA c Greenwood Ear, Nose and Throat Center, Greenwood, SC 29646, USA d Department of Radiology, College of Medicine, Uni6ersity of Florida, P.O. Box 100374, Gaines6ille, FL 32610 -0374, USA
Received 18 December 1998; received in revised form 25 May 1999; accepted 27 May 1999
Abstract Objecti6es: To determine the incidence and severity of sinus abnormalities in children undergoing computed tomography (CT) of the sinuses for suspected chronic sinusitis. To compare these findings with abnormalities noted on random CT scans. Methods: Sixty CT scans, performed for evaluation of sinus disease in symptomatic children aged 2–12, were compared with 50 CT scans of children aged 2 – 12 of the orbits or sinuses obtained for indications other than sinusitis. A staging system was applied to assess the severity of abnormalities. Results: Mucoperiosteal thickening was present in 60% of symptomatic and 46% of random CT scans (logistic regression, P= 0.144). Children aged 2–4 and 9–12 had an increased prevalence of abnormalities in both groups, although these findings were not statistically significant (logistic regression, P= 0.817). Early stage sinus disease was present in the majority of random (96%) and symptomatic (85%) children. Conclusions: There is a high incidence of mucoperiosteal thickening in the paranasal sinuses of children. CT scans of the sinuses should be obtained from children who are being considered for sinus surgery after failing the appropriate medical therapy. Decisions regarding the need for sinus surgery should not be solely based on imaging abnormalities. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Sinus; Computed tomography; Mucoperiosteal
1. Introduction
Presented at the American Society of Pediatric Otolaryngology 10th Annual Meeting, Durango, CO, USA, 29th May, 1995. * Corresponding author. +1-904-390-3690; fax: + 1-904390-3548. E-mail address: [email protected]. (C.S. Cotter)
Endoscopic sinus surgery is increasingly used as a treatment for chronic sinusitis in children. There remains, however, difficulty in reaching a consensus regarding the accurate diagnosis of sinusitis and optimal medical therapy. Patient symptomatology, response to medication and endoscopic findings are important tools in diagnosing pedi-
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 2 0 4 - 9
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C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68
atric sinusitis. Computed tomography (CT) has been considered the radiographic gold standard in the diagnosis of sinus abnormalities in both children and adults. The frequency of radiographic abnormalities is reported to be from 18% [1] to 50% [2] in asymptomatic children. The present study is the first to apply a standardized staging system to the severity of sinus abnormalities as demonstrated by CT scanning in both symptomatic and random pediatric patients.
2. Materials and methods The study population consisted of children aged 2 through 12 who were referred to a tertiary center for CT of the brain, orbits or maxillofacial region between November 1989 and January 1994. Patients were excluded if the child had recent surgery, craniofacial anomalies, facial trauma, nasogastric tubes or nasal or facial neoplasms. There were two study groups: (1) symptomatic children, suspected of having chronic sinusitis by history and physical examination performed by an otolaryngologist; and (2) random children. The CT scans were considered random if the scans were obtained for indications other than nasal symptomatology or headache. All patients’ charts were reviewed for evidence of respiratory tract infection or risk factors for sinus disease. None of the children in the random group had historical information suggesting sinus disease or immunocompromised status. The CT scans were reviewed and staged by the authors. We adapted the Massachusetts Eye and Ear Infirmary scale [3] for the staging of sinus disease to our study population. The CT staging scale is presented in Table 1. The Harvard system was modified as follows: Stage IIA describes bilateral mucoperiosteal thickening limited to the ethmoid or maxillary sinuses; Stage IIB also describes bilateral mucoperiosteal thickening limited to the ethmoid or maxillary sinuses, but is used to distinguish the younger child without mature frontal and/or sphenoid si-
nus development. Significant disease was defined as the presence of mucosal thickening \ 2 mm. Fig. 1a,b are CT scans from a patient with Stage IIB disease; Fig. 2a,b are CT scans from a patient with Stage IV disease. The absence of mature sinus development differentiates Stage IIB from Stage IV disease.
3. Results The study population consisted of 60 symptomatic and 50 random children. The population was characterized by age group, which was fairly evenly distributed (Table 2). The mean age of the symptomatic group was 7.4 years and the random group mean was 6.9 years. Symptoms and signs in the symptomatic population are presented in Table 3. Rhinorrhea, nasal obstruction and headache were the most common symptoms. The incidence of symptoms according to age is presented in Table 4. The following co-morbid conditions were present in the symptomatic population: asthma– 11 (18.3%); allergic rhinitis–22 (36.6%); cystic fibrosis–4 (6.6%); glycogen storage disease–1 (1.6%); and immune deficiency–3 (5%) patients. The incidence of mucoperiosteal thickening was 60% in symptomatic and 46% in random patients (Table 5). Children aged 2–4 and 9–12 had a higher prevalence of abnormalities in the
Table 1 CT staginga system for pediatric chronic sinusitis Stage 0 Stage I Stage IIA Stage IIB
Stage III Stage IV a
Normal (B2 mm mucosal thickening on any sinus wall) Unilateral disease or anatomic abnormality Bilateral disease limited to ethmoid or maxillary sinuses, normal sinus development Bilateral disease limited to ethmoid or maxillary sinuses, absence of frontal and/or sphenoid sinus development Bilateral disease with involvement of at least one sphenoid or frontal sinus Pansinusitis
Adapted from Massachusetts Eye and Ear Infirmary scale.
C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68
65
Fig. 1. (a) Coronal view. (b) Axial view. CT scans of the sinuses in a symptomatic 3-year-old male. This patient was staged as Stage IIB due to immature frontal and sphenoid sinus development.
symptomatic group. Logistic regression of both age (P =0.817) and symptoms (P = 0.144) failed to show a statistically significant difference in the presence of mucoperiosteal thickening between the study populations. Staging of the degree of sinus disease by age and symptoms is presented in Table 6. A total of 85% of symptomatic patients and 96% of random patients had Stage II disease or less. Patients in the symptomatic group had a slightly higher incidence of Stages III and IV disease, although the numbers in each group were too small for statistical analysis. Six of 11 (54.5%) patients with asthma and 13 of 22 (59%) patients with allergic rhinitis had mucoperiosteal thickening. The majority of patients with these co-morbidities had Stage II disease. This was not significantly different from random children. Children with immune deficiency primarily had Stage IV disease. Children with cystic fibrosis had Stages IIB or IV disease, depending on the age of the patient. Nasal polyps were associated with cystic fibrosis in one patient, who had Stage IV disease. The remaining three children with nasal polyps had Stages I or IV disease, based on unilateral or bilateral disease.
4. Discussion The most common symptom of sinusitis in children is reported to be rhinorrhea, which is usually purulent, but may be of any quality. Rhinorrhea is often accompanied by nasal obstruction. If the rhinorrhea is posterior, it may present as a chronic cough [4]. Headache and facial pain are more common symptoms in older children. The most commonly reported symptoms in children undergoing sinus surgery are rhinorrhea and cough [5,6]. In the present study, we also found rhinorrhea to be the most common symptom, however, cough was present in only 13% of our patients. Headache was a common symptom in children 5–12 years old, which may simply reflect the relative difficulty in obtaining historical information from younger children. The significance of radiographic sinus abnormalities in children remains a controversial issue. Several studies have demonstrated a correlation between the presence of sinus symptoms and CT documented sinus abnormalities with percentages ranging from 64 to 81% [7–9]. This compares to a 60% incidence of mucoperiosteal thickening in symptomatic patients in the present study.
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C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68
The prevalence of CT sinus abnormalities in pediatric patients has recently been reported. Glasier et al. [1] prospectively studied cranial CT scans of 101 children and found 31% of abnormalities overall. Excluding patients B1 year old, the incidence was 22%. A history of recent URI was associated with a trend towards more sinus
Table 2 Patient population Age
Symptomatic (%)
Random (%)
2–4 5–8 9–12
14 (23) 19 (32) 27 (45)
16 (32) 15 (30) 19 (37)
Total
60
50
abnormalities, but this was not significant. Diament et al. reported their findings in 137 pediatric patients, referred for cranial CT and found that 47% of patients B 13 years old had some degree of incidental maxillary or ethmoid sinus opacification [2]. They concluded that most sinus opacification is probably related to uncomplicated upper respiratory tract infection that may be active or resolving. Lesserson et al. found a 41% incidence of sinus abnormalities in asymptomatic pediatric patients undergoing CT scans for orbital or temporal bone disease [10]. No correlation between sinus abnormalities and the presence or history of chronic otitis media was identified. The present study found a 46% incidence of sinus abnormalities in a comparable random group, which is consistent with the prior studies. Children have a higher frequency of sinus disease when compared with adults [11]. It is proposed that the higher incidence of upper respiratory infection, the smaller dimensions of the sinus ostia and possibly adenoid tissue play a significant role. Calhoun et al. analyzed the frequency of sinus abnormalities documented by CT scanning in symptomatic and asymptomatic Table 3 The incidence of symptoms and signs in the symptomatic population (N= 60)a
Fig. 2. (a) Coronal view. (b) Axial view. CT scans of the sinuses in a 5-year-old male obtained for non-sinus diagnosis. Bilateral mucoperiosteal thickening with involvement of the sphenoid and/or frontal sinuses was classified as Stage IV disease.
Rhinorrhea Nasal obstruction Headache Allergic rhinitis Post-nasal drip Cough Nasal polyps a
36 25 22 22 11 8 4
Historical information collected retrospectively.
(60%) (42%) (37%) (37%) (18%) (13%) (7%)
C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68 Table 4 The incidence of the most common presenting symptoms according to age group Symptom
2–4 years
5–8 years
9–12 years
Rhinorrhea Nasal obstruction Headache
11/14 3/14 0/14
10/19 5/19 9/19
15/27 17/27 13/27
adults and found the incidence to be 60 and 15%, respectively [12]. The incidence of abnormalities in asymptomatic adults is less than the incidence in pediatric patients in the present study and most other previous analyses of pediatric patients. It is possible that there may be a difference in the degree of sinus abnormalities on CT scan between the symptomatic and random groups. Lesserson et al. used a rating system of clear, mild, moderate and severe to grade the radiologic findings [10]. This was simply an estimated volume of involvement in any given sinus. There was a non-significant trend towards more severe disease in the symptomatic group. The present study represents the first to utilize a standardized sinus CT staging system in an effort to allow a comparison of the severity of abnormalities between symptomatic and random pediatric patients. The Harvard system was adopted because it is easy to use, concise and has the best rate of inter-rater agreement in a recent study [3]. The majority of patients in our study had Stage II or less disease. The modification for Stage II disease was made in order to differentiate between older children and younger children with immature sinus development. In the younger children, it is unknown Table 5 The prevalence of mucoperiosteal thickening in symptomatic and random pediatric patients Age
Symptomatic (%)
Random (%)
2–4 5–8 9–12
9/14 (64) 10/19 (52) 17/27 (63)
7/16 (44) 7/15 (47) 9/19 (47)
Total
36/60 (60)
23/50 (46)
67
whether bilateral ethmoid and maxillary disease represents a continuum to future Stage IV disease, or merely a reflection of the sinus physiology at a younger age. The literature would tend to support characterizing bilateral ethmoid and maxillary mucoperiosteal thickening in young children as a less severe stage of disease, as there is supporting data to suggest a majority of these findings are self-limited [13]. If, alternatively, we had upgraded younger children with Stages IIB–IV disease, 14 (39%) of symptomatic and nine (39%) of random children would have been staged with advanced disease. These numbers are not significantly different. Children with asthma may have a significant predisposition to sinus disease [11]. Manning et al. reported improvement in sinus symptoms and asthma in the majority of patients who underwent endoscopic sinus surgery for refractory symptoms [14]. Patients were selected for surgery when CT scans demonstrated residual ethmoid and maxillary disease after ‘maximum medical therapy’, although the severity of disease was not described. Over 50% of the children with asthma and/or allergic rhinitis in this study had mucoperiosteal thickening, which was primarily Stage II disease. This was not different from the incidence of mucoperiosteal thickening in random children. All children in our study with cystic fibrosis had Stages IIB or IV disease, depending on the age of the child and the level of sinus development. Nasal polyps were associated with Stages I or IV disease, based on unilateral or bilateral disease. Advanced disease in children with cystic fibrosis and nasal polyps is well documented [11,15]. The majority of our patients in both the symptomatic and random groups had Stage II or less disease. This finding reinforces the difficulty in interpreting radiographic abnormalities.
5. Conclusions Significant mucoperiosteal thickening is present in a large percentage of the pediatric population. Application of a CT staging system revealed a similar spectrum of sinus disease in both symptomatic and random pediatric patients. The pres-
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C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68
Table 6 Staging of sinus disease by age group in symptomatic and random pediatric patients Age
Stage I
Stage IIA
Stage IIB
Stage III
Stage IV
Random pediatric patients (N= 50) 2–4 (N =16) 9 5–8 (N =15) 8 9–12 (N =19) 10
0 1 6
0 3 3
7 1 0
0 1 0
0 1 0
Total (N =50)
7 (14%)
6 (12%)
8 (16%)
1 (2%)
1 (2%)
0 3 4
8 2 0
0 1 4
0 1 3
7 (12%)
10 (17%)
5 (8%)
4 (7%)
Symptomatic pediatric 2–4 (N =14) 5–8 (N =19) 9–12 (N =27) Total (N = 60)
Stage 0
27 (54%)
patients (N= 60) 5 1 9 3 10 6 24 (40%)
10 (17%)
ence of symptoms was more predictive of advanced sinus disease in children with cystic fibrosis, nasal polyps and immune deficiency. Children with asthma and allergic rhinitis had an incidence and severity of sinus disease similar to that in random pediatric patients. The extent to which mucoperiosteal thickening in children is related to the high incidence of upper respiratory infections in this age group and the rate at which these changes resolve remain unclear. CT scans are a useful adjunct when also considering the patient’s endoscopic findings and response to medical therapy. However, the presence or degree of mucoperiosteal thickening as demonstrated by CT scanning does not alone provide justification for sinus surgery in children.
References [1] C.M. Glasier, D.P. Ascher, K.D. Williams, Incidental paranasal sinus abnormalities on CT of children: Clinical correlation, Am. J. Neuroradiol. 7 (1986) 861–864. [2] M.J. Diament, M.O. Senac, V. Gilsanz, S. Baker, T. Gillespie, S. Larsson, Prevalence of incidental paranasal sinuses opacification in pediatric patients: A CT study, J. Comput. Assist. Tomogr. 11 (Suppl. 3) (1987) 426 – 431. [3] R.E. Gliklich, R. Metson, A comparison of sinus computed tomography (CT) staging systems for outcomes research, Am. J. Rhinol. 8 (Suppl. 5) (1994) 291– 297. [4] S.C. Manning, Pediatric sinusitis, Otolaryngol. Clin. North Am. 26 (Suppl. 4) (1993) 623–638.
.
[5] H.R. Muntz, R.P. Lusk, Nasal antral windows in children: A retrospective study, Laryngoscope 100 (1990) 643 – 646. [6] R.H. Lazar, R.T. Younis, C.W. Gross, Pediatric functional endonasal sinus surgery: Review of 210 cases, Head Neck 14 (1992) 92 – 98. [7] W.H. McAlister, R. Lusk, H.R. Muntz, Comparison of plain radiographs and coronal CT scans in infants and children with recurrent sinusitis, Am. J. Roentgenol. 153 (1989) 1259 – 1264. [8] P.J.V. Van der Veken, P.A.R. Clement, T. Buisseret, B. Desprechins, L. Kaufman, M.P. Derde, CT scan study of the incidence of sinus involvement and nasal anatomic variations in 196 children, Rhinology 28 (1990) 177 – 184. [9] R.H. Lazar, R.T. Younis, L.S. Parvey, Comparison of plain radiographs, coronal CT, and intraoperative findings in children with chronic sinusitis, Otolaryngol. Head Neck Surg. 107 (1992) 29 – 34. [10] J.A. Lesserson, S.P. Kieserman, D.G. Finn, The radiographic incidence of chronic sinus disease in the pediatric population, Laryngoscope 104 (1994) 159 – 166. [11] M.M. April, J. Zinreich, F.M. Baroody, R.M. Naclerio, Coronal CT scan abnormalities in children with chronic sinusitis, Laryngoscope 103 (1993) 985 – 990. [12] K.H. Calhoun, G.A. Waggenspack, C.B. Simpson, J.A. Hokanson, B.J. Bailey, CT evaluation of the paranasal sinuses in symptomatic and asymptomatic populations, Otolaryngol. Head Neck Surg. 104 (1991) 480 – 483. [13] F.W.A. Otten, A. Aarem, J.J. Grote, Long-term followup of chronic therapy-resistant purulent rhinitis in children, Clin. Otolaryngol. 17 (1992) 32 – 33. [14] S.C. Manning, R.L. Wasserman, R. Silver, D.L. Phillips, Results of endoscopic sinus surgery in pediatric patients with chronic sinusitis and asthma, Arch. Otolaryngol. Head Neck Surg. 120 (1994) 1142 – 1145. [15] J.K. Duplechain, J.A. White, R.H. Miller, Pediatric sinusitis. The role of endoscopic sinus surgery in cystic fibrosis and other forms of sinonasal disease, Arch. Otolaryngol. Head Neck Surg. 117 (1991) 422 – 426.
The role of computed tomography scans in evaluating sinus disease in pediatric patients Cheryl S. Cotter a,*, Scott Stringer b, Kevin R. Rust c, Anthony Mancuso d b
a Di6ision of Pediatric Otolaryngology, Nemours Children’s Clinic, 807 Nira Street, Jackson6ille, FL 32207, USA Department of Otolaryngology, College of Medicine, Uni6ersity of Florida, P.O. Box 100264, Gaines6ille, FL 32610 -0264, USA c Greenwood Ear, Nose and Throat Center, Greenwood, SC 29646, USA d Department of Radiology, College of Medicine, Uni6ersity of Florida, P.O. Box 100374, Gaines6ille, FL 32610 -0374, USA
Received 18 December 1998; received in revised form 25 May 1999; accepted 27 May 1999
Abstract Objecti6es: To determine the incidence and severity of sinus abnormalities in children undergoing computed tomography (CT) of the sinuses for suspected chronic sinusitis. To compare these findings with abnormalities noted on random CT scans. Methods: Sixty CT scans, performed for evaluation of sinus disease in symptomatic children aged 2–12, were compared with 50 CT scans of children aged 2 – 12 of the orbits or sinuses obtained for indications other than sinusitis. A staging system was applied to assess the severity of abnormalities. Results: Mucoperiosteal thickening was present in 60% of symptomatic and 46% of random CT scans (logistic regression, P= 0.144). Children aged 2–4 and 9–12 had an increased prevalence of abnormalities in both groups, although these findings were not statistically significant (logistic regression, P= 0.817). Early stage sinus disease was present in the majority of random (96%) and symptomatic (85%) children. Conclusions: There is a high incidence of mucoperiosteal thickening in the paranasal sinuses of children. CT scans of the sinuses should be obtained from children who are being considered for sinus surgery after failing the appropriate medical therapy. Decisions regarding the need for sinus surgery should not be solely based on imaging abnormalities. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Sinus; Computed tomography; Mucoperiosteal
1. Introduction
Presented at the American Society of Pediatric Otolaryngology 10th Annual Meeting, Durango, CO, USA, 29th May, 1995. * Corresponding author. +1-904-390-3690; fax: + 1-904390-3548. E-mail address: [email protected]. (C.S. Cotter)
Endoscopic sinus surgery is increasingly used as a treatment for chronic sinusitis in children. There remains, however, difficulty in reaching a consensus regarding the accurate diagnosis of sinusitis and optimal medical therapy. Patient symptomatology, response to medication and endoscopic findings are important tools in diagnosing pedi-
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 2 0 4 - 9
64
C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68
atric sinusitis. Computed tomography (CT) has been considered the radiographic gold standard in the diagnosis of sinus abnormalities in both children and adults. The frequency of radiographic abnormalities is reported to be from 18% [1] to 50% [2] in asymptomatic children. The present study is the first to apply a standardized staging system to the severity of sinus abnormalities as demonstrated by CT scanning in both symptomatic and random pediatric patients.
2. Materials and methods The study population consisted of children aged 2 through 12 who were referred to a tertiary center for CT of the brain, orbits or maxillofacial region between November 1989 and January 1994. Patients were excluded if the child had recent surgery, craniofacial anomalies, facial trauma, nasogastric tubes or nasal or facial neoplasms. There were two study groups: (1) symptomatic children, suspected of having chronic sinusitis by history and physical examination performed by an otolaryngologist; and (2) random children. The CT scans were considered random if the scans were obtained for indications other than nasal symptomatology or headache. All patients’ charts were reviewed for evidence of respiratory tract infection or risk factors for sinus disease. None of the children in the random group had historical information suggesting sinus disease or immunocompromised status. The CT scans were reviewed and staged by the authors. We adapted the Massachusetts Eye and Ear Infirmary scale [3] for the staging of sinus disease to our study population. The CT staging scale is presented in Table 1. The Harvard system was modified as follows: Stage IIA describes bilateral mucoperiosteal thickening limited to the ethmoid or maxillary sinuses; Stage IIB also describes bilateral mucoperiosteal thickening limited to the ethmoid or maxillary sinuses, but is used to distinguish the younger child without mature frontal and/or sphenoid si-
nus development. Significant disease was defined as the presence of mucosal thickening \ 2 mm. Fig. 1a,b are CT scans from a patient with Stage IIB disease; Fig. 2a,b are CT scans from a patient with Stage IV disease. The absence of mature sinus development differentiates Stage IIB from Stage IV disease.
3. Results The study population consisted of 60 symptomatic and 50 random children. The population was characterized by age group, which was fairly evenly distributed (Table 2). The mean age of the symptomatic group was 7.4 years and the random group mean was 6.9 years. Symptoms and signs in the symptomatic population are presented in Table 3. Rhinorrhea, nasal obstruction and headache were the most common symptoms. The incidence of symptoms according to age is presented in Table 4. The following co-morbid conditions were present in the symptomatic population: asthma– 11 (18.3%); allergic rhinitis–22 (36.6%); cystic fibrosis–4 (6.6%); glycogen storage disease–1 (1.6%); and immune deficiency–3 (5%) patients. The incidence of mucoperiosteal thickening was 60% in symptomatic and 46% in random patients (Table 5). Children aged 2–4 and 9–12 had a higher prevalence of abnormalities in the
Table 1 CT staginga system for pediatric chronic sinusitis Stage 0 Stage I Stage IIA Stage IIB
Stage III Stage IV a
Normal (B2 mm mucosal thickening on any sinus wall) Unilateral disease or anatomic abnormality Bilateral disease limited to ethmoid or maxillary sinuses, normal sinus development Bilateral disease limited to ethmoid or maxillary sinuses, absence of frontal and/or sphenoid sinus development Bilateral disease with involvement of at least one sphenoid or frontal sinus Pansinusitis
Adapted from Massachusetts Eye and Ear Infirmary scale.
C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68
65
Fig. 1. (a) Coronal view. (b) Axial view. CT scans of the sinuses in a symptomatic 3-year-old male. This patient was staged as Stage IIB due to immature frontal and sphenoid sinus development.
symptomatic group. Logistic regression of both age (P =0.817) and symptoms (P = 0.144) failed to show a statistically significant difference in the presence of mucoperiosteal thickening between the study populations. Staging of the degree of sinus disease by age and symptoms is presented in Table 6. A total of 85% of symptomatic patients and 96% of random patients had Stage II disease or less. Patients in the symptomatic group had a slightly higher incidence of Stages III and IV disease, although the numbers in each group were too small for statistical analysis. Six of 11 (54.5%) patients with asthma and 13 of 22 (59%) patients with allergic rhinitis had mucoperiosteal thickening. The majority of patients with these co-morbidities had Stage II disease. This was not significantly different from random children. Children with immune deficiency primarily had Stage IV disease. Children with cystic fibrosis had Stages IIB or IV disease, depending on the age of the patient. Nasal polyps were associated with cystic fibrosis in one patient, who had Stage IV disease. The remaining three children with nasal polyps had Stages I or IV disease, based on unilateral or bilateral disease.
4. Discussion The most common symptom of sinusitis in children is reported to be rhinorrhea, which is usually purulent, but may be of any quality. Rhinorrhea is often accompanied by nasal obstruction. If the rhinorrhea is posterior, it may present as a chronic cough [4]. Headache and facial pain are more common symptoms in older children. The most commonly reported symptoms in children undergoing sinus surgery are rhinorrhea and cough [5,6]. In the present study, we also found rhinorrhea to be the most common symptom, however, cough was present in only 13% of our patients. Headache was a common symptom in children 5–12 years old, which may simply reflect the relative difficulty in obtaining historical information from younger children. The significance of radiographic sinus abnormalities in children remains a controversial issue. Several studies have demonstrated a correlation between the presence of sinus symptoms and CT documented sinus abnormalities with percentages ranging from 64 to 81% [7–9]. This compares to a 60% incidence of mucoperiosteal thickening in symptomatic patients in the present study.
66
C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68
The prevalence of CT sinus abnormalities in pediatric patients has recently been reported. Glasier et al. [1] prospectively studied cranial CT scans of 101 children and found 31% of abnormalities overall. Excluding patients B1 year old, the incidence was 22%. A history of recent URI was associated with a trend towards more sinus
Table 2 Patient population Age
Symptomatic (%)
Random (%)
2–4 5–8 9–12
14 (23) 19 (32) 27 (45)
16 (32) 15 (30) 19 (37)
Total
60
50
abnormalities, but this was not significant. Diament et al. reported their findings in 137 pediatric patients, referred for cranial CT and found that 47% of patients B 13 years old had some degree of incidental maxillary or ethmoid sinus opacification [2]. They concluded that most sinus opacification is probably related to uncomplicated upper respiratory tract infection that may be active or resolving. Lesserson et al. found a 41% incidence of sinus abnormalities in asymptomatic pediatric patients undergoing CT scans for orbital or temporal bone disease [10]. No correlation between sinus abnormalities and the presence or history of chronic otitis media was identified. The present study found a 46% incidence of sinus abnormalities in a comparable random group, which is consistent with the prior studies. Children have a higher frequency of sinus disease when compared with adults [11]. It is proposed that the higher incidence of upper respiratory infection, the smaller dimensions of the sinus ostia and possibly adenoid tissue play a significant role. Calhoun et al. analyzed the frequency of sinus abnormalities documented by CT scanning in symptomatic and asymptomatic Table 3 The incidence of symptoms and signs in the symptomatic population (N= 60)a
Fig. 2. (a) Coronal view. (b) Axial view. CT scans of the sinuses in a 5-year-old male obtained for non-sinus diagnosis. Bilateral mucoperiosteal thickening with involvement of the sphenoid and/or frontal sinuses was classified as Stage IV disease.
Rhinorrhea Nasal obstruction Headache Allergic rhinitis Post-nasal drip Cough Nasal polyps a
36 25 22 22 11 8 4
Historical information collected retrospectively.
(60%) (42%) (37%) (37%) (18%) (13%) (7%)
C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68 Table 4 The incidence of the most common presenting symptoms according to age group Symptom
2–4 years
5–8 years
9–12 years
Rhinorrhea Nasal obstruction Headache
11/14 3/14 0/14
10/19 5/19 9/19
15/27 17/27 13/27
adults and found the incidence to be 60 and 15%, respectively [12]. The incidence of abnormalities in asymptomatic adults is less than the incidence in pediatric patients in the present study and most other previous analyses of pediatric patients. It is possible that there may be a difference in the degree of sinus abnormalities on CT scan between the symptomatic and random groups. Lesserson et al. used a rating system of clear, mild, moderate and severe to grade the radiologic findings [10]. This was simply an estimated volume of involvement in any given sinus. There was a non-significant trend towards more severe disease in the symptomatic group. The present study represents the first to utilize a standardized sinus CT staging system in an effort to allow a comparison of the severity of abnormalities between symptomatic and random pediatric patients. The Harvard system was adopted because it is easy to use, concise and has the best rate of inter-rater agreement in a recent study [3]. The majority of patients in our study had Stage II or less disease. The modification for Stage II disease was made in order to differentiate between older children and younger children with immature sinus development. In the younger children, it is unknown Table 5 The prevalence of mucoperiosteal thickening in symptomatic and random pediatric patients Age
Symptomatic (%)
Random (%)
2–4 5–8 9–12
9/14 (64) 10/19 (52) 17/27 (63)
7/16 (44) 7/15 (47) 9/19 (47)
Total
36/60 (60)
23/50 (46)
67
whether bilateral ethmoid and maxillary disease represents a continuum to future Stage IV disease, or merely a reflection of the sinus physiology at a younger age. The literature would tend to support characterizing bilateral ethmoid and maxillary mucoperiosteal thickening in young children as a less severe stage of disease, as there is supporting data to suggest a majority of these findings are self-limited [13]. If, alternatively, we had upgraded younger children with Stages IIB–IV disease, 14 (39%) of symptomatic and nine (39%) of random children would have been staged with advanced disease. These numbers are not significantly different. Children with asthma may have a significant predisposition to sinus disease [11]. Manning et al. reported improvement in sinus symptoms and asthma in the majority of patients who underwent endoscopic sinus surgery for refractory symptoms [14]. Patients were selected for surgery when CT scans demonstrated residual ethmoid and maxillary disease after ‘maximum medical therapy’, although the severity of disease was not described. Over 50% of the children with asthma and/or allergic rhinitis in this study had mucoperiosteal thickening, which was primarily Stage II disease. This was not different from the incidence of mucoperiosteal thickening in random children. All children in our study with cystic fibrosis had Stages IIB or IV disease, depending on the age of the child and the level of sinus development. Nasal polyps were associated with Stages I or IV disease, based on unilateral or bilateral disease. Advanced disease in children with cystic fibrosis and nasal polyps is well documented [11,15]. The majority of our patients in both the symptomatic and random groups had Stage II or less disease. This finding reinforces the difficulty in interpreting radiographic abnormalities.
5. Conclusions Significant mucoperiosteal thickening is present in a large percentage of the pediatric population. Application of a CT staging system revealed a similar spectrum of sinus disease in both symptomatic and random pediatric patients. The pres-
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C.S. Cotter et al. / Int. J. Pediatr. Otorhinolaryngol. 50 (1999) 63–68
Table 6 Staging of sinus disease by age group in symptomatic and random pediatric patients Age
Stage I
Stage IIA
Stage IIB
Stage III
Stage IV
Random pediatric patients (N= 50) 2–4 (N =16) 9 5–8 (N =15) 8 9–12 (N =19) 10
0 1 6
0 3 3
7 1 0
0 1 0
0 1 0
Total (N =50)
7 (14%)
6 (12%)
8 (16%)
1 (2%)
1 (2%)
0 3 4
8 2 0
0 1 4
0 1 3
7 (12%)
10 (17%)
5 (8%)
4 (7%)
Symptomatic pediatric 2–4 (N =14) 5–8 (N =19) 9–12 (N =27) Total (N = 60)
Stage 0
27 (54%)
patients (N= 60) 5 1 9 3 10 6 24 (40%)
10 (17%)
ence of symptoms was more predictive of advanced sinus disease in children with cystic fibrosis, nasal polyps and immune deficiency. Children with asthma and allergic rhinitis had an incidence and severity of sinus disease similar to that in random pediatric patients. The extent to which mucoperiosteal thickening in children is related to the high incidence of upper respiratory infections in this age group and the rate at which these changes resolve remain unclear. CT scans are a useful adjunct when also considering the patient’s endoscopic findings and response to medical therapy. However, the presence or degree of mucoperiosteal thickening as demonstrated by CT scanning does not alone provide justification for sinus surgery in children.
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