Chronic Rhinosinusitis in Children: Pathophysiology, Evaluation, and Medical Management

Abstract

Chronic rhinosinusitis as a diagnosis is a conglomeration of multiple phenotypes and endotypes. As such, the diagnosis and management are complex. New survey studies provide some consensus on prevalence and management of this disease in children. In this review, we highlight the differential diagnosis of pediatric CRS, including non-eosinophilic/infectious variants, eosinophilic variants with and without nasal polyps, allergic fungal sinusitis, aspirin-exacerbated respiratory disease, primary immunodeficiency, and disorders of mucociliary clearance. Further, we detail treatment options that should be considered. Finally, we feature emerging potential treatment options of CRS, including anti-immunoglobulin E, interleukin-5, and interleukin-4 receptor alpha subunit.

Pediatric Chronic Rhinosinusitis: Unmet Needs

“…Reviews and consensus statements on diagnostic modalities are recently summarized by Heath et al [4] and Chandy et al [12]. An otolaryngology focused consensus statement was published in 2014 [15].…”

“…These manuscripts provide perspective on the diagnostic modalities in chronic rhinosinusitis in children; however, the radiology issues, limitations, radiation effects, and cost have been a constant theme for years [4,12,15,16]. The reviews do not support use of standard radiography of paranasal sinuses in children (Waters view) due to sensitivity and specificity issues (as compared to computerized tomography (CT)) [4,12,15], or the confusion of plain films with upper respiratory tract infection edema [12]. Plain radiography (waters view only) has limitations of sensitivity and specificity (as compared to CT) [16], and further details of the history of sinus radiological assessment has been reviewed [10].…”

“…Interestingly, the sinus radiography showed strong associations with the disease activity, in the first (Version 1) of two study groups [41]. A review of the questions shows over-lap with clinical correlates to acute sinusitis, but also clinical connectivity to chronic sinusitis, such as cough (day or night) or stuffy nose [1,4,5,7,42]. Cough is debated in some reviews, however [42].…”

“…A reasonable place to initiate this discussion is a list of the manuscripts on pediatric rhinosinusitis (CRS) in the recent past, which will serve as backdrop to the lingering issues in pediatric CRS [1][2][3][4][5][6][7][8][9][10][11][12].…”

The Role of the Adenoids in Pediatric Chronic Rhinosinusitis

“…As the PCRS definition states, CT is the gold standard for imaging when establishing a PCRS diagnosis or preparing for sinus surgery, particularly a non-contrasted CT with axial, coronal, and sagittal views. The sensitivity and specificity of plain radiographs, such as a lateral soft tissue neck X-ray evaluating the adenoids, are limited in evaluating the patient’s need for adenoidectomy [10,11]. According to the AAO-HNS consensus on appropriate use of CT imaging, it is recommended in patients with PCRS when medical management and/or adenoidectomy have failed to control symptoms [11].…”