Indications for Referral for Pediatric Rhinosinusitis

Abstract

Rhinosinusitis in children is defined as inflammation of the nose and paranasal sinuses (Fokkens et al. Rhinology. 2012;50:1–12). Pediatric chronic rhinosinusitis (CRS) is relatively uncommon compared to acute rhinosinusitis (ARS) and is characterized by sinus symptoms lasting over 12 weeks despite medical therapy. Pathogenesis of this disease is multifactorial and generally involves an initial insult (usually a viral sinusitis) followed by bacterial seeding and mucosal inflammation. The diagnosis of chronic rhinosinusitis in the pediatric population can be challenging as symptoms can be very similar to common conditions such as allergic rhinitis or adenoiditis. In many cases, objective findings such as inflammation seen on nasal endoscopy or sinus CT scans are necessary to confirm the diagnosis of CRS. The mainstay of treatment of pediatric CRS is medical therapy with surgical therapy reserved for the minority of patients. Standard medical therapy usually includes a combination of nasal corticosteroid sprays, nasal irrigation, and decongestants. Antibiotics are usually reserved for bacterial acute exacerbations of CRS and usually target the most common offending pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis). Referral to an otolaryngologist is recommended for children who fail medical therapy, have orbital complications of sinusitis, or require surgery. There are currently many alternate medical treatment options available to physicians; however, data supporting their efficacy is lacking in many cases. Recent studies show that even minimally invasive surgical procedures, such as adenoidectomy and/or balloon sinuplasty can lead to significant symptom improvement. Further, traditional endoscopic sinus surgery offers a safe, highly effective treatment option when necessary.