| Abstract: |
Background: Pediatric chronic sinusitis is a complex disease whose natural history and pathogenesis are poorly understood. Primarily because of its multifactorial etiology, management of chronic sinusitis in children is complicated, and there is uncertainty about the best method of treatment. Most otolaryngologists who treat pediatric chronic sinusitis agree that a prolonged course of a broad-spectrum, beta-lactamase stable oral antibiotic is the cornerstone of medical therapy. Additional measures, such as topical and systemic steroid therapy, systemic antihistamine and decongestant use, nasal irrigations, and immunotherapy, may also be beneficial. All sinusitis cases are treated without suppurative complications with medical therapy. If maximum medical therapy is unsuccessful in a child with chronic or recurrent sinusitis, evaluation for underlying medical disorders (e.g. immunodeficiency, allergic rhinitis, Cystic Fibrosis ”CF” and immotile cilia syndrome) is warranted. If chronic sinus infections continue following treatment for an associated condition, consider surgery. A CT scan of the paranasal sinuses is performed. This imaging study allows us to determine the presence or absence of sinus disease and to assess adenoid size. The CT scan also permits an identification of any significant anatomic abnormalities. Several surgical options are available for the treatment of chronic sinusitis in children. Endoscopic sinus surgery has been most widely used for the treatment of refractory sinusitis in children. The reported success rates for pediatric ESS range from 80% to 93%. Despite its apparent benefits, pediatric ESS carries serious risks and, because of the smaller anatomy, requires greater technical skill and more meticulous surgery than in adults. Based on the findings in CT scan, IV antibiotic therapy with selective adenoidectomy is offered to appropriate patients as an alternative to ESS. In the event that patients fail to respond to the IV antibiotics, they subsequently undergo ESS. Pediatric FESS has been shown to provide effective treatment for children with chronic sinus disease refractory to maximum medical therapy with success rates from 80-93%. In patients with polyposis, especially associated with CF, recurrence instead of cure is the norm. In patients with CF and polyposis, resolution of preoperative symptoms occurs in 40-70% of cases. Recurrence rates are over 50%. For patients with AFS, decreased recurrence rates, which are quoted to be 10-100%, have been observed with immunotherapy. The main controversy is over whether or not any child should have sinus surgery because most rhinologists believe that the problem basically is a medical condition. Children have maturation of their immune system from birth to age 6-8 years. Over this time, if they are exposed to pathogens repeatedly, they are likely to have recurrent or chronic infections of the upper respiratory tract.Objectives: Trends in the management of pediatric chronic sinusitis.
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