The diagnosis of sinusitis is clinical while the evaluation with X-ray is not indicated for the low sensitivity and specificity as the maxillary sinuses before the age of 6 are small and poorly pneumatized. The cavities are commonly opaque, even in healthy children, because the mucosa is physiologically thick and redundant, so as to occupy all the air space. Therefore, a dull appearance of the sinuses in a child under 6 years of age does not indicate sinusitis but is a normal appearance. The radiography could show a hydro-air level in acute sinusitis but the necessary examination technique (standing position, immobility) can be difficult to carry out in the small child, with the risk of radiogenic exposures useless for diagnosis. According to the appropriateness criteria of the ACR (American College of Radiology), the X-ray of the paranasal sinuses is never appropriate. In selected cases, based on precise clinical indications (for example if the symptoms are worsening and medical therapy is not effective or if surgery is expected to be performed), CT is the gold standard for optimal evaluation in detail. The CT sign of thickening of the mucosa alone is not sufficient for the diagnosis of chronic sinusitis but must be associated with reduced sinus volume, sclerosis and thickening of the surrounding bone. CT is also used for the differential diagnosis with tumors, but in these cases MRI is preferable for the best delimitation of the mass and the absence of ionizing radiation.

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