xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

XIII.B Pediatric Chronic Rhinosinusitis XIII.B.1 Pediatric CRS: Incidence/Prevalence Epidemiologic data regarding pediatric CRS (PCRS) are limited compared to adult CRS, but recent data provide some insight into the prevalence of this condition. A US National Health Interview Survey in 1994 reported a PCRS prevalence of 8%, although this survey predates current diagnostic definitions. 2319 A 2017 study examining data from the US Centers for Disease Control National Center for Health Statistics found that CRS was diagnosed in 2.1% of patients younger than 20 years in ambulatory health care visits per year. 36 This study was limited by reliance on administrative diagnostic coding rather than on estab lished diagnostic criteria. A prospective study of a Swedish population-based cohort estimated a 12-month prevalence of self-reported CRS symptoms to be 1.5% in adolescents. At the time of follow-up (average 16 months) prevalence of self-reported symptoms dropped to 0.8%, with nasal endoscopy confirming a diagnosis of CRS in 0.3% of all adolescents. 37 A family history of CRS significantly increases the inci dence of a PCRS diagnosis in children 12 years or younger. Having a sibling with CRS increases the risk 57.5-fold of a child developing PCRS; having a first- or second-cousin also increases the risk albeit less so. Likewise, adult rela tives of children with PCRS have an increased incidence of CRS. 2320 The exact prevalence of PCRS in patients with under lying conditions such as CF, PCD, or immunodeficiency is unknown but may be higher than in healthy children. Depending on the diagnostic criteria used for PCRS, some studies estimate the incidence of PCRS in children with CF to be 11% to 38%, 38,2321 for children with PCD to be as high as 40%, 39 and for children with CVID to be as high as 36%. 40 Healthy children with chronic rhinorrhea, nasal conges tion, and cough are commonly seen in primary care and otolaryngology settings. One study of 196 children (ages 3 to 14 years) with chronic rhinorrhea, nasal obstruction, and cough found on CT that maxillary sinus inflamma tion was noted in 63%, ethmoid in 58%, and sphenoid in 29% of children, with sinus involvement decreasing with age. 2322 Another study examined sinus CT scans of 91 chil dren (ages 2 to 17 years) presenting to an allergy clinic with 3 months or longer of 2 or more symptoms of rhinorrhea, postnasal drip, and cough. Sinus inflammation was seen on CT in 63% of children, and younger age was a risk fac tor for abnormal CT findings. 2323

XIII.A.5 Pediatric ARS: Complications Complications arising from pediatric ARS are uncom mon but require immediate medical attention. The main complications from pediatric ARS are orbital (60 75%), intracranial (15-20%), and osseous (5-10%). 31,2290 Orbital complications range from pre-septal cellulitis to orbital abscess as described by Chandler. 462 Additional orbital complications can include blindness, optic neu ritis, corneal ulceration, and panophthalmitis. Intracra nial complications can include epidural abscess, subdural abscess, parenchymal brain abscess, meningitis, cerebri tis, as well as superior sagittal and/or cavernous sinus thrombosis. Osseous complications include osteomyelitis of the frontal and maxillary bones. Signs and symptoms of complications arising from pediatric ARS include lethargy, headache, eye pain, pain with eye movement, periorbital edema, high fever, nausea/vomiting, diplopia, photopho bia, papillary edema, seizures, cranial neuropathies, and focal neurologic deficits. Early orbital complications can sometimes be managed with IV antibiotics alone while the more severe complica tions of pediatric ARS require a combination of IV antibi otics and emergent surgical treatment. A recent systematic review indicates that cases of pre-septal and post-septal cellulitis as well as some subperiosteal abscesses can be managed non-surgically. This same article supports urgent surgical intervention for patients with orbital abscesses and cavernous sinus thrombosis. 2313 The volume of subpe riosteal abscess or proptosis severity may predict the like lihood of requiring surgical intervention. 2314,2315 CT scan with contrast is the diagnostic study of choice except when intra-cranial complications are suspected. In such cases, MR Imaging may have superior sensitivity to detecting intracranial findings. 2313 Surgical management of complications of ARS often require multi-disciplinary care with infectious diseases, ophthalmology, and neurosurgical specialists. Particu lar attention should be paid to antibiotic choice in regions with high MRSA or pneumococcal vaccination prevelance. 2316,2317 For intra-orbital complications, both external and trans-nasal endoscopic techniques have been described with good outcomes. For intracranial complica tions, combined otolaryngology – neurosurgery interven tion may be required with both ESS and craniotomy and drainage being performed under the same anesthetic. In a systematic review of intracranial complications of ARS, the majority were adolescent males (70%) that required multi disciplinary surgical intervention. Only 73% of the patients in this review regained baseline neurological status. 2318