This document discusses pediatric rhinosinusitis. It begins by noting that pediatric rhinosinusitis is often misdiagnosed and inappropriately treated. Over the past decades, more has been learned about chronic rhinosinusitis in children, recognizing it as a continuum of disease that usually begins with a viral upper respiratory infection progressing to bacterial sinus infection. The natural history in children is not well understood and likely involves different predisposing factors than in adults, such as a maturing immune system. Diagnosis is based on clinical evidence and symptom duration, with imaging and testing only indicated in certain cases. Treatment involves antibiotics and nasal steroids, with surgery reserved for complications or failure of medical management.

1. Pediatric rhinosinusitis
RODNEYP.LUSK,MD,and JAMESA. STANKIEWICZ,MD,St. Louis, Missouri, and Chicago, IlLinois
Pediatric rhinosinusitis is often misdiagnosed and
inappropriately treated. On the one hand, all upper res-
piratory viral infections may be considered acute rhi-
nosinusitis and therefore treated with antibiotics. On
the other hand, some physicians and parents view puru-
lent rhinorrhea as part of "growing up" and do not inter-
vene with medical management.
Over the past several decades much has been learned
about chronic rhinosinusitis in children. II is now rec-
ognized that infections of the nasal mucosa and sinuses
are actually a continuum of disease, that rhinitis or rhi-
nosinusitis rarely occurs in isolation, and that most
pediatric sinus infections begin with an upper respirato-
ry tract viral infection and progress to a bacterial sinus
infection.
The natural history of pediatric chronic rhinosinusi-
tis is not well understood. Rhinosinusitis is a multifac-
torial disease, and predisposing factors change in
importance over time. For example, the maturing
immune system and enlarging anatomy of the sinuses
may be factors that separate pediatric chronic rhinosi-
nusitis from adult chronic rhinosinusitis. 13 Other spe-
cial conditions yet to be defined as predisposing factors
for chronic rhinosinusitis in children are allergy,4 air
pollution, 5 gastroesophageal reflux,6-8 day care set-
tings, and enlarged tonsils and adenoids. Although sig-
nificant growth retardation does not seem to occur after
surgery, it remains a concern.
DIAGNOSIS
Definition
Rhinosinusitis, which is the preferred term,
acknowledges that most sinus infections start in the
nasal passages as part of a continuum of disease. 9 Viral
From the Department of Pediatric Otolaryngology, St. Louis
Children's Hospital (Dr. Lusk), and the Department of
Otolaryngology-Head and Neck Surgery, Loyola University,
Chicago,Ill.(Dr.Stankiewicz).
Reprint requests: Rodney R Lusk, MD, Department of Pediatric
Otolaryngology, St. Louis Children's Hospital, One Children's
Place, St. Louis,MO 63110.
OtolaryngolHeadNeck Surg 1997;117:$53-$57.
Copyright © 1997 by the AmericanAcademy of Otolaryngology-
Head and NeckSurgeryFoundation,Inc.
0194-5998/97/$5.00+ 0 23/0/83511
rhinitis cannot be differentiated from rhinosinusitis on
clinical grounds alone. Isolated rhinitis probably exists,
but isolated sinusitis is rare. I°
Signs and Symptoms
The diagnosis of rhinosinusitis is usually based on
the clinical evidence and the duration of symptoms. In
the first 7 to 10 days of illness it is virtually impossible
to tell the difference between an upper respiratory tract
infection and rhinosinusitis. In some circumstances,
however, an acute infection may rapidly progress to
complicated rhinosinusitis. In acute rhinosinusitis the
signs and symptoms last longer than 10 days. Chronic
rhinosinusitis is associated with low-grade symptoms
that persist more than 12 weeks, although acute exacer-
bations can occur in chronic infection. Recurrent acute
rhinosinusitis consists of repeated acute episodes, with
the signs and symptoms resolving completely between
episodes. In patients who are being treated with antibi-
otics, it is often difficult to differentiate chronic rhino-
sinusitis from acute rhinitis on the basis of the signs and
symptoms alone, because the clinical features may be
masked by the drugs.
The signs and symptoms of pediatric rhinosinusitis
are listed in Table 1.11-t4 Severe symptoms and compli-
cations are usually associated with acute rhinosinusi-
tis. I5 The signs and symptoms associated with chronic
rhinosinusitis include nasal congestion, rhinorrhea,
headaches, irritability, day and night cough, postnasal
discharge, and halitosis. 3,t2-14,16
Testing
Cultures may be necessary if infections do not
respond to conventional treatment (i.e., antibiotics that
cover ~3-1actamase-prodncing bacteria) or if symptoms
return within 1 week after antibiotic therapy is stopped.
There is no consensus on whether middle meatal cul-
tures can substitute for sinus punctures. 10,17,18Cultures
from the middle meatus or the ethmoid bulla appear to
give the best results in chronic rhinosinusitis. 19-21
Cultures are necessary in the following situations:
when a child is severely ill or toxic, when symptoms
progress despite appropriate medical management,
when the child is immunocompromised, and when sup-
purative complications are present. The most likely
S53

2. S54 LUSKand STANKIEWICZ
Otolaryngology-
Head and Neck Surgery
September 1997
Table 1. Signs and symptoms of pediatric rhinosinusitis
Rhinosinusitis
Sign/symptom Nonsevere Severe
Rhinorrhea Yes Yes: frank, purulent
Nasal congestion Yes Yes
Headaches, facial pain May be present Yes
Fever None or low grade High grade
Frequent cough Yes Yes
Postnasal discharge Mild Mild
Data from Wald ER. N Engl J Med 1992;326:319-23; Wald ER. Ann Oto/Rhinol Laryngol Supp11992;155:37-41; Muntz HR et al. In: Lusk RP, editor.
Pediatric sinusitis. New York: Raven Press; 1992. p. 1-5;Parsons DS et al. Otolaryn9ol Clin North Am 1996;29:11-25.
Table 2. Indications for endoscopic sinus surgery
Absolute indications
Complete nasal obstruction caused by the following:
Cystic fibrosis
Allergic fungal sinusitis
Antrochoanal polyps
Other causes of nasal polyps
Intracranial complications
Cavernous sinus thrombosis
Mucoceles and mucopyoceles
Subperiosteal or orbital abscess
Traumatic injury to optic canal (decompression)
Dacryocystorhinitis from rhinosinusitis
Allergic or invasive fungal rhinosinusitis
Meningoencephaloceles
Cerebrospinal fluid leaks
Tumors of the nasal cavity or sinuses
Relative indications
Subacute rhinosinusitis after failure of optimal
medical therapy
Chronic rhinosinusitis after failure of optimal
medical therapy
Recurrent acute rhinosinusitis occurring frequently
enough that patient takes antibiotics most of the time
causes of infection are Staphylococcus aureus,
Streptococcus pneumoniae, Moraxella (Branhamella)
catarrhalis, and Haemophilus influenzae. 15,20-22
Imaging is not needed to make the diagnosis of rhi-
nosinusitis in all children. Controversy exists concern-
ing the value of diagnostic ultrasound examination, but
this modality appears to be of little use in children. 23-28
Transillumination is of no value in diagnosing rhinosi-
nusitis in children. 24Although sinus radiographs are of
little use in assessing the ethmoid sinuses or the sphe-
noid and frontal sinuses in small children, they can be
helpful in diagnosing acute maxillary sinusitis in older
children. 29-32 Computed tomographic scanning is indi-
cated if endoscopic sinus surgery is being considered or
if symptoms indicate that medical management has
failed.33-37
The workup should also include investigations for
allergy,38-43immune deficiency, 38'4°'44-47cystic fibrosis, 48-
51 ciliary disorders,52-54and gastroesophageal reflux.8
MEDICAL MANAGEMENT
Antibiotics and nasal steroids may mask the signs
and symptoms of acute and chronic rhinosinusitis. It is
also important to remember that the current practice of
using broad-spectrum antibiotics for less well-docu-
mented infections is likely to increase resistant strains
of bacteria.55
Antibiotics may be given for bronchitis and acute
otitis media as necessary. The severely ill or toxic child
with symptoms of purulent rhinorrhea, nasal obstruc-
tion, cough, and headache should be treated with oral
antibiotics, whereas the severely ill or toxic child with
evidence of suppurative complications should be treat-
ed with intravenously administered antibiotics that are
effective against H. influenzae, S. pneumoniae, and M.
catarrhalis.10,17,56-59
Nonsevere acute rhinosinusitis may be treated with
amoxicillin. If no improvements occur in 48 to 78
hours, the antibiotic should be changed to a ~}-lacta-
mase stable agent. An oral ~-lactamase stable agent
should be used for the initial therapy of severe acute
rhinosinusitis and for the treatment of prolonged symp-
tomatic chronic rhinosinusitis.
For chronic rhinosinusitis a 4- to 6-week course of
antibiotics is appropriate. 1°,6°-62 For acute rhinosinusi-
tis 10 to 14 days of antibiotic therapy is appropri-
ate. 10,63,64If symptoms continue or recur within 5 to 7
days after antibiotic therapy is stopped, the infection
should be considered persistent. However, the infection
should be considered a new one in a child who was free
of symptoms for 2 or more weeks and who was not tak-
ing antibiotics. If the symptoms progress after 72 hours
of antibiotic therapy, it is appropriate to reevaluate the
patient, to change to a broader spectrum antibiotic, or to
obtain a culture from the middle meatus.
SURGICAL MANAGEMENT
Complications of acute rhinosinusitis such as subpe-
riosteal abscess, orbital cellulitis, or intracranial
abscess must receive aggressive surgical management.

3. Otolaryngology-
Head and Neck Surgery
Volume 117 Number 3 Part 2 LUSKand STANKIEWICZ $55
Adenoidectomy
In children with rhinosinusitis characterized by
moderate to severe nasal obstruction caused by adenoid
hypertrophy, adenoidectomy has been shown to be ben-
eficial, although not statistically valid, as the cause of
resolution.65-69 The degree of symptomatic improve-
ment is greatest when the adenoid pads are large.7°
Therefore adenoidectomy should be considered as a
first-line treatment in a child with rhinosinusitis symp-
toms and an obstructive adenoid pad.
The size of the adenoid is best assessed with flexible
endoscopy of the nasopharynx, but the degree of
obstruction can also be documented on a lateral radi-
ograph. The lateral tomogram on the sinus computed
tomography scan will show good definition of the
nasopharynx and allow evaluation of the adenoids.
Antral Lavage
As a diagnostic corollary of fluid in the maxillary
sinus, air-fluid levels on radiographs or computed
tomography scans are the only reliable predictors of
retrievable fluid.7°-72 Most of the literature discussing
lavage was published in the early 1980s; r.hese studies
related the procedure to the diagnostic criteria for rhi-
nosinusitis, the bacteriology of the illness, and the effi-
cacy of sinusitis treatment. 72
Antral lavage is not a viable therapeutic modality for
the treatment of rhinosinusitis, because it involves only
the maxillary sinus and not the ethmoid sinuses.73-75
Although lavage is no longer used as a therapeutic
modality, it remains a valuable diagnostic tool in the
immunocompromised patient. An accepled use for
lavage is where disease is primarily maxillary.
Nasal Antrol Window
The nasal antral window (inferior antrostomy) was
popularized as a less aggressive and more effective
method of treating rhinosinusitis than the Caldwell-Luc
procedure. 75 In 1941 Hilding76 cited the nasal antral
window as a safer and better procedure than antrostomy
of the natural maxillary sinus ostium, because it was
less likely to cause infection of the maxillary sinus in a
rabbit animal model. Kennedy et al.77,78 cited Proetz79
as being concerned about the possibility of traumatizing
the natural ostium with this procedure. Wilkerson8°
repopularized the nasal antral window, and it is now
frequently used with endoscopic sinus surgery]v,78
The inferior antrostomy has not been a successful
modality for treating rhinosinusitis. 81-83 One reason is
that the cilia continue to beat toward the obstructed nat-
ural ostium. In addition, the diseased ethmoid sinuses are
not addressed. Exceptions for placing an inferior antros-
tomy include cilial dysfunction and cystic fibrosis.
Endoscopic Sinus Surgery
Pediatric endoscopic surgery became a viable option
after success was demonstrated with adult endoscopic
sinus surgery77,84-87 and special instruments were
developed for use in children. 19Because of the smaller
anatomy, pediatric sinus procedures are thought to
require greater technical skill and more meticulous
surgery than the same procedures in adults. Frontal and
sphenoid sinuses are rarely entered in children. 19,62,88
Because pediatric rhinosinusitis in chil&en is usual-
ly located in the anterior ethmoid and maxillary sinus-
es, extensive surgery usually is not necessary. Instead,
children generally require only a limited procedure con-
sisting of anterior ethmoidectomy and possibly maxil-
lary antrostomy. In an anterior ethmoidectomy the
entire uncinate process is removed. The dissection is
carried through the bulla and posteriorly to the basal
lamella. The lateral dissection goes to the lamina
papyracea. If a maxillary antrostomy is neces-
sary,19,64,88-91 a conservative enlargement of the natur-
al ostium seems effective. Generally, the ostium
remains patent and appears to function well most of the
time.78
Absolute and relative indications for endoscopic
sinus surgery are listed in Table 2. Children with under-
lying immune deficiency, cystic fibrosis, allergy, asth-
ma, and mncociliary dyskinesia are more likely to
require surgical intervention. Only a small number of
children with rhinosinusitis will actually require
surgery. In the authors' practice each pediatrician refers
an average of one or two patients per year for the eval-
uation of chronic rhinosinusitis. Approximately one
third of these referred children will require surgery.
Good outcomes occur in a large percentage of chil-
dren who undergo endoscopic procedures. 19,64,92,93
Most parents who have realistic expectations (i.e., who
understand that their children will continue to have
viral upper respiratory tract infections) believe that
their children are significantly improved after the
surgery.
CONCLUSION
More research is necessary to examine the patho-
physiology of pediatric rhinosinusitis and its medical
and surgical treatment. Prospective controlled trials are
also needed to evaluate the available surgical modali-
ties.
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