Nearly everyone has either been diagnosed with or knows someone who has been diagnosed with a sinus infection. This common condition, which is more accurately known as acute bacterial sinusitis, is incredibly common and is estimated to complicate between 6% and 7% of cases of such respiratory conditions like colds and allergies. As one can imagine, 
sinus infections result in hundreds of thousands of visits to physicians every year for this condition. The treatment of sinus infections has recently been in the news because the American Academy of Pediatrics (AAP) has just updated its guidelines for the definition, workup and treatment of sinus infections for the first time since 2001. These guidelines apply to children between the ages of 1 to 18 without complicating medical conditions. Children with such conditions like cystic fibrosis will continue to use different guidelines. The following questions and answers are intended to help understand these guidelines.
How does a cold (a viral upper respiratory illness or URI) differ from a sinus infection? A cold is caused by a virus and, other than keeping the patient comfortable and well hydrated, no further treatment is usually necessary. One of the key features of a cold is clear nasal discharge that later becomes cloudy. Fevers tend to occur early in the illness and are often accompanied by other symptoms such as headache and achy joints. Typically, the fever and muscle aches disappear in the first 24 to 48 hours, and the stuffy nose and cough become the primary symptoms. Most colds last 5-7 days but some may last longer.
What is sinusitis or a sinus infection? One thing that is important to stress is that a sinus infection is NOT just yellow/green nasal drainage. Such drainage is common in viral illnesses and the great majority of children with such drainage do not have a sinus infection.
To meet the criteria for a sinus infection, there are multiple things that must be present. This is one of the focuses of the new AAP guidelines and the new definition includes:
Persistent illness, i.e., nasal discharge (does not have to be yellow/green) or daytime cough or both lasting more than 10 days without improvement (in other words, cold symptoms that fail to improve after more than 10 days);
OR
- Worsening course, i.e., worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement (In other words, a cold that was getting better and then began to worsen again);
OR
- Severe onset, i.e., concurrent fever (temperature ≥39°C/102.2°F) and purulent nasal discharge for at least 3 consecutive days (in other words, a cold with high fevers and thick yellow/green nasal drainage for at least three days with no improvement)
Since the features of a sinus infection overlap so much with the symptoms of a cold, what tests are available to help make the diagnosis? This is a huge challenge for both families and doctors to answer this question. Many techniques that were used in the past such as taking cultures of the mucus in the nose, shining a light in the nose to determine how full with mucus the sinuses are, tapping on the face over the sinuses or even looking into the patient’s nose have not been shown to be useful in making the diagnosis. In addition, the new guidelines specifically state that doctors should not use x-rays or CT scans to make this diagnosis as these do not give reliable information that can distinguish between a common cold and a bacterial infection of the sinuses (with a few exceptions for some complications that can develop with a sinus infection). Rather, the diagnosis should be made just on whether the patient meets the definition outlined above of a sinus infection.
How is a sinus infection treated differently than a cold? The major difference in treatment is that a sinus infection can be treated with antibiotics while there is zero role for treating a cold with such medications. If a patient meets the criteria for a sinus infection, one of two steps could be taken. The first would be to start antibiotics immediately. If the patient does not show evidence of being severely ill, then a second option could be taken. This would include a course of close observation for three days before any antibiotics would be started. If the patient does not improve in the three days or if they worsen at any time, then antibiotics would be started. The benefit of this second course, which is part of the new guidelines, is that it may allow a large percentage of patients who either just had a cold that lingered longer than the typical time for a virus or a patient who only had a mild sinus infection to get over the infection without the need for medications. Such a treatment course has proven to be effective in reducing antibiotic use for other conditions such as ear infections and can now be used for sinus infections as well.
If my child has been diagnosed with a sinus infection, when can I expect that they will improve? Most children will improve within 72 hours of starting medication. If they are not improving, they should return to the doctor’s office to be reassessed by the physician and the doctor may consider changing the antibiotic that was given at that time.
