Chronic Rhinosinusitis
David A. Gudis, MD
As this special issue of Down Syndrome Amongst Us magazine makes clear, people with Down syndrome may develop several ear, nose, and throat (Otolaryngology) issues over the course of their lives, both as children and adults. Several factors, including the development of facial anatomy and the immune system, may predispose people with Down syndrome to these problems.
In people with Down syndrome, the bones of the “midface” may be underdeveloped and small, leading to malformation of the Eustachian tube, resulting in increased number of ear infections and even hearing loss. Patients may also have a smaller palate, larger tongue, narrowing of the throat, and lower muscle tone, all of which can combine to increase the risk of sleep apnea (airway obstruction while sleeping). Lastly, changes in the development of the face and the mucus membranes can result in increased risk of chronic rhinosinusitis (CRS).
CRS is a chronic inflammatory condition in the nasal cavity and sinuses. The nasal cavity extends straight back from the front of the nose to the throat, and the sinuses are air-filled cavities within the bones of the face and skull. There are four pairs of sinuses: the frontal sinuses (in the forehead), the ethmoid sinuses (between the eyes), the maxillary sinuses (in the cheeks), and the sphenoid sinuses (all the way in the back).
Several things can result in inflammation inside the nose and sinuses, causing rhinosinusitis. Sometimes a regular cold, or a viral upper respiratory infection, can result in rhinosinusitis. Other times, allergies can cause similar effects. Lastly, bacterial infections, which may develop after and as a result of a viral upper respiratory infection, can also cause inflammation in the nose and sinuses. Rhinosinusitis will typically cause symptoms including nasal congestion and stuffiness, increased thick nasal discharge, feelings of pressure, fullness, or pain around the sinuses, postnasal drip, cough, and reduced sense of smell. When the nasal cavity and sinuses develop inflammation resulting in these symptoms lasting for three months or longer, CRS should be considered. Contrary to popular belief, the color of nasal discharge (green, yellow, etc.) does NOT indicate that a child needs antibiotics. Viruses can also result in green or yellow nasal discharge, and antibiotics are effectively only against bacteria (not viruses).
Many children both with or without Down syndrome have enlarged adenoids. The adenoids are very similar to tonsils, but they sit in the back of the nose instead of the back of the throat. When the adenoids are enlarged (adenoid hypertrophy) or chronically infected (chronic adenoiditis), children may develop symptoms very similar to those with CRS. It can be very challenging to distinguish pediatric CRS from adenoid problems, but the initial treatments are generally the same regardless.
Children with Down syndrome are more likely to develop nasal and sinus problems than other children for a few important reasons. First, the nose and sinuses are smaller, and therefore a small amount of inflammation and swelling may result in more significant obstruction – there is less “wiggle room” to begin with. Second, the adenoids are more likely to cause obstruction of the back of the nose when the spaces are anatomically smaller. And third, people with Down syndrome are more likely to have abnormalities of the immune system that make them more susceptible to infections.
Common helpful treatments for people with Down syndrome who develop nasal or sinus problems could include nasal saline spray, neti pots saline rinse, and prescription medications from a pediatrician or ENT doctor like nasal steroid sprays (for example, fluticasone/Flonase) or antibiotics. When CRS is significantly impacting a child’s quality of life, it can be very helpful to see an ENT specialist to consider other treatment options. Fortunately, there are lots of great treatments for these problems so that these great kids can get back to running around and playing outside!
Dr. David A. Gudis MD – Chief, Rhinology & Anterior Skull Base Surgery
Dept of Otolaryngology – Head & Neck Surgery
Columbia University Irving Medical Center