Practice Guidelines and Clinical Consensus on Pediatric Sinusitis

Educational Objectives

The goal of this lecture is to improve diagnosis and treatment of rhinologic disorders. After hearing and assimilating this lecture, the clinician will be better able to:

1. Review the guidelines for medical and surgical management of pediatric chronic rhinosinusitis.

Summary

Overview: pediatric chronic rhinosinusitis (pCRS) associated with large expenditures; <10% of children have symptoms for >10 days; 5% to 13% of children with VRS progress to ABRS

Definitions: ABRS — signs include acute fever (>102°F for 3 days), symptoms for >10 days, and worsening of upper respiratory infection after initial improvement; RARS — characterized by 3 infections in 6 mo lasting <30 days and separated by intervals of 10 days; CRS — characterized by >90 days of ≥2 symptoms, including purulent rhinorrhea, nasal obstruction, facial pressure or pain, or cough, with corresponding findings on endoscopy or CT

Pathophysiology: inflammation of mucosa results in closure of ostia, reduced secretions and stasis, lowering of pH, injury to cilia, and consequent retention of secretions, bacterial infection, and increase in mucosal inflammation

Clinical Consensus Statements

Basis: review of literature, conferences, and surveys; management of pCRS differs by age group (≤12 yr of age vs ≥13 yr of age)

Comorbidities: consensus states that allergic rhinitis (AR) important part of pCRS; adenoiditis contributes to pCRS; adenoids of any size may serve as bacterial reservoir for pCRS; children improve after undergoing adenoidectomy for CRS, regardless of size of adenoids

Medical management: daily topical INS and daily nasal irrigation beneficial; study — included 61 children with mean age of 8 yr; although only 28% of parents anticipated that child would tolerate saline irrigation, 86% of children able to do so; symptoms improved in 84%, and 77% continued treatment; study — 6 wk of saline alone for CRS compared with saline plus gentamicin among 104 children (mean age 8 yr); 57% of children in saline group improved; findings confirmed on CT; Lund-MacKay score also improved; 20 consecutive days of antibiotic therapy associated with better clinical response than 10 days; compared with empiric therapy, culture-directed therapy may improve outcomes

Gastroesophageal reflux: no consensus reached on contribution to pCRS; data mixed and heterogeneous populations studied; sensitivity and specificity of milk scan and barium swallow low

Topical antibiotics: no consensus reached; topical saline not found superior to saline plus gentamicin

Antral irrigation: no consensus reached; many data derived from cohorts of children who had undergone adenoidectomy

Adenoidectomy: initial surgical therapy for children ≤6 yr of age; consensus less strong for children 6 to 12 yr of age; not first-line surgery for children >13 yr of age; tonsillectomy ineffective; biofilm found at adenoidectomy in 95% of children with CRS vs 1.9% of children undergoing adenoidectomy for obstructive symptoms; cultures from adenoids and middle meatus similar; >50% of 84 children with CRS had drug-resistant bacteria on adenoids; antibiotics improved quality of life (QOL) in 75% of children; in meta-analysis, 69% of studies showed that adenoidectomy for pCRS improves outcomes

Endoscopic sinus surgery: effective when medical management or adenoidectomy inadequate; evidence that surgery associated with impaired facial growth lacking; postoperative debridement not required; QOL improved in children undergoing endoscopic sinus surgery (ESS), based on scores on Sino-Nasal 5; in prospective nonrandomized study, ESS associated with improvement in 75% of children and low rates of revisions and complications; European Position Paper on Rhinosinusitis and Nasal Polyps reported good outcomes in 89% of children 3.7 yr after ESS; panel did not reach consensus on efficacy of balloon sinuplasty

Turbinoplasty: no consensus reached on indications, potential benefits, optimal candidates, or efficacy of procedure; near-consensus reached on value of reducing or removing concha bullosa of obstructive middle turbinate as component of surgical management of pCRS

Imaging: use of CT should be minimized in children

Readings

Brietzke SE et al: Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg 2014 Oct;151(4):542-53; Fokkens WJ et al: European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Available at: www.southernstatesrhinology.org/files/2013_SpeakerTalks/EPOSpocketguide2012.pdf. Accessed August 24, 2015; Lee D and Rosenfeld RM: Adenoid bacteriology and sinonasal symptoms in children. Otolaryngol Head Neck Surg 1997 Mar;116(3):301-7; Pham V et al: Long-term outcome of once daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis. Laryngoscope 2014 Apr;124(4):1000-7; Rosenfeld R: Pilot study of outcomes in pediatric rhinosinusitis. Arch Otolaryngol Head Neck Surg 1995 Jul;121(7):729-36; Rudnick EF and Mitchell RB: Long-term improvements in quality-of-life after surgical therapy for pediatric sinonasal disease. Otolaryngol Head Neck Surg 2007 Dec;137(6):873-7; Wald ER et al: Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics 2013 Jul;132(1):e262-80.

Disclosures

For this lecture, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Chun was recorded at Best Evidence ENT 2015, presented by Medical College of Wisconsin, and held on July 25-28, 2015, in Kohler, WI. For information about upcoming CME conferences from the Medical College of Wisconsin, please visit ocpe.mcw.edu. The Audio Digest Foundation thanks the speakers and Medical College of Wisconsin for their cooperation in the production of this lecture.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT482002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.