Chronic sinusitis among pediatric patients with chronic respiratory complaints

Pediatric chronic sinusitis: diagnosis and management

PURPOSE OF REVIEW

Review the diagnosis and management of pediatric chronic sinusitis given recent advances in both surgical and medical management.

RECENT FINDINGS

Balloon catheter dilation (BCD) of the sinuses has been used as an adjunct to adenoidectomy or in lieu of traditional endoscopic sinus surgery. BCD has been shown to be a safe technique in children although its efficacy compared to maxillary sinus irrigation or traditional sinus surgery cannot be determined based on current studies.

SUMMARY

New advances in BCD and biologics may serve as useful adjuncts in surgical and medical therapy respectively with additional research needed to better delineate the optimal indications for each in the treatment continuum.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Evolution of sinonasal clinical features in children with cystic fibrosis

OBJECTIVE

to assess the evolution of sinonasal manifestations in children with cystic fibrosis, since the improvement of their prognosis over the last decades.

METHODS

an observational, monocentric study with a retrospective cohort. We included 173 children (from 4 to 18 years old) with cystic fibrosis followed at the pediatric cystic fibrosis center of lyon, france. We collected respiratory, infectious and nutritional data, sinonasal complaints and physical examination at the onset of sinonasal symptoms (t-0), at the most severe of evolution (t-max) and at the end of followup (t-end).

RESULTS

sinonasal symptomatology appeared early around 5.4 years old, then rapidly reached the maximum at 6.9 years and finally improved during childhood (p < 0.0001), reaching scores at t-end significantly better than at t-0 (p < 0.0001). This evolution was significant for nasal obstruction, rhinorrhea and snoring. The other symptoms were rarer, with no significant 38,7% at t-max (p < 0.0001), and 29,5% at t-end (p = 0.52). The lildholdt score, turbinate hypertrophy and medial bulging of medial wall of the maxillary sinus followed the same evolution (p < 0.003). There was no association between sinonasal evolution and cystic fibrosis disease at infectious, respiratory or nutritional level.

CONCLUSION

it is the only recent study evaluating the evolution of each sinonasal manifestations in children with cystic fibrosis. Rhinosinusitis improved during childhood, reaching better scores than at the beginning of management. This particular improvement may be related to good effectiveness to ent management, but also to a positive effect of nasal cavity growth, independently to extra-ent manifestations.

Endoscopic sinus surgery for pediatric patients: Prognostic factors related to revision surgery

OBJECTIVES

In the past two decades, endoscopic sinus surgery (ESS) has been performed frequently in children with medically recalcitrant chronic rhinosinusitis (CRS). However, surgical success rates vary according to age. The causes of failure and prognostic factors for revision ESS remain unclear. The aims of the present study were to evaluate prognostic factors related to revision surgery after ESS, and to determine the most optimal timing for surgery in the pediatric population.

METHODS

This was a retrospective review in a tertiary medical center. Children who underwent ESS for CRS between 2004 and 2017 were enrolled. Demographics, sinonasal examination findings, previous operation history, laboratory data, comorbidities, and computed tomography (CT) results were collected from medical records. Prognostic factors for revision surgery were analyzed.

RESULTS

A total of 188 pediatric patients were enrolled in this study. Twenty-four patients (12.8%) required revision surgery. Multivariate logistic regression analysis identified patients with nasal allergy (OR = 6.258; P = .010) and higher Lund-Mackay score on preoperative sinus CT (OR = 1.658; P = .043) had worse outcomes, while older age was a positive prognostic factor (OR = 0.702; P = .018). A cut-off point of 15.68 years of age and mean Lund-Mackay score of 10.5 showed the best predictive power for revision surgery.

CONCLUSION

Because ESS is performed with increasing frequency in children, knowledge of prognostic factors for revision surgery is important. In this study, patients with younger age, nasal allergy, and higher Lund-Mackay score on preoperative sinus CT had worse outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1051-1055, 2020.

Multimorbidities of Pediatric Allergic Rhinitis

PURPOSE OF REVIEW

Most children and adolescents with allergic rhinitis (AR) present extra-nasal multimorbid conditions, including conjunctivitis, asthma, atopic dermatitis, rhinosinusitis, or seromucous otitis. Additionally, they may present nasal obstructive disorders, such as septal deformity, turbinate enlargement, and adenoidal hyperplasia, which worsen nasal symptoms, especially nasal obstruction. This is a narrative review on the current state of the concomitant presence of AR and one or more multimorbidities.

RECENT FINDINGS

The presence of AR and one or more accompanying multimorbidities is associated to a higher severity and duration of the disease, a negative impact on quality of life, with worse control and lack of improvement with medical treatment. Therefore, AR needs to be managed with a multidisciplinary collaborative approach. Pediatric AR needs to be considered in the context of a systemic disease, which requires a coordinated therapeutic strategy.

Chronic Rhinosinusitis in Children

Purpose of review

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.

Recent findings

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.

Summary

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.

Could seasonal allergy be a risk factor for acute rhinosinusitis in children?

OBJECTIVE

To evaluate the incidence of acute rhinosinusitis in children with grass pollen induced rhinitis during the period of grass pollinosis.

METHODS

Children with nasal symptoms from grass pollen induced rhinitis but without rhinosinusitis symptoms were selected. Their parents were asked to complete a diary during pollen exposure to report nasal symptoms and drugs used daily. When rhinosinusitis was suspected, the confirmatory diagnosis of acute rhinosinusitis was made by fibro-endoscopy. Children without inhalant allergy served as controls.

RESULTS

Seventeen out of 242 children (7.0 per cent) had a diagnosis of acute rhinosinusitis, confirmed by fibro-endoscopy, during grass pollination, compared to 3 out of 65 (4.6 per cent) in the control group (p = 0.49). Among allergic children, those with acute rhinosinusitis had symptoms for a greater number of days and/or a higher symptoms score than children without acute rhinosinusitis.

CONCLUSION

Children with grass pollen induced rhinitis during exposure to pollen have an incidence of endoscopically confirmed acute rhinosinusitis comparable to non-allergic children. This suggests that grass pollen induced rhinitis is a negligible risk factor for acute rhinosinusitis.

Association of Allergic Rhinitis and Sinusitis with Childhood Asthma

OBJECTIVE

To study the point prevalence of allergic rhinitis and sinusitis in childhood asthma and to examine the relationship among them.

METHODS

In 250 children (age <13 y) with mild-to-moderte asthma, allergic rhinitis was diagnosed by clinical plus nasal eosinophilia criteria, and sinusitis was diagnosed clinically plus confirmation by computerized tomography scan.

RESULTS

The point prevalence of allergic rhinitis was 13.6%, and of sinusitis was 2%. On multivariate analysis, allergic rhinitis, sinusitis, and family history were significantly associated with asthma severity.

CONCLUSION

Allergic rhinitis is common in childhood asthama, but sinusitis is rare.

Clinical consensus statement: pediatric chronic rhinosinusitis

OBJECTIVE

To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS).

METHODS

A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus.

RESULTS

After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty.

CONCLUSION

Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Diseases of the nose and paranasal sinuses in child

Diseases of the pediatric nose and nasal sinuses as well as neighboring anatomical structures encompass a variety of pathologies, especially of inflammatory nature. Congenital disease, such as malformations and structural deviations of the nasal septum, as well as systemic metabolic pathologies affecting the nose and sinuses, rarely require medical therapy from an Otolaryngologist. The immunological function of the mucosa and genetic factors play a role in the development of disease in the pediatric upper airway tract, especially due to the constantly changing anatomy in this growth phase. Disease description of the nose and nasal sinuses due to mid-facial growth must also take developmental age differences (infant, toddler, preschool, and school age) into account. Epidemiological examinations and evidence based studies are often lacking in the pediatric population. The wide range of inflammatory diseases of the nose and paranasal sinuses, such as the acute and chronic rhinosinusitis, the allergic rhinitis, and adenoid disease, play a role in the susceptibility of a child to infection. The susceptibility to infection depends on the pediatric age structure (infant, young child) and has yet to be well defined. The acute rhinosinusitis in children develops after a viral infection of the upper airways, also referred to as the "common cold" in the literature. It usually spontaneously heals within ten days without any medical therapy. Antibiotic therapy is prudent in complicated episodes of ARS. The antibiotic therapy is reserved for children with complications or associated disease, such as bronchial asthma and/or chronic bronchitis. A chronic rhinosinusitis is defined as the inflammatory change in the nasal mucosa and nasal sinus mucosa, in which the corresponding symptoms persist for over 12 weeks. The indication for CT-imaging of the nasal sinuses is reserved for cases of chronic rhinosinusitis that have been successfully treated with medication. A staged therapeutic concept is followed in CRS based on conservative and surgical methods. Nasal sinus surgery is considered nowadays as effective and safe in children. Based on the assumption that adenoids are a reservoir for bacteria, from which recurrent infections of the nose and nasal sinus originate, the adenoidectomy is still defined as a cleansing procedure in rhinosinusitis. 69.3% of the children had benefit from adenoidectomy. Comorbidities, such as pediatric bronchial asthma, presently play an even more important role in the therapy of rhinosinusitis; therefore, it is often wise to have the support of pediatricians. In western European countries 40% of children presently suffer from allergic rhinitis, in which pronounced nasal obstruction can cause disturbed growth in facial bones. An early therapy with SIT may prevent the development of bronchial asthma and secondary sensitization to other allergens. Therefore, SIT is recommended in treatment of allergic rhinitis whenever, if possible. The assessment of diagnostic tools is for the examiner not often possible due to the lack of evidence. Rhinosurgical approaches are often described in study reports; however, they lack the standard prospective randomized long-term study design required nowadays and can only be evaluated with caution in the literature.

Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation

The relationship between allergic rhinitis and chronic rhinosinusitis has been assessed in a number of observational and experimental studies. In this review, we attempt their synthesis and evaluation using the modified Bradford Hill guidelines for causation. Although there is no proof of causation, especially in the pediatric literature, an evaluation of underlying allergies is recommended at least as an initial measure of symptoms relief.

The role of secondhand smoke in sinusitis: a systematic review

BACKGROUND

The objective of this study was to systematically review existing literature on the association between sinusitis and secondhand smoke (SHS) exposure.

METHODS

We performed a literature search encompassing the last 25 years in PubMed, EMBASE, and Cochrane CENTRAL. Inclusion criteria included English language papers containing original human data with at least 7 subjects. Data was systematically collected on study design, patient demographics, clinical characteristics/outcomes, and level-of-evidence (Oxford Center for Evidence-Based Medicine). Quality assessment was performed using the Newcastle-Ottawa scale. Two investigators independently reviewed all manuscripts.

RESULTS

The initial search yielded 116 abstracts, of which 19 articles were included. Thirteen (68.4%) of the 19 articles showed a statistically significant association between sinusitis and SHS. Seven (36.8%) studies specifically evaluated chronic rhinosinusitis (CRS) with 5 (71.4%) CRS studies demonstrating a significant association between CRS and SHS. Seventeen articles were case-control studies (Level 3b). For characterizing sinusitis, 6 (31.6%) studies included computed tomography (CT) or endoscopy in the diagnostic criteria, with 5 of these studies following rhinosinusitis taskforce guidelines. For determining presence of SHS, all studies used questionnaires and 2 (10.5%) studies also reported serum or urine cotinine levels.

CONCLUSION

A majority of the studies (68.4%) included in this systematic review showed a significant association between sinusitis and SHS. Furthermore, 5 (83.3%) of the 6 studies with objective diagnostic criteria (CT, endoscopy) found a significant association between sinusitis and SHS. Further higher-quality studies with objective diagnosis of sinusitis and quantification of SHS exposure should be performed in the future to better evaluate the relationship between sinusitis and SHS.

Chronic rhinosinusitis and age: is the pathogenesis different?

Chronic rhinosinusitis (CRS) is a common disease with a significant impact on quality of life, which is seen across all age groups. There are differences in symptomatology, histopathology and associated diseases when comparing pediatric versus adult patients with CRS. Nasal polyposis tends to be less commonly seen in pediatric CRS compared with adults except in children with cystic fibrosis or allergic fungal rhinosinusitis. The differences in histopathology of CRS in different age groups include higher cellularity and more prominent lymphocytic infiltration in children compared with adults who tend to have a stronger eosinophilic infiltration and more prominent glandular hyperplasia. There are data supporting a stronger association of gastroesophageal reflux disease and otitis media with CRS in children compared with adults. Adenoids may play a role in pediatric, but not adult CRS. Immunodeficiencies and asthma are strongly associated with CRS in all age groups. There is a paucity of data on pathophysiology of disease on elderly CRS.

Pathophysiology, favoring factors, and associated disorders in otorhinosinusology

The pathogenesis of rhinosinusitis (RS) is related to inflammation, caused by infections in the acute form of the disease but also by other agents in the chronic forms. Cytology allows to evaluate the defensive components, such as hair cells and muciparous cells, while the presence in the nasal mucosa of eosinophils, mast cells, bacteria and/or fungal hyphae, or spores indicates the nasal pathology. The anatomic and physiologic characteristics of the otorhinosinusal system account for the frequent concomitant involvement of the different components. The pivotal pathophysiologic sites are the ostiomeatal complex, the spheno-ethmoidal recess, and the Eustachian tube. The latter is the link with acute otitis media (AOM), which is the most common disease in infants and children and has major medical, social, and economic effects. Moreover, because of the strict relationship between upper and lower airways, nasal sinus disease may contribute to asthma and sinusitis may be considered as an independent factor associated with frequent severe asthma exacerbations. Concerning the role of allergy, the available data do not permit to attribute a central role to atopy in sinusitis and thus allergy testing should not be a routine procedure, while an allergologic evaluation may be indicated in children with OM, especially when they have concomitant rhinitis.

Sinusitis and chronic cough in children

Background:

Chronic cough in children is a common problem, and sinusitis is a common etiology. The diagnosis of sinusitis is often clinical, but confirmation is thought to require a CT scan due to the difficulty of interpreting a Water’s view sinus X-ray.

Objectives:

The purposes of the study were (1) to examine the frequency of an abnormal sinus X-ray in children with a chronic cough of more than 4 weeks duration; (2) to compare the interpretation of the sinus film between allergy/pulmonary clinicians and radiologists; and (3) to correlate symptoms with X-ray results.

Methods:

A chart review of 2- to 18-year-old patients with coughing exceeding 4 weeks was performed. Data was collected for patients who had received a Water’s view sinus film as part of their evaluation. Exam, X-ray results, and clinical outcomes were categorized and statistical analyses performed.

Results:

A total of 86 patients were included. Clinicians found that 65% of the children had positive Water’s view films, compared with the radiologist’s reading of 62% (non significant). Significant associations between post-tussive emesis (P = 0.01) and purulence (P = 0.03) were noted with a positive film. Positive sinus X-ray was highly associated with all findings except wheeze when present together (P < 0.001).

Conclusion:

Sinus abnormalities on X-ray are associated with prolonged cough in 65% of children. The Water’s view sinus film is a clinically useful screening tool for clinicians in the workup of chronic cough. Certain physical findings and clinical complaints, when present concurrently, correlate with the X-ray results.

Predisposing factors associated with chronic and recurrent rhinosinusitis in childhood

Purpose

There is currently no information regarding predisposing factors for chronic and recurrent rhinosinusitis (RS), although these are considered to be multifactorial in origin, and allergic diseases contribute to their pathogenesis. We evaluated the predisposing factors that may be associated with chronic and recurrent RS.

Methods

In this prospective study, we examined patients with RS younger than 13 years of age, diagnosed with RS at six tertiary referral hospitals in Korea between October and December, 2006. Demographic and clinical data related to RS were recorded and analyzed.

Results

In total, 296 patients were recruited. Acute RS was the most frequent type: 56.4% of the patients had acute RS. The prevalences of other types of RS, in descending order, were chronic RS (18.9%), subacute RS (13.2%), and recurrent RS (11.5%). Factors associated with recurrent RS were similar to those of chronic RS. Patients with chronic and recurrent RS were significantly older than those with acute and subacute RS. The prevalences of allergic rhinitis, atopy, and asthma were significantly higher in patients with chronic and recurrent RS than those with acute and subacute RS.

Conclusions

An association between atopy and chronic/recurrent RS, compared to acute and subacute RS, suggests a possible causal link.

Pediatric chronic rhinosinusitis: a retrospective review

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.

Chronic rhinosinusitis and allergy

The role of allergic sensitization in chronic sinusitis in childhood is currently unclear, as contrasting results were reported in the studies thus far available. In fact, some surveys found prevalence of atopy up to 60% in subjects with chronic sinusitis, while other failed to confirm any association between the two conditions. The data we obtained in a cross-sectional study on a large population of children should help in better defining such issue. Among 2200 children referring for evaluation of chronic respiratory symptoms, subjects satisfying at least two of major criteria for the definition of chronic sinusitis were recruited, and underwent to allergen sensitization workup by skin prick test with common inhalant allergens and total IgE measurement. Patients were stratified according to age lower than 3 years (group 1), age between 3 and 6 years (group 2), and age above 6 years (group 3). In all, 351 children (217 boys, 134 girls, mean age 5.23+/-2.11 years, range 1.5-15 years) were available for evaluation and formed three groups (27 in group 1, 261 in group 2 and 63 in group 3). Prevalence of both sensitization to at least one inhalant allergen by skin test and of high total IgE was 29.9%, with significant difference for the former across age groups, with a value of 7.4% in group 1, 31.4% in group 2 and 33.3% in group 3 (p=0.028), but after adjusting for age, sinusitis and aeroallergen sensitization were not significantly correlated. The difference across groups for high total IgE did not reach statistical significance, with respective prevalence of 22.7%, 30.1% and 32.1%. It is possible to conclude that the prevalence of sensitization to aeroallergens in children with chronic sinusitis is comparable with that of the general paediatric population, as assessed in the Italian arm of the ISAAC study and this does not account for routine investigation for allergy in children with chronic sinusitis.

The role of sinus disease in asthma

PURPOSE OF REVIEW

Some time ago, a link between upper and lower respiratory disease was described, which gave rise to the concept of 'united airways disease'. This concept primarily refers to the well established link between allergic rhinitis and asthma, but it also covers a possible link between sinus disease and asthma (allergic or nonallergic) and other lower airway disease.

RECENT FINDINGS

The current classification of chronic rhinosinusitis (CRS) includes disease without and with nasal polyps, which are considered subgroups of CRS. Different patterns of inflammatory and regulatory cytokines (involving distinguishable T-helper lymphocyte populations) and of remodelling markers, however, were recently described to differentiate nasal polyposis from CRS, yielding two discrete entities. These patterns resemble those of lower airway diseases, such as asthma and chronic obstructive pulmonary disease, and suggest a common aetiological/pathogenetic background. Whereas the link between nasal polyps and asthma is well established (indeed, asthma improves after medical or surgical treatment of sinus disease), that between CRS and lower airway disease is not well understood. Recently, Staphylococcus aureus enterotoxins, acting as superantigens, were identified as a possible link between nasal polyps and asthma, resulting in severe disease manifestations in both upper and lower airways.

SUMMARY

The role played by sinus disease in asthma is only partially understood, largely because of deficits in the clinical classification and in basic knowledge of pathophysiological pathways. Recent research into upper airway and sinus inflammation and remodelling may reveal new perspectives and lead to a classification of sinus disease, which will facilitate appropriate clinical and epidemiological studies.

Relationship between pediatric sinusitis and middle turbinate pneumatization--ethmoidal sinus pyocele thought to be caused by middle turbinate pneumatization

OBJECTIVE

To investigate whether the presence of pediatric middle turbinate pneumatization causes narrowing of the ostiomeatal complex (OMC) and is associated with the development of paranasal sinusitis.

METHODS

CT scans of 190 nasal sides of 95 children (1-15 years old) were analyzed for the presence of middle turbinate pneumatization and mucosal thickness in the paranasal sinus.

RESULTS

Middle turbinate pneumatization was detected in nine (4.6%) of the nasal cavities. Only one of these sides was in a patient younger than 10 years of age, while the other eight sides were in patients at least 13 years old. In six of those nine sides with pneumatization, paranasal sinusitis was also found. However, the images showed that in five sides the middle turbinate pneumatization itself did not obstruct the OMC. In addition, the mean +/- standard deviation (S.D.) of the total score for the paranasal sinus opacification on the side which had the middle turbinate pneumatization was 5.67 +/- 2.95. The corresponding value for the 76 sides without pneumatization was 5.29 +/- 2.53, and the difference between these mean total scores was not statistically significant. However, in one side, the OMC was obstructed or narrowed due to the middle turbinate pneumatization, and an ethmoidal sinus pyocele formed on this side.

CONCLUSION

A causal relationship was not found between middle turbinate pneumatization and the mechanism of development of paranasal sinusitis in children. However, in the event that the OMU becomes obstructed at some time, frequent cycles of improvement and aggravation of pediatric paranasal sinusitis may occur and lead to the development of a serious condition.

[Chronic cough in childhood]

Introduction

La toux chronique de l’enfant bien que moins fréquente que les toux répétées liées aux infections virales reste un problème diagnostique parfois difficile à résoudre.

États des connaissances

La majorité des auteurs estiment que sa durée doit être supérieure à trois semaines. Peu d’études ont été consacrées au diagnostic étiologique de la toux chronique chez l’enfant mais celles-ci retrouvent les mêmes causes principales que chez l’adulte : l’asthme, les pathologies ORL (dont la sinusite), le reflux gastro-œsophagien. Chaque tranche d’âge connaît des étiologies plus spécifiques ; notamment malformatives entre 0 et 1 an, et toux psychogène chez l’adolescent.

Perspectives

Des techniques « nouvelles » comme l’étude de l’expectoration induite permettent d’affiner le diagnostic d’une toux chronique de l’enfant en tout cas après 7 ans. La découverte d’une bronchite à éosinophiles quelle soit associée ou pas à une hyperréactivité bronchique a des conséquences thérapeutiques indiscutables compte tenu de sa corticosensibilité.

Conclusions

L’exploration d’une toux chronique de l’enfant doit reposer sur un raisonnement anatomique et sur des arguments de fréquence. Le contrôle et la disparition de la toux ne seront possibles qu’avec un diagnostic précis et un traitement adapté.

Adverse effects of smoke exposure on the upper airway

OBJECTIVE

This paper reviews secondhand smoke (SHS) exposure and diseases and symptoms of the upper airway, including the sinuses. Risks to flight attendants, who were occupationally exposed until smoking was banned on all flights, are emphasised.

DATA SOURCES

A systematic database search was conducted; the US Surgeon General's reports and other major reviews were evaluated. Literature summarised by National Research Council (NRC) reports on the airline cabin environment are included.

STUDY SELECTION

A limited number of research publications on adults were identified; these are included. Many studies cited by the NRC were never published and information is taken directly from the reports.

DATA EXTRACTION

Data from observational studies of cabin crews and the general public were extracted from surveys; exposure monitoring of cabin crews is reported. Data from controlled exposure studies are included; most are challenge studies using volunteers screened for sensitivity to SHS.

DATA SYNTHESIS

Evidence shows that active and passive smoking cause upper airway diseases, including sinonasal and laryngeal cancers in adult active smokers. Experimental studies indicate that brief exposures to SHS result in nasal mucosa inflammation. However, direct evidence on sinusitis is limited.

CONCLUSIONS

Evidence does not show a strong connection between active smoking and sinusitis, and active smokers have substantial exposures to SHS. However, extrapolation of these studies to cabin crews needs to be cautious, as other environmental conditions may increase risk for upper airway disease and symptoms. Surveys of cabin crews, while flawed, consistently indicate high rates of upper airway symptoms.

Pulmonary and sinus diseases in primary humoral immunodeficiencies with chronic productive cough

AIMS

To prospectively evaluate sinopulmonary disease in 24 patients with primary humoral immunodeficiency (11 with agammaglobulinaemia, nine with isolated IgA deficiency, and two with common variable immunodeficiency) and chronic productive cough, ascertain the usefulness of chest high resolution computed tomography (HRCT) in evaluating the progression of lung disease, and test a therapeutic approach to chronic sinusitis.

METHODS

Pulmonary abnormalities were evaluated using lung function tests and HRCT (Bhalla score); chronic sinusitis was diagnosed clinically and confirmed by flexible fibreoptic endoscopy. Sixteen patients entered the three year follow up.

RESULTS

Lung function testing revealed an obstruction in four patients; chest HRCT was abnormal in 16. There was a linear relation between the Bhalla score > or =4 and the number of months with cough/year over the previous two years (clinical score), and between the difference in clinical scores during follow up and in the previous two years and the difference in Bhalla score. The pulmonary lesions did not significantly progress over a three year period. Thirteen patients had chronic sinusitis; 6/10 patients followed up were successfully treated with antibiotics plus topical therapy and two with nasal polypoid disease with endoscopic sinus surgery.

CONCLUSIONS

In patients with primary humoral immunodeficiency and chronic productive cough, HRCT is very useful in delineating the extent of lung damage. The correlation between Bhalla score and clinical findings and the favourable outcome of the disease suggests that in most patients chest HRCT should not be repeated annually as previously suggested. Medical therapy seems to be effective in many cases of chronic sinusitis.

Treatment of pediatric sinusitis

The successful management of RS in children relies on careful diagnosis, recognition of causative factors, and judicious yet adequate antibiotic usage. Refractory cases will require surgical therapy, with adenoidectomy as the first-line intervention and ESS reserved for those cases refractory to adenoidectomy. This overall approach will improve quality of life and prevent complications in children with RS.

Rhinitis (allergic and nonallergic) in an atopic pediatric referral population in the grasslands of inland South Africa

BACKGROUND

Allergic rhinitis is a common condition, which causes considerable morbidity. South African data are scarce.

OBJECTIVE

We sought to describe allergic rhinitis in atopic children in inland South Africa.

METHODS

An observational, descriptive study of rhinitis occurring in 771 new patients seen consecutively by a single observer at a referral pediatric allergy clinic (Universitas Hospital, Bloemfontein) over an 8 1/2-year period (August 1984 to March 1993) was carried out. A detailed questionnaire was used to record clinical data. Chest and sinus x-rays, skin prick testing, and radioallergosorbent test were performed, and serum immunoglobulin E levels were determined. Response to drug treatment regimens was recorded at subsequent followup visits.

RESULTS

Significant rhinitis was reported in 78.1% of patients, and mild intermittent rhinitis was reported in 21.4%. Male to female ratio was 1.6:1. Median age at onset of rhinitis symptoms was 6 months (range 0 months to 12 years), with 30.1% experiencing symptoms from birth. Rhinitis was chronic in 61.3%, although 53.5% reported seasonal variation. More children with rhinitis were born in midsummer than during other seasons, although this did not reach statistical significance (P = 0.46). Breast-feeding had no protective effect, and parental smoking and household pets were not found to be risk factors. Family history was positive for allergic rhinitis in 88% of patients. Exposure to dust, weather changes, strong odors, pets, pollens, and tobacco smoke were the most common trigger factors. Sinus x-ray findings associated poorly with clinical findings. The most common allergens identified were grass pollen, tree pollen, and cat. Oral antihistamines provided good symptomatic relief in 62.9% of patients who used them. Intranasal corticosteroids provided good relief in 78.0% of those who used them, and ketotifen provided relief in 54.4% of those who used it.

CONCLUSIONS

Rhinitis is a common manifestation of allergy in the population studied. Onset occurs early in childhood. A family history of allergy is a risk factor for the development of the condition, and grass pollen is the most common allergen involved. Special investigations are of limited value. Appropriate treatment is very effective.

Pharmacological treatments for rhinosinusitis

Acute bacterial rhinosinusitis (ABRS) is a well-recognised and common problem confronting many primary care physicians but the abuse of antibiotic therapy for viral aetiologies of ABRS has lead to widespread bacterial resistance. The once easily-eradicated pathogens have developed many mechanisms to resist antimicrobial therapies. The most common pathogens Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are still found in cultures of sinus cavities but Staphylococcus and possibly some anaerobes play an important role in the development of the chronic stage of rhinosinusitis. The choice of antibiotic therapy for both ABRS and chronic rhinosinusitis (CRS) are reviewed, along with considerations for ancillary therapy. Note is made of the role of chemical mediators in the inflammatory stage possible strategies to reduce this problem. Allergic fungal rhinosinusitis results from a hypersensitivity reaction to demetiaceous fungi. Cure of the effects of rhinosinusitis depends on the establishment of a healthy sinus cycle.

Allergen-induced murine upper airway inflammation: local and systemic changes in murine experimental allergic rhinitis

The role of inflammatory effector cells in the pathogenesis of airway allergy has been the subject of much investigation. However, whether systemic factors are involved in the development of local responses in both upper and lower airways has not been fully clarified. The present study was performed to investigate aspects of the pathogenesis of isolated allergic rhinitis in a murine model sensitized to ovalbumin (OVA). Both upper- and lower-airway physiological responsiveness and inflammatory changes were assessed, as well as bone marrow progenitor responses, by culture and immunohistological methods. Significant nasal symptoms and hyper-responsiveness appeared after intranasal OVA challenge (P < 0.0001 and P < 0.01, respectively), accompanied with significant nasal mucosal changes in CD4+ cells (P < 0.001), interleukin (IL)-4+ cells (P < 0.01), IL-5+ cells (P < 0.01), basophilic cells (P < 0.02) and eosinophils (P < 0.001), in the complete absence of hyper-responsiveness or inflammatory changes in the lower airway. In the bone marrow, there were significant increases in CD34+ cells, as well as in eosinophils and basophilic cells. In the presence in vitro of mouse recombinant IL-5, IL-3 or granulocyte-macrophage colony-stimulating factor (GM-CSF), the level of bone marrow eosinophil/basophil (Eo/Baso) colony-forming cells increased significantly in the OVA-sensitized group. We conclude that, in this murine model of allergic rhinitis, haemopoietic progenitors are upregulated, which is consistent with the involvement of bone marrow in the pathogenesis of nasal mucosal inflammation. Both local and systemic events, initiated in response to allergen provocation, may be required for the pathogenesis of allergic rhinitis. Understanding these events and their regulation could provide new therapeutic targets for rhinitis and asthma.

Paranasal sinus computed tomographic findings of children with chronic cough

OBJECTIVE

Chronic cough is a frequent problem in the practice of clinical pediatrics, and sinusitis is a common etiologic factor. In this study, our aim was to determine the prevalence of sinus abnormalities in pediatric patients presenting with chronic cough.

METHODS

Forty-two patients, ranging from 3 to 16 years of age from both sexes completed the study. Paranasal sinuses were examined by coronal paranasal sinus limited computed tomographic scan. The CT scan findings were categorized as no disease, minimal, moderate and severe sinusitis.

RESULTS

The most frequent symptoms after cough were rhinorrhea, sniffling, and halitosis. We found sinus abnormalities in 66.6% and no abnormality in 33.3% of the children. Age and sex were not important factors in sinus disease. There was no correlation between sinus findings and any of symptoms. The most common anatomical abnormalities were concha bullosa, paradoxical middle turbinate, Haller's cells, and deviated nasal septum. These abnormalities were not correlated with sinus disease.

CONCLUSION

Paranasal sinus abnormalities are common among pediatric patients with chronic cough and imaging studies of the sinuses should be considered in these children.

Nasal endoscopy in asthmatic children: assessment of rhinosinusitis and adenoiditis incidence, correlations with cytology and microbiology

BACKGROUND

Upper respiratory airway diseases may induce a worsening of asthma. Sinusitis represents one of the most common chronic diseases. The association of asthma and sinusitis varies greatly in different studies, depending on diagnostic procedures.

OBJECTIVE

The aims were: (i) to demonstrate that nasal endoscopy may be easily feasible in asthma at paediatric age; (ii) to evaluate the incidence of rhinosinusitis and adenoiditis in children with asthma by nasal endoscopy; (iii) to correlate inflammatory parameters such as cytology and microbiological cultures with nasal endoscopy findings.

SUBJECTS AND METHODS

One hundred and forty-five asthmatic children were evaluated, 48 males and 97 females, with an average age of 7.27 years. Evaluated parameters were the incidence of rhinosinusal infections in asthmatic children, and the role of: (i) nasal endoscopy, (ii) nasal cytology, and (iii) nasal microbiology in their diagnoses.

RESULTS

Nasal endoscopy was successfully performed on 128 patients. Twenty-six children had endoscopic rhinosinusitis alone, 10 had adenoiditis alone, and 35 showed endoscopic rhinosinusitis associated with adenoiditis. There were significant correlations between endoscopic rhinosinusitis and adenoiditis (P < 0.001), between clinical and endoscopic rhinosinusitis (P < 0.001), between endoscopic rhinosinusitis and adenoiditis and microbiology (P < 0.05 and P < 0.0001, respectively), and between microbiology and cytology (P < 0.05).

CONCLUSION

This study shows that rhinosinusal infections are common in asthmatic children. Moreover, nasal endoscopy might represent a fruitful tool in the management of asthmatic children.

Surgical intervention for sinusitis in children

Pediatric rhinosinusitis represents a common endpoint of many potential etiologic factors, but fixed anatomic obstruction of sinus outflow is relatively unusual in pediatric patients. Surgical therapy is considered when medical therapy for underlying mucosal inflammation fails. Adenoidectomy is usually the first surgical intervention to be considered for young children, with the goal of improving sinus drainage and eliminating a potential source of bacteria. Endoscopic sinus surgery is considered for the small percentage of patients, most commonly those with underlying pulmonary disease, who fail less aggressive treatment measures. Every decision for surgery involves a risk-benefit analysis.

A randomized controlled trial of azithromycin and amoxycillin/clavulanate in the management of subacute childhood rhinosinusitis

OBJECTIVE

Subacute childhood rhinosinusitis is a disorder commonly seen in children with allergic rhinitis. Antibiotics have been recommended as a major component of the treatment regime. The objective of the present study was to compare the effectiveness of a 3-day course of azithromycin and a 2-week course of amoxycillin/clavulanate in the treatment of subacute childhood rhinosinusitis.

METHODOLOGY

A randomized single-blinded control study of subacute rhinosinusitis was conducted, comparing a 3-day course of azithromycin and a 2-week course of amoxycillin/clavulanate. Inclusion criteria were children aged between 5 and 16 years, duration of nasal blockage or discharge between 30 and 120 days, and abnormal sinus radiographs. All enrolled children were prescribed budesonide nasal spray (Rhinocort Aqua Nasal Spray, Astra Pharmaceuticals, Sodertalje, Sweden) as adjuvant treatment.

RESULTS

Forty-two children were recruited into the study and one defaulted on follow-up. Failure occurred in 6 of 20 for the azithromycin group and 5 of 21 for the amoxycillin/clavulanate group. The odds ratio was 1.46 (95%CI 0.37-5. 80, P = 0.73). No relapse occurred in azithromycin group and 5 of 21 in amoxycillin/clavulanate group. The odds ratio was 0.16 (95%CI 0. 017-1.51, P = 0.18). Both antibiotics were well tolerated, however, two children, one from each group, complained of mild transient epigastric discomfort.

CONCLUSIONS

This small study did not provide evidence of a difference between 14 days of amoxycillin/clavulanate and 3 days of azithromycin. Larger studies will be needed to determine which, if any, antibiotic regimen should be used in treating subacute childhood rhinosinusitis.

Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors

BACKGROUND

The reported association of allergy and sinusitis varies greatly between study, and the exact role of allergy in predisposing to sinusitis is not clear. We attempted to determine whether patients with perennial allergic rhinitis are at greater risk of developing sinusitis with respect to a control group, and to determine whether there is a correlation between rhinomanometry, endoscopy, and nasal swab, and computed tomography (CT) findings.

METHODS

Forty adult patients with perennial allergic rhinitis underwent CT scans of the paranasal sinuses, and the results were then compared to CTs of the paranasal sinuses of 30 control subjects. All allergic patients underwent nasal endoscopy, nasal swab, and active anterior rhinomanometry, and the results were studied in relation to the CT findings.

RESULTS

We found sinusitis in 67.5% of the allergic patients and in 33.4% of the controls, with a statistically significant difference between the two groups (P = 0.017). Twenty-three patients had a positive nasal swab; 22 showed increased nasal resistance on rhinomanometry, and 36 had positive endoscopy, but the association of CT findings with endoscopy, rhinomanometry, or nasal swab was not statistically significant (P = 0.583, P = 1.00, P = 0.506, respectively).

CONCLUSIONS

Allergic rhinitis is often associated with sinusitis, but the underlying mechanism has yet to be determined. Evidently, factors other than classical pathogen growth and mechanical factors, such as the association of the various factors and immunologic mechanisms, may contribute to the pathogenesis of chronic sinusitis in allergic patients.

The relationship of serum-eosinophil cationic protein and eosinophil count to disease activity in children with bronchial asthma

BACKGROUND

The serum-eosinophil cationic protein level (S-ECP) has been promoted as a biomarker of asthma that reflects the degree of bronchial eosinophilic inflammation.

PATIENTS AND METHODS

To investigate whether S-ECP is indeed a clinically useful objective parameter, especially in mild or moderate chronic childhood asthma, we studied 100 outpatient children with chronic asthma symptoms (63 boys and 37 girls, aged three to 15 years, median of age eight) and 25 controls (12 boys and 13 girls aged three to 15 years, median of age eight). Symptom scores, lung function parameters and atopy were compared with S-ECP determined by commercially available tests and eosinophils measured by an autoanalyser.

RESULTS

Asthma symptom scores in the patient group ranged between one and 13 (median of 8), S-ECP between 2.1 and 75.6 microg/l (median of 13.3 microg/ l), and eosinophils between 30/microl and 2002/microl (median of 314). Symptom scores and S-ECP were correlated significantly (P < 0.001) as were symptom scores and eosinophils (P = 0.001). S-ECPs were significantly higher in children with chronic asthma symptoms compared with non-asthmatic, non-atopic children (P = 0.005 for non-atopic chronic asthmatics and P < 0.001 for atopic asthmatics); similar results were found comparing eosinophils in these groups. There was no difference in S-ECP between atopic and non-atopic asthmatic children, but the 25 polysensitised asthmatic children especially with sensitisations to mite, pollen and pet allergens were found to have significantly higher S-ECP compared to 15 monosensitised children (P = 0.002). Similar results were found when correlating eosinophil numbers with atopy. Polysensitised (mite, pollen, pet) asthmatics had significantly higher eosinophil counts compared with monosensitised (pollen) asthmatics (P = 0.01); there was, however, a better discrimination between atopic and non-atopic asthmatics (P = 0.001). Non-asthmatic, non-atopic controls had significantly lower eosinophil counts compared with asthmatics (P < 0.001 for both non-atopic and atopic asthmatics). No correlation between S-ECP or eosinophils and any of the lung function parameters measured (FEV1, FEV1/FVC, MEF50, airway resistance and ITGV) was found.

SUMMARY

Our data thus indicate that 1) S-ECP is higher than normal in children with asthma symptoms and correlates with asthma symptom score. 2) S-ECP is better correlated to symptom score than to lung function parameters especially in children with mild and moderate asthma symptoms. 3) Raised S-ECP appears to reflect the extent of allergen sensitivity and may also reflect current allergen exposure. 4) Similar correlations were seen when measuring eosinophil number by an autoanalyser instead of S-ECP.

CONCLUSIONS

Although S-ECP and eosinophils are not diagnostic of asthma they are useful inflammation markers especially in the context of clinical studies. However, both methods are not yet suitable for use in daily practice because they require extensive procedures and special equipment.

Pediatric Sinusitis: A Literature Review with Emphasis on the Role of Allergy

Evaluation and treatment of pediatric sinusitis is a challenging area that has been subject to many different opinions and options during the past decade. Sinusitis is among the most commonly encountered diseases of childhood and has been the major area of interest for many otolaryngologists, allergists, and pediatricians. We have searched the medical literature to review the many aspects of the problem and the opinions of various authors. The increasing importance of allergic diseases and their relationship to sinus disease have been evaluated through a review of relevant literature. The poorly understood variations of the presentation of sinusitis and its signs and symptoms in the pediatric age group have been reviewed. Recommendations concerning the method, duration, and timing of the therapeutic intervention or interventions are summarized. The natural course of pediatric sinusitis in association with related respiratory tract diseases is discussed. Allergies and viral upper respiratory infections are among the most common predisposing factors of sinus disease. Every child with sinusitis is a candidate for an allergy evaluation.

Radiographic imaging studies in pediatric chronic sinusitis

BACKGROUND

The diagnosis of chronic sinusitis is dependent on the radiographic evidence of sinus disease.

METHODS

We evaluated the performance of radiographs and computed tomographic (CT) scans for the examination of the paranasal sinuses of 91 patients of both sexes, ranging in age from 2 to 17 years, who had chronic upper respiratory tract symptoms for at least 3 months. The CT scan findings were categorized as no disease; minimal disease, and mild, moderate, and severe sinusitis.

RESULTS

Fifty-eight patients (63%) had chronic sinusitis: CT scan abnormalities were minimal in 17%, mild in 19%, moderate in 21%, and severe in 43%. There was a statistically significant correlation between rhinorrhea (r = 0.25, p = 0.01), cough (r = 0.27, p = 0.009), and the severity of sinus abnormality as determined by CT scan. Clinical presentation in the mild, moderate, and severe sinusitis groups (p < 0.05) was significantly different from that of the no disease group, whereas the minimal disease group had subclinical presentation (p = 0.11). Clinically significant chronic sinusitis often occurred at multiple sites: 44% of patients had pansinusitis, 50% had disease involvement of at least two sinuses, and 6% had disease in a single sinus. When sinus radiographs were compared with CT scans (n = 70 cases), radiographs could not identify minimal disease. For clinically significant sinusitis, sinus radiographs detected disease in 1 of 5 (20%) frontal sinuses, 0 of 12 (0%) sphenoidal sinuses, and 17 of 31 (54%) ethmoidal sinuses. With the minimal criteria of 40% to 50% opacification or fluid level filling of the maxillary antrum, radiographs detected disease in 37 of 49 (75%) cases. The sensitivity and specificity for a Waters view to confirm clinically significant chronic sinusitis without specifying the sites and severity were acceptable at 76% and 81%, respectively. When limited sinus CT scans were compared with full CT evaluation (n = 49 cases), limited studies detected 5 of 5 (100%) frontal, 9 of 11 (82%) sphenoidal, 14 of 19 (73%) ethmoidal, and 39 of 40 (97%) cases of maxillary sinusitis. The overall agreement was 88%.

CONCLUSIONS

A single Waters view is an acceptable part of the initial evaluation of pediatric chronic sinusitis; however, a limited CT scan is a better alternative.