There are significant controversies regarding the diagnosis and management of pediatric sinusitis. Space does not allow an in-depth discussion of each potential controversy, but several areas warrant discussion.

Imaging Studies

The diagnosis of acute and chronic sinusitis remains primarily a clinical diagnosis.¹ Although it is now clear that plain films do not adequately image the pediatric sinuses, some clinicians continue to use plain films in the acute setting.² In general, plain films are not warranted to make the diagnosis of acute sinusitis.¹ This approach, however, is not accepted in many parts of the developed world.

In Europe, ultrasound continues to be used to make the diagnosis of acute sinusitis and to follow its resolution.³ Haapaniemi⁴ recently reported that a negative ultrasound finding excludes the presence of sinusitis. The study was more useful if the findings were negative; positive results were not of significant use. A major flaw of this study⁴ is that ultrasound was compared with plain films of the maxillary sinus, and previous studies have not supported the accuracy of plain films.² Unfortunately, ultrasound and plain films image only the maxillary sinus, and we know from previous studies that the ethmoids are involved with equal frequency and that approximately 25% of affected children will have only ethmoid disease.^{5, 6} In the acute setting, we would expect these studies to be positive, and therefore of little use, because the infection is not limited to the nasal cavity. Gwaltney’s and Glasier’s work showed a high incidence of opacification of the anterior ethmoid and maxillary sinuses with acute rhinovirus infections.^{7, 8}

Culture

In general, cultures of the nasal cavity have not been readily used in the pediatric population. The primary reasons are poor patient compliance and the inability to obtain an uncontaminated specimen. Recently cultures of the middle meatus have shown a high correlation with antral punctures.⁹ In the cooperative patient, endoscopically directed cultures of the middle meatus may be very useful, particularly in communities with increased resistance. Cultures of the maxillary sinus in patients who have complicated acute sinusitis or in those who fail to respond appropriately are indications that a culture should be obtained by antral puncture.¹

Pathophysiology

The multifactorial cause of sinusitis continues to fuel the controversy regarding the underlying pathophysiologies of chronic sinusitis. Age is clearly one of the most significant factors in pediatric sinusitis. The younger the child, the higher the incidence of sinusitis and the more likely the maxillary sinus will be diseased.^{6, 10} Children also have an immature immune system, making them more likely to develop upper respiratory tract viral infections and associated acute sinusitis. There is a strong association between sinusitis and respiratory viral infections.¹¹ The viral infections cause mucosal edema that obstructs the ostium and increases the risk of bacterial infection in the sinuses. As the infundibulum is one of the narrowest drainage sites, the adjacent anterior ethmoid sinuses and maxillary sinuses would be the most likely to be involved with sinusitis. Van der Veken and Clement and colleagues,⁶ and Lusk et al.⁵ found that this indeed is the case and that the maxillary sinus takes the longest to clear. Viral infections are also thought to cause significant ciliary dysfunction by decreasing the ciliary beat frequency¹² or destroying the ciliary blanket.¹³ Poor ciliary function would increase the chance of bacterial infection through stasis of the secretions and the inability to move these secretions from the sinus.¹⁴ As the sinus clears, there is corresponding improvement in the ciliary function.¹³

The role of allergy and sinusitis remains controversial. Rachelefsky and colleagues^15–17 were the first to point out an association between allergic symptoms and sinusitis in children. The highest incidence of sinusitis and allergic symptoms does not show a high degree of correlation, however. Numerous studies show that approximately 50% of children with sinusitis also have allergies, but the cause and effect have not been demonstrated satisfactorily. Some patients do appear to bear out a well-founded association between allergy and fungal sinusitis.^18–20

Without a doubt, the increasing resistance of bacteria, especially Streptococcus pneumoniae , has made medical treatment of chronic sinusitis more difficult. This problem is unfolding, and the ultimate impact on medical and surgical management is uncertain. With continued use of broad-spectrum antibiotics in the treatment of chronic sinusitis, it seems logical that resistance will increase, rather than decrease. The ramifications of this problem remain unknown, but it will likely mean less effective medical management and perhaps an increase in the number of surgical procedures performed. The incidence of complicated acute sinusitis may also increase significantly.

Gastroesophageal reflux disease (GERD) can be associated with chronic sinusitis.21 The incidence of GERD in children is unknown, but Barbero²¹ is convinced that it is present in most patients. There is a paucity of information on the subject in the literature. Over the past 4 years, only 14 articles in the literature have associated gastroesophageal reflux and sinusitis in their titles or abstracts. Most of these articles have concentrated on airway disease as the primary manifestation of reflux. Clearly, there are cases of patients with sinusitis and GERD, and treatment of the GERD is associated with improvement in their sinus symptoms. In our experience to date, it is not frequent and usually associated with additional symptoms such as cough or airway disease. Because both sinusitis and GERD can be associated with chronic cough, it is very difficult to differentiate between the two. The disease should diagnosed with a 24-hour pH probe study. If present, therapy should consist of a pro-kinetic agent such as metaclopramide, 0.1 to 0.2 mg kg dose three to four times a day; an H₂-blocker such as ranitidine, 1 to 4 mg kg dose; and or a H₂-blocker such as omeprazole 20 mg h.s. The prokinetic agent cisapride was removed from the market July 14, 2000. Like most studies in chronic sinusitis, good prospective data are needed to elucidate the role of GERD in sinusitis when the study is performed.

Anatomic Abnormalities

VARIATIONS

The importance of anatomic abnormalities as a cause of sinusitis remains an area of significant controversy, especially in the pediatric population. It is best to think of these anatomic structures as variants of normal, and not as abnormalities. This issue is of some importance because if anatomic variations are not associated with increased sinusitis, the cause of sinusitis is more likely to be systemic, and possibly more amenable to medical management. If the problem is more systemic, conservative surgical procedures may be adequate. The anatomy is most effectively assessed by computed tomography (CT) scans.

Most anatomic variations are found equally in control and sinusitis patients.^{22, 23} There is convincing evidence that the incidence of anatomic variations increases with age.²⁰ In general, anatomic variations are not associated with increased sinusitis²⁴ and the incidence of anomalies is similar in diseased and control patients.²² The variations thought to be most likely associated with increased sinusitis are septal deviation, infraorbital cells, choncha bullosa, and a narrowed middle meatus or infundibulum. Jones et al.²⁴

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