Sinusitis in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Template:Archana

Synonyms and keywords: Sinusitis in kids, Sinusitis in children , Pediatric rhinosinusitis, Pediatric sinusitis

Overview

• Rhinosinusitis is defined as an inflammation of the paranasal and nasal sinus mucosae. Sinusitis in children is a very common condition. It is being seen more and more by primary care physicians and pediatricians. Children average six to eight colds per year. Of those, 0.5 to 5% will develop a sinus infection. Rhinosinusitis is the inflammation of the mucous membranes of nose and paranasal sinus(es). 5–13% of upper respiratory tract infections in children complicate into acute rhinosinusitis. Though not life threatening, it profoundly affects child's school performance and sleep pattern. If untreated, it could progress to chronic rhinosinusitis (CRS). Symptoms of a cold or allergy overlap with those of rhinosinusitis in the child. Distinguishing rhinosinusitis from a cold or allergy may be challenging. It is agreed that if cold symptoms are not improving by 7 to 10 days, a sinus infection should be seriously considered. Chronic rhinosinusitis (CRS)is a common problem in the pediatric age group, and the diagnosis and treatment are challenging due to the chronicity and similarity of symptoms with allergic rhinitis and adenoid hypertrophy. Although it is less common than acute rhinosinusitis, CRS is becoming more frequent and significantly affects the quality of life in children and can substantially impair daily function. CRS is characterized by sinus symptoms lasting more than 3 months despite medical therapy. Many factors are involved in the pathogenesis of this disease and include a primary insult with a virus followed by bacterial infection and mucosal inflammation, along with predisposition to allergies. The pathogens involved in perpetuation of CRS consist of multidrug-resistant mixed microflora. CRS is challenging to manage and could further extend to cause eye or intracranial complications. In children, CRS diagnosis is often either missed or incomprehensive. Due to this, morbidity and strain on healthcare budget are tremendous. Plain radiographs can be helpful for maxillary sinusitis especially if an air-fluid level is seen; otherwise, the sensitivity and specificity of plain radiographs are poor. Computed tomography (CT) should not be used for diagnostic purposes. The role of CTis mainly in children with chronic rhinosinusitis when surgery is being considered. In cases of complicated sinusitis, a CT scan is necessary. Treatment of most rhinosinusitis cases in children is medical. Optimal management entails specific appropriate antimicrobials as well as treatment of underlying causes. The aim is to normalize sinus anatomy and physiology and regain normal mucociliary function and clearance. Medical treatment should be with an appropriate antibiotic. Adjunctive treatment with saline irrigations and topical and systemic decongestants may be helpful. The standard treatment of pediatric acute bacterial rhinosinusitis (ABRS) is nasal irrigation and antibiotic use. Medical treatment of pediatric CRS includes avoidance of allergens in allergic patients (environmental or food) and therapy with nasal irrigation, nasal corticosteroids sprays, nasal decongestants, and antibiotics directed at the most common sinonasal organisms(Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis). Surgical therapy is rarely needed after appropriate medical therapy. Surgical intervention is necessary for complicated cases and for cases that do not respond to prolonged course of medical management. Currently adenoidectomy and endoscopic sinus surgery are the most common procedures used. Flexible fiberoptic endoscopy has revolutionized management of CRS. Its utility in children is being increasingly recognized. Children needing surgical intervention are a small percentage because of the success of medical treatment. Referral to an otolaryngologist and allergy specialist is recommended in case of failure of medical treatment.

Historical Perspective

• Rhinosinusitis was first coined by Task Force of Rhinology and Paranasal Sinus Committee, in 1997 because sinusitis is invariably accompanied by rhinitis.

Classification

• Anatomically paranasal sinuses are classified in to [four] paired sinuses, divided into subgroups that are named according to the bones within which the sinuses lie. The paranasal air sinuses are lined with respiratory epithelium (ciliated pseudostratified columnar epithelium). Understanding the embryologic development of the paranasal sinuses is crucial for the diagnosis and treatment of pediatric rhinosinusitis. For example, treatment of CRS in children below twelve years is different than children between 13 and 18 years due to differences in sinus growth. The ethmoid and maxillary sinuses develop in the 3rd month of gestation and are usually present at birth and display early growth and reach adult size by the age of ten. The sphenoid sinuses are generally appreciable on imaging before 3 years of age, become aerated at age 5 years, and expand in size into the second or third decade of life, typically becoming fully developed by age 12–14.The frontal sinuses develop from an anterior ethmoidal air cell and are pneumatized by age 5 or 6 years. The majority of all sinuses will reach adult size by the age of 15 years with the frontal sinus, the last to develop, reaching adult size by 19 years. The outflow tract of the maxillary sinus is situated at the most superior portion of the medial wall which makes gravitational drainage difficult. There are six anatomic drainage pathways from the sinuses -- three for each side. The frontal sinus drains via the nasofrontal duct into the anterior superior nasal cavity. The maxillary and anterior ethmoid sinuses drain via a common area, the ostiomeatal unit. The sphenoid and the posterior ethmoid sinuses drain via the sphenoethmoidal recess. Obstruction of any one pathway leads to sinusitis in the respective sinus areas.

• Maxillary Sinuses, the largest of the paranasal sinuses, are under the eyes, in the maxillary bones (open in the back of the semilunar hiatus of the nose). They are innervated by the trigeminal nerve (CN Vb)
• Frontal Sinuses, superior to the eyes, in the frontal bone, which forms the hard part of the forehead. They are also innervated by the trigeminal nerve (CN Va)
• Ethmoidal Sinuses, which are formed from several discrete air cells within the ethmoid bone between the nose and the eyes. They are innervated by the ethmoidal nerves, which branch from the nasociliary nerve of the trigeminal nerve (CN Va)
• Sphenoidal Sinus, in the sphenoid bone. They are innervated by the trigeminal nerve (CN Va & Vb)

• Sinusitis may be classified into four subtypes/groups:

• Acute Rhinosinusitis Sudden onset, lasting less than 4 weeks with complete resolution.
• Subacute Rhinosinusitis A continuum of acute rhinosinusitis but less than 12 weeks.
• Recurrent Acute Rhinosinusitis Four or more episodes of acute, lasting at least 7 days each, in any 1-year period.
• Chronic Rhinosinusitis Signs of symptoms persist 12 weeks or longer.

Pathophysiology

• Most commonly a viral upper respiratory infection causes rhinosinusitis secondary to edema and inflammation of the nasal lining and production of thick mucus that obstructs the paranasal sinuses and allows a secondary bacterial overgrowth. There are frontal, maxillary, sphenoid, and ethmoid sinuses. Allergic rhinitis can lead to sinusitis also due to ostial obstruction. Ciliary immobility can lead to increased mucus viscosity, further blocking drainage. Bacteria are introduced into the sinuses by coughing and nose blowing. Bacterial sinusitis usually occurs after a viral upper respiratory infection and worsening symptoms after 5 days, or persistent symptoms after 10 days. A key concept in understanding the pathogenesis of acute bacterial sinusitis is that the nasal and nasopharyngeal mucosae are continuous with the paranasal sinus mucosa. Any process that affects the nasal mucosa may also affect the sinus mucosa; moreover, the nasal mucosa is heavily colonized with bacteria and investigations of the sinus microbiome have shown diverse colonization of healthy paranasal sinuses by Firmicutes, Proteobacteria, and Actinobacteria in all subjects, Bacteroides spp. in 83 % of subjects and S. aureus in 68 % of subjects. The mucosa consists of mucus secreting goblet cells and pseudo-stratified ciliated columnar epithelium. The role of the mucus covering the mucosa is to catch the dust, stimulating particles and microorganisms. The drainage of mucus is by active mucociliary transport, and not by gravity. Nasal secretions originate from goblet cells, epithelial cells, epithelial cell proteins, vascular transudation and lacrimal fluid. The essential protein parts of these secretions are mucin glycoproteins composed of oligosaccharide side chains and a peptide core structure. Those glycoproteins affect the composition of the mucus and facilitate the interaction between microorganisms and host. Mucin binds surface adhesins on microorganisms therefore inhibiting their ability to colonize the epithelium. Mucociliary movement transports mucus from the paranasal sinuses to the nasal cavity and pharynx where it is swallowed. The large nasal mucosal surface consists of a mucus layer that moistens the air flowing over it and filters the air particles. In the nasal submucosa, vascular plexi swell and produce nasal congestion after exposure to certain stimuli such as noxious or allergic triggers, and temperature changes.
• The [Familial association] studies have demonstrated strong heritability of CRS within immediate and secondary family members. According to a recent study by Orb, Q.et al on 496 patients with CRS, a strong genetic predisposition was involved in CRS pathogenesis, where relativesof patients with CRS had a 57.5 times higher risk of having CRS. First cousins had 9 times increased risk and second cousins had a 2.9times increased risk of pediatric CRS. Another study has suggested that this genetic predisposition may be related to the genes encoding potassium channels on the airway epithelium. Theseapical potassium channels mediate mucociliary clearance, air surface liquid hydration and control ion transport in epithelial cells[19*]. Other genetic diseases, like primary immunodeficiencies, primary ciliary dyskinesia (Kartagener's syndrome), and cystic fibrosis are highly associated with CRS, but their contribution to the overall prevalence is low
• On microscopic histopathological analysis, Tissue and culture results will reveal:

Fifteen percent of aspirates contain viruses Streptococcus pneumoniae 3%, Haemophilus influenzae 21%, anaerobes 6%, Staphylococcus aureus 4%, Streptococcus pyogenes 2%, Moraxella 2% Chronic: S. aureus 20%, anaerobes 3%, S. pneumoniae 4%, multiple organisms 16% Fungal incidence is 2% to 7%, most commonly Aspergillus and most commonly seen in immunocompromised patients.

Causes

Sinusitis predisposed by a number of local and systemic factors. Any local condition that interferes with normal sinus drainage predisposes to the development of infection. Obstruction of the sinus outflow tract may be due to mucosal swelling (allergic rhinitis, viral URI) or mechanical obstruction (nasal polyp, foreign body, tumor, anatomic abnormality). The obstruction will decrease oxygen supply to the sinus that in turn will result in 1) vasodilation of local vasculature, 2) ciliary dysfunction, and 3) mucus gland dysfunction. These events conspire to cause transudation and stagnation of the viscid fluid thus leading to acute rhinosinusitis with retained thick secretions. Instrumentation (with nasotracheal, nasogastric, orotracheal, or orogastric tubes) is an essential risk factor for ABRS. In fact, in a study of pediatric intensive care unit (PICU) patients, Moore et al found that almost 50% of PICU patients who underwent imaging for reasons other than assessment for sinus abnormality had evidence of sinusitis. This finding raised the concern that sinusitis in PICU patients is frequent and should be considered in the differential diagnosis of fever in PICU patients.

[Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Differentiating [disease name] from other Diseases

For further information about the differential diagnosis, click here.

Epidemiology and Demographics

There are higher rates of sinusitis in the South, Midwest, and among women.

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [sinusitis].
• [Sinusitis] is more commonly observed among children younger than 15 years of age and adults aged [25 to 64] years.

Gender

• Women are more commonly affected with sinusitis than men.

Race

• There is no racial predilection for [disease name].

• [Disease name] usually affects individuals of the [race 1] race.
• [Race 2] individuals are less likely to develop [disease name].

Risk Factors

• Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Other risk factors or sinusitis include: Anatomic defects such as septal deviations, polyps, conchae bullosa, other trauma and fractures involving the sinuses or the facial area surrounding them Impaired mucous transport from diseases such as cystic fibrosis, ciliary dyskinesia Immunodeficiency from chemotherapy, HIV, diabetes mellitus, etc. Body positioning, intensive care unit (ICU) patients due to prolonged supine positioning that compromises mucociliary clearance. Rhinitis medicamentosa, toxic rhinitis, nasal cocaine abuse, barotrauma, foreign bodies Prolonged oxygen use due to drying of mucosal lining Patients with nasogastric or nasotracheal tube

Natural History, Complications and Prognosis

• The majority of patients with [disease name] remain asymptomatic for [duration/years].
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

Diag: The IDSA guidelines suggest that ABRS can be diagnosed with each of the following clinical scenarios:

• URI symptoms lasting more than 10 days without any improvement;
• Severe onset of signs and symptoms lasting more than 3-4 consecutive days,like high grade fever (>39°C),facial pain or purulent nasal discharge;
• Worsening of signs and symptoms following a typical viral URI that lasted 5-6 days and were initially improving, like new onset of fever, headache, or increase in nasaldischarge“double-sickening”.

• The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:

• [criterion 1]
• [criterion 2]
• [criterion 3]
• [criterion 4]

Symptoms

• [Disease name] is usually asymptomatic.
• Symptoms of [disease name] may include the following:

• [symptom 1]
• [symptom 2]
• [symptom 3]
• [symptom 4]
• [symptom 5]
• [symptom 6]

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

Diagnosis of rhinosinusitis in children is not easy. It should be suspected when cold does not improve beyond 10 days or nasal stuffiness is present with purulent discharge, facial pain, headache, fever, and diminution/loss of sense of smell. Dental, ear, or eye problems, allergies, or environmental pollutants can produce similar symptoms and cause confusion. Sneezing and nasal itching are common with allergic rhinitis. In these children with isolated allergic rhinitis, purulent nasal discharge is usually not seen. In those children of allergic rhinitis with superadded sinusitis, the picture is altered, and along with nasal itching and sneezing, purulent nasal secretions and loss of olfaction sense may also be associated. Allergic rhinitis is not uncommonly seen associated with sinusitis; hence a search for triggering allergies needs to be performed in children presenting with rhinosinusitis. Anterior rhinoscopy and fibreoptic nasal endoscopy may be useful for accurate assessment of the middle meatus pathologies and detection of associated adenoiditis, nasal polyps, or nasal masses. This can also be used to collect specimen for testing secretions or mucosa. Patient cooperation is of utmost importance for these procedures.

Transillumination of sinuses is useful in hands of experienced person. In this, a flashlight is placed against the patient's cheek and the doctor looks into the patient's open mouth. A lit-up reddened area is seen in the palatal area with normal sinuses. When sinuses are fluid-filled, this reddened area will not be visualized. Near-infrared light (750–1100 nm) can penetrate deeper and permit enhanced illumination of deeper structures. But since this light is invisible normally, a charge-coupled device camera is used to capture and record images. This technique has been found to be a safe, reliable, low-cost, and simple aid for diagnosis of sinusitis.

Plain radiography of paranasal sinuses can be performed, but it has a limited diagnostic role. Water and Caldwell-Luc's views are taken for sinusitis. Haziness, opacification, or fluid level is suggestive of sinusitis. CT scan of sinuses gives a better visualization and is a useful tool preoperatively. Limited axial and coronal cuts ordinarily suffice. Contrast is reserved for suspected suppuration. CT scan can pick up noninvasively ostiomeatal anomalies with great accuracy. Mucosal changes, intrasinus collections or growths, and adjacent bone changes can be visualized. Soft-tissue algorithms of CT scan reveal heterogeneity of signal intensity in AFS. Accumulations of heavy metals (iron, manganese, calcium) within the allergic mucin elicit enhanced signals. For orbital and intracranial extensions or in AFS, MRI is more informative. In AFS, allergic mucin is hyperdense on T1W1 images with signal void on T2 imaging. USG can be used for assessment of maxillary sinuses, but results are found to be inconsistent.

In acute cases, complete blood count, ESR, and blood cultures provide useful data. Tests for allergy, immunodeficiency, cystic fibrosis, and immotile cilia syndrome assist to detect associated conditions. In AFS, total serum IgE and skin or in vitro tests for fungi and common allergens are usually positive . For collection of specimen for culture from the maxillary sinus, a maxillary sinus puncture is the standard criterion. However, it is painful, needs patient cooperation, and can be done only under anaesthesia in children. Culture swabs obtained from middle meatus or anterior middle turbinate correlate well with cultures from maxillary or ethmoid sinuses. However, random nasal swab cultures bear no correlation with maxillary sinus cultures. Gram-staining, aerobic and anaerobic cultures, and fungal cultures can be performed on the collected swabs to guide appropriate antimicrobial therapy. Flexible endoscopes are also employed for such specimen collections. Biopsy taken during endoscopic sinus procedures shows submucosal inflammatory infiltrates in acute and chronic rhinosinusitis. In AFS, eosinophils and Charcot-Leyden crystals predominate. A positive fungal culture grown from infected sinuses is not confirmative of allergic fungal sinusitis. The isolated fungi may be a saprophyte, or the method of specimen collection and handling may also influence the yield. Presence of allergic mucin is a reliable pointer towards the disease.

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].
• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

An acute attack of rhinosinusitis is usually self-limiting and recovers with symptomatic treatment and with minimal intervention. Steam inhalation, adequate hydration, instillation of topical decongestants, warm facial packs application, and saline nasal drops are useful. Elevation of head while sleeping gives relief. The nasal decongestants decrease mucus production and can be safely used for 5–7 days. Extended use beyond this period may lead to rebound vasodilatation and worsening of nasal stuffiness. The study by McCormick et al., however, did not show any benefit of topical decongestant with oral antihistamine in children with acute rhinosinusitis. Nasal saline irrigations, nasal steroids, and topical cromolyn have been found to be useful. The saline irrigations assist to mechanically clear secretions, minimize bacterial and allergen burden, and improve mucociliary function. Nasal steroidal or cromolyn drops or sprays improve symptoms in children with concurrent nasal allergy. Short burst of systemic steroids is employed preoperatively to minimize intraoperative blood loss in children with nasal polyp . Antihistamines are beneficial in those with associated nasal allergy. But they have a tendency to inspissate the secretions and further worsen rhinitis and ostial obstruction. Mucolytics have been noticed to have variable effects. No proper randomized and controlled studies have been performed to evaluate their efficacy in such patients. Environmental pollutants worsen the situation, and hence avoidance of them tends to improve rhinosinusitis . Antibiotics are usually not warranted. A “wait-and-watch” policy for 7–10 days is fruitful and cost-effective. About 90% recover without antibiotics in a week. Antibiotics are reserved for children with severe acute sinusitis, toxic features, suspected complications, or persistence of symptoms. Choice of antibiotics should be guided by local susceptibility studies, safety profile, and child's age. Usual preferred are amoxicillin, coamoxiclav, oral cephalosporins, and macrolide group of antibiotics. 2 weeks course is usually required. Associated conditions should be simultaneously and individually addressed as follows.

Respiratory allergy. Allergen avoidance, environmental control, topical nasal steroids, second-generation antihistamine, leukotriene receptor antagonist, and immunotherapy are common measures to control allergic rhinitis. Immunotherapy is valuable for children with known allergens that cannot be avoided and where conservative therapy has not been advantageous. Anti-IgE therapy has been found to provide clinical benefit in patients with seasonal allergic rhinitis. Inhaled bronchodilators and optimal use of steroids could control bronchial asthma. Removal of trigger factors from the environment or diet also aid in minimizing asthmatic attacks. Active and/or passive smoking should be curtailed.

Gastroesophageal reflux. Elevation of the head end of bed, small, frequent and thickened feeds, avoiding near-bedtime feeds, H2-blockers, prokinetic agents, and hydrogen ion pump inhibitors are used to control reflux.

Cystic fibrosis. Nasal irrigations, nasal steroids, antibiotic courses, nebulized antibiotics, chest physiotherapy, and exercises aid to clear the copious secretions and thwart infections.

Immunodeficiencies. Aggressive treatment of recurrent infections and regular immunoglobulin infusions could control secondary infections in such patients.

Immotile cilia syndrome. This requires vigorous removal of secretions which in turn causes a decline in infection rate and associated complications.

Removal or correction of nasal obstructions.

Since CRS harbours extended-spectrum β-lactamase- (ESBL-) producing multi-drug-resistant polymicrobes, a broad-spectrum β-lactamase-stable second-line antibiotic is preferred as the first choice [99]. Antibiotics with activity against aerobic and anaerobic ESBL-producing bacteria and group A β-hemolytic streptococci (GABHS) will be able to provide clinical and microbiological clearance. Lincomycin, clindamycin, coamoxiclav, metronidazole with a macrolide, fluoroquinolone, aminoglycoside, expanded-spectrum cephalosporins, or carbapenems are usually effective. The therapy could be later deescalated based on susceptibility tests. This lessens chances of increasing resistance. Cefuroxime, cefpodoxime, cefdinir, vancomycin, clindamycin, and antipseudomonal antibiotics are all useful for polymicrobial infections. Parenteral therapy may be required in severe resistant cases. Though there is no grade 1 evidence to support antibiotic usage in CRS in children, antibiotics are often used to treat CRS in children. Duration of therapy is for 3–6 weeks. Improvement in symptoms was seen after 22.35 ± 5.04 days (mean) of antibiotic treatment. The role of long-term intravenous antibiotics for CRS is not universally established, though a subset of CRS may benefit from such therapy. Topical antibiotics have also been tried with varied results. Various modes of drug delivery are employed with ongoing research to enhance the drug delivery and deposition into the sinuses. Prolonged low-dose oral antibiotics were found to be beneficial for CRS, but more studies are needed before recommending it as standard treatment. Saline nasal irrigation is useful as adjuvant therapy in CRS and is found to be well tolerated in children. Since biofilm formation is the rule in CRS, modulation of the matrix and novel methods of biofilm disruption may be tried. Drugs targeted against production or action of the AMCase enzyme could be fruitful in the management of persistent and recurrent sinus infections . Oral enzymes such as rutin and bromelain are useful as adjunctive therapy . Some traditional ayurvedic decoctions such as Pitawakka Navaya are relatively safe and useful as supplementary treatment in chronic sinusitis . In AFS, it is difficult to remove the thick fungal debris and mucin in the sinal cavity. Surgical cleansing, antifungal medicines, steroids, and immunotherapeutic measures are used to achieve eradication with variable success. Follow ups of cases with immunotherapy showed no recurrence after 7–17 months .

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

Adenoidectomy is usually the first surgical intervention considered for children with CRS. It removes the obstruction as well nidus of infection. A risk-benefit analysis should be carried out before considering other surgical approaches in children. There has been major transformation in diagnosis and therapy of rhinosinusitis due to the technical advances in medical endoscopes. When appropriate, maximal medical therapy fails or with associated anatomic aberrations, surgical interventions are contemplated in rhinosinusitis. About 2/3rd of patients of CRS fail maximal medical therapy and need to go ahead with surgery. Almost universally, children with diagnosis of AFS need operative intervention, postoperative medical management, and close long-term monitoring and followup. Surgery aims to restore sinus ventilation and ciliary function. Functional endoscopic sinus surgery (FESS) is done via a flexible endoscope and is beneficial for management of chronic sinusitis. However, in children, it is reserved only for complicated cases. FESS can remove the thick tenacious secretions, debris, and mucin in allergic fungal sinusitis which are otherwise difficult without open surgical methods. Detergent, 1% solution in normal saline of Johnson and Johnson baby shampoo, topical antibiotics such as gentamycin/tobramycin or antifungal drugs, and tea or sinu fresh could be used during surgery to irrigate the sinus and improve outcomes. Baby shampoo contains a zwitterionic surfactant, which disrupts the biofilm. This could also be used for nasal irrigation post surgery. Naraghi et al. found that the quality of life was improved significantly in patients after FESS. FESS should be done with great care especially in those with AFS because in them bone dissolution is common and there is a potential risk of inadvertent penetration into orbit or cranium. Animal studies have shown that even limited surgeries could affect sinus and facial growths. Hence FESS in children should be considered only after weighing the pros and cons of the procedure.

Other more invasive surgical techniques for maxillary sinusitis include antral washout, natural ostotomy, intranasal inferior meatal antrostomy (INA, nasoantral window), middle meatal antrostomy, Caldwell-Luc's operation (intraoral maxillary antrostomy), and uncinectomy (with or without endoscope and with or without maxillary antrostomy). All of these operations have their own indications, limitations, and problems. Natural ostotomy and INA have been compared in rabbits and found to have similar outcome results. Such comparisons unfortunately have not been studied in humans or children. Endoscopic middle meatal antrostomy has been shown to be better for maxillary sinusitis compared to the Caldwell-Luc operation. Mycetomas and fungal balls in chronic rhinosinusitis also often require surgical debridement. Intranasal antifungals have been studied and found to be of benefit for fungal chronic sinusitis; however, Cochrane analysis has shown no significant usefulness of topical or systemic antifungals over placebo for chronic sinusitis. Balloon sinuplasty is a new procedure in which ostia are dilated with the help of balloons. It could be tried before FESS for those who fail to respond to medical treatment and have minimal anatomic findings on CT scan. A comparative outcome analysis of FESS alone versus balloon catheter sinuplasty in pediatric CRS revealed that both have similar outcomes, but antibiotics were required significantly lesser in the balloon catheter sinuplasty group.

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Management of complications

Intra orbital and intracranial complications are common in chronic sinusitis, and fungal sinusitis and with cystic fibrosis and immunodeficient states. Meningitis, abscess, and cavernous sinus thrombosis may occur. Sinusitis may extend to adjacent tissues and cause adenoiditis, serous or purulent otitis media, laryngitis, and dacryocystitis. Osteomyelitis and mucocele formation are also noted. Hospitalization and intravenous antibiotics may be required for treatment of these complications. Resistance rates are higher in complicated cases and culture-targeted antimicrobial therapy may be more beneficial for early resolution of symptoms. Prolonged course of antibiotics for 4–6 weeks may be necessitated in them. Cerebral venous thrombosis needs anticoagulation. Nasal decongestants and steroids and nasal saline irrigation may be required for a longer time in such patients even after cessation of antimicrobial therapy. Pollutants, irritants, and allergens in the environment increase symptoms and avoidance of them is of benefit. Specific immunotherapy will be advantageous in cases where allergens cannot be avoided. Aggressive management of acute attacks will preserve mucosal integrity and ciliary function. Dental management for odontogenic sinusitis should be performed and children with sinusitis-associated HSP should be managed appropriately.

Prevention

As a general rule, prevention of risk factors can help avoid development of rhinosinusitis. These include environmental pollutants including tobacco smoke, repeated colds and upper airway infections, daycare centre attendance, nasal allergies, and anatomical aberrations. These should be managed on a war footing in order to avoid their development into rhinosinusitis. Acute attacks of rhinosinusitis should be optimally managed to prevent progress to chronicity. Prevention of adhesion and inhibition of quorum signalling may diminish biofilm formation and its associated problems of nonresponse to medical line of treatment. Influenza and pneumococcal vaccines could also lead to fall in upper airway infections and hence rhinosinusitis. Swimming in pools with high chlorine content may also worsen mucosal swelling and lining. Hence care should be taken at such places. Frequent plane flyers may also see worsening of symptoms with flights and precautions during such flights may help.

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Conclusion

Rhinosinusitis is an upper airway infection with chronic implications. Prompt management of acute cases would prevent cases slipping into chronicity with resistant polymicrobial infections. Management of chronic rhinosinusitis is an expensive, long-term affair with high likelihood of complications. Hence prevention and control of rhinosinusitis will assist in decreasing morbidity and lessen the burden on healthcare expenditure. Achieving sinonasal eutrophism and efficient mucociliary transport is the keystone to sinus health and reduction of recurrences.