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Dr. A. Clark
Dr. A. Clark, Pediatrician
Category: Pediatrics
Satisfied Customers: 4437
Experience:  33 years of experience as a general pediatrician in private practice and in pediatric urgent care.
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How do you diagnose a sinus infection using an otoscope?

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How do you diagnose a sinus infection using an otoscope? What does it look like? Our 3yo has had 3 different antibiotics over 30 days to treat a diagnosed sinus infection, including zithromax (5 days), augmentin (taken only 3 days), then 10 days of Bactrim. However, he is still coughing and has nasal symptoms. He is having nosebleeds, is frequently picking his nose and complaining about "boogers". We purchased an otoscope to see for ourselves. His sinuses look slighly inflamed, with spotty areas of blood and some areas that look slightly swollen with a white color. He also has thick secretions (boogers) that are somewhat green and bloody. We are trying to figure out if he still has a sinus infection after the antibiotic treatment and are concerned that his condition has been misdiagnosed.
First of all, you can't see the sinuses with any otoscope as they are cavities connected to the nasopharynx by small openings and are located on either side of the nose under the eyes and just above the nose on the forehead, as well as just behind the nose - all hidden by bone and tissue. What you can see is pus and mucous in the nose but that does not make the diagnosis of a sinus infection. The only accurate method of seeing the sinuses is with a limited CT scan of them but that is not done very often as it may require sedation and is expensive. Thus we make the diagnosis every day based on the history of chronic purulent (pus) nasal discharge with fever and cough.

As to the antibiotics, sinuses have a pretty poor blood supply and therefore require either potent antibiotics like Augmentin and Omnicef, or sometime it can be treated by prolonged courses of less potent antibiotics like amoxicillin. Unfortunately, Bactrim and zithromax have a somewhat limited spectrum of bacteria they kill and/or poor tissue penetration so I would not expect him to get well on either of those antibiotics. Rocephin is used for severe ear infections with a 3 day course and perhaps a sinus infection might be helped but probably it would take many days, again because of the poor blood supply (how the antibiotics get to the sinuses). I have seen lots of kids get a PIC line (indwelling IV catheter in the arm) to receive daily infusions of Rocephin for 2-3 weeks in cases where the sinusitis is not clearing, but usually only after a CT scan demonstrates chronic sinusitis.

You might want an ENT specialist to take a look at him in light of what you have said here and my response.
Customer: replied 7 years ago.
Thank you for the reply and the helpful information. I see I was confused about sinuses vs nasal passages or nostrils. Since you didn't mention the nose bleeding, I would like to know if this could be a symptom of continued infection? It is not really a nose bleed but rather bloody areas in the nostrils and we are wondering if possibly this could be caused by infection or possibly just dryness or maybe irritation from picking the nose. You also referred to pus. What would that look like? Could the white "swollen" area possibly be pus?
Nosebleeds are common in kids anyway, especially when it is cold and the heat is on inside as the air dries out the nasal passages. Bloody mucous is sometimes a sign of sinusitis so it is significant. The difference between pus and mucous is that pus is yellow while mucous is green and allergy drainage can even be clear and watery. Of course, pus can be caused by viruses too. The swollen area is just congestion I suspect.
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Customer: replied 7 years ago.
Thank you for the help! I am so glad to find justanswer and will probably be asking you more questions. I will leave a positive feedback as soon as I figured out how to go back to the feedback screen as I missed it the first time.
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