xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

particularly helpful in distinguishing between children with normal vs abnormal radiographs. In another study of 69 children between the ages of 3 and 12 years, ARS was diagnosed by purulent nasal drainage for more than 7 days and abnormal findings in the maxillary sinuses on Waters’ view X-ray. In these children, the most trouble some symptoms were postnasal drainage, nasal obstruc tion, and cough. 2303 In a mail survey of American gen eral pediatricians, symptoms thought to be very impor tant in the diagnosis of ARS included prolonged symptom duration, purulent rhinorrhea, and nasal congestion. 2304 In another survey of pediatric primary care, urgent care and otolaryngology providers, the diagnostic criteria for ARS used most frequently by all providers (95%) was persistent nasal drainage of any quality, day or night time cough, or both lasting more than 10 days with out improvement. 2305 Other commonly used criteria were symptoms of a classic viral URI with worsening of symp toms at day 5-7 (69.7%) and severe onset of illness with con current fever and purulent nasal discharge for at least 3 consecutive days (46.97%). A pediatric RS symptom scale which includes questions about congestion, rhinorrhea, cough (daytime and nighttime), tiredness, irritability, and sleeping problems has been developed. 2306 After testing in children with ARS, it was found to correlate with objec tive measures and be responsive to change as disease improved. Physical exam in the evaluation of children with pos sible ARS includes anterior rhinoscopy to examine the middle meatus, inferior turbinates, mucosal character, and presence of purulent drainage. This is often accomplished using the largest speculum of an otoscope, or alternatively, a headlight and nasal speculum. Topical decongestion may be used to improve visualization. Nasal endoscopy allows superior visualization of the middle meatus, adenoid bed, and nasopharynx, and is strongly recommended in chil dren who are able to tolerate it. An oral cavity exam may reveal purulent postnasal drainage, “cobblestoning” of the posterior pharyngeal wall, or tonsillar hypertrophy. Because some younger children might not tolerate nasal endoscopy and endoscopy is not available to primary care practitioners and pediatricians, who are the most likely to diagnose ARS in children, clinicians must rely on history and/or imaging studies for appropriate diagnosis. Other diagnostic tests have sparse supporting evidence in the pediatric age group. In a study of 217 patients between the ages of 4 and 61 years, an assay of protein, pH, leukocyte esterase and nitrite in nasal secretions allowed the accurate diagnosis of bacterial sinusitis (as supported by history and positive CT or X ray) in 90% of patients. 2307 This approach and testing would be impractical to per form in physicians’ offices. Obtaining a culture is usu ally not necessary in the context of uncomplicated ARS.

However, it should be considered in patients who have not responded to empiric antibiotic treatment within 48-72 hours, in immunocompromised patients, in the presence of complications, or if the child presents with severe ill ness and appears toxic. 2308 Although a maxillary sinus tap would confirm the diagnosis, this is a relatively invasive procedure and is difficult to perform in a child in the office. Wen and colleagues measured nasal and fractional exhaled NO in a study of pediatric patients with perennial aller gic rhinitis (PAR) with and without acute unilateral maxil lary sinusitis as defined with clinical signs and symptoms, radiographic examination, and nasal fibroendoscopy. 2309 They found significantly lower mean nasal NO and higher fractional exhaled NO levels in patients with PAR and RS compared to patients with PAR and normal controls with out RS. Lindbaek and colleagues evaluated 201 primary care patients aged ≥ 15 years with a clinical diagnosis of ARS. 321 Fluid level or total opacification of any sinus on CT were used as diagnostic of ARS. Blood tests including erythrocyte sedimentation rate (ESR), C-reactive protein, and white blood count were obtained. A total of 127 (63%) patients had fluid levels or total opacification in 1 or more sinuses. “Double sickening,” purulent rhinorrhea, puru lent nasal secretions, and ESR > 10 had the highest like lihood ratios and were independently associated with CT confirmed ARS. The diagnosis of pediatric ARS is generally made on clin ical grounds, and imaging is usually not necessary. A com bination of symptoms and clinical presentation helps dif ferentiate uncomplicated URIs from ARS. Physical exam findings support the clinical impression, and additional diagnostic testing is usually unnecessary. XIII.A.4 Pediatric ARS: Management Both the 2012 EPOS guidelines and 2013 AAP guide lines recommend only symptomatic treatment for chil dren with uncomplicated ARS given the likely viral eti ology in the first 10 days. 32,2290 The 2013 AAP guidelines recommend antibiotic treatment for patients with severe onset of disease or worsening course. Patients with a per sistent illness defined as “nasal discharge of any qual ity or cough or both for at least 10 days without evi dence of improvement” can be offered antibiotic treat ment or 3 days of outpatient observation. The AAP rec ommends amoxicillin with or without clavulanate for empiric treatment of ABRS. For patients allergic to amox icillin, the AAP guideline recommends a second or third generation cephalosporin as monotherapy for ABRS as the vast majority of patients with penicillin sensitivity tolerate cephalosporin therapy. 2290 For patients under 2 years of age with a documented type-1 hypersensitivity to