Sinus Infection: Why Antibiotics Are Probably Not Necessary

By this point in the season, most people, adults and kids alike, have had at least one cold. It’s just one of those unfortunate realities about being human. That also means I see a lot of patients at KidMed for “sinus infection.”


I really don’t like the term “sinus infection.” It gets thrown around, willy-nilly, almost as a synonym for antibiotic. Let me clear up some of the misconceptions about sinus infections, or rhinosinusitis, in kids. Disclaimer: this applies to otherwise healthy children, with normal development and no underlying conditions.


The Physiology:


The (paranasal) sinuses are open spaces in the face that lighten the skull, impact the sound of your voice, and produce mucus. The mucus moisturizes the inside of the nose and catches anything that shouldn’t enter the body. In this respect, mucus is good. The frontal sinus is in the forehead, right between the eyebrows. The ethmoid and sphenoid sinuses are behind that bony part of the bridge of your nose. And lastly, the maxillary sinus is in your cheeks, under both eyes.


The ethmoid and maxillary sinuses are the only two nasal sinuses present at birth. The sphenoid sinus doesn’t form until 5 years old. The frontal sinus doesn’t form until 8 years old, and isn’t completely developed until late adolescence.


Great, you say, who cares?


If there’s not a sinus then there can’t be a sinus infection.


The Biology:


Kids under 6, average 8 viral URIs a year. Each one lasts about 14 days, and the cough symptom can last even longer. As the virus multiplies, the body recognizes it as bad, and mounts an “inflammatory response.” Basically, everything gets red, swollen, and gooey because the immune system sends extra blood and fighter cells to get rid of the virus.


Kids make an adult amount of snot in a little tiny baby space. They can’t blow their noses, so that mucus fills everything up. It can even start leaking out of the eyes when there’s no place left for it to go (remember, it’s all connected).


In children less than 5 years old, the ears are the most likely place for mucus to linger and bacteria to grow. Because, like I mentioned above, the nasal sinuses are too small to matter.


The pathophysiology:


So, here’s the reason I don’t like the term “sinus infection.” It’s too vague, and ultimately confusing. A sinus infection just means there is a disease process in a sinus. It does not differentiate viral (the most common) versus bacterial (only about 5%).


Even if your child has green, brown, red, (fill in the color) snot, it does not mean he/she has a bacterial sinus infection requiring antibiotics. Dry, stagnant snot turns colors. Snot sitting on a tissue will turn green if you leave it long enough. That doesn’t mean the tissue requires Amoxicillin.


The gold standard diagnosis for bacterial sinus infection is sinus aspiration: pulling snot out of the nasal sinus and sending it to the lab to culture. This is not practical or comfortable, and therefore not feasible. Especially in pediatrics. If I can’t convince your child to say “ah” for a strep test, I certainly can’t convince him to let me stick a needle deep into his face.


Instead, we use clinical criteria to diagnose a sinus infection requiring antibiotics:


  1. Length of illness: It takes bacteria about 10 days to grow. So, if your child has a stuffy nose for 2 days, it’s not a sinus infection requiring antibiotics. If your child was sick for 3 days, started getting better, and is now sick as snot again, he may need antibiotics.
  2. Severity of symptoms: if your child has a fever of 102 or higher, with thick, opaque, pus-like snot, for 3-4 consecutive days, he may need an antibiotic.


Viral sinus infection is just as uncomfortable as bacterial sinus infection. The pediatric providers at KidMed can give you tips and tricks to help your child feel better, whether or not he/she needs an antibiotic.


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