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Orlandi et al.

TABLE XIII-2 Aggregate grade of evidence for studies on contributing factors for pediatric ARS Contributing Factor Impact of Factor

Grade of Evidence

Allergic Rhinitis

Tendency of the aggregate studies to suggest a contribution of AR to ARS, with reservation based on study limitations Coexistence of ARS and adenoiditis, difficult to distinguish

C (Level 3: 2 studies; level 4: 2 studies)

Adenoiditis

C (Level 3: 1 study) C (Level 4: 2 studies)

Immune Function

Some evidence of immune defects in RARS

RARS, recurrent ARS; AR, allergic rhinitis.

as defined by ICD-9 codes. The authors identified a cohort of children with newly diagnosed allergic rhinitis between 2000 and 2012 and compared them to a matched cohort without such a diagnosis. They followed the children until a diagnosis of ARS was made or until the date of the last outpatient visit. In this large cohort of 43,588 patients, the overall incidence of ARS in the allergic cohort was 111.8 per 1000 person-years, significantly higher than 33.9 per 1000 person-years in the non-allergic control cohort. Most of the available studies suffer from some limitations, which include referral bias (conducted in allergy practices), fail ure to distinguish positive skin tests from clinical allergic disease, and making the diagnosis of ARS based on diag nostic codes. Adenoiditis. Adenoiditis in children can have a very similar clinical presentation to ARS, including anterior and posterior purulent drainage and cough, and is part of the differential diagnosis. In an attempt to differen tiate between adenoiditis and ARS based on endoscopic findings, Marseglia and colleagues performed a cross sec tional study of 287 consecutive children in whom ARS was suspected based on symptoms lasting for more than 10 days. 2300 The diagnosis of ARS was made if purulent discharge was identified in the OMC or sphenoethmoidal recess on nasal endoscopy, and the diagnosis of adenoidi tis was made if there was purulent drainage over the ade noids. Based on those criteria, ARS was confirmed in 89.2% of the patients; it was isolated in 80.8% and coupled with adenoiditis in 19.2%. Adenoiditis alone was confirmed in 7% of the cohort. Combined involvement of the sinuses and adenoids was more frequent in younger patients (2 5 years age group), whereas isolated ARS was more fre quent in older children. These data suggest a correlation between pediatric adenoiditis and ARS, although the dif ferentiation between these diagnoses based on clinical pre sentation alone is difficult. Immune Abnormalities. Veskitkul and colleagues ret rospectively reviewed the records of 94 children presenting with RARS between 2010 and 2012. 489 The most common predisposing factor for RARS was immunoglobulin G sub class deficiency (78.7%), followed by NAR (64.9%) and AR (35.1%). A similar single-center retrospective study exam ined the prevalence of abnormal results on immunologic testing in pediatric patients with RARS. 2301 There were

variable results in the 10 patients with RARS. Among the relevant results were high IgE in 2 patients, and low, non protective, S. pneumonia titers in 4/10 patients.

XIII.A.3 Pediatric ARS: Diagnosis Pediatric ARS is a common problem in children. 31,32,2290 and is defined as the onset of 2 or more of the following symptoms: nasal blockage/ obstruction/congestion, dis colored nasal discharge, or cough (daytime and nighttime) for < 12weeks. 26,31,2290 Because these symptoms are similar to those of a viral URI, there is a strong relation between URIs and ARS. The clinical diagnosis of pediatric ARS can be made in the following situations. Post-viral RS is defined as URI symptoms persisting for more than 10 days, or an abrupt increase in severity of symptoms after an initial improve ment (known as double sickening). Pediatric ARS can also present as the acute onset of 2 or more signs and/or symptoms: discolored nasal discharge with unilateral predominance, purulent secretions, severe local pain with unilateral predominance, fever ( > 38 ◦ C), elevated ESR/CRP, or “double sickening,” which is the worsening of clinical status after initial improvement. The clinical diagnosis of ARS in children is challenging as symptoms are often subtle and the history may be lim ited to a caregiver’s observations of the child. When eval uating a child with suspected ARS, there is a wide differ ential diagnosis including acute viral RS, acute post-viral RS, intranasal foreign body, adenoiditis, and structural anatomic pathology such as choanal atresia/stenosis. The initial diagnostic work-up for such patients should include a thorough history and physical examination, including nasal endoscopy when appropriate. 31 Prospective studies have been used to evaluate the diag nostic utility of plain X-rays of the sinuses in the con text of suspected pediatric ARS. In 1 of these studies, 54/258 (21%) children with suspected ARS had normal sinus radiographs, suggesting an uncomplicated URI and not ARS. 2302 The absence of green nasal discharge and disturbed sleep, as well as milder symptoms, were asso ciated with a normal radiograph and the diagnosis of an uncomplicated URI. No physical exam findings were