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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International consensus statement on rhinosinusitis

XIII.B.2 Pediatric CRS: Contributing Factors Several medical comorbidities have been identified as contributing factors in the pathogenesis of PCRS (Tables XIII-4 and XIII-5). In children with asthma, as many as 48% may have endoscopic signs of RS. 2324 In chil dren with asthma and PCRS, treating PCRS often leads to better asthma control. In a series of 48 children with moderate to severe asthma refractory to medi cal treatment, 79% of children were able to discon tinue their asthma medications after their CRS was managed with oral antibiotics alone. Seventy-nine per cent of these children had normal findings on sinus radiographs after treatment. Asthma symptoms returned when RS recurred. 2325 In another study of 18 children with poorly controlled asthma, RS was treated with oral antibi otics, intranasal and systemic corticosteroids. Subjects were evaluated at baseline and 1 month later, and sinonasal symptoms resolved after treatment, with 8 of 18 children having intermittent asthma and 10 of 18 children having mild asthma based on symptoms and spirometry. 2326 These data support the concept that in children sinonasal and pulmonary inflammation often occur simultaneously and improve or worsen together. The association between AR and PCRS is controversial. In a 2007 study, 2200 children were referred for chronic respiratory symptoms and 351 were diagnosed with CRS. Subjects underwent skin prick testing, of which 29.9% were found positive, an incidence similar to that noted in the general population (31.8%). 2327 Similarly, in a retrospective study of 4044 children with PCRS, AR was found to be present in 26.9% of patients. 2328 In 1 cohort of children with AR, those who developed PCRS did not have any evidence of more severe AR than those without PCRS. 2329 On the other hand, in a 2019 study of 110 children with PCRS, 52.7% had positive skin prick testing, and patients with atopy had worse endoscopy and QoL scores. 2330 It is impor tant to note that positive skin testing does not necessar ily equate to clinically meaningful allergic disease, which may explain the discrepancy in rates of positive skin test ing between this and other studies. The potential associa tion between AR and PCRS is thought to be multifactorial and remains a topic of investigation. Immunodeficiency has been reported to be a factor in several studies of PCRS. Abnormalities commonly seen include IgG subclass deficiencies, IgA deficiency and poor response/deficiencies in pneumococcal titers. 492,2331,2332 Management with systemic therapy directed at immunod eficiency, such as IVIG, was associated with improvement in CRS in a case report. 2333 Children with CRS may bene fit from a quantitative Ig evaluation and specific titers for

antibodies to polysaccharide antigens including S. pneu moniae , H. influenzae , and consideration of testing for response to tetanus and diphtheria immunization. 2301,2334 Cystic fibrosis is an autosomal recessive disease that adversely impacts MCC throughout the upper and lower airways. This disease is associated with a high incidence of CRS and nasal polyposis in both pediatric and adult patients, and nearly all individuals with CF have sinonasal inflammation. Cystic fibrosis-related CRS is often refrac tory due to the underlying genetic defect and requires multidisciplinary care, including consideration of surgi cal intervention as well as targeted therapies. 2335 A diag nosis of CF should be considered in children with NPs or severe CRS, with evaluation via a sweat chloride test and/or genetic testing. 2336,2337 Rhinosinusitis is common in patients with PCD, 39 though overall PCD is a rare cause of PCRS based on its low prevalence. A diagnosis of PCD should be considered in cases of refractory PCRS, particularly with concomi tant chronic otitis media. Primary ciliary dyskinesia is an autosomal recessive disorder involving dysfunction of cilia with an incidence of 1 in 15,000 individuals. In 50% of the cases of PCD, situs inversus and bronchiectasis are present and, with the association of CRS, is known as Kartagener’s syndrome. 2338 Screening tests include nasal NO and in vivo tests such as the saccharin transit test, which shows increased mucociliary transit times. However, screening tests may be falsely negative in some children. Definitive diagnosis can be made by high speed videomicroscopy analysis and transmission electron microscopy of ciliated epithelium, obtained either from a nasal turbinate or bronchial brushing. The most common ciliary structural abnormality is lack of outer dynein arms or a lack of both inner and outer dynein arms. 2339,2340 The role of GERD in the pathogenesis of PCRS remains unclear, and no consensus among experts exists. In a recent PCRS consensus statement and in a European Position paper, there was agreement that routine empiric treat ment for GERD is not indicated in the management of PCRS. 26,2341 XIII.B.3 Pediatric CRS: Diagnosis PCRS is defined as the presence of 2 or more of the follow ing cardinal symptoms lasting for 12 weeks or longer: nasal obstruction, nasal discharge (anterior or posterior), facial pain/pressure, and cough. Symptoms must be accom panied by objective evidence of inflammation, demon strated on rhinoscopy, nasal endoscopy, or radiography. Nasal endoscopy may demonstrate purulent discharge, mucosal edema, or polyposis, and allows for examination of the adenoids. 31,2341 One study found that rhinorrhea is