Now that we’ve examined treatments for the most common forms of sinusitis, it’s a good time to look at some special circumstances.

Children and Sinusitis

Like adults, children can develop sinus infections. Most often, kids’ infections follow on the heels of a cold, but they can also be triggered by allergies. Although the infection process is the same as in grown-ups, several factors specific to children affect the way we diagnose and treat pediatric sinusitis.

First, doctors have a harder time distinguishing between a child’s sinusitis and severe cold or allergies. In an infant or a young child, the only symptom of sinusitis that parents may notice is green nasal drainage, a nighttime cough, fever, or increased irritability.

Physicians, meanwhile, usually do not have the benefit of a sinus CT scan. This tool is only used for the most persistent cases because we are hesitant to expose the child’s developing body to radiation.

So, faced with the never-ending supply of runny-nosed children, pediatricians must use clinical judgment to make their best assessment and treat the illness.

Over-the-counter medications combining decongestants, antihistamines, and cough suppressants are helpful for both colds and sinusitis.

Antibiotics are prescribed when symptoms persist and sinusitis seems probable. Another difference is that sinus surgery is performed much less commonly in children than in adults.

It’s only done in the most severe cases in which antibiotics don’t work and a CT scan shows definite sinus obstruction. And even in these cases, patience may pay off.

Children catch fewer colds as they age and frequently outgrow their allergies, so the number of sinus infections often will drop without surgical intervention. But when sinus surgery is performed on children, it can be just as successful as in adults.

Children heal faster from surgery and are usually back to school within three to five days. Young children are often unwilling to undergo postoperative cleaning in the office under local anesthesia; such cases may require a second trip to the operating room one week after surgery for cleaning under general anesthesia.

While sinus surgery on children is rare, another type of surgery related to the sinuses is not. Because cystic fibrosis arises in childhood and commonly causes nasal polyps, children with polyps need a test that analyzes the amount of salt in their perspiration to determine if they have this disorder.

Sinusitis During Pregnancy

Women’s bodies tend to retain fluid during pregnancy, and among the tissues that become swollen are the mucous membranes lining the nose and sinuses.

Similar to a cold or allergies, this swelling can block the sinus ostia and trigger an infection. As a result, it’s not uncommon for women with sinusitis to have more flare-ups than usual during pregnancy.

Treatment of pregnant women is complicated by physicians’ reluctance to prescribe medication, since we don’t want to risk harming the developing fetus. As a general rule, pregnant women should not take medication during the first trimester and should use caution thereafter.

However, an untreated infection that persists also presents risks to the fetus, especially if it causes a fever, so exceptions are sometimes necessary. If you are pregnant and have a persistent sinus infection, check with your obstetrician before taking any medication.

Obstetricians often will OK use of medications that have been used for decades and have a safe pregnancy profile, such as the decongestant pseudoephedrine and the antibiotic amoxicillin. On the plus side, once a pregnant woman with sinusitis symptoms gives birth, the fluid retention recedes and the sinusitis usually subsides.

Genetic Causes of Sinusitis

Although it’s likely that many genetic links to sinusitis will be found in the future, for now these are the two we know the most about.

Cystic Fibrosis (CF)

This inherited disorder, which is usually diagnosed in childhood, is caused by a genetic defect (called a DNA mutation) that leads to abnormal secretions in various organs of the body, including the lungs, pancreas, liver, and reproductive tract.

In the respiratory system, this dysfunction produces very thick mucus, which can block the lungs and sinuses, triggering pneumonia and sinusitis. More than 90 percent of patients with CF have chronic sinusitis; large nasal polyps are also common.

Many need sinus surgery to clear the polyps, which often regrow, requiring repeated surgery. Although in the past most people with CF did not survive into adulthood, treatments have become so effective in recent years that many CF patients are now living well into middle age.

In addition, some children and adults are now being diagnosed with a milder form of CF that is caused by a partial defect in the DNA gene; it’s less likely to affect longevity, but secretions can still be thick, causing frequent bouts of sinusitis.

Primary Ciliary Dyskinesia (PCD)

The lungs, nose, and sinuses are lined with microscopic hairs called cilia, which beat rhythmically, clearing mucus and debris from air passages.

PCD, also known as immotile-cilia syndrome or Kartagener’s syndrome, is a genetic disorder that results in a structural defect in the cilia, leaving them unable to beat properly. Mucus builds up within the sinuses, leading to chronic infections and the formation of nasal polyps.

As with CF, this genetic defect can cause problems throughout the body. Its effect on the lungs means people with PCD are prone to chronic cough and recurrent bouts of pneumonia.

Medications can provide some improvement. Sinus surgery to remove the polyps and clear the sinuses is effective but usually needs to be repeated.

Sarcoidosis

Sarcoidosis is a rare illness that produces small beadlike patches of inflamed tissue known as granulomas throughout the body. These granulomas are most common in the lungs but can also occur in the nasal passages, triggering sinus inflammation and infection.

The cause of sarcoidosis is not known, but it’s believed to be due to an abnormal stimulation of the immune system. It occurs three to four times more frequently in blacks and is also more common in women than in men.

In some cases, people find out they have sarcoidosis after surgery for sinusitis, when microscopic examination of the removed tissue reveals granulomas.

More commonly, it’s picked up during a routine chest x-ray. Sarcoidosis produces a cobblestone appearance of the nasal mucosa, which is visible during endoscopic examination.

If an ENT doctor suspects sarcoidosis as a cause of sinusitis, the diagnosis can be confirmed by a biopsy of the nasal tissue. The diagnosis can also be confirmed by a blood test known as an ACE level, which measures the amount of angiotensin converting enzyme in the blood, a substance known to be elevated in those with this disease.

Sarcoidosis can often be treated with oral steroids to reduce inflammation throughout the body. In more severe cases affecting the sinuses, surgery may be needed to relieve obstruction caused by inflammation and scarring.

Wegener’s Granulomatosis

Wegener’s is another rare disease that causes granulomas to form throughout the body, including the nose and sinuses. Here, however, the granulomas damage the walls of small- and mediumsized blood vessels.

This damage interferes with normal blood supply, which can lead to injury and destruction of nearby tissues. The cause of Wegener’s is also unknown, but research suggests it’s an immune disorder in which the body’s defenses are mistakenly aimed at the blood vessels.

Wegener’s most commonly affects three areas: the lungs, the kidneys, and the nose and sinuses. Unlike most people with sinusitis, whose nasal membranes are swollen and secrete too much mucus, those with Wegener’s have excessively thin and dry nasal tissues.

The blood vessels in these membranes become fragile, leading to frequent nosebleeds. What mucus there is in the nose tends to dry out, leading to the formation of crusts.

More advanced cases of Wegener’s cause erosion of cartilage in the nose, resulting in a hole in the septum (also known as a septal perforation). Sinus infections are common among people with Wegener’s, and the disease is often diagnosed during treatment for sinusitis.

An ENT doctor who suspects a patient has Wegener’s will order a series of blood tests, including one that detects the presence of antineutrophil cytoplasmic antibody, a marker for Wegener’s. The diagnosis can also be confirmed with a biopsy of tissue from a turbinate.

Wegener’s is treated with oral steroids and medications known as immunosuppressive agents, which blunt the response of the body’s immune system. With treatment, more than 90 percent of people with Wegener’s enter remission, although as many as half will relapse when medication is reduced or stopped.

Those who do not relapse may remain in remission for many years, often without needing more medication. Like sarcoidosis, sinus surgery is reserved for those cases in which the sinuses become blocked by diseased tissue.

Immune Deficiency Syndromes

Your body depends on an intact immune system to fight infections. This system functions by the complex interaction of many components, including white blood cells known as T lymphocytes and B lymphocytes.

It is the B lymphocytes that produce antibodies, specialized molecules essential for the identification and destruction of foreign substances such as bacteria.

With certain inherited diseases, one or more of these components are missing and the body cannot mount an effective immune response. In rare cases, such as with the disease known as severe combined immunodeficiency, even a simple infection can be fatal.

You may remember the 1970s movie The Boy in the Plastic Bubble, about a child with this disorder. Less severe but more common immune deficiencies also exist, and they may affect the sinuses.

One example is a disorder known as IgG subclass deficiency. IgG is the name of the most common type of antibody. People with low levels of this antibody often have a history of recurrent bouts of pneumonia and sinusitis.

A diagnosis of immune deficiency may be considered in cases in which a CT scan fails to show any obstructions that would trigger sinus infections.

In other words, the sinus doors are open and the ostiomeatal complex is clear, but the person’s sinuses nonetheless are perpetually infected. Such infections are believed to occur in these people because their immune systems are incapable of keeping the bacteria that normally exist in the sinuses in check.

Immune deficiencies are diagnosed by tests that measure the amount of white blood cells and antibodies in the blood. If these tests reveal low levels of IgG, treatment to replace the antibody through monthly transfusions of IgG may be initiated.

Next, we’ll look at some disorders that seem like sinusitis but aren’t.