Sinusitis in Children

Recognizing the Signs and Seeking the Right Care

Almost every parent has asked this question by day five of a runny nose: “Is this still a cold, or is it a sinus infection?” It is one of the most common questions I hear as a pediatric ENT in Frisco, and the answer matters. Most children with cold symptoms do not need antibiotics. A smaller group does, and a very small group needs urgent care. This guide explains how pediatricians and ENT specialists tell those groups apart, what treatment actually helps, and when a child with repeated or long-lasting sinus problems should see a specialist.

Key takeaways

• Most “sinus” symptoms in children are a cold. Colds usually peak around days 3 to 6 and are clearly improving by day 10.
• Bacterial sinusitis follows one of three patterns defined by the American Academy of Pediatrics (AAP): symptoms lasting more than 10 days without improvement, a “double sickening” after initial improvement, or a high fever (102.2°F / 39°C or more) with thick nasal discharge for at least three days in a row.
• Mucus color does not tell you whether an infection is bacterial. Green or yellow mucus is common with ordinary colds.
• X-rays and CT scans are not used to diagnose routine sinusitis in children. CT is reserved for suspected complications or for planning surgery.
• Swelling or redness around the eye, a severe headache, a stiff neck, or unusual sleepiness are emergencies. Go to the emergency department.
• Sinus symptoms lasting 90 days or more (chronic sinusitis) or infections that keep coming back deserve an ENT evaluation, because there is often an underlying, treatable reason.

What is sinusitis?

The sinuses are air-filled spaces in the bones of the face that drain into the nose through small openings. When the lining of the nose and sinuses swells, usually from a cold or allergies, those openings can block. Mucus collects, and in some children bacteria multiply in the trapped mucus. That secondary bacterial infection is acute bacterial sinusitis.

Children’s sinuses are still developing, which changes how sinusitis looks at different ages. The maxillary sinuses (behind the cheeks) and the ethmoid sinuses (between the eyes) are present at birth. The frontal sinuses in the forehead develop later and are usually not a factor until school age or beyond. This is one reason young children rarely complain of “sinus headaches.” In a toddler or preschooler, sinusitis more often shows up as a persistent runny nose, daytime cough, bad breath, and crankiness than as facial pain.

A cold or a sinus infection? How to tell the difference

A typical viral cold in a child starts with a sore or scratchy throat, then nasal congestion and a runny nose. Fever, if present, usually comes early, in the first day or two. The nasal discharge often starts clear, turns thick and colored for a few days, then clears again. Symptoms peak around days 3 to 6 and are improving by day 10, although a mild cough can linger for two to three weeks.

The AAP’s clinical practice guideline for children ages 1 to 18 describes three patterns that point toward bacterial sinusitis instead of a cold:

Children get a lot of colds. Young children typically have six to eight a year, and children in daycare or early school often have more, sometimes back to back through the fall and winter. Studies estimate that only about 5 to 13 percent of colds in children are complicated by bacterial sinusitis. Back-to-back colds can look like one long illness, which is why I ask parents whether there was a “good stretch” in between.

If your child also sneezes, has itchy eyes, and has clear drainage that comes and goes with the seasons, allergies may be the bigger factor. My post on allergies versus colds in children walks through those differences, and our Frisco pollen and allergen forecast shows what is in the air this week.

How sinusitis is diagnosed

For uncomplicated sinusitis, the diagnosis is clinical: it is based on the pattern of symptoms over time plus an examination. The AAP guideline recommends against X-rays, CT scans, MRI, or ultrasound to tell sinusitis from a cold. Imaging cannot reliably separate the two, because the sinus lining also swells during ordinary colds, and a CT scan exposes a child to radiation without changing treatment.

Imaging does have a role in two situations. The first is a suspected complication, such as infection spreading to the eye socket or brain, where a contrast-enhanced CT or MRI is appropriate. The second is planning surgery for chronic sinusitis, when a CT gives the surgeon a map of the child’s anatomy.

In the ENT office, I often add a quick look inside the nose with a thin, flexible endoscope after a numbing and decongesting spray. Most school-age children tolerate it well, and it shows the adenoids, the drainage pathways, any pus, and any polyps. Younger children often do not need it at all.

Treatment: when antibiotics help, and when they do not

Watchful waiting is a legitimate option

For a child who meets the “persistent” pattern (more than 10 days without improvement) but is not very ill, the AAP guideline allows either starting an antibiotic or observing for three more days. Many children improve during that window. Children with the “worsening” or “severe onset” pattern should start an antibiotic.

When an antibiotic is used

Amoxicillin, with or without clavulanate, is the usual first choice. Your child’s doctor chooses the medication and dose based on age, weight, allergy history, and recent antibiotic use. If a child is not better, or is worse, after about 72 hours, the plan should be reassessed: start an antibiotic if you were observing, or change it if one was already started.

Using antibiotics only when they are likely to help is not stinginess. Unnecessary antibiotics cause diarrhea and rashes, disrupt the normal bacteria in the gut, and contribute to resistant bacteria that are harder to treat the next time your child really needs an antibiotic.

Comfort measures

• Saline: salt-water sprays or gentle rinses thin mucus and help clear the nose. They are safe at any age. For infants, a few saline drops followed by gentle bulb suction before feeds can help.
• Fever and pain relief: acetaminophen, or ibuprofen for children 6 months and older, dosed by your child’s weight and the package label.
• Fluids and rest: they do not cure the infection, but they help a sick child feel better.
• Avoid over-the-counter cough and cold medicines in young children. The FDA advises against them under age 2, and product labels say not to use them under age 4. Medicated decongestant nose sprays can cause rebound congestion after a few days and are not intended for young children.

The evidence for adding nasal steroid sprays, antihistamines, or decongestants to treatment of acute bacterial sinusitis in children is limited, and the AAP guideline does not recommend them routinely. If allergies are clearly part of the picture, treating the allergies helps prevent the next episode.

Red flags: when sinusitis is an emergency

Serious complications are uncommon but real. In children, the most common is spread of infection to the tissues around the eye. Infection can rarely spread inside the skull, especially in adolescents. Take your child to the emergency department for any of the following:

• Swelling, redness, or drooping of the eyelid or the skin around the eye
• A bulging eye, pain when moving the eye, double vision, or any change in vision
• A severe headache, especially with vomiting
• A stiff neck, confusion, or unusual sleepiness or difficulty waking
• A soft, swollen area on the forehead
• High fever with a child who looks very ill

When should a child see a pediatric ENT for sinusitis?

Your pediatrician can diagnose and treat most episodes of sinusitis. An ENT evaluation is worthwhile when:

1. Symptoms last 90 days or longer. This is the definition of pediatric chronic rhinosinusitis used by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS): two or more symptoms (thick nasal drainage, nasal blockage, facial pressure or pain, or cough) for at least 90 days, with evidence of sinus inflammation on endoscopy or CT.
2. Infections keep coming back. Many specialists use a threshold of about three or more well-documented episodes in six months, or four or more in a year, with full recovery in between.
3. There has been a complication, such as an eye-socket infection.
4. Polyps or a structural problem is suspected, such as a deviated septum after an injury or a blocked drainage pathway.
5. Your child has another condition that makes sinus disease more likely, such as asthma, cystic fibrosis, an immune deficiency, or a cleft palate.

Chronic sinusitis in children: the treatment ladder

Chronic sinusitis in children is usually managed in steps, starting with the simplest and least invasive. The AAO-HNS clinical consensus statement on pediatric chronic rhinosinusitis supports this order:

1. Daily saline irrigation and a nasal steroid spray. Both are useful adjuncts. Several nasal steroid sprays are labeled for children as young as 2; your child’s doctor will recommend which one and how to use it. Aim the spray toward the outer wall of the nose, away from the center.
2. A longer course of antibiotics for a flare, sometimes guided by a culture taken in the office.
3. Adenoidectomy. The adenoids sit at the back of the nose, right where the sinuses drain, and can act as a reservoir for bacteria. The consensus statement supports adenoidectomy as an appropriate first surgery for children up to age 12, with the strongest agreement for children under 6. It is a short outpatient procedure, and I often combine it with a sinus rinse and culture under the same anesthetic. You can read more in The ABCs of Adenoids.
4. Endoscopic sinus surgery. For children who still have significant disease after medical treatment and adenoidectomy, endoscopic sinus surgery opens the natural drainage pathways using small cameras through the nostrils, with no external incisions. The consensus panel found it safe and effective in this setting and found no convincing evidence that it impairs facial growth, which is a common worry for parents.

When surgery is recommended, I perform outpatient procedures at Stonebridge Surgery Center, which is my primary surgical venue for children who are good candidates for an outpatient setting.

Looking for an underlying cause

A child with chronic or frequently recurring sinusitis deserves a look for contributing conditions, because treating them changes the long-term course:

• Allergies: allergy testing identifies triggers that can be avoided or treated, including with allergy immunotherapy.
• Enlarged adenoids: a common driver in younger children.
• Nasal polyps: uncommon in otherwise healthy children. A child with polyps should be evaluated for cystic fibrosis. Learn more about nasal polyps.
• Immune problems: blood tests can check antibody levels and responses to vaccines in children with repeated infections in several places.
• Rarer conditions: such as primary ciliary dyskinesia, which affects the tiny hairs that sweep mucus, often with a wet cough since infancy.

From my research and practice

Pediatric sinus disease has been part of my academic work for most of my career. In 2006, Dr. Eric Mair and I published Pediatric Functional Endoscopic Sinus Surgery: Frequently Asked Questions in the Annals of Otology, Rhinology & Laryngology, a review written to answer the questions parents and referring physicians ask most about sinus surgery in children: who needs it, when it is safe, and what to expect. Earlier laboratory work I co-authored studied corticosteroids in experimental sinusitis (2000) and the effect of xylitol on bacterial killing in the sinus (2004). Those were animal studies, so they do not on their own prove what works in children, but they shaped how I think about inflammation and mucus clearance in the sinuses. The full list is on my publications and research page.

What 20-plus years of practice has taught me is that the best sinus care for children is usually conservative: confirm the diagnosis by its pattern, use antibiotics when the evidence supports them, and when problems keep returning, look for the reason rather than prescribing the next course.

Frequently asked questions

Does green or yellow mucus mean my child needs an antibiotic?

No. Mucus often turns thick and colored partway through an ordinary viral cold. Color alone does not distinguish a viral infection from a bacterial one. Duration and pattern matter much more.

Can a toddler get a sinus infection?

Yes. The maxillary and ethmoid sinuses are present from birth, so even young children can develop sinusitis. In toddlers it usually looks like a runny nose and daytime cough that will not go away, rather than facial pain.

Does my child need a sinus X-ray or CT scan?

Not for routine sinusitis. The AAP recommends against imaging to diagnose uncomplicated sinusitis in children. CT is used when a complication is suspected or when planning surgery for chronic disease.

Will my child outgrow sinus problems?

Many do. As the immune system matures, children get fewer colds, and the adenoids shrink with age. Children whose sinus problems are driven by allergies, polyps, or another underlying condition often need ongoing treatment of that cause.

Is sinus surgery safe for children?

When it is truly needed, endoscopic sinus surgery in children is generally safe and effective. It is usually reserved for children who have not improved with medical treatment and, in younger children, adenoidectomy. Your surgeon should explain the specific benefits and risks for your child.

References

1. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262–e280. doi:10.1542/peds.2013-1071
2. Brietzke SE, Shin JJ, Choi S, et al. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014;151(4):542–553. doi:10.1177/0194599814549302
3. Cable BB, Mair EA. Pediatric functional endoscopic sinus surgery: frequently asked questions. Ann Otol Rhinol Laryngol. 2006;115(9):643–657. doi:10.1177/000348940611500901
4. Cable BB, Wassmuth Z, Mann EA, et al. The effect of corticosteroids in the treatment of experimental sinusitis. Am J Rhinol. 2000;14(4):217–222. doi:10.2500/105065800779954400
5. Brown CL, Graham SM, Cable BB, et al. Xylitol enhances bacterial killing in the rabbit maxillary sinus. Laryngoscope. 2004;114(11):2021–2024. doi:10.1097/01.mlg.0000147939.90249.47

If your child’s sinus symptoms keep returning or never quite clear, I’m happy to help sort out why. You can contact my office to schedule a visit in Frisco or at the McKinney office of ENT and Allergy Centers of Texas.