September 2019 HSC Section 1 Congenital and Pediatric Problems

Annals of Otology, Rhinology & Laryngology 126(9)

Table 3.  Comparison of Selected Consensus Guideline Statements to Survey Results.

Clinical Consensus Statement (2014)

International Consensus Statement (2016)

ARS Survey Result

ASPO Survey Result

Agree/Disagree

Diagnosis Nasal endoscopy is appropriate in evaluating a child with CRS to document purulent drainage, mucosal edema, nasal polyps, and/or adenoid pathology Medical management Daily saline irrigations are a beneficial adjunctive medical therapy for PCRS Daily topical nasal steroids are a beneficial adjunctive medical therapy for PCRS 20 days of antibiotic therapy may be superior to 10 days (but no consensus that antibiotics should be given for a minimum of 10 days) No consensus that GERD can contribute to PCRS; empiric treatment for GERD is not a beneficial adjunctive medical therapy for PCRS Adenoidectomy Adenoidectomy is effective first-line surgical treatment for children up to 12 y Endoscopic sinus surgery ESS is an effective procedure for PCRS that is best performed after medical therapy, adenoidectomy, or both have failed There is a lack of convincing evidence that ESS for PCRS causes clinically significant facial growth impairment Postoperative debridement after ESS for PCRS is not essential for treatment success Balloon catheter dilation The effectiveness of BCD relative to ESS cannot be determined; no consensus that BCD is safe or effective in children

48% always/almost always use endoscopy for diagnosis, 21% usually do, 26% sometimes do, and 3% rarely/never do

25% always/almost always use endoscopy for diagnosis, 27% usually do, 37% sometimes do, and 12% rarely/never do

Partially agree

Nasal saline irrigations are beneficial, level 1a evidence

90% use nasal saline in initial medical management, 97% in maximal 93% use nasal steroids in initial medical management, 98% in maximal

88% use nasal saline in initial medical management, 93% in maximal 90% use nasal steroids in initial medical management, 96% in maximal

Agree

The efficacy of intranasal corticosteroids is uncertain, but they are recommended as first-line treatment given low risk Empiric treatment transitioned to cultured- directed antibiotics for 3 to 12 weeks is supported Systemic steroid use is supported in select cases based on DBRCT There is a lack of evidence to support the association of GERD with PCRS

Agree

52% use oral antibiotics in initial medical management, 90% in maximal

57% use oral antibiotics in initial medical management, 91% in maximal

Agree

20% use oral steroids in initial medial therapy, 72% in maximal

8% use oral steroids in initial medical therapy, 43% in maximal

Agree for ARS, partially agree for ASPO

12% use anti-reflux medication in initial medical management, 26% in maximal

4% use anti-reflux medication in initial medical management, 26% in maximal

Agree

With Lund Mackay >6, the addition of maxillary sinus irrigation concurrent with adenoidectomy improves clinical symptoms 1 y later

90% include adenoidectomy in initial surgical treatment, 43% perform adenoidectomy alone, 31% concomitantly include sinus lavage, 17% BCD, 17% ESS, and 2% turbinate reduction After initial surgical treatment fails, 85% perform ESS, 20% BCD, 15% sinus lavage, 12% adenoidectomy, 2% septoplasty, 2% turbinate reduction, 5% increase nonsurgical treatments Most perform ESS when indicated, 12% avoid ESS because of concern of facial growth retardation Second-look procedures are not very common; 58% rarely/ never use a second look, 23% sometimes do, 12% usually do, and 7 % always/almost always do

94% include adenoidectomy in initial surgical treatment, 70% perform adenoidectomy alone, 18% concomitantly include sinus lavage, 9% BCD, 8% ESS, and 6% turbinate reduction If initial surgical treatment fails, 88% perform ESS, 17% sinus lavage, 13% BCD, 12% other treatments Most perform ESS when indicated, 4% avoid ESS due to facial growth concern 73% rarely/never employ a second look, 21% sometimes do, 4% usually do, and 2% always/ almost always do 71% rarely/never use BCD, 23% sometimes do, 4% usually do, and 1% always/almost always do; 9% include BCD in initial surgical treatment, and 13% perform BCD if initial surgical management fails

Agree for ASPO, largely agree for ARS

There are roles for ESS in treating PCRS including facilitating irrigation and delivery of topical therapies

Agree

Agree

Agree

BCD does not have robust data supporting efficacy in children

66% rarely/never use BCD, 20% sometimes do, 12% usually do,

Largely agree

and 3% always/almost always do; 17% include BCD in initial surgical therapy, and 20% perform BCD after initial surgical therapy fails

Abbreviations: ARS, American Rhinologic Society; ASPO, American Society of Pediatric Otolaryngology; BCD, balloon catheter dilation; CRS, chronic rhinosinusitis; DBRCT, double blind randomized controlled trial; ESS, endoscopic sinus surgery; GERD, gastroesophageal reflux disease; PCRS, pediatric chronic rhinosinusitis.

Acknowledgment The authors gratefully acknowledge Yifei Ma, MS, for his assis- tance with statistical analysis.

for initial surgical management. Future studies in these areas could help evaluate if either treatment paradigm yields improved outcomes.

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