xRead - Nasal Obstruction (September 2024) Full Articles

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646

International consensus statement on rhinosinusitis

TABLE XIII-4 (Continued) Study

Year LOE Study Design Study Groups

Clinical Endpoint

Conclusions

Rachelefsky 2325 1984 4

Multiple asthma outcomes were improved after treating PCRS.

Asthma medication usage Sinus radiographs Pulmonary function tests Symptoms

Case series

48 children with asthma and PCRS treated with antibiotics + / − antral lavage

*Level 3 study based on study quality and magnitude of effect

dence confirming the diagnosis of PCRS, 31,2341 the diag nosis is typically made by the clinical impression 31 and physical examination and/or nasal endoscopy. To mini mize pediatric radiation exposure, CT imaging can then be saved for when sinus surgery is being considered.

TABLE XIII-5 Aggregate grade of evidence for contributing factors to pediatric CRS Item Explanation Asthma as a contributing factor to PCRS C (Level 4: 2 studies) AR as a contributing factor to PCRS D, (conflicting Level 4 studies) Immunodeficiency as a contributing factor to PCRS C (Level 4: 4 studies) PCD as a contributing factor to PCRS N/A (Level 4: 1 study) GERD as a contributing factor to PCRS N/A, lack of direct evidence

Diagnosis of Pediatric CRS Aggregate Grade of Evidence: C (Level 3: 2 studies; level 4: 2 studies; Table XIII-6).

XIII.B.4 Pediatric CRS: Management The goals of PCRS management include control of sinonasal symptoms, restoration of normal sinonasal func tion, reduction of the inflammatory burden, and mini mizing the side effects of therapeutic interventions (Table XIII-7). PCRS management begins with medical therapy. Consensus exists that nasal saline irrigations (NSI) are beneficial in the pediatric population as a sole treatment modality or as a treatment adjunct. 26,2346 However, there is no consensus about the optimal method of delivery or concentration of saline. In a recent systematic review of NSI for PCRS, Gallant et al. reported that the magnitude of benefit from NSI is unknown, as prior studies have lacked control arms or used inconsistent outcome metrics. 2311 A retrospective study and cross-sectional survey in 104 CRS children aged 5-9 years concluded that the use of once daily NSI for a 6-week period is effective and leads to symptom resolution in PCRS. 2347 A phone survey of parents of 61 children aged 2-16 years diagnosed with CRS, AR and NAR, reported high tolerance and subjective improvement in nasal symptoms with NSI. 2348 There is limited data regarding topical antibiotic irri gations for PCRS. One prospective randomized double blinded study found equal efficacy of once-daily nasal irrigations and once-daily saline plus gentamicin irriga tions in reducing symptom scores and CT scores. Both

the most common symptom of PCRS, followed by nasal obstruction, cough, and lastly facial pain. 2342 Plain X-rays have poor specificity and sensitivity for PCRS. One prospective study of 70 infants and children (age 4 months to 19 years) with sinus disease found that plain radiographs failed to correspond to CT scans in 75% of patients. About 45% of patients in the study had normal plain film findings of at least 1 sinus, with abnormalities of that sinus seen on CT scan; 35% of patients had an abnor mality of at least 1 sinus on plain films, with that sinus found to be normal on CT. 2343 A subsequent study con firmed that CT scans were more sensitive and specific than plain films and also correlated to intraoperative findings of sinus inflammation. 2344 One study compared sinus CT scans of 66 children undergoing ESS for PCRS (mean age 8 years) to sinus CT scans of 192 children undergoing imaging for non-RS diag noses (mean age 9 years). The mean Lund-Mackay score was 10.4 in the PCRS group and 2.8 in the control group. A Lund-Mackay score cutoff of 5 for diseased vs non-diseased patients conferred a sensitivity of 86% and specificity of 85%. 2345 With history and physical exam alone, it may not be pos sible to distinguish PCRS from chronic adenoiditis, espe cially in younger children. However, since adenoidectomy alone is often an effective treatment option in this pop ulation, this distinction may not be critical. For PCRS, although CT imaging may be used to provide objective evi