International Journal of Pediatric Otorhinolaryngology 77 (2013) 13831384

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International Journal of Pediatric Otorhinolaryngology

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Evolution of guidelines for pediatric rhinosinusitis

A B S T R A C T

Rhinosinusitis is a prevalent disorder in the pediatric population. Unfortunately, during the past two
decades, guidelines related to denitions, diagnostic procedures and management have been much more
focused on adult than on pediatric rhinosinusitis. First consensus document on management of pediatric
rhinosinusitis was published in 1998, followed by several documents related only to acute
rhinosinusitis. The most extensive consensus document on rhinosinuistis, including pediatric
rhinosinusitis, is European position paper on rhinosinusitis and nasal polyps, EPOS, updated in 2012.
2013 Elsevier Ireland Ltd. All rights reserved.

Rhinosinusitis is a prevalent disorder in the pediatric popula-
tion. It is diagnosed according to characteristic symptoms and
clinical signs. However, overlapping does occur with some other
upper respiratory airway disorders. Radiological studies of
children thought to have just a common cold, allergic or non-
allergic rhinitis, have shown that a majority of children were
actually suffering from rhinosinusitis too. Pediatric rhinosinusitis
is similar to that as seen in adults, however, children have specic
clusters of symptoms. Purulent rhinorrhea and cough are more
common and headache and hyposmia are less common symptoms
than in adults. Unfortunately during the past two decades
guidelines related to denitions, diagnostic procedures and
management have been much more focused on adult than on
pediatric rhinosinusitis.
The International Conference on Sinus Disease: Terminology,
Staging and Therapy, which was held July 1993 in Princeton, began
to develop guidelines for rhinosinusitis. The Consensus meeting in
Brussels in 1996 was the rst to dene the specic features and
management of pediatric rhinosinusitis. The panel published a
brief report in 1998 explaining the terminology, denitions,
classication, diagnosis criteria and treatment for pediatric
rhinosinusitis [1]. The guidelines primarily followed previous
adult protocols. The term rhinosinusitis was considered as a
continuum of the disease as rhinitis and sinusitis in children are
difcult to differentiate solely based on clinical criteria. Classi-
cations of acute and chronic forms were adopted on the basis of
persistent symptoms lasting for more than 12 weeks. The term
subacute mentioned in other reports was avoided. Acute
rhinosinusitis was dened as a sinus infection where resolution
of symptom may take up to 12 weeks. According to its severity, it
was subdivided into severe and non-severe forms. Chronic
rhinosinusitis was dened as a sinus infection with milder
symptoms and signs that persist for more that 12 weeks. The
recogized symptoms were rhinorrhea, nasal congestion cough,
variable headache, facial pain and low grade fever for non-severe
acute rhinosinusitis. Purulent rhinorhea, periorbital edema and
high-grade fever were reserved for severe acute rhinosinusitis. The
document supports clinically based diagnosis, however, it did not
dene which symptoms have to be present for the actual diagnosis.
Imaging and microbiology assessments by sinus puncture were
recommended for the complicated cases. Only two other
diagnostic procedures, i.e. allergy and immunological evaluations
were recommended. Systemic medical treatment with antimicro-
bials was recommended for treating acute and chronic rhinosi-
nusistis. Topical nasal steroid therapy was suggested, by the
consensus panelists, for treating chronic non-purulent rhinosi-
nusitis, especially in allergic children. Proposed surgical inter-
vention included adenoidectomy, antral lavage and endoscopic
surgery. Panel members agreed that surgical management was not
supported by literature, and that it may be indicated in a limited
number of patients which are unresponsive to conservative
medical treatment.
The panel was not trying to reevaluate current evidence for
recommendation within this report. The denitions are in
contradiction, with more recent papers suggesting that rhinosi-
nusitis (in both adults and children) is an inammatory disease,
and not an infection. Infection is obviously involved when causes
inammation in acute rhinosinusitis. Whereas the role of infection
is less clear in the chronic form of the disease. Colonization with
pathogens, common in children, may also obscure the true
pathogenic mechanisms. The next consensus report was published
in 2001, clinical practice guidelines for the management of
sinusitis, as dened by the Subcomittee on Management of
Sinusitis of the American Academy of Pediatrics [2]. This report
described acute, subacute and recurrent rhinosinusitis, and did not
include chronic rhinosinusitis. Despite previous consensus on
terminology in the ENT world, the Subcomittee adopted the term
sinusitis. They explained that rhinosinusitis was a term which
could be used for viral disease. Whereas bacterial sinus disease
was dened as when a patient with an bacterial infection of the
paranasal sinuses has purulent (thick, colored and opaque) nasal
drainage. The site of the bacteial infection is within the paranasal

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1384 Evolution of guidelines for pediatric rhinosinusitis / International Journal of Pediatric Otorhinolaryngology 77 (2013) 13831384
sinuses and the nose acts as a conduit for secretions produced in
the sinuses. This report has offered numerous denitions and
subclassications including acute, subacute, and recurrent bacte-
rial sinusitis where infections of the paranasal sinuses presented as
either persistent or severe symptoms. Persistent symptoms were
those that lasted longer than 10 to 14, but less than 30 days.
Symptoms included nasal or postnasal discharge (any quality),
daytime cough (which may be worse at night), while more severe
symptoms included a fever of at least 39 8C and purulent nasal
discharge, in an apparently ill child lasting 34 days. The report
recognizes viral rhinosinusitis, as a disease which resolves in 10
days or becomes complicated by bacterial infection, also excluding
it from bacterial sinusitis by dening the latter as being persistent
and severe in symptoms. Chronic sinusitis was dened as episodes
of inammation of the paranasal sinuses lasting more than 90 days.
The Subcomittee evaluated all available high quality trials for an
evidence based recommendations. However, the data did not
allow for a formal meta analysis. Rates were pooled across
different studies and data assessed. For the diagnosis of acute
bacterial sinusitis, microbial studies and CT imaging were not
recommended in uncomplicated cases. CT imaging was reserved
only for patients evaluated for surgical intervention. Treatment by
antibiotics were recommended for the management of acute
bacterial sinusitis to achieve a more rapid clinical response (by the
consensus panel based only on clinical experience). It is important
to note, recommendations for the treatment choice was based on
patterns of antimicrobial resistance to the most common agents in
the U.S., which are different from EU antimicrobial resistance.
A recent report by the Infectious Disease Societies of America,
redenes approaches to diagnosis and management of acute
bacterial rhinosinusitis in children and adults [3]. Denitions
recognized persistent, not improving, and severe symptoms, as
well as, those with risk for antibiotic resistance (children age < 2,
prior antibiotics used within past month, previous hospitalization,
comorbidities and immunocompromised). An expected response in
3 to 5 days was needed before changing to a different antimicrobial
class. The choice of antibiotic treatment within this report was also
based on patterns of resistance currently seen in the U.S.
The most extensive reports related to diagnosis and treatment
of rhinosinusitis are EPOS (acronym for European position paper on
rhinosinusitis and nasal polyps) guidelines, published in 2005,
revised in 2007 and 2012 [46]. The EPOS has been developed by a
panel of experts, mostly ENT physicians, who extensively
evaluated denitions for clinical practice and research, evi-
dence-based diagnostic procedures and management. Each report
thoroughly evaluated current knowledge of pathogenesis of
diseases. Each version offers a denition and treatment algorithm
for treating pediatric rhinosinusitis. Their denition of the disease
is based on at least two symptoms and one objective clinical sign.
In the EPOS from 2007 rhinosinusitis in children and adults were
dened as an inammation of the nasal and paranasal passages
characterized by two or more symptoms, one of which was either
nasal blockage, obstruction, congestion or nasal discharge
(anterior or posterior nasal drip), facial pain or pressure, reduction
or loss of smell, conrmed by at least one endoscopic sign or CT
changes [5]. The EPOS in 2012 redened rhinosinusitis in children
by changing reduction or loss of smell with cough, as a more
common symptom seen in the pediatric population. Unlike reports
from the U.S., EPOS in 2005 and 2007 failed to dene acute
bacterial rhinosinusitis. Acute rhinosinusitis was dened as
persistent symptoms lasting up to 12 weeks and was subdivided
into viral and non-viral (2007) or post-viral (2012) [6]. Viral, or the
common cold lasting up to 5 days, while non-viral or post-viral
seem to worsen after 5 days or last longer than 10 days. EPOS 2012
introduced a denition of acute bacterial rhinosinusitis, which
included at least 3 of these symptoms: discolored unilateral and
purulent secretion, severe local pain, fever, elevated ESR/CRP and
worsening of symptoms after short improvement following viral
infection. EPOS 2012 recommended for the treatment of acute
pediatric rhinosinusitis, that antibiotic treatment be only consid-
ered in select cases suggestive of acute bacterial rhinosinusitis.
Topical steroids are recommended for post-viral rhinosinusitis of
moderate severity, while in viral saline irrigation and symptomatic
relief of symptoms are recommended. Predisposing factors should
be evaluated in children with rhinosinusitis, such as allergies and
asthma. Less common predisposing factors like cystic brosis,
primary ciliaria dyskinesia and immunodeciency have received
substantial attention within the EPOS 2012 report. Recent data on
biolm in difcult unresponsive rhinosinusitis was also presented.
The role of adenoids and adenoidectomy in children with chronic
rhinosinusitis was evaluated, as well. The management of younger
children with chronic rhinosinusitis including nasal irrigation
and nasal steroids in milder cases was formulated. Treatment
plans for moderate to severe cases unresponsive to previous
treatments, considered cultures and long term antibiotic therapy.
If still unresponsive, then adenoidectomy should be considered, as
well as, sinus irrigation before considering endoscopic sinus
surgery.
As there is a paucity of high quality controlled trials in children,
evidence based recommendations in the main are unanswered.
Controlled studies are needed to understand the relationship
between colonization and infection, virulence and host responsive-
ness, predisposing factors and comorbidities, and the role of
multiple surgical revisions in difcult to treat patients with
predisposing factors for rhinosinusitis (cystic brosis, PCD, immu-
nodeciency) and many other aspects rhinosinusitis.
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Livije Kalogjera*
Zagreb School of Medicine, ENT/Head and Neck Surgery Department,
University Hospital Centre Sestre Milosrdnice,
Vinogradska 29, 10000 Zagreb, Croatia
*Tel.: +38 3513787450
E-mail address: kalogjera@sfzg.hr (L. Kalogjera)
3 March 2013
14 June 2013
16 June 2013