Elsevier

American Journal of Otolaryngology

Volume 29, Issue 6, November–December 2008, Pages 372-378
American Journal of Otolaryngology

Original contribution
Pediatric chronic rhinosinusitis: a restropective review

https://doi.org/10.1016/j.amjoto.2007.11.003Get rights and content

Abstract

Purpose

Chronic rhinosinusitis (CRS) is a major cause of morbidity in the pediatric population and a difficult entity to treat with a poorly defined pathophysiology and diagnostic criteria. Functional endoscopic sinus surgery (FESS) has proven to be effective for these patients, but concerns remain regarding its possible interference with facial growth. Recently, stepwise treatment protocols, which include maxillary sinus irrigation followed by long-term intravenous (IV) antibiotics, have been demonstrated to be effective alternatives to FESS. However, long-term IV therapy is inconvenient and not without complications. The purpose of this study is to review one institution's experience in treating medically refractory pediatric CRS, specifically to describe the epidemiology of the affected population and estimate the success of a stepped treatment protocol using long-term double oral antibiotic therapy for its treatment.

Materials and Methods

A retrospective review of the medical records of 23 patients who received treatment.

Results

Mean age was 2.3 years. Clinical resolution was achieved in 96% of patients and in 78% without the use of IV antibiotics. Four patients who required IV antibiotics subsequently tested positive for immune deficiency. Long-term resolution rate was 78% overall and 86% for those that did not require IV antibiotics. No complications were reported, and no patients required FESS.

Conclusions

A stepwise protocol that includes concurrent adenoidectomy and bilateral maxillary sinus irrigation followed by long-term double oral antibiotic therapy is safe and effective for the treatment of pediatric CRS. Patients with immunodeficiency may require long-term IV therapy to achieve symptom resolution.

Introduction

Chronic rhinosinusitis (CRS), defined as an inflammatory process involving the paranasal sinuses for at least 3 months, is a major cause of morbidity in the pediatric population [1]. Although it is difficult to estimate the incidence of pediatric CRS, 5–10% of children with upper respiratory tract infections will go on to develop acute rhinosinusitis with a subset of these progressing on to chronic disease [2].

The diagnosis of CRS remains largely a clinical one. Although symptoms in children lack specificity rhinorrhea, nasal congestion and obstruction, chronic cough, purulent nasal discharge, and post nasal drip are often seen.

The etiology of CRS remains poorly defined but is thought to be multifactorial and may include defects in the mucociliary clearance system, immunologic incompetence, allergy, environmental or social factors, gastroesophageal reflux disease and chronic bacterial infection. Recently, biofilms have been implicated as a nidus for chronic bacterial infection in children with CRS [3], [4], [5].

Multidisciplinary task forces have been created to better define the epidemiology, pathology, diagnosis and treatment of CRS in adults [6], [7]. Pediatric CRS, however, is likely distinct from that in the adult, and it is unclear how and if the recommendations for the adult population apply to children.

The cornerstone of treatment for children with CRS remains aggressive antibiotic therapy, but many patients fail to improve even after extended courses of broad-spectrum oral therapy. Although functional endoscopic sinus surgery (FESS) has been shown to be effective in such patients, [8] concerns exist regarding its effects on facial skeletal development [9], [10], [11]. Recently, 2 separate studies have shown that a stepwise treatment protocol utilizing aggressive intravenous (IV) antibiotic therapy after maxillary sinus irrigation is effective for achieving long-term amelioration of CRS symptoms in the pediatric population [12], [13]. However, administration of IV antibiotics is inconvenient and not without complications. Adenoidectomy has also been described as an effective treatment for CRS. One study reported a 58% success rate in eradication of symptoms [14].

We describe the epidemiology of and review our recent experience in managing a series of pediatric patients with CRS and propose a stepped protocol for treating this difficult entity using broad-spectrum double oral antibiotic therapy after maxillary sinus irrigation and adenoidectomy and reserving IV antibiotics for those that do not resolve.

Section snippets

Materials and methods

This study is a retrospective review of the medical records of 23 pediatric patients with a clinical diagnosis of CRS at Wayne State University who underwent concurrent adenoidectomy and bilateral maxillary sinus irrigation followed immediately by a long-term course of broad-spectrum oral antibiotics. The procedures took place between January 1, 2004, and June 30, 2006. Approval from the institutional review board at Wayne State University was obtained before proceeding with the study.

All

Results

This study compared 23 patients: 16 boys and 7 girls, mean age of 2.3 years, with a range from 6 months to 6 years. The duration of symptoms was greater than 3 months in all patients. For those with specific data available, the mean duration of symptoms was 11.5 months, ranging from 3 to 24 months.

Regarding medical history, 9 patients (39%) had reactive airway disease; 3 (13%), anemia; 3 (13%), pneumonia; 2 (9%), neonatal jaundice; 1 (4%), scarlet fever; and 1 (4%), glucose-6–phospate

Discussion

Chronic rhinosinusitis has a severe impact on the health-related quality of life in the pediatric population [1] and is a challenging entity to treat for physicians. Poorly defined pathophysiology, epidemiology, and diagnostic criteria contribute to this challenge. Although the mainstay of treatment is oral antibiotic therapy, a large number of patients prove to be refractory to even long courses of broad-spectrum therapy. This has led to the exploration of alternative effective treatments such

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