Management Of Pediatric Chronic Rhinosinusitis Research Articles

Pediatric chronic rhinosinusitis.

An up-to-date overview of diagnosis, differential diagnosis, comorbidities, and current medical and surgical management of pediatric chronic rhinosinusitis (PCRS). Review of current evidence-based literature on PCRS. Diagnosis of PCRS seems to be improving based on recent evidence using nasal endoscopy as well as computed tomography scanning. Recent literature supports the fact that chronic adenoiditis can be an independent etiology of symptoms of chronic sinusitis, that are very similar to chronic adenoiditis. Allergic rhinitis and immune deficiency play important roles in the management of PCRS. Surgery for PCRS has evolved significantly in the last 15-20 years to include adenoidectomy as well as endoscopic sinus surgery. PCRS is very common in children causing poor QOL for these children. Medical management remains the main stay of treatment with attention to management of co-morbidities that may contribute to the disease severity. Making the correct diagnosis will help with the choice of surgical intervention if medical management fails.

Working towards consensus in the management of pediatric chronic rhinosinusitis in cystic fibrosis

ObjectiveThe prevalence of chronic rhinosinusitis (CRS), defined by mucosal thickening on imaging, approaches 100% in the cystic fibrosis (CF) population. CRS is associated with significant morbidity in CF, including its ability to trigger pulmonary exacerbations. CRS in CF is typically managed by pediatricians, otolaryngologists and pulmonologists. This survey evaluates the variance in practice patterns of CRS in CF amongst specialists. MethodsThis is a cross-sectional, electronic survey in which maximum variation purposive sampling was used by a multi-disciplinary group of pediatric, otolaryngology and pulmonology providers in order to select a survey population with expertise in CRS in CF patients. The survey was distributed to 381 practitioners from September to October 2019. Results175 participants responded (45% response rate). Ten (of 54) statements achieved 75% consensus agreement. Consensus statements included: The decision to pursue surgical intervention for CRS in CF is a multi-disciplinary approach (94%; n = 146); maximal medical management should include nasal saline irrigation (93%; n = 142), topical steroids (75%; n = 117), maximal medical management should not include intravenous steroids (79%; n = 122); image guidance in surgery is necessary for all surgery involving the frontal sinuses (77%; n = 43), and all revision surgery(80%, n = 45); the appropriate setting for sinus surgery in a CF patient varies depending on patient presentation (89%; n = 133); post-operative regimen should include nasal saline (93%; n = 137); but does depend on the severity of disease discovered intra-operatively (84%; n = 124); post-operative antibiotics should be guided by intra-operative culture data (82%; n = 121). ConclusionsThere is a great deal of variation amongst specialists in the treatment of CRS in CF, however 10 statements met consensus criteria and should be considered when forming clinical care guidelines in this population.

Balloon Catheter Dilation in Pediatric Chronic Rhinosinusitis: A Meta-analysis.

Paranasal sinus balloon catheter dilation (BCD) represents a tool that has been shown to be safe in the management of pediatric chronic rhinosinusitis (pCRS); however, its efficacy compared to standard treatment regimens has not been well established. The purpose of this meta-analysis was to evaluate the clinical utility of BCD in pCRS. Articles reporting BCD for pCRS in patients under 18 years of age were identified via the following search terms: sinusitis OR rhinosinusitis AND balloon dilatation OR balloon dilation OR balloon sinuplasty OR sinuplasty AND adolescent OR children OR infant OR pediatric OR toddler. The primary outcome analyzed includes quality of life improvement as measured via Sinus and Nasal Quality of Life Survey (SN-5) or Sino-nasal Outcome Test (SNOT-22) scores. Eighty studies were abstracted; 10 studies were included for final qualitative analysis after dual investigator screening. Three studies described BCD with surgical controls, including adenoidectomy, saline irrigation, or maxillary antrostomy. Noninferiority was not demonstrated (ie, BCD is inferior) in 2 of 3 studies. Pooled analysis utilizing a random effects model revealed a decreased effect size yet no statistically significant difference between BCD and standard operative techniques as measured by quality of life measures (g = -0.04, I2 = 41%). This work highlights a lack of published evidence regarding the role of BCD in pCRS. Two of the 3 included studies demonstrated the inferiority of BCD when compared to other standard surgical interventions, whereas meta-analysis was unable to detect any statistically significant difference between standard treatment regimens. Future scientific investigations are necessary to assess the comparative effectiveness of BCD in pCRS.

Chronic Rhinosinusitis in Pediatric Immunodeficiency

Chronic rhinosinusitis and other sinopulmonary infections can be a hallmark of impaired immunity in children. Rhinosinusitis in the setting of immunodeficiency can often be chronic and refractory, and involve opportunistic pathogens. We review the evaluation and management of pediatric chronic rhinosinusitis in the context of primary immunodeficiency diseases. Immunodeficiencies found to be associated with chronic rhinosinusitis include common variable immune deficiency, X-linked agammaglobulinemia, antibody deficiencies, hyper-IgM syndrome, hyper-IgE syndrome, Wiskott–Aldrich syndrome, activated PI3K disease, DiGeorge syndrome, and chronic granulomatous disease. Chronic rhinosinusitis in children may be a clinical manifestation of immunodeficiency. The evaluation and diagnosis of immunodeficiencies are essential for initiating appropriate therapeutic strategies, including antibiotics, prophylaxis, topical therapy, surgery, and immunoglobulin replacement.

Balloon Sinuplasty in Pediatric Rhinosinusitis

Balloon catheter dilation (BCD) is increasingly utilized as an adjunct to adenoidectomy or functional endoscopic sinus surgery in the surgical management of pediatric chronic rhinosinusitis (CRS). The goal of this review is to analyze existing evidence for the efficacy of BCD in treating pediatric CRS. We also assess expanded indications of BCD such as acute complications of sinusitis or surgery for critically ill patients. Pearls and pitfalls of the technique are discussed. BCD shows potential as an effective adjuvant procedure in addition to adenoidectomy and as a stand-alone procedure. Multiple studies have shown its safety; however, studies on efficacy have been limited by lack of randomized control. BCD is safe and an important addition to the surgical treatment of selected pediatric CRS. Further randomized controlled studies are necessary to clearly define the efficacy of BCD as an adjuvant or stand-alone procedure in the management of pediatric CRS and to investigate expanded indications.

Chronic Rhinosinusitis in Children

Pediatric chronic rhinosinusitis (CRS) is a common condition that is often misdiagnosed and can be challenging to treat. This review aims to 1) Review definitions, presentation, complications, and management of CRS in children. 2) Highlight the paucity of evidence in the management of pediatric CRS. There are few studies supporting the usual recommended medical therapy for pediatric CRS (antibiotics, nasal saline irrigations, intranasal steroid). Adenoidectomy remains a mainstay of surgical treatment, but recent evidence demonstrates the utility of balloon sinuplasty and functional endoscopic sinus surgery (FESS) for patients who fail adenoidectomy alone. Pediatric CRS is distinct from ARS and adult CRS. It is a common problem that is poorly studied, in part because of significant symptomatic overlap with related conditions. Recent evidence supports the use of surgical treatment in children who fail medical management. However, further outcome studies are needed to better evaluate the effectiveness of current medical and surgical management protocols.

An Overview of Surgical Approaches to Pediatric Chronic Sinusitis for Primary Care Providers

Pediatric chronic rhinosinusitis is a common condition amongst pediatric patients. Despite its prevalence, debate continues regarding the best treatment strategies. The current paper examines the literature as it pertains to the surgical management of pediatric chronic rhinosinusitis. Adenoidectomy remains the mainstay in the initial surgical management. Both maxillary sinus irrigation and balloon dilation of the sinuses have been studied with disagreement as to the timing and patient selection for those procedures. Functional endoscopic sinus surgery is an accepted treatment modality, especially in initial surgical failures. Further studies will be needed to better delineate patient selection and timing of specific surgical techniques.

Diagnosis and management of pediatric sinusitis: A survey of primary care, otolaryngology and urgent care providers

ObjectivesThe aims of this project were two-fold: 1) To assess pediatric primary care (PCP), pediatric otolaryngology (ENT) and pediatric urgent care (UC) providers' perception of their adherence to the 2013 American Academy of Pediatrics (AAP) established guidelines for the diagnosis and management of acute bacterial rhinosinusitis (ABRS) in children 1–18 years old and 2) to assess the same providers' practice patterns in the diagnosis and management of pediatric chronic rhinosinusitis (PCRS). MethodA 21-item questionnaire (CVI .9) was designed by th investigators using Survey Monkey®. The survey was emailed to pediatric providers (including physicians and advanced practice providers) in a Midwestern USA healthcare system (94 PCP, 25 UC, 19 ENT providers) from 20 pediatric primary care practices, 1 pediatric UC practice and 1 pediatric otolaryngology practice. ResultsDiagnosis: The following diagnostic criteria are utilized: persistent nasal congestion/cough lasting >10 days (95%), worsening of classic viral URI symptoms at days 5–7 (70%), severe onset and purulent nasal discharge for at least 3 consecutive days (45%). ENT will most commonly culture their patients. ENT providers (57%) approve of a nasal culture being obtained by PCPs. Management: Typically used antibiotics: amoxicillin (72%), Amoxicillin-clavulanic acid (98%), cefdinir (73%), azithromycin (15%). ENT providers will also use clarithromycin and Bactrim more often compared to PCPs. For PCN allergy patients, most providers choose cefdinir. Typical length of antibiotic therapy for providers is 10 days (70%) and 14 days (17%); ENT (21%) prescribes 7 days past any symptom compared to PCP (6%) and UC (5%). Use of adjuvant therapy is variable among the groups. ConclusionThis quality initiative project demonstrates that providers' diagnosis of ABRS is consistent with the 2013 AAP guidelines while variation in clinical management exists for both ABRS and PCRS. This survey demonstrates the need to educate all providers on the current 2013 AAP guidelines and define practice across all settings.

Practice patterns in pediatric chronic rhinosinusitis: A survey of the American Rhinologic Society.

The management of pediatric chronic rhinosinusitis (PCRS) is evolving. To assess current practice patterns of members of the American Rhinologic Society (ARS) in managing PCRS. A 27-item Web-based survey on treatment of PCRS was electronically distributed to the ARS membership. The survey was completed by 67 members, 40% of whom had completed a rhinology fellowship. The most frequently used medical therapies as part of initial treatment for PCRS were nasal saline solution irrigation, (90%), topical nasal steroids (93%), oral antibiotics (52%), and oral steroids (20%). For initial surgical therapy, 90% performed adenoidectomy; in addition, 31% also performed sinus lavage, 17% performed balloon catheter dilation (BCD), and 17% performed endoscopic sinus surgery (ESS). Sixty percent performed adenoidectomy before obtaining computed tomography imaging. When initial surgical treatment failed, 85% performed traditional ESS. In patients with pansinusitis, 50% of the respondents performed frontal sinusotomy and 70% performed sphenoidotomy. BCD was not frequently used; overall, 66% never or rarely used it, 20% sometimes used it, 12% usually used it, and 3% always or almost always used BCD. Most aspects of PCRS management among ARS members were aligned with published consensus statements. Adenoidectomy was almost always included as part of first-line surgical treatment but was also combined with adjunctive surgical procedures with moderate frequency. ESS was performed by a minority of rhinologists as a primary procedure for medically refractory PCRS but was favored when previous surgery failed. BCD was uncommonly used in PCRS.

Pediatric chronic rhinosinusitis

The timing and role of surgery in the management of pediatric chronic rhinosinusitis (pCRS) remains unclear. This review attempts to summarize the existing literature regarding this topic. pCRS is a complex clinical syndrome that results from multiple potential causes. Multimodal medical therapy is the accepted primary treatment. Adenoidectomy continues to be the appropriate first-line surgical therapy, and the addition of antral lavage or balloon dilation to this procedure may improve outcomes. Functional endoscopic sinus surgery (FESS) in children is safe and effective in relieving symptoms in the majority of patients. Failure to respond to maximal medical therapy continues to be a commonly cited, although poorly defined, requisite for proceeding to surgery. Recent literature has been focused on the outcomes after FESS rather than specifically defining when this intervention should be considered. Nevertheless, the literature seems to continue to support FESS in children with persistent symptoms despite adenoidectomy and appropriate medical treatment for pCRS. As the symptoms of chronic rhinosinusitis (CRS) may result from multiple underlying causes, clinicians must understand that the role and timing of surgery may vary with particular patients' disease. Surgical management of CRS in children continues to be a frequent topic of study in the otolaryngology literature. As recent research tends to be focused on outcomes after surgery, further prospective studies comparing surgical versus nonsurgical treatment of CRS will likely be required to better define indications for proceeding to surgery at all.