Clinical consensus statement: pediatric chronic rhinosinusitis

Evaluation of balloon sinuplasty for the treatment of pediatric chronic rhinosinusitis

PURPOSE OF REVIEW

This year marks 10 years from the publication of the clinical consensus statement on pediatric chronic rhinosinusitis (CRS). Balloon sinuplasty did not meet criteria for consensus at that time because there was insufficient evidence on its efficacy and safety. The purpose of this review is to summarize the current evidence on balloon sinuplasty treatment for pediatric CRS.

RECENT FINDINGS

Balloon sinuplasty is not a cost-effective measure compared to adenoidectomy and endoscopic sinus surgery (ESS). In the pediatric population, benefits include short operative time, reduced tissue manipulation, and potential for decreased antibiotic courses. Alternatively, balloon dilation has increased equipment costs and there is a lack of robust prospective data that fully elucidates balloon sinuplasty's role in the management of pediatric CRS.

SUMMARY

Pediatric otolaryngologists should continue to perform first-line adenoidectomy and consider ESS based on imaging and other validated clinical scoring systems. Balloon sinuplasty has not yet been proven as an effective treatment for pediatric CRS and further large-scale investigations are required to overcome its lack of cost-effectiveness.

Biologic Therapy in Pediatric Chronic Rhinosinusitis: A Systematic Review

OBJECTIVE

Provide clinicians with current evidence for biologic therapy in children with chronic rhinosinusitis with nasal polyposis (CRSwNP).

DATA SOURCES

PubMed, MEDLINE, Cochrane, and clinical trial registries.

REVIEW METHODS

Key search terms related to biologic therapy in pediatric CRSwNP were identified via a structured query of current medical literature and clinical trial databases.

CONCLUSIONS

There is a dearth of active clinical trials and research studies for biologics targeting pediatric CRSwNP. There is an ongoing compassionate-use clinical trial involving Dupilumab for children with nasal polyps as well as only 1 published work specifically focused on Dupilumab for pediatric CRSwNP in the setting of aspirin-exacerbated respiratory disease.

IMPLICATIONS FOR PRACTICE

For children with atopic dermatitis, asthma, and chronic idiopathic urticaria, biologic therapies such as Omalizumab, Dupilumab, and Mepolizumab have gained Food and Drug Administration approval. The role of biologic therapy in pediatric CRSwNP demonstrates significant promise in the comprehensive management of the unified airway. Additional Phase III trials are necessary to broaden clinical indications for children with comorbid conditions and complex sinonasal disease.

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

[Pediatric chronic rhinosinusitis]

Pediatric chronic rhinosinusitis (PCRS) differs from adult chronic rhinosinusitis (CRS) in several aspects. The confrontation with the environment takes place in the growing sinus system, and the immune system is also developing. The inflammatory mechanisms differ to some extent from those of adult CRS patients. The adenoid vegetations play an important role, particularly during the first 6 years of life. Other pathogenetic aspects are important (e.g., asthma, gastroesophageal reflux disease, immunodeficiency). Genetically determined systemic diseases such as cystic fibrosis cause specific challenges in diagnostics and treatment already in childhood. Consistent conservative therapy is often successful, but surgical procedures that have been proven to be effective and associated with few complications are also increasingly used.

Pediatric chronic rhinosinusitis

PURPOSE

An up-to-date overview of diagnosis, differential diagnosis, comorbidities, and current medical and surgical management of pediatric chronic rhinosinusitis (PCRS).

METHODS

Review of current evidence-based literature on PCRS.

RESULTS

Diagnosis of PCRS seems to be improving based on recent evidence using nasal endoscopy as well as computed tomography scanning. Recent literature supports the fact that chronic adenoiditis can be an independent etiology of symptoms of chronic sinusitis, that are very similar to chronic adenoiditis. Allergic rhinitis and immune deficiency play important roles in the management of PCRS. Surgery for PCRS has evolved significantly in the last 15-20 years to include adenoidectomy as well as endoscopic sinus surgery.

CONCLUSIONS

PCRS is very common in children causing poor QOL for these children. Medical management remains the main stay of treatment with attention to management of co-morbidities that may contribute to the disease severity. Making the correct diagnosis will help with the choice of surgical intervention if medical management fails.

Predictors of Success of Adenoidectomy in the Treatment of Pediatric Chronic Rhinosinusitis

Objectives: There is consensus for adenoidectomy as treatment of chronic rhinosinusitis (CRS) in children younger than 6 years but less consensus for those aged 6 years and older. The present clinical research study investigated predictors of adenoidectomy success for pediatric CRS. Methods: A retrospective chart review was conducted for 107 children who presented to an otolaryngology clinic and had an adenoidectomy for CRS after failure of maximal medical therapy. Results: The majority of sample was male (N = 63; 58.9%) with mean age of 4.88 (SD = 2.54) and mean Lund-Mackay score of 7.76 (SD = 3.87). Patients who had success with adenoidectomy were older on average [mean (M) = 5.46; SD = 2.83] than patients who failed the procedure (M = 4.36; SD = 2.40; F = 4.06, P = .047). This equated to 67.9% of children aged 6 years and older and 39.2% of children younger than 6 years succeeding with the surgery. Conclusions: Adenoidectomy is a good first-line surgery for children aged 12 years and younger, especially in the 6 to 12 years group which had a high rate of success with 68% experiencing remission of symptoms after surgery.

Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia

INTRODUCTION

Cough is the most common symptom leading to medical consultation. Chronic cough results in significant health care costs, impairs quality of life, and may indicate the presence of a serious underlying condition. Here, we present a summary of an updated position statement on cough management in the clinical consultation.

MAIN RECOMMENDATIONS

Assessment of children and adults requires a focused history of chronic cough to identify any red flag cough pointers that may indicate an underlying disease. Further assessment with examination should include a chest x-ray and spirometry (when age > 6 years). Separate paediatric and adult diagnostic management algorithms should be followed. Management of the underlying condition(s) should follow specific disease guidelines, as well as address adverse environmental exposures and patient/carer concerns. First Nations adults and children should be considered a high risk group. The full statement from the Thoracic Society of Australia and New Zealand and Lung Foundation Australia for managing chronic cough is available at https://lungfoundation.com.au/resources/cicada-full-position-statement.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

Algorithms for assessment and diagnosis of adult and paediatric chronic cough are recommended. High quality evidence supports the use of child-specific chronic cough management algorithms to improve clinical outcomes, but none exist in adults. Red flags that indicate serious underlying conditions requiring investigation or referral should be identified. Early and effective treatment of chronic wet/productive cough in children is critical. Culturally specific strategies for facilitating the management of chronic cough in First Nations populations should be adopted. If the chronic cough does not resolve or is unexplained, the patient should be referred to a respiratory specialist or cough clinic.

[Acute and chronic rhinosinusitis age characteristics]

Children's and adults' rhinosinusitis are two diseases that have both similarities and differences in anatomy, epidemiology, causes, pathogenesis, diagnosis and treatment. At the same rhinosinusitis is one of the most common in otorhinolaryngology's practice, both in children and adults. The of adults paranasal sinuses (PNS) anatomy differs from children's PNS anatomy. Although ostiomeatal complex occlusion is recognized as a major cause of poor ventilation and drainage of the adult paranasal sinuses, it does not have a strong effect on pediatric rhinosinusitis, but adenoids play a key role. Adenoids are bacteria and biofilms reservoirs that cause chronic refractory rhinosinusitis regardless of pharyngeal tonsil size. The prevalence of chronic rhinosinusitis (CRS) is lower in children than in adults. Diagnosis of children's rhinosinusitis is more difficult because nasal cavity endoscopic examination is performed rarely due to the occasional need of general anesthesia during the procedure. Moreover, it's necessary to take into account prevailing etiological role of viruses in ARS at children's age and chronic adenoiditis often accompanies pediatric CRS, which requires attention prescribing medical therapy as the basis of rhinosinusitis treatment. The DysheLORz based on Pelargonium sidoides roots is highly effective and safe for children's and adults ARS and CRS treatment, both as monotherapy and in combination with topical steroids and antibiotics. This herbal medicine immunomodulatory effect is mediated mainly by stimulating the production of TNF-α, IL-1, IL-12 and IFN-γ. It activates macrophages and improves their phagocytic activity. IL-12, together with TNF-α, enhances NK and cytotoxic CD8+ lymphocytes' activity against infected cells. IL-12 effect on Th1 lymphocytes maturation provides a link between innate and adaptive immunity. This is also increasing MCP-1, IP-10 and MIP-1β chemokines synthesis and decreasing MIP-1α, ENA-78, GROα and IL-8 production in PNS and nasal mucosa. This leads to decrease of neutrophils chemotaxis to the inflammation site, and decline of serine proteases concentration (neutrophils main enzymes), that increases mucous membrane epithelial barrier permeability, reducing bacterial infections risk. Additionally, Pelargonium sidoides increases epithelial cells beating cilia frequency and inhibits hemagglutinin and neuraminidase present on influenza virus surface. The drug increases antimicrobial peptides production as defensins, human neutrophil peptides (HNP) and bactericidal permeability-increasing protein (BPI), which is also important for rapid inflammation regression in rhinosinusitis. It causes bacterial adhesion to epithelial cells inhibition, phagocytosis stimulation, nitric oxide (NO) release and oxidative burst. The medicine had a direct effect on Streptococcus pneumoniae, Staphylococcus aureus, Neisseria, Moraxella catarrhalis and Haemophilus influenza. Based on these data, it is possible to explain the high effectiveness and safety of the drugs based on Pelargonium sidoides in ENT organs inflammation treatment, for both adults and children over 1 year old.

Changes in Pre- and Post-adenoidectomy Bacterial Profile in Children With Chronic Rhinosinusitis

OBJECTIVE

We aimed to investigate the difference between the bacterial profiles of the nasal cavities and adenoid surfaces of children with chronic rhinosinusitis (CRS). We also intended to determine and analyze the potential correlation between the pre- and post-adenoidectomy differences in the nasal bacterial profile and clinical prognosis.

METHODS

The clinical information of pediatric patients was collected. All the children underwent adenoidectomy (with or without tonsillectomy), and swab samples were collected during the operation. Visual analog scales (VAS) were used at 3, 6, and 12 months postoperatively. At the 12-month follow-up examination, swab samples were collected again. PCR amplification was performed of the v3-v4 variable regions of 16S rRNA of the collected specimens, as well as high-throughput sequencing using the Illumina platform. The species information was obtained by OTUs clustering, species annotation, and α-diversity analysis.

RESULTS

Twenty-two male and eight female pediatric patients were included in the investigation The most abundant genus level bacterial representatives on the nasal surface before adenoidectomy were Moraxella catarrh, Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus, whereas on the surface of adenoids, they were Streptococcus pneumonia, Haemophilus influenza, Nucleobacter, and Moraxella catarrhalis. One year postoperatively, the bacteria with the highest abundance on the nasal surface at the genus level were Moraxella catarrhalis, Streptococcus pneumonia, Staphylococcus aureus, and non-culturable Dolosigranulum. One year postoperatively, the bacterial richness in the nasal cavity was significantly higher than at baseline (P < .05). Furthermore, the subjective nasal score of all children significantly decreased at 3, 6, and 12 months postoperatively (P < .01).

CONCLUSION

The preoperative bacterial abundance of the nasal cavity and the adenoid surfaces was similar, showing a clear correlation. No single specific bacterium was established to be a dominant species associated with the development of CRS in children. The post-adenoidectomy bacterial richness in the nasal cavity was significantly increased, which may be closely related to the relief of postoperative sinusitis symptoms.

Clinical and Genetic Characterization of Patients with Primary Ciliary Dyskinesia in Southwest Saudi Arabia: A Cross Sectional Study

BACKGROUND

Primary ciliary dyskinesia (PCD, MIM 244400) is an inherited ciliopathy disorder characterized by recurrent sinopulmonary infections, subfertility, and laterality defects. The true incidence of PCD in Saudi Arabia is not known, but it is likely underdiagnosed due to the high prevalence of consanguineous marriages. In this study, we aim to study the clinical and genetic characteristics of PCD patients in the southwestern region of Saudi Arabia to provide guidance to clinicians and researchers studying PCD.

METHODS

This was a cross-sectional study conducted between 2019 and 2023 in Abha Maternity and Children's Hospital. Twenty-eight patients with clinically diagnosed PCD were recruited. The diagnosis of PCD was confirmed via whole-exome sequencing.

RESULTS

A total of 28 patients from 20 families were identified and recruited for this study. The median age of patients was 7.5 years (IQR = 3, 13 years). The people of different sexes were evenly distributed, and 18 patients (64%) had neonatal respiratory distress (NRD). The median age of diagnosis was 5.5 years (IQR = 2, 11 years), while the age when the first symptoms appeared was 3 months old (IQR = 1, 6 months). The prevalence of a chronic wet cough, chronic rhinosinusitis, ear infections were 100% (n = 28), 78.6% (n = 22), and 67.9% (19), respectively. The most common gene in our study was DNAH5, which represented 17.9% (five out of twenty-eight) of the cases. Furthermore, the remaining pathogenic variants included: 14.3% with RSPH9 in four individuals (three families), 14.3% with DNAI2 in four individuals (two families), and 10.7% with LRRC56 in three individuals (one family). The most common findings on the chest CT scans were consolidation (seen in all patients), mucus plugging (seen in 95%), and bronchiectasis (seen in 77%). In the patients with bronchiectasis, the most commonly affected lobes were the right lower lobe (88%) and left lower lobe (76%). The patients with PCD and situs inversus were more likely to experience NRD than the patients with PCD and situs solitus. The median PICADAR score in the patients with PCD and situs inversus (median: 11.5; Q1: 10-Q3: 12.5) was significantly higher compared to those with PCD and situs solitus (median: 7.5; Q1: 5.8-Q3: 8) (U = 10.5; p < 0.001).

CONCLUSION

This study provides preliminary data on the clinical and genetic characteristics of PCD patients in the southwestern region of Saudi Arabia. We found that DNAH5 and RSPH9 genes were the most common genes among the studied population. Furthermore, PCD should be considered for each child with early NRD and laterality defects, and further confirmatory tests are recommended. These findings also highlight the need for greater awareness of the disease in daily clinical practice to facilitate early diagnosis and avoid irreversible lung damage.

Nasal Nitric Oxide in Children: A Review of Current Outreach in Pediatric Respiratory Medicine

Nasal nitric oxide (nNO) is a gas synthesized by the inducible and constitutive NO synthase (NOS) enzyme in the airway cells of the nasal mucosa. Like lung nitric oxide, it is thought to be associated with airway inflammation in various respiratory diseases in children. The aim of our review was to investigate the current state of use of nNO measurement in children. A comprehensive search was conducted using the Web of Science and PubMed databases specifically targeting publications in the English language, with the following keywords: nasal NO, children, allergic rhinitis, chronic rhinosinusitis, acute rhinosinusitis, primary ciliary dyskinesia (PCD), and cystic fibrosis (CF). We describe the use of nNO in pediatric allergic rhinitis, chronic rhinosinusitis, acute rhinosinusitis, PCD, and CF based on the latest literature. nNO is a noninvasive, clinically applicable test for use in pediatric allergic rhinitis, chronic rhinosinusitis, acute rhinosinusitis, PCD, and CF. It can be used as a complementary method in the diagnosis of these respiratory diseases and as a monitoring method for the treatment of allergic rhinitis and acute and chronic rhinosinusitis.

Otorhinologic Disorders in 22q11.2 Deletion Syndrome

OBJECTIVE

Investigate incidence and natural history of otologic and sinonasal disease associated with 22q11.2 deletion syndrome.

STUDY DESIGN

Case series.

SETTING

Tertiary care children's hospital.

METHODS

Charts from consecutive children born 2000 to 2018 with a diagnosis of 22q11.2 deletion, DiGeorge, or velocardiofacial syndrome based on the International Classification of Diseases (ICD)-9 and ICD-10 codes were reviewed. Otologic and rhinologic diagnoses and surgeries and immune and microbiologic laboratory findings were collected from the medical record.

RESULTS

After the exclusion of patients with no 22q11.2 deletion (n = 101), otologic care at an outside hospital (n = 59), and loss to follow-up prior to 3 years of age (n = 22), 128 were included. Males comprised 80 (62.5%) patients, 115 (89.8%) were white, and the median age at genetic confirmation of 22q11.2 deletion was 119 days (range 0 days to 14.6 years). Recurrent acute otitis media (RAOM), chronic otitis media with effusion, chronic rhinosinusitis, and recurrent acute sinusitis were diagnosed in 54 (42.2%), 37 (28.9%), 10 (7.8%), and 8 (6.3%), respectively. Tympanostomy tubes were placed in 49 (38.3%). Adenoidectomy and sinus surgery were performed in 38 (29.7%) and 4 (3.1%), respectively. Neither immunoglobulin nor cluster of differentiation deficiency increased the odds of RAOM diagnosis, tympanostomy tube placement, or chronic/recurrent sinusitis. Methicillin-resistant Staphylococcus aureus was the most common organism in sinus cultures (4/13, 30.8%). Streptococcus pneumonia dominated otorrhea cultures (11/21, 52.4%).

CONCLUSION

Approximately half of children with 22q11.2 deletion may experience otologic disease that often requires surgical management. Future studies will utilize a larger cohort to examine the role of immunodeficiency in otologic and rhinologic disease in this population.

A Rare Case of Chronic Rhinosinusitis With Elevated Levels of Immunoglobulin G4

Chronic rhinosinusitis is a condition characterized by inflammation of the paranasal sinuses causing several symptoms, including facial pain, anosmia, nasal drainage, and obstruction for a minimal duration of three months. It is a commonly occurring disease and is diagnosed through direct visualization or the detection of inflammation on a CT scan. A mucosal tissue biopsy typically reveals stromal fibrosis and an increase in submucosal glands, and infiltration of mixed mononuclear cells, neutrophils, and eosinophils may also be present but typically makes up less than 10% of the total cells. T helper type 2 releasing cytokines, interleukins (IL-5 and IL-13), as well as histamine, are frequently found in high concentrations in polyp tissue. We report a case of rare chronic rhinosinusitis. The patient's specimen shows a very high number of immunoglobulin G4 (IgG4)-positive plasma cells.

Development of an optimized preoperative computed tomography imaging checklist for endoscopic sinus surgery utilizing a systematic review of the literature and the modified Delphi method

BACKGROUND

Critical review of computed tomography (CT) imaging is essential in preoperative planning for endoscopic sinus surgery. In this study, we used a systematic review and a modified Delphi method to develop a comprehensive checklist that facilitates preoperative review of sinus CT imaging.

METHODS

We performed a systematic review of PubMed, Embase, CINAHL, Cochrane, and Web of Science databases to identify existing checklists developed to evaluate sinus CT imaging. An inclusive list of items from these checklists was compiled and a modified Delphi methodology was used to assign ranked priority. The Delphi process involved 14 rhinologists and had three phases: an initial survey with Likert priority (scale of 1-9) and two rounds of live discussions followed by survey to confirm consensus.

RESULTS

Ninety-seven possible checklist items were identified from a systematic review and panelist input. On initial survey, 63 items reached a consensus score of 7+, and 13 items had near consensus scores between 6 and 7; two of these 13 borderline items were retained after subsequent panelist discussion. The resulting items were consolidated into an 11-item disease checklist and a 24-item anatomical checklist; the anatomical checklist was further divided into six subsections: nasal cavity, maxillary, ethmoid, sphenoid, frontal, skull base, and orbit. Additionally, panelists identified six core aspects of patient history to consider prior to surgery.

CONCLUSIONS

After establishing content validity through a systematic literature review and a modified Delphi method, we developed a comprehensive checklist for preoperative sinus CT imaging review; implementation and evaluation of validity among trainees will suggest overall utility.

Naturopathic Management of Acute Pediatric Respiratory Infections: A Modified Delphi Study

Objective: Both the United Nations and the World Health Organization have identified antimicrobial resistance as a significant threat to global health. The Centers for Disease Control and Prevention identified five pediatric respiratory conditions as requiring particular scrutiny in terms of antibiotic stewardship. This study sought to identify strategies used by experienced naturopathic practitioners to treat acute respiratory infections in children. The authors theorize that naturopathic strategies safely fill the gap between watchful waiting and antibiotic prescription, thus reducing the use of antibiotics. Methods: Naturopathic practitioners in Canada, the United States, and Australia with a minimum of 5 years of experience in clinical naturopathic care of children were recruited for a modified Delphi study. A 14-person panel of practitioners was selected to complete a series of four iterative surveys assessing agreement to statements in five domains of knowledge/attitudes, assessment/diagnosis, management, monitoring, and education. Items were deemed to have reached consensus if they reached a predetermined threshold of 70% agreement, or failed to reach a threshold of 40% agreement. Items between these boundaries were modified and retested until either consensus was reached or the four surveys had been completed. Results: Results yielded a large degree of agreement on core naturopathic approaches to the management of acute pediatric respiratory infections, especially lifestyle strategies, including adequate rest and dietary recommendations. The use of vitamins C and D was strongly supported, as were herbs, particularly echinacea and elderberry. Some hydrotherapy and topical applications specific to the individual focus on infection also reached consensus. Results suggested that most respondents, even if they have the authority to prescribe antibiotics, rarely deem it necessary to do so. Conclusion: Findings of this study provide (1) clarity on the role of naturopathic doctors in the management of pediatric health concerns and the stewardship of antibiotics; and (2) initial guidance to less experienced naturopathic practitioners. The findings also identify key priorities for research into the safety and effectiveness of naturopathic interventions to reduce the unnecessary prescribing of antibiotics.

Histopathologic differences between adult and pediatric patients with chronic rhinosinusitis

BACKGROUND

Adult and pediatric patients with chronic rhinosinusitis (CRS) may have differing philosophies in therapeutic management. Few studies have examined sinonasal tissue-level comparisons of these groups. This study examines histopathologic differences between children and adults with CRS, with the goal of understanding disease pathogenesis and optimizing medical management for both populations.

METHODS

In a retrospective cohort of CRS patients who underwent functional endoscopic sinus surgery (FESS), demographic factors, pertinent comorbidities, and a structured histopathologic report of 13 variables were compared across pediatric and adult CRS patients with and without nasal polyps (pCRSwNP, pCRSsNP, aCRSwNP, aCRSsNP, respectively).

RESULTS

A total of 378 adult (181 aCRSsNP, 197 aCRSwNP) and 50 pediatric (28 pCRSsNP, 22 pCRSwNP) patients were analyzed. Significantly more children compared with adults had a comorbid asthma diagnosis (64.5% vs. 37.2%, p = 0.003). Adults with CRS exhibited significantly more tissue neutrophilia (28.9% vs. 12.0%, p = 0.006), basement membrane thickening (70.3% vs. 44.0%, p < 0.001), subepithelial edema (61% vs. 30.0%, p < 0.001), squamous metaplasia (22.0% vs. 4.0%, p < 0.001), and eosinophil aggregates (22.8% vs. 4.0%, p < 0.001) than children with CRS. The majority (66.5%) of adult CRS patients exhibited a lymphoplasmacytic-predominant inflammatory background, whereas the majority (57.8%) of children with CRS exhibited a lymphocyte-predominant inflammatory background.

CONCLUSIONS

Sinonasal tissue of adult and pediatric CRS patients demonstrates clear histopathologic differences. Our findings provide insight into differing pathophysiology, which may enable optimization of targeted therapies for patients in each of these unique clinical groups.

The use of SN-5 to differentiate chronic rhinosinusitis and chronic adenoiditis in children

BACKGROUND

Chronic adenoiditis (CA) and chronic rhinosinusitis (CRS) present with similar symptoms, but an accurate diagnosis is critical for optimal treatment. We aim to differentiate CRS and CA based on sinonasal symptoms using the Sinus and Nasal Quality of Life Survey (SN-5) in children.

METHODS

This is a retrospective cohort study. Children (age 12 and younger) presenting with chronic sinonasal symptoms were divided into 2 groups based on CT scan sinus findings: CA group included patients with CT Lund-Mackay (LM) score <5 and CRS group included patients with CT LM score of 5 and more. SN-5 scores for each group were then compared, and both groups were compared to a control group. Other demographic data were also collected and analyzed.

RESULTS

There were 27 patients in the CA group, 42 patients in CRS group and 38 patients in the control group. Mean SN-5 scores were 2.03±0.71 for the control group, 3.49±1.00 for the CA group, and 4.53±0.77 for the CRS group (p < 0.0001); Statistical significance persisted when CA and CRS were compared in subset analysis (p < 0.0001). CT LM score was 2.70±2.07 for the CA group and 9.94±3.46 for the CRS group (p < 0.0001). Rates of asthma, allergic rhinitis, and smoke exposure differed between the three groups (p < 0.01), but they were not statistically different when CA and CRS were compared in subset analysis.

CONCLUSION

Children with CRS have higher SN-5 score than children with CA. SN-5 score can be used to help otolaryngologists differentiate between these two clinical entities.

Cystic Fibrosis Foundation otolaryngology care multidisciplinary consensus recommendations

BACKGROUND

Cystic fibrosis (CF) is a multisystem disease that often requires otolaryngology care. Individuals with CF commonly have chronic rhinosinusitis but also present with hearing loss and dysphonia. Given these manifestations of CF, otolaryngologists are frequently involved in the care of patients with CF; however, there is limited consensus on optimal management of sinonasal, otologic, and laryngologic symptoms.

METHODS

The Cystic Fibrosis Foundation convened a multidisciplinary team of otolaryngologists, pulmonologists, audiologists, pharmacists, a social worker, a nurse coordinator, a respiratory therapist, two adults with CF, and a caregiver of a child with CF to develop consensus recommendations. Workgroups developed draft recommendation statements based on a systematic literature review, and a ≥80% consensus was required for acceptance of each recommendation statement.

RESULTS

The committee voted on 25 statements. Eleven statements were adopted recommending a treatment or intervention, while five statements were formulated recommending against a specific treatment or intervention. The committee recommended eight statements as an option for select patients in certain circumstances, and one statement did not reach consensus.

CONCLUSION

These multidisciplinary consensus recommendations will help providers navigate decisions related to otolaryngology consultation, medical and surgical management of CF-CRS, hearing, and voice in individuals with CF. A collaborative and multidisciplinary approach is advocated to best care for our patients with CF. Future clinical research is needed utilizing standardized, validated outcomes with comprehensive reporting of patient outcome, effects of modulator therapies, and genetic characteristics to help continue to advance care, decrease morbidity, and improve the quality of life for individuals with CF.

Chronic and Recurrent Sinusitis in Children, as Manifestation of Immune Dysfunction and Atopic Background

Rhinosinusitis in children, as in adults, can be classified by duration (acute, recurrent, and chronic) and by cause (viral, bacterial, and inflammatory) and needs to be treated accordingly after careful investigation which include through clinical history, laboratory tests, and, if necessary, nasal endoscopy and imaging studies.

Effectiveness of pediatric nasal irrigation solution with or without xylitol

OBJECTIVES

/Hypothesis: The aim of this study was to compare the efficacy and outcome of daily hypertonic saline irrigation versus saline/xylitol for treating pediatric chronic rhinosinusitis (CRS).

STUDY DESIGN

This was a prospective, randomized, single-blinded study.

METHODS

One hundred and twenty-five children diagnosed with CRS were enrolled in this study. The patients were randomized to twice-daily hypertonic irrigations with saline or saline/xylitol for 6 weeks. The treatment outcomes were measured using: Sinonasal Quality of Life Survey (SN-5) completed at baseline and after 6 weeks of irrigation.

RESULTS

There were statistically significant improvements in the hypertonic nasal saline group's (reduction in SN-5 domain scores) four domains and an increase in the overall QoL score within each group after 6 weeks of treatment compared to baseline; however, there were no differences in the activity limitation (p = 0.1803). The xylitol solution groups had no differences between the two groups in the SN-5 scores in any of the domains or the overall score at baseline, and post irrigation treatment.

CONCLUSIONS

Due to low tolerance, compliance, and the side effects, xylitol irrigation is not recommended as a first-line treatment for pediatric CRS. The use of a large volume of low pressure, twice-daily intranasal hypertonic irrigation for 6 weeks is safe and effective in the treatment of pediatric CRS; therefore, it can be used as a baseline treatment for pediatric CRS before considering surgical interventions.

Epidemiology of Chronic Rhinosinusitis: Prevalence and Risk Factors

Knowledge of chronic rhinosinusitis (CRS) epidemiology may directly impact patient care: aiding patient identification and establishing accurate diagnosis as well as informing treatment decisions. The objective of this review is to summarize the current evidence on the epidemiology of CRS, with a focus on prevalence and risk factors. Although the presence of either symptoms or objective findings alone have yielded CRS prevalence estimates of over 10%, the presence of both-consistent with guideline-based diagnostic criteria for CRS-has suggested that the true prevalence of CRS is consistently less than 5%, with approximately one-third of patients with CRS having nasal polyps, in epidemiologic studies from around the world. In comparison, the prevalence of CRS endotypes-pathophysiologic subclassification of CRS most commonly as related to type 2 or non-type 2 inflammation-has been found to vary significantly by region. The epidemiology of CRS is modified and ultimately determined by risk factors: genetic/hereditary, demographic, environmental, and imparted by predictive pre-/comorbid disease. The understanding of these epidemiologic relationships may help the provider to optimally identify and understand each individual's CRS disease process, thereby improving both diagnosis and treatment.

Frontal Balloon Sinuplasty in Complicated Acute Pediatric Rhinosinusitis (ARS)

Utilization of frontal balloon sinuplasty in pediatric complicated acute rhinosinusitis (ARS) is demonstrated to be a safe and expedient alternative to other procedures such as trephination or functional endoscopic sinus surgery (FESS) in this case series. We performed a retrospective review of six pediatric cases of frontal balloon sinuplasty for ARS with intracranial complications at a tertiary academic center. Patients underwent unilateral (n = 5) or bilateral dilation (n = 1) in addition to functional endoscopic sinus surgery (FESS) including anterior ethmoidectomy (n = 5) and maxillary antrostomy (n = 6). This technique effectively addressed frontal sinus obstruction and served as an alternative to procedures such as trephination or functional endoscopic sinus surgery. No immediate or short-term complications of balloon dilation were observed in these cases. A larger cohort and extended follow-up are necessary to determine the use and long-term impact of this technique.

Headache Diagnosis in Children and Adolescents

Pediatric headache is a common medical complaint managed across multiple subspecialties with a myriad of unique factors (clinical presentation and disease phenotype) that make accurate diagnosis particularly elusive. A thorough understanding of the stepwise approach to headache disorders in children is essential to ensure appropriate evaluation, timely diagnosis, and efficacious treatment. This work aims to review key components of a comprehensive headache assessment as well as discuss primary and secondary headache disorders observed in children, with a particular focus on clinical pearls and "red flag" symptoms necessitating ancillary diagnostic testing.

Epidemiology and Management of Orbital Cellulitis in Children

BACKGROUND

The epidemiology of orbital cellulitis likely has evolved due to the emergence of methicillin-resistant Staphylococcus aureus (MRSA) and the adoption of pneumococcal conjugate vaccination. In the absence of published guidelines, management is highly variable. We characterized epidemiology and management over an 11-year period.

METHODS

A retrospective cohort study of children 0 to 21 years of age with orbital cellulitis +/- subperiosteal orbital abscess hospitalized at a large quaternary children's hospital from January 2008 to June 2018. We reviewed charts for demographic characteristics, clinical features, management, and outcomes. Using multivariable logistic regression, we evaluated predictors of surgical intervention and assessed whether corticosteroid use or antibiotic duration was related to clinical outcomes.

RESULTS

Among 220 patients, methicillin-susceptible S. aureus was the most common organism (26.3%), with MRSA found in only 5.0%. Rates of vancomycin use fluctuated annually from 40.9% to 84.6%. Surgery was performed in 39.5% of the patients. Corticosteroids, used in 70 patients (32.1%), were unrelated to treatment failure (n = 9), defined as persistent signs and symptoms or initial clinical improvement followed by worsening (P = .137). The median antibiotic duration was 17 days (interquartile range 14-26). After controlling for age, gender, proptosis, eye pain with movement, eyelid swelling, neutrophil count, and corticosteroid use, treatment failure was not significantly associated with receipt of ≥ 3 weeks of antibiotic therapy (8/84, 9.5%) compared with > 2 but < 3 weeks (0/51, 0.0%) or ≤ 2 weeks (1/85, 1.2%) (adjusted odds ratio = 5.83 for ≥ 3 vs ≤2 weeks; 95% confidence interval: 0.58, 59.0).

CONCLUSIONS

Although MRSA was rare, empiric vancomycin use was high. Treatment failure was uncommon in patients who received ≤ 2 weeks of therapy, suggesting that shorter durations are adequate in some patients.

Pediatric Rhinosinusitis

Rhinosinusitis is a common diagnosis encountered by providers of all disciplines. Pediatric acute and chronic rhinosinusitis account for up to 2% of the total annual visits to the outpatient clinics and emergency departments. Once correct diagnosis is made, appropriate treatment measures can be initiated. It is important to recognize rhinosinusitis in children due to the potential serious complications and the impact it may have on quality of life of those children. Medical management is the mainstay of treatment, and, fortunately, it is successful in most of those children. When medical management fails, or a complication occurs, surgery may be required.

Tonsillectomy and Adenoidectomy - Pediatric Clinics of North America

Tonsillectomy and adenoidectomy are among the most commonly performed major pediatric operations in the United States, with more than 500,000 procedures performed annually. This procedure can be performed with or without adenoidectomy. These procedures were traditionally performed for recurrent tonsillitis; however, the vast majority of tonsillectomies are currently performed for obstructive symptoms. When performed for appropriate indications, tonsillectomy and adenoidectomy can greatly improve a child's quality of life and general health. Given the prevalence of these conditions and subsequent surgical procedures, evidence-based recommendations are regularly evaluated and updated. As such, familiarity with these guidelines is necessary for pediatric practitioners. This review summarizes the indications, complications, and outcomes for tonsillectomy and adenoidectomy, as well as provides a brief overview of operative techniques.

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.

A National Analysis of Inpatient Pediatric Adenoidectomy

OBJECTIVE

Hospital admission following pediatric adenoidectomy without tonsillectomy is not well characterized. The objective of our study is to better characterize risk factors for post-operative complications in younger children undergoing inpatient adenoidectomy.

METHODS

A cross-sectional analysis using data derived from the Kid's Inpatient Database (KID) was performed. Study participants included children <3 years of age who underwent an adenoidectomy and were admitted to hospitals participating in the KID for years 1997, 2000, 2003, 2006, 2009, and 2012. Descriptive statistical analysis and a multivariate logistic regression analysis were performed to identify risk factors for post-operative complication.

RESULTS

A total of 3406 children (mean age 1.1 ± 0.7 years) were included. The overall post-operative bleeding and respiratory complication rates were 0.6% and 5.4%, respectively. Children less than 18 months of age demonstrated increased rates of post-operative respiratory complications (P = .009), but not bleeding complications (P = .857). Presence of cardiopulmonary congenital malformations (OR 1.54, 95% CI 1.07-2.20), chronic respiratory disease of the newborn (OR 5.03, 95% CI 2.86-8.85), and neuromuscular disorders (OR 1.97, 95% CI 1.09-3.57) were associated with post-operative respiratory distress.

CONCLUSIONS

This analysis of a national dataset suggests that otherwise healthy children less than 18 months of age and children 18 months to 3 years of age with certain comorbidities may benefit from overnight observation following adenoidectomy.

Precision Medicine in Chronic Rhinosinusitis: Where Does Allergy Fit In?

Chronic rhinosinusitis (CRS) is a clinical syndrome stemming from persistent inflammation of the sinonasal mucosa. Phenotypically, it is traditionally and widely described according to the presence or absence of polyps. While this distinction is simple to use, it has little bearing on prognosis and treatment, for CRS is essentially an inflammatory disease resulting from dysregulated interaction between a multitude of host and environmental factors. Allergy is merely one of them and, like many of the proposed aetiologies, has been subject to much debate which will be discussed here. As our understanding of CRS continues to evolve, previous so-called conventional wisdom about phenotypes (e.g. CRS with nasal polyps is associated with Type 2 inflammation) is being challenged, and new phenotypes are also emerging. In addition, there is growing interest in defining the endotypes of CRS to deliver precise and personalised treatment, especially pertaining to the development of biologics for the group of severe, difficult-to-treat CRS patients. A proposed model of precision medicine tailored to management of CRS will also be introduced to readers, which can be continually modified to adapt to new discoveries about this exciting condition.

Long-term, low-dose macrolide antibiotic treatment in pediatric chronic airway diseases

Macrolide antibiotics are one of the most commonly used broad-spectrum antibiotics. They have an inhibitory effect on a variety of respiratory pathogens; besides, they have non-anti-infective effects, including anti-inflammatory, regulating airway secretion, immune regulation, and other effects. A growing number of studies have shown that the non-anti-infective effects of macrolides have important and potential value in the treatment of pediatric chronic airway diseases; the therapy was described as "long-term, low-dose usage"; unfortunately, there is no guideline or consensus that applies to children. To better carry out the mechanism and clinical research of non-anti-infective effect and promote its rational use in children, the authors summarize the evidence of the usage of long-term, low-dose macrolide antibiotic therapy (LLMAT) in the treatment of chronic airway diseases in children and the progress in recent years. IMPACT: This review summarizes the evidence (mostly in recent 5 years) of the usage of long-term, low-dose macrolide antibiotic therapy in the treatment of chronic airway diseases. The recent studies and guidelines support and enrich the point that long-term, low-dose macrolide antibiotic therapy has potential benefit for children with severe asthma, CF, non-CF bronchiectasis, and BO, which provides clinical references and is of clinical interest. Long-term, low-dose macrolide antibiotic therapy has good safety, and no serious events have been reported; however, potential cardiac side effects and macrolide resistance should be clinically noted.

Health-Related Quality of Life Assessed in Children with Chronic Rhinitis and Sinusitis

INTRODUCTION

Quality of life (QoL) can be simply defined as an area of human life that directly affects people which they consider to be important. This can be defined in greater detail as 'an individual perception of an individual's life position within a cultural context, value system and in relation to their tasks, expectations and standards determined by environmental conditions'. The health-related quality of life (HRQoL) more specifically focuses on how the QoL affects health (including both medical and non-medical issues). Limitations in well-being will, by association, also occur in those children suffering with sinus diseases.

STUDY AIM

To compare the quality of life in children-adolescents suffering from some of the most commonly occurring childhood diseases of chronic rhinitis and sinusitis on a group of healthy children-adolescents. Test materials and methods: Subjects were children-adolescents with at least one of the aforementioned conditions afflicting the upper respiratory tract. Admission criteria were: ages 5 to 18 years in the presence of a chronic disease such as chronic rhinitis and paranasal sinusitis. The Child Health Questionnaire-Parent Form 50 CHQ-PF-50 (CHQ-PF50) was used, which is a general-purpose research instrument based on psychometric testing designed for assessing physical and mental well-being in children-adolescents aged 5 to 18 years.

RESULTS

Wellbeing significantly deteriorated in sick children within the following areas: current health status of the child (STAND), physical fitness (PF), social functioning resulting from behaviour or emotional state (REB), the impact of physical health on limitations in social functioning (RP), pain and discomfort (BP), behaviour (BE), mental health (MH), self-esteem (SE), general health perception (GH), influence of the child's health condition on parental emotions (PE), limitations on parental leisure time due to the child's health (PT) and restrictions on joint family activities (FA).

CONCLUSIONS

The greatest impairment to well-being in children with chronic rhinitis and paranasal sinusitis was on the impact of the child's health status on parents' emotions, pain and discomfort and general perception of health. This study confirms that parents of healthy children attach great importance to their health and health-related quality of life.

A follow-up study of mucociliary clearance and trace element and mineral status in children with chronic rhinosinusitis before and three months after endoscopic sinus surgery

BACKGROUND

The existing data demonstrate the potential role of trace elements in nasal mucociliary clearance, although the association between trace element and mineral status and ciliary function in children with chronic rhinosinusitis is insufficiently studied. Therefore, the objective of the present study is evaluation of trace element and mineral status and mucociliary function in pediatric CRS patients before and after functional endoscopic sinus surgery.

METHODS

The present study involved 30 children with chronic rhinosinusitis without nasal polyps. During this follow-up the patients were examined preoperatively (point 0), underwent functional endoscopic sinus surgery, and were repeatedly examined at three months postoperatively (point 1). At both points the patients were subjected to quality-of-life assessment using SNOT-20 questionnaire; endoscopic and computer tomography examination of the nasal sinuses; evaluation of ciliary function and mucosal cytology using high-speed videomicroscopy; assessment of blood count and inflammatory markers; as well as analysis of trace element and mineral levels in whole blood, serum, and hair using inductively-coupled plasma mass-spectrometry.

RESULTS

The obtained data demonstrate that endoscopic sinus surgery significantly improved sinonasal pathology in children with chronic rhinosinusitis, as evidenced by significantly reduced Lund-Mackay, Lund-Kennedy, and SNOT-20 scores. At the same time, no significant improvement of ciliary functions or mucosal cytology was observed postoperatively. Trace element status assessment demonstrated that postoperative serum Zn, whole blood Mg and Cu were significantly lower as compared to preoperative values. In contrast, serum Mn and Cr, as well as whole blood Cr and hair Se were characterized by a significant increase at three months postoperatively. Multiple linear regression analysis demonstrated that serum Zn is significantly associated with the number of ciliated cells and cell viability, whereas serum Mn and whole blood Cu concentrations are inversely associated with cell viability and ciliary length, respectively. Hair Se was found to be associated with the number of neutrophils in the mucosa biopsy.

CONCLUSION

Redistribution of trace elements and minerals may at least partially mediate prolonged recovery of mucosal ciliary function in children with chronic rhinosinusitis in three months after functional sinus surgery, although the particular mechanisms of these alterations in trace element levels are to be discovered.

Choosing Wisely Canada - pediatric otolaryngology recommendations

The Choosing Wisely Canada campaign raises awareness amongst physicians and patients regarding unnecessary or inappropriate tests and treatments. Using an online survey, members of the Pediatric Otolaryngology Subspecialty Group within the Canadian Society of Otolaryngology – Head & Neck Surgery developed a list of nine evidence based recommendations to help physicians and patients make treatment decisions regarding common pediatric otolaryngology presentations: (1) Don’t routinely order a plain film x-ray in the evaluation of nasal fractures; (2) Don’t order imaging to distinguish acute bacterial sinusitis from an upper respiratory infection; (3) Don’t place tympanostomy tubes in most children for a single episode of otitis media with effusion of less than 3 months duration; (4) Don’t routinely prescribe intranasal/systemic steroids, antihistamines or decongestants for children with uncomplicated otitis media with effusion; (5) Don’t prescribe oral antibiotics for children with uncomplicated tympanostomy tube otorrhea or uncomplicated acute otitis externa; (6) Don’t prescribe codeine for post-tonsillectomy/adenoidectomy pain relief in children; (7) Don’t administer perioperative antibiotics for elective tonsillectomy in children; (8) Don’t perform tonsillectomy for children with uncomplicated recurrent throat infections if there have been fewer than 7 episodes in the past year, 5 episodes in each of the past 2 years, or 3 episodes in each of the last 3 years; and (9) Don’t perform endoscopic sinus surgery for uncomplicated pediatric chronic rhinosinusitis prior to failure of maximal medical therapy and adenoidectomy.

Efficacy of Adenoidectomy for the Management of Chronic Rhinosinusitis in Children Older Than 7 Years of Age

OBJECTIVES

While adenoidectomy is the first-line surgical management of chronic rhinosinusitis (CRS) in young children, evidence regarding its utility in older children is lacking. This study aimed to assess the efficacy of adenoidectomy in children 7 to 18 years old with regard to symptom control, postoperative medication use, and the need for additional surgery.

METHODS

Single-institution retrospective chart review of patients ages 7 to 18 undergoing adenoidectomy for CRS from 2009 to 2019. Patients with cystic fibrosis and ciliary disorders were excluded. Comorbidities, preoperative and postoperative symptoms (rhinorrhea, congestion, anosmia, and facial pain), medication use (antibiotics, antihistamines, nasal steroids, and irrigations), and Lund-Mackay scores were extracted. McNemar's or Wilcoxon Rank Sum Tests were used to assess rates of symptom control and medication use. Fisher's exact or Chi-square tests were used to assess for factors associated with symptom persistence.

RESULTS

Ninety-seven patients with a mean age of 9 years (range 7-18) were identified. Patients were shown to experience significantly decreased rates of rhinorrhea (64.9% vs 20.6%, <.001), congestion (95.9% vs 26.8%, <.001), facial pain (17.5% vs 3.1%, .001), use of nasal steroids (79.4% vs 36.1%, <.001), antihistamines (47.4% vs 20.6%, <.001), and number of antibiotics (median 1 vs 0, <.001) after adenoidectomy. No patient or disease factors were associated with symptom persistence. Nine patients (9.3%) required additional nasal surgery.

CONCLUSION

In this cohort of older children with CRS with limited follow up, additional surgery is not routinely done following adenoidectomy, the results suggest that adenoidectomy alone may provide adequate symptom control and medication reduction.

Complete manuscript title: Neurological complications from sinugenic orbital cellulitis

INTRODUCTION

This study was undertaken with an aim to identify any common factors or trends among patients of orbital cellulitis that developed neurological complications.

METHODS

A 24-month retrospective review of patients was undertaken to include those showing clinical deterioration and neurological complications on radiological imaging, after being treated for orbital cellulitis at Manchester Royal Eye Hospital. The study specifically looked at the site of orbital collection, sinus involvement, types of neurological complications and whether these were detected at initial presentation, surgical input and microbiology findings.

RESULTS

Nine patients (9/26) developed associated neurological complications during the study period. (February 2018 and January 2020) This included subdural empyema in six patients; leptomeningeal enhancement in two and septic emboli in one patient. All the patients had associated significant pan-sinusitis at initial presentation. Neurological complications were detected in three patients at the time of admission and after clinical deterioration and further investigations in the rest.

CONCLUSION

A superior orbital abscess and Streptococcus mileri infection had higher risk of neurological complications. It is worth debating whether patients with chronic sinusitis who develop orbital cellulitis need earlier surgical input rather than a conservative treatment. Patients who fail to improve clinically need to be re-imaged to look for possible neurological complications.

Effects of the Traditional Mediterranean Diet in Childhood Recurrent Acute Rhinosinusitis

Introduction: There are more and more studies that demonstrate the anti-inflammatory effects of the traditional Mediterranean diet (TMD). The aim of the study was to assess the effects of an intervention with the TMD in patients with recurrent acute and chronic rhinosinusitis. Material and Methods: We performed a pretest–posttest comparison study in 114 patients (56 girls and 58 boys) aged one to five years who had three or more acute rhinosinusitis episodes in the period of 1 year. They were included for a year in the nutritional program “Learning to eat from the Mediterranean”. The anthropometric, clinical, and therapeutic characteristics were studied. Results: All the studied indicators showed a positive and statistically significant evolution. Of the patients, 53.5% did not have any episode of acute rhinosinusitis, and 26.3% had only one, compared to the 3.37 they had on average in the previous year. The use of antibiotics decreased by 87.6%. The degree of satisfaction of the families was very high. The Mediterranean Diet Quality Index (KIDMED) that assesses the quality of the TMD rose from 7.7 to 11 points. Conclusions: The adoption of the TMD could have promising effects in the prevention and treatment of recurrent acute and chronic rhinosinusitis, limiting the pharmacological and surgical intervention in many of these patients.

The management of paediatric rhinosinusitis

Paediatric rhinosinusitis (PDRS) is commonly used as a synonym for rhinitis within healthcare. Although they may share common symptoms, the pathophysiology does differ; PDRS is the inflammation of the nasal mucosa in addition to the sinuses whereas rhinitis is the inflammation of just nasal mucosa. This review provides a comprehensive overview of the epidemiology, pathophysiology, symptoms, diagnosis and management of PDRS. There is a greater emphasis on the diagnosis and management of PDRS within this review due to a lack of clear guidelines, which can lead to the common misconception that PDRS can be treated indifferently to rhinitis and other upper respiratory conditions. PDRS has detrimental effects on children's current health, long-term health into adulthood and education. Therefore, having a comprehensive guide of PDRS would provide a greater understanding of the condition as well as improved diagnosis and management. This article primarily focuses on the position of Europe and the United Kingdom; however, the recommendations can be applied to other countries as the causes and treatments would not differ significantly.

Identification of Risk Factors for Coexisting Sinusitis and Inflammatory Bowel Disease

Background

This study aimed to analyze the association of coexisting sinusitis and inflammatory bowel disease (IBD), establish significant factors involved in their development, and enable further biological correlation between these 2 diseases.

Methods

The IBD and Sinusitis Study at UChicago Medicine (TISSUe) is a retrospective, single-center study. We reviewed patients to confirm IBD and chronic sinusitis diagnoses. Case-control propensity score matching was performed using matched controls with IBD only or sinusitis only. Statistical methods included chi-squared test and Wilcoxon rank sum test. Logistic regression analysis was performed, and factors were considered significant if P &lt; .05.

Results

Stratifying 214 patients with coexisting IBD and sinusitis, 176 patients had IBD first and 38 patients had sinusitis first. Multivariable analysis of factors associated with subsequent disease with matched controls determined that duration of disease, UC, steroid exposure ever, and younger age of IBD diagnosis were associated with subsequent sinusitis in patients with IBD; steroid exposure ever and duration of sinusitis were significantly associated with subsequent IBD in patients with sinusitis.

Conclusion

This study suggests that IBD maintenance therapies are not associated with increased risk of sinusitis, as proposed by adverse events in clinical trial data; rather, UC diagnosis and duration of disease may be more influential in sinusitis development. While further studies are necessary, this study also demonstrates that sinusitis precedes IBD in some patients, probing its biological association with IBD and possible classification as an extraintestinal manifestation.

Drug delivery to the pediatric upper airway

Pediatric upper airway disorders are frequently life-threatening and require precise assessment and intervention. Targeting these pathologies remains a challenge for clinicians due to the high complexity of pediatric upper airway anatomy and numerous potential etiologies; the most common treatments include systemic delivery of high dose steroids and antibiotics or complex and invasive surgeries. Furthermore, the majority of innovative airway management technologies are only designed and tested for adults, limiting their widespread implementation in the pediatric population. Here, we provide a comprehensive review of the most recent challenges of managing common pediatric upper airway disorders, describe the limitations of current clinical treatments, and elaborate on how to circumvent those limitations via local controlled drug delivery. Furthermore, we propose future advancements in the field of drug-eluting technologies to improve pediatric upper airway management outcomes.

Ciliary function and sinonasal mucosal cytology in pediatric patients with chronic rhinosinusitis during a year after functional endoscopic sinus surgery

BACKGROUND

The objective of the study is evaluation of ciliary function and mucosal cytology after endoscopic sinus surgery in children with chronic rhinosinusitis (CRS).

METHODOLOGY

A total of 132 children with CRS who underwent endoscopic sinus surgery, as well as 15 healthy controls were involved in the study. In this follow-up study patients were examined preoperatively, as well as 3, 6, 9, and 12 months after endoscopic sinus surgery. Assessment of ciliary function and sinonasal mucosal cytology was performed using high-speed videomicroscopy. Lund-Kennedy, Lund-Mackay, and sinonasal outcome test 20 (SNOT20) scores were also evaluated.

RESULTS

Total SNOT-20, Lund-Mackay, and Lund-Kennedy values significantly decreased after sinus surgery. In contrast, ciliary function and mucosal cytology only tended to improve after 6 months. 9 months after surgery the number of ciliated cells, ciliary beat frequency, cell viability, and ciliary length were significantly higher than preoperatively. The most significant improvement of ciliary function and cell height was observed 12 months after operation, whereas epithelial dystrophy and neutrophil infiltration were significantly reduced.

CONCLUSIONS

Substantial improvement was observed only in a year after surgery, whereas 0 to 3 months after the surgery ciliary function was severely impaired thus predisposing to recurrent sinusitis or other complications.

French translation and validation of the Sinus and Nasal Quality of Life Survey (SN-5) in children

PURPOSE

Chronic rhinosinusitis (CRS) is a frequent, quality-of-life (QOL) impairing disease in pediatrics. The SN-5 is a reliable, sensitive and reproductible QOL questionnaire, validated in English for evaluation of CRS disease-specific QOL in children. This study aims to adapt and validate the French version of this test.

METHODS

The SN-5 score was adapted into French language through a forward-backwards translation process, and validated through a monocentric prospective controlled study. Inclusion criteria were 2-12 years of age, CRS symptoms for at least 12 weeks, or absence of sino-nasal symptom for controls. Reproducibility was assessed through Spearman's correlation between initial answers and a re-test conducted 15 days later. Internal consistency was measured through Cronbach's alpha, construct validity through Spearman's correlation between items, discriminative ability through Mann-Whitney tests.

RESULTS

40 patients and 37 controls filled the score between November 2019 and March 2020. Retest was returned by 35 patients and 35 controls. Mean cases age was 8.5 ± 2.6 years old. 26 patients had primary CRS, 10 had cystic fibrosis, 4 had ciliary dyskinesia. All had diffuse disease. Mean SN-5 overall score was 3.63/7 ± 6.4 for CRS patients and 1.89/7 ± 0.9 for controls (p < 0.001). Test-retest coefficient was 0.84 (0.70-0.92; p < 0.001), Cronbach's alpha was 0.83 for CRS patient. Item per item construct validity was good to excellent.

CONCLUSIONS

The French version of the SN-5 showed good statistical properties, with good test-retest reliability, internal consistency, structural validity and discriminative ability between CRS and control patients.

Serum, Whole Blood, Hair, and Mucosal Essential Trace Element and Mineral Levels in Children with Verified Chronic Rhinosinusitis Undergoing Functional Endoscopic Sinus Surgery

The objective of the present study was to assess hair, serum, whole blood, and excised tissue essential element content in children with chronic rhinosinusitis (CRS). Eighty-eight children with chronic rhinosinusitis and 66 healthy controls were enrolled in the present study. Evaluation of endoscopic Lund-Kennedy and computed tomography Lund-Mackay scores, as well as tissue sampling, was performed only in children with chronic rhinosinusitis. Assessment of Sino-Nasal Outcome Test-20 (SNOT-20) scores was performed in both cases and controls. Hair, whole blood, blood serum, and excised mucosal tissue (only in patients) analysis was performed using inductively coupled argon plasma mass-spectrometry. The obtained data demonstrate that whole blood Ca, Mg, Se, and Zn, as well as hair Ca, Cu, Mg, and Zn levels in the examined patients were significantly lower as compared with the control values. Only serum Zn concentration in children with CRS exceeded the respective control values, whereas serum Cu levels only tended to decrease in CRS. In turn, hair Fe content in children with CRS exceeded that in healthy controls. Regression analysis demonstrate that hair Ca levels, as well as whole blood Ca, Se, and Zn concentrations, were considered as negative predictors, whereas increased hair iron level was significantly directly associated with CRS. Significant associations between hair, serum, whole blood, and tissue element levels and Lund-Kennedy and Lund-Mackay scores were also revealed. Generally, the obtained data demonstrate that chronic rhinosinusitis is associated with impaired essential metal levels in pediatric patients with chronic rhinosinusitis. The observed alterations may contribute to CRS pathogenesis through modulation of mucociliary clearance, immunity, inflammatory response, and redox environment.

Extraesophageal signs of gastroesophageal reflux disease: otorhinolaryngologist’s view

The data on association between various pathologies of the ENT organs and gastroesophageal reflux disease (GERD) is analysed in the article. The variety of extraesophageal signs of GERD in children and adults is given, what is advisable to inform physicians of different specialties about the possibilities of antireflux therapy. These options are expanded with the emergence of a unique new drug, Alfasoxx. Its bioadhesive formula is based on hyaluronic acid and chondroitin sulphate thereby protecting the esophageal mucosa. Alfasoxx acts on the surface of the esophageal mucosa without penetrating into the systemic bloodstream and it also has a low allergenic potential, which has been confirmed by numerous studies. With its healing and repairing effect on erosive lesions of the esophageal epithelium, Alfasoxx in combination with proton pump inhibitors is more effective in achieving regression of clinical manifestations of the disease and improving patients quality of life (according to SF-36 questionnaire) compared to proton pump inhibitors monotherapy.

Comparative clinicopathological aspects of chronic tonsillitis and adenoiditis in children

Chronic palatal and nasopharyngeal inflammations are common lesions in pediatric pathology, with major effects on children’s development. The study included 34 cases of chronic tonsillitis and adenoiditis for which we quantified immunohistochemically and analyzed the distribution of inflammatory elements in the follicular, extrafollicular and epithelial compartments, in relation to the composite histological scores and the clinico-epidemiological profile of the lesions. The cases were more frequent under the age of 10, in female patients, coming from urban areas, with the diagnosis of tonsillitis. B-lymphocytes have been associated with follicular areas in tonsillitis and epithelial areas in adenoiditis. In all compartments, T-lymphocytes were more frequently associated with tonsillitis and plasma cells associated with adenoiditis. Macrophages and dendritic cells had a relatively uniform distribution for the three compartments in all cases. The results obtained indicate different inflammatory phenotypes for chronic tonsillitis and adenoiditis, an aspect that may be useful for stratifying patients for optimal therapy.

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.

Clinical and Radiologic Characterization of Frontal Sinusitis in the Pediatric Population

INTRODUCTION

Frontal sinusitis in the pediatric population is a disease that has not been thoroughly studied or characterized. The goals of this study are to characterize the clinical presentation, radiologic variables, treatment modalities, complications, and prognosis associated with acute and chronic frontal sinus disease in the pediatric population.

METHODS

IRB-approved retrospective cohort study of pediatric patients who were diagnosed with acute (AFS) or chronic frontal sinusitis (CFS) and underwent frontal sinus surgery at a tertiary level Children's Hospital from 2006 to 2016. Patients with AFS were compared to patients with CFS. Statistical analysis completed using chi-square test or Fisher's exact test, statistical significance set at P < .05.

RESULTS

A total of 19 patients with AFS and 15 patients with CFS were analyzed. There was a male predominance in AFS and female predominance in CFS (P < .05).AFS patients were less likely to have allergies, prior sinus disease, or significant comorbidities (P < .05).Additionally, AFS patients presented with constitutional, neurologic, and ocular symptoms. The CFS group had predominantly sinonasal symptoms. CT-scan analysis showed that AFS patients had higher prevalence of complex frontal anatomy (Type-II cells, concha bullosa) compared with CFS patients (P < .05). Culture results were positive in 78% of the AFS group, with S. Anginosus (53%), Anaerobes (20%), and normal flora (17%). In the CFS group cultures were positive in 60% of the patients, 56% grew normal flora, 13% H. Influenzae, 6.5% Pseudomonas, and 24.5% other species. CFS patients were more likely to have persistent sinus disease and require repeat sinus procedures (P < .05).

CONCLUSION

There are 2 distinct presentations of frontal sinus disease in the pediatric population. Patients with AFS vary significantly from those with CFS. Males, ages 13 to 18 years old, who cultured positive for S. Anginosus (former S.Milleri) dominated the AFS subgroup. Whereas as female patients with a history of allergic rhinitis and muco-cilliary disease were more prominent in the CRS subgroup. Correct identification and understanding of these 2 different entities are crucial for the appropriate short and long-term patient management.

Otolaryngologic Management of Chronic Cough in School-aged Children: A Review

Importance

The causes of pediatric chronic cough are numerous and span across several medical subspecialties. In addition to the vast array of underlying causes, there are also several different ways to approach and evaluate chronic cough. Given the frequency with which children present to otolaryngology clinics with this problem, a review of common otolaryngologic causes and an algorithm for evaluation and treatment can be beneficial.

Observations

The primary 3 causes of pediatric chronic cough presenting to an otolaryngologist include infectious causes, reflux, and airway hyperreactivity. In these cases and other instances of specific cough, treatment should be directed at the underlying cause-which may include supportive care, antibiotics, antireflux medication, bronchodilators, inhaled steroids, or other intervention. Patients with nonspecific cough should be treated according to pediatric-specific cough algorithms.

Conclusions and Relevance

Appropriate workup and treatment of chronic cough can lead to higher cure rates, shorter cough duration, and improved quality of life for both patients and caregivers. A systematic approach using cough algorithms can help otolaryngologists effectively manage this common yet complex problem.

Efficacy and safety of paranasal sinus balloon catheter dilation in pediatric chronic rhinosinusitis: a systematic review

Objective

Chronic rhinosinusitis (CRS) negatively affects quality of life (QoL), and balloon catheter sinuplasty (BCS) has shown good outcomes in adult patients. However, there has not been much research on the effects of BCS on pediatric patients. The objective of this review is to systematically assess the literature for studies demonstrating the effectiveness and safety of BCS in pediatric CRS patients.

Data sources

PubMed, Embase and Cochrane Library.

Study selection

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations (PRISMA) to conduct our study. Observational- and interventional-based studies reporting efficacy and/or side effects of BCS among pediatric populations were included. Efficacy was evaluated by clinically reliable measures including Sino-Nasal 5 (SN-5) QoL scale. Antibiotic usage and revision surgery were also evaluated.

Data extraction

Articles were screened, and data were obtained. Study design, sample size and demographics, treated sinuses, criteria of inclusion, adjunct procedure(s), follow-up time, and outcomes measured were reported.

Main findings

Out of 112 articles identified, 10 articles were included: two interventional controlled trials and eight observational studies. All studies evaluating QoL by SN-5 showed a remarkable reduction in SN-5 score postoperatively. Improvement in the computed tomography (CT) and endoscopic findings for up to 1 year after operation was reported. Furthermore, the majority of patinets treated with BCS did not recieve any course of sinusitis-indicated antibiotics during long-term follow-up, and they had low surgical revision rates. Minor side effects were reported, most commonly synechia.

Conclusion

Available evidence suggests that BCS is safe and effective for the treatment of CRS in pediatric patients. Future randomized controlled studies with large sample size are warranted. Such studies can further determine the efficacy of BCS in managing children with CRS.