Pediatric Chronic Rhinosinusitis

Abstract

The goal of this review is to elucidate the pathogenic factors, histopathologic features, and special considerations that relate to pediatric versus adult chronic rhinosinusitis (CRS) and to emphasize differences and similarities between the adult and pediatric conditions. Emphasis is placed on understanding of the differences in pathogenic mechanisms, host-microbial interactions, potential defects in innate antimicrobial immunity, and the role of biofilm formation in pediatric versus adult CRS and how these translate to different approaches toward both medical and surgical management. Pediatric CRS can be viewed as evolving from acute bacterial rhinosinusitis into an uncomplicated "early" stage of CRS, later evolving into a persistent stage and, in some cases, evolving into a late "maladaptive-eosinophilic" stage disease. Given this potential evolution toward more irreversible disease, a plea can be made for improved recognition of and more aggressive early intervention for pediatric CRS, it is hoped, to prevent these long-term consequences. For the primary care physician, this may necessitate enlisting the support of a sinus specialist before the symptoms of CRS have persisted for months or years. It may also necessitate, in some cases, the use of sinus computed tomography imaging to demonstrate that sinus abnormalities have resolved. Other arguments can be made for prompt and comprehensive management of pediatric CRS, including the need to reduce the burden of illness, reduce health care costs, avoid unnecessary antibiotic use and its attendant effects toward promoting antibiotic resistant infections and, potentially, to reduce the development of important comorbidities, e.g., asthma.

Do Adult Forms of Chronic Rhinosinusitis Exist in Children and Adolescents?

“…CRS in the vast majority of children, especially pre-school age, likely starts as viral rhinosinusitis that, without resolution, develops into pediatric infectious CRS [11,12,14]. The natural history of pediatric infectious CRS is unknown, and some small percentage will require surgical intervention.…”

“…Two contemporary articles have presented an integrative approach to the discussion of pediatric chronic rhinosinusitis [11,12]. These two articles have provided brief discussions on additional phenotypes of pediatric CRS beyond its infectious nature.…”

“…Hamilos proposed a scenario where persistent pediatric CRS might evolve into a complex condition, reflecting a potential for a CRSsNP status; however, he further proposed a "maladaptive-eosinophilic" state in a minority of children [11,12].…”

“…Areas of future research include the microbiome of pediatric chronic rhinosinusitis, imaging specificity, alternative antibiotic selection, ancillary therapy, and optimal surgical therapy [11,12,14]. Recent detailed discussions on pediatric CRS was presented by Hamilos and included proposals for the potential route from acute sinusitis to the more chronic state [11,12].…”

“…In brief, there is a good consensus as to the standards for diagnosis, the selection of a first-round antibiotic, and length of treatment, but the therapy for refractory patients and determining the presence of refractoriness is not well defined [12]. Areas of future research include the microbiome of pediatric chronic rhinosinusitis, imaging specificity, alternative antibiotic selection, ancillary therapy, and optimal surgical therapy [11,12,14]. Recent detailed discussions on pediatric CRS was presented by Hamilos and included proposals for the potential route from acute sinusitis to the more chronic state [11,12].…”