Saturday, April 23, 2011

Mastering the Snotty Nose: Sinusitis


In previous posts, I have described ways for parents to sort out the difference between allergies and the common cold (or upper respiratory infection).  You are becoming very strong in the ways of the snot.  I believe you are ready for the next step.   I am going to give away another trade secret.  I am going to show you how you can diagnose sinusitis, a bacterial infection in the sinus cavities.  Unfortunately, my medical degree does not give me the capacity to view the sinuses with x-ray vision to determine if there is a bacterial infection present.  I must rely on the history of the illness to make the diagnosis, which you can do also. 

The American Academy of Pediatrics and the American Academy of Family Practice have published guidelines regarding the management of sinusitis.  These are recommendation for how physicians should diagnose and treat sinusitis based on the current scientific evidence.  The central theme from both of these guidelines is that the diagnosis should be based on the duration of the illness.  Before diagnosing sinusitis (and prescribing an antibiotic), the child should have had upper respiratory symptoms (runny nose and cough) for at least 10 days.  Most cases of bacterial sinusitis are going to occur after a child has a cold virus.  A cold virus will typically get better, or at least be improving, by 10 days.  Pretty simple, right?  Less than 10 days, you are dealing with a cold.  Over 10 days, you have a sinus infection.  One requires an antibiotic, the other does not. 

Note: I am using 10 days as the cut off for simplicity's sake, but in reality 10-14 days is probably a more realistic cut off.  See the chart below of cold symptoms and note that many people will still have symptoms from a common cold beyond 10 days. 



Here are a few common misconceptions about sinusitis:

Facial Pressure/Pain Means Bacterial Sinusitis:  Nope.  Colds and allergies can cause sinus pressure also.  Over 10 days means bacterial sinusitis, facial pressure or pain does not.

"But His Mucus is Green!":  Sorry, it means absolutely nothing.  Mucus can be clear, yellow, or green with a common cold or allergies.  In fact there is a normal transition that occurs as a child progresses through a cold.  Typically, the mucus thickens up and becomes more yellow or green  towards the end of the illness.  Look at duration of symptoms, not the color of mucus. 

Sinus Infections are Contagious:  Wrong.  I often see a child who has an obvious cold virus, and the dad tells me that he saw his doctor and was diagnosed with a sinus infection. 
Me: "Really? Were you put on an antibiotic?"
Dad: "Yes, I am on Zithromax."
Me: "How long have you been sick for?"
Dad: "I got sick about the same time as Johnie, three or four days ago, I guess."
Me: "Hmmm, let me explain why I do not think Johnie needs an antibiotic at this point...."

Viruses (colds) are very contagious.  If a family has several people with a runny nose and cough, almost always this is a viral illness and antibiotics are not going to do anything to help.  Sinus infections are not contagious, the cold virus that can lead to the sinus infection is.  Once again, over 10 days of symptoms is the key. 

In reality, it is not always this cut and dried, there are times when I will make the diagnosis earlier than 10 days, such as when a child has had a cold for 8 days and now has 102 degree fever.  There are other times where I will hold off on antibiotics beyond the 10 days.  Some children just take longer than 10 days to get better from a cold, but these kids are typically showing gradual improvement by the 10th day. 

I always suggest parents wait out a runny nose and cough for at least 10 days before coming to see me (assuming the child is not extremely sick and does not have other confounding factors).  Before 10  days I am unlikely to do much beyond reassure the parent, after 10 days I am likely to treat the child for sinusitis.  Sometimes that reassurance is very valuable to a parent, so I never begrudge a parent for coming in under 10 days, but my medical management is going to be vastly different after 10 days of symptoms.

Congratulations! You can now tell the difference between a cold, allergies, and a sinus infection.  You are the master of all things snotty!

1 comment:

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