This chapter is intended to guide the sophisticated consumer of otolaryngology literature through many of the challenging clinical problems for which there are no straightforward answers, no definite proofs of efficacy, and no consensus. Pediatric sinusitis, particularly those aspects that pertain to surgical therapy, is an ideal topic for such a work, especially because so few published pertinent works are intellectually sound, scientifically rigorous, and unbiased in their conclusions. Nonetheless, pediatric sinusitis is a common and important entity, and clinicians can better manage patients, families, and other clinicians through improved understanding of the diagnostic and therapeutic dilemmas we face. This review includes a brief historic overview and then considers controversies and problem areas in the definition, diagnosis, and treatment of disease. It is my intent to pull no punches, but rather to expose the reader to the range of critical opinions about current literature and practice.

A Brief History of Pediatric Sinusitis

Before the 1980s, pediatric sinusitis, especially in the young child or infant, was rarely entertained as a distinct clinical entity. Most cases were apparently dismissed as an unimportant “allergy” or a “cold” and were rarely treated with anything beyond decongestants or antihistamines, or both, perhaps not an altogether bad approach. Through a series of well-designed and executed studies, Dr. Ellen Wald and her associates in Pittsburgh established a logical framework for diagnosing and treating children with sinus infections.^{1, 2} These and other studies, many with pharmaceuticals industry support, demonstrated the efficacy of antimicrobial therapy.^{3, 4}

During the late 1980s the recognition of the value of coronal computed tomography (CT) and sinus telescopes led to the rise of “osteomeatal fundamentalism” as a predominant sinus doctrine, especially among rhinologic surgeons. Obstruction of the osteomeatal complex (OMC), recognized as being involved in selected cases of persistent or chronic sinusitis, was put forward as a unifying event in acute, recurrent, and chronic sinusitis. Initially focusing on adult disease, support for OMC doctrine proliferated, as did endoscopic sinus surgery courses and surgical cases.

During the early 1990s, several individuals and groups began performing and reporting hundreds of cases of pediatric endoscopic sinus surgery (mostly infants and young children).^5–9 Applied enthusiasm for the procedure made more than a few pediatric otolaryngologists wealthy. The excitement for the procedure, among surgeons, was understandable—suddenly, the most common childhood illness (rhinitis/sinusitis) could be viewed as a surgical disease. The surgical indications were, in general, some type of sinus symptomatology, with rhinorrhea the most common, and CT evidence of mucosal disease, and sometimes simply an abnormal CT. This occurred before the nature of the “sinus disease” was defined or understood, in terms of etiology or pathogenesis. A number of otolaryngologists went on record against this trend, and the topic was the subject of the 1994 Great Debate in Otolaryngology at the Annual Meeting of the American Academy of Otolaryngology^{10, 11} Over the past 3 years, the number of pediatric and infantile cases has moderated substantially, and several of the busiest surgeons have withdrawn support for the operation, at least for nonmorbid indications.

The 1990s saw an explosion in the number of oral antimicrobial agents that might be used in sinusitis, but also a dramatic rise in resistance to those antimicrobials. This decade has seen an increase in our understanding of the pharmacokinetic and pharmacodynamic properties of antimicrobials that contribute to their clinical effectiveness in respiratory infections. Recent and forthcoming recommendations from consensus panels have reflected that understanding and the outcome from a few comparative trials—making a handful of antimicrobials “winners” and the rest either “also-rans” or losers. The array of antimicrobial choices, resistance issues, and selection considerations has complicated the selection process.¹²

Problems in Definitions

SINUSITIS, RHINOSINUSITIS, OR NASOPHARYNGITIS?

The organisms classically associated with acute bacterial respiratory infections—Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis—are not usually considered pathogens of abscess cavities. Rather, they are mucosal pathogens that have proclivities for thriving on damaged respiratory epithelium, whether in the cigarette smoke—damaged lungs of the adult with chronic bronchitis or in the virally damaged airway of the child in daycare. Unfortunately, any attempt to use bacterial samples from the nasal specimens, as opposed to maxillary antral aspirates, would prompt critics to decry the results on the grounds that (1) nasal cultures do not correlate with antral cultures, and (2) the organisms recovered are considered “normal” nasal flora, particularly in children and infants.

To the critics, we might respond by asking, Who cares what is in the maxillary sinus? Our job is to characterize the disease present in the symptomatic patient. Although typical sinusitis pathogens may be present in low to modest numbers in the asymptomatic patient, it appears difficult to classify as “normal” a symptomatic nasal airway with significant damage to the epithelial ultrastructure, a heavy concentration of acute inflammatory cells, and the presence of pathogenic bacteria in high concentrations. This condition may be common, and often self-limiting, but it is certainly not normal. A more accurate differentiation of significant from insignificant bacterial infection should probably be based on quantitative bacteriology combined with an assessment of the inflammatory and immuno-logic responses, and not by the specific sinus involved. Easier said than done, perhaps, but to assume otherwise leads us clinically astray. The above considerations can be turned into a case for the use of nasal cultures of visible purulence when that purulence is persistent, has failed empirical therapy and is thought to be related to the disease process of interest. Purulent secretions probably have some, but not absolute, predictive value for bacterial infection versus viral processes. Some viral infections can present with thick purulent secretions, especially in the morning, after nocturnal stasis of the nasal secretions.1

WHY THE MAXILLARY SINUS?

Although the frontal and sphenoid sinuses have long been recognized as occasional sites of clinically important disease, the maxillary sinus has traditionally been the focus for defining bacterial sinusitis. Emphasis on the OMC has only recently shifted new attention to the importance of the ethmoidal cells. In retrospect, it was our ability to “image” the maxillary sinuses satisfactorily with standard radiographic equipment, that led to that site as the gold standard for assessing the microbiology and efficacy issues surrounding sinusitis. The insistence by established sinus investigators and regulatory agencies, such as Food and Drug Administration (FDA), that sinusitis primarily be considered by maxillary investigations is not consistent with our current understanding. In all likelihood, for most cases of symptomatic acute sinusitis, mucosal disease in the ethmoids and nasal cavity accounts for more symptoms than what transpires in the maxillary sinus, especially in children.

WHAT IS “CHRONIC” PEDIATRIC SINUSITIS?

Whereas most clinicians would easily accept that a chronic sinus condition exists when a single process persists for more than several months, there is little evidence to suggest that this occurs in young children at a rate beyond rarely. By contrast, the pediatric sinus is frequently, and sometimes continually, assailed by the multitude of respiratory pathogens typical of the day-care flora. It appears that a number of clinicians have extrapolated certain diagnostic and therapeutic approaches from otitis media to the assessment and management of pediatric sinusitis. At first glance, the rationale appears sound—the same organisms, similar respiratory epithelium, closed-space infections, and the like. The two major inconsistencies relate to the failure to differentiate accurately between the various clinical types of sinusitis and the failure to understand the real pathophysiologic basis of pediatric rhinosinusitis.

Most cases of pediatric endoscopic sinus surgery are performed after a period of chronicity or multiple sinus infections. Some clinicians have advocated protocols in which sinus surgery was recommended after failure of an adenoidectomy to control the disease.¹³ But what is the definition of failure, and what is the process responsible for these clinical failures? Is it persistent bacterial infection? Perhaps—but that, we believe, can be completely eliminated as a problem by effective antimicrobial use, even considering today’s resistance problems (see Treatment Issues, below). Is it uncontrolled allergic disease? I am not aware of anyone admitting to recommending pediatric sinus surgery for allergic disease (without polyps). Most chronic disease actually represents the reemergence of symptoms related to intercurrent new viral and bacterial respiratory infections. Perhaps just as important as a determinant of which child receives aggressive sinus management is the presence of a family member who is uncommonly focused on, and intolerant of, sinus symptoms. Those symptoms and associated findings are typically identical to those of thousands of other children who are receiving no specific care for their rhinosinusitis.

IS PEDIATRIC RHINOSINUSITIS AN OBSTRUCTIVE PROCESS?

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