Nasal and Sinus Conditions of Childhood

What does it mean when my child's nose is running?

The nose is actually much larger than it seems from the outside. It is a passageway that leads from the nostrils to the back of the throat, and is more like a large cave than a simple tunnel- wide and tall in the middle. The purpose of the nose is to clean, warm and moisten the air we inhale, in order to keep the lungs healthy. To do this, the lining of the nose is covered with a thin layer of a fluid called mucus. The nose produces a lot of this mucus each day, most of which we simply swallow as it drains out the back of the nose. When the mucus gets dried out, it can form crusts ("snot"). Mucus may drain out of the front of the nose if there is a blockage in the back, or if the nose is producing more mucus than usual.

Blockage of the drainage in the back of the nose is often caused by large adenoids in children. The adenoids are like a third tonsil, that sits up high behind the roof of the mouth. Other things that can cause blockage in the nose include an abnormally small nasal pathway, swollen tissue lining the sides of the nose (the turbinates) or a deviated septum (the wall between the nostrils). A small child who always has foul smelling drainage from only one nostril may have a foreign body stuck in the nose (such as a piece of plastic or food).

Cutaway view of the nose, as seen from the side

Excessive mucus production can result from infection, such as a cold virus or sinusitis (usually caused by bacteria). Allergies often cause the nose to produce a large amount of clear drainage, as do reactions to irritating fumes or dust.

What are sinuses?

The sinuses (also known as the paranasal sinuses) are a number of air filled spaces in the bones of the face that surround and are connected to the nasal cavity through small passages. At birth these sinuses are very small. They continue to enlarge throughout childhood, and are not fully developed until late adolescence. No one knows what the purpose of the sinuses is, but they may help to make the head lighter (by replacing bone with air), improve the resonance of the voice, or provide a larger surface area for the lining of the nose to help with cleaning, warming and humidifying the air we breath.

There are four paired sets of sinuses. The maxillary sinuses are large spaces located behind the cheek between the upper teeth and the eyes. The ethmoid sinuses are a series of small cavities between the eyes. The maxillary and ethmoid sinuses are present at birth (but fairly small) and enlarge as the child grows. The sphenoid sinuses are deep inside the head, at the back of the nose. The frontal sinuses are in the forehead, and do not develop to any significant size until the child is older - usually the later teenage years.

The paranasal sinuses

What does it mean when the liquid draining from my child's nose changes color?

During the course of an infection, the mucus may change in consistency. Depending on how dried out the fluid is, it may appear yellow, white or green. Although clear drainage is more commonly associated with allergies, it can also be seen in viral or bacterial infections. Occassionally, nasal drainage can be tinged with a small amount of blood, from local irritation. There is no good way to determine the cause of the drainage simply by looking at the color of the liquid.

What does it mean when my child can't breathe easily through the nose?

Obstruction can be caused by fixed, unchanging, anatomical problems such as a deviated septum or a narrow nasal cavity. Most children only suffer from occasional nasal obstruction, such as when the lining of the nose is swolled from allergies or infection. Another common cause of nasal obstruction in children is enlargement of the adenoids, which may develop in the first few years of life, and then resolve with age. There are a number of potential causes for childhood nasal obstruction, and an internal examination of the nose is usually necessary to make an accurate diagnosis.

What is sinusitis?

Sinusitis refers to inflammation, swelling and/or infection of the sinuses. It can be acute, in which the sinuses fill up with pus and the child will have cold-like symptoms for more than ten days. These children may also have facial or tooth pain, although this is more common in adults. Sinusitis can also be chronic, in which the lining of the sinuses thickens and obstructing tissue known as polyps may develop. Chronic sinusitis may have an infectious component with bacteria in the sinuses, but it can also be present without true bacterial infection. These children usually have symptoms of nasal obstruction and drainage lasting several months. The drainage can either come out of the front of the nose (a "runny nose", also known as rhinorrhea) or out of the back of the nose into the throat ("post nasal drip").

What are nasal allergies?

An allergy is a condition in which the body responds to some foreign substance such as pollen or certain foods. The substance causing the allergic reaction is called an allergen. The reaction can be mild (for example, a rash) or severe and life threatening. In nasal allergy, the nose responds to an inhaled allergen by increasing the normal output of mucus and by swelling shut internally. This results in a sensation of nasal obstruction and nasal drainage, similar to sinusitis. The symptoms of nasal allergies are different from sinusitis in that they may start suddenly after exposure to the allergen, the drainage is usually thin and clear, and there is generally no facial pain. Furthermore, allergic children may have other symptoms such as watery eyes, itching, rashes and hives.

How do you know if a child has sinusitis?

The diagnosis of acute sinusitis is not always easy to make, since the common symptoms in children- nasal obstruction, runny nose and cough- are very much the same as those of a simple cold. Children rarely have the facial pain that adults will get with acute sinusits. X-rays are not usually helpful, since clouding of the sinuses on plain x-rays or even a CAT scan is a common finding in children with colds. Very young children may have abnormal sinus x-rays even if they have no infection at all. Cultures of the nose can also be misleading, since they do not reflect the actual contents of the sinuses. Therefore, children with cold symptoms lasting more than ten days are often simply assumed to have sinusitis and treated appropriately. The diagnosis may be made earlier if facial pain is present, or if there is a complication of sinusitis (such as spread of infection to the eye).

Children with chronic symptoms of sinusitis (lasting more than a few months) are usually treated with a variety of medications as outlined below. If medical management is unsuccessful in relieving symptoms, a CAT scan may be useful if surgery is being considered. This scan will accurately show the anatomy and any inflammmation in the sinus cavities. Although an MRI scan can also sometimes show sinusitis (and does not involve x-rays), it is not as good for planning sinus drainage procedures since it does not show bone detail well.

What should be done to treat sinusitis in children?

Acute sinusitis is treated with antibiotics, usually for a two to three week course. A short course of nasal decongestant spray (no more than three days) may be helpful to open the sinus drainage pathways and allow the infection to clear more rapidly.

Chronic sinusitis can be helped by nasal steroid sprays, which reduce inflammation and swelling. These sprays are fairly safe, and are not absorbed in significant amounts. Therefore, they do not have the same side effects as steroids taken by mouth, and can be used for prolonged periods of time. Antibiotics are also given to these patients, to treat the bacteria which may be contributing to congestion, inflammation and polyp formation.

If there is an allergic component to the nasal disease, specific allergy treatment (such as antihistamines or Singulair) may be useful. However, if allergy is not present, the use of antihistamines is not indicated. Many of these drugs have drying effects on the lining of the nose, which interferes with the body's ability to keep the nose clean and eliminate bacteria and other debris. Also, some of the agents may have undesirable behavioral side effects in young children.

One very effective and safe treatment for both acute and chronic sinusitis is the use of humidification and nasal irrigation. Keeping the lining of the nose moist is important to the body's own natural defenses. Moisture also keeps the nasal secretions from drying out and blocking the natural sinus drainage pathways. Room humidifiers are helpful, but care must be taken to keep them clean, or they can grow colonies of bacteria and/or fungus. Nasal saline spray should be used frequently as well.

Do children ever need surgery for nasal problems?

While sinus surgery is common in older children and adults, I feel that it is rarely indicated in young children. The goal of sinus surgery is to remove bone and other tissue that is blocking the natural sinus drainage pathways, allowing the sinuses to return to health. Nasal disease in young children is often more complicated than simple blockage of the sinus "bottleneck", and may be the result of a number of factors such as an immature immune system, frequent exposure to colds, poor nasal hygiene and enlarged adenoids. Sinus surgery may be appropriate for a few selected children who have significant symptoms that cannot be controlled by medical management.

In some cases, removing the adenoids - a simpler, quicker and safer operation than sinus surgery - will be enough to address the patient's nasal symptoms (such as nasal obstruction and drainage), even though the adenoids are not near the sinuses themselves. Many of the symptoms that are just assumed to be caused by sinusitis will actually improve when the back of the nose is opened and better drainage and airflow is allowed by removing adenoid tissue.