Sinusitis- AAP Guidelines

Sinusitis1As one who suffers from intermittent chronic sinusitis, I have a wealth of personal experience with the pros and cons of antibiotics use, surgery, and alternative approaches.


The article, “Clinical Practice Guidelines for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years” (you can read it here… ) published July 2013 in Pediatrics, does not deal specifically with chronic sinusitis but is a starting point for discussion.


New to these recommendations is that one can wait or treat with antibiotics the sinus infection that is less than three days duration even if there is a worsening course (high fever over  39c/102f, with cough), and that imaging studies are not warranted at all in cases of acute sinusitis.


The diagnosis of sinusitis is made when:

  1. Nasal discharge and or daytime cough of 10 days not getting better.

  2. Worsening of cough nasal discharge or fever.

  3. Fever over 39c/102f, or persistent purulent nasal discharge for at least 3 days in a row.


Imaging is discouraged, but if you are worried about orbital (bulging eye or infection around the eye), or CNS/ brain symptoms, then a contrast-enhanced CT of paranasal sinuses should be obtained. MRI can also work for this situation.


Prescribe antibiotics when onset is severe or the above criteria are met. Initial treatment can be with amoxicillin at 80-90 mg/Kg/ day which will overcome resistance of streptococcus pneumonia. However, to cover the other two common pathogens in children (Haemophilus influenza and moraxella cataralis) you should treat with Amox-clav. (Augmentin). Dose the amox. component at 80-90  mg/kg/day.  I find the only way for children to tolerate this is to use the ES 600mg/5ml product.  All the rest have too high a clavulanate acid % resulting in abdominal pain and diarrhea.


So what to do with those pesky colds our young ones seem to have all winter long?  You sure don’t want to use antibiotics every time your child has a green runny nose, since most of these are not sinus infections and viral illness (the common cold) doesn’t respond to antibiotics.  Antibiotics have huge down sides in that they destroy your child’s healthy bacteria in the gut and this lowers your child’s immune system and ability to fight off future infections. 


Remember that the maxillary sinuses (the ones just below your eyes) form around age 3-4 years.  The frontal sinuses (the ones in your forehead) form around age 8-10 years.  This is why I rarely ever diagnose sinusitis under the age of 3 years.


So what about chronic sinusitis, the kind where there seems to be a green nasal discharge on and off for months (in my case years)?. Remember that in the young preschool child in day care, this is probably one viral infection after another.  The typical daycare child has 5-7 colds a year, all clustered in the winter months. 


Sometimes nasal flushing with a nedi-pot or sinus rinse using saline can help clear much of the infection and provide some relief. Sometimes you may have a sensitivity to a food (e.g. dairy or gluten) that is keeping your level of inflammation high.  Sometimes, a person has an immune deficiency (though this is less than 1 in 1000  and super rare).  Rarely, in adolescents and adults you may need to see an ENT for possible sinus surgery. 


 You can read more about the AAP guidelines for sinusitis here…




Dr. Paul


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