Acute Bacterial Sinusitis in Children

July 12, 2013

Acute Bacterial Sinusitis in Children

  1. Deborah Lehman, MDAU3106

The AAP updates management guidelines for diagnosis and treatment of sinusitis.

  1. Deborah Lehman, MDAU3106

Sponsoring Organization: American Academy of Pediatrics

Purpose and Objective: Update of 2001 recommendations for diagnosis and management of acute sinusitis in children between ages 1 and 18 years.

What's Changed:

  • Addition of diagnosis based on clinical presentation of worsening course

  • Watchful-waiting optionin those with persistent illness

  • Imaging should not be used to diagnose acute bacterial sinusitis

Key Recommendations:


  • Diagnosis of acute sinusitis can be made when a child with acute upper respiratory infection (URI) has persistent illness (>10 days), including nasal discharge of any quality and/or daytime cough, or worsening course of URI symptoms, or severe onset of fever with purulent nasal discharge lasting at least 3 days.

  • Physical exam findings are not helpful in differentiating sinusitis from uncomplicated URI.

  • Imaging should not be used to diagnose acute bacterial sinusitis because children with uncomplicated URIs may have abnormal plain films, computed tomography (CT), and magnetic resonance images (MRI). Contrast CT and/or MRI of the paranasal sinuses are indicated in children with orbital or central nervous system complications.


  • Antibiotics are indicated in children with severe sinusitis or worsening symptoms. Outpatient observation for 3 days prior to antibiotics can be considered in those with persistent illness.

  • Amoxicillin or amoxicillin/clavulanate is recommended first-line treatment for acute bacterial sinusitis because Streptococcus pneumoniae, nontypable Haemophilus influenzae, and Moraxella catarrhalis are the most common causative organisms in acute bacterial sinus disease. Decisions about antibiotic choice should be individualized for each patient. Amoxicillin is the preferred antibiotic in children aged >2 years with mild symptoms who are not in child care and have not received antibiotics in the previous month. For others, amoxicillin/clavulanate with high-dose amoxicillin is recommended. Amoxicillin dose (45 mg/kg vs. 80–90 mg/kg) should be dictated by local pneumococcal-resistance rates.

  • Penicillin-allergic children can be prescribed an oral second- or third-generation cephalosporin (cefdinir, cefuroxime, or cefpodoxime), and consultation with an allergist may be warranted for children with anaphylaxis to penicillin. Trimethoprim-sulfamethoxazole and azithromycin are not recommended because of high resistance rates.

  • Duration of therapy should be individualized, but a minimum of 10 days, or 7 days after symptom resolution, is proposed. Reassess patients after 72 hours to confirm improvement.

  • No recommendations are made for use of adjuvant therapies (including intranasal corticosteroids, saline nasal irrigation, decongestants, and antihistamines).


  • Influenza vaccine and PCV-13 should be administered to all children at the recommended ages.

  • Treat appropriately conditions that promote sinusitis (e.g., allergic rhinitis and gastroesophageal reflux).


This guideline provides evidence-based recommendations that support the clinical diagnosis of sinusitis and allow for a “wait-and-see” option for patients with mild disease. The recommendation to avoid imaging in uncomplicated disease is an important one and will help reduce unnecessary radiation exposure. Amoxicillin as first-line therapy for most children is consistent with otitis media treatment recommendations and is a key component of judicious antibiotic use.

  • Disclosures for Deborah Lehman, MD at time of publication Nothing to disclose


Reader Comments (5)

Ant?nio Francisco Resident, Urology, Hospital Municipal

so i liked the text, but in my country the major part of sinusite case apear in alergic people, but you are saing the we must use other terapy without antibiotc terapy like anti histaminic.
how could i do the manegement of this sicker.

xiaohong wang Other, Pediatrics/Adolescent Medicine

Acute Bacterial Sinusitis in Children

FLAVIO DI CHIARA Physician, Pediatrics/Adolescent Medicine

Usually, antibiotic therapy should be at least 14 days, otherwise you will have relapse of sinusitis

BENJAMIN GORDON Physician, Pediatrics/Adolescent Medicine, retired

An excellent technique for draining sinuses, either for infection or to relieve headache was taught to me by my father and I have used it hundreds of times with great success: Wrap half of an applicator stick with cotton leaving about 1/2" - 3/4" over the end and soak this with Afrin. Gently rotate the stick as you work it back into the floor of the nostril as far as it will go easily. Let it sit for 5 -10 minutes and try to move it a few mm further as shrinkage will permit. After 20 minutes, there will be enough shrinkage of swollen mucosa to allow drainage of the sinuses. One patient brought me back a box of candy because she had never had such effective relief before. As in the old commercial: Try it! you'll like it!

BENJAMIN GORDON Physician, Pediatrics/Adolescent Medicine, retired

1) Most sinuses don't even develop before 5 years of age.
2) Why aren't they using the standard technique of putting a high-intensity light source in the mouth and then close the mouth in a dark room? This illuminates the sinuses and an infected one will be obvious.

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