Pediatric chronic rhinosinusitis (PCRS) is a heterogeneous entity that can often be frustrating to patients and physicians alike. When evaluating children with sinonasal symptoms, one must clearly differentiate between acute and chronic rhinosinusitis. Acute rhinosinusitis is manifested by symptoms such as acute (< 12 weeks) onset of fever, pain, nasal obstruction, purulent rhinorrhea and anosmia. Orbital and intracranial complications occur most often in the setting of acute bacterial rhinosinusitis and are rare in cases of PCRS. In PCRS, symptoms are persistent for greater than 12 weeks. Comprehensive guidelines and evidence based recommendations have recently been published by an international group. It is efforts like this which will aid clinicians in optimizing therapies (EPOS 2012). The diagnosis of PCRS requires two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip). Additional symptoms may include facial pain/pressure or cough. The diagnosis also requires the presence of objective inflammation on either endoscopy or CT. In younger children, the adenoid can play a prominent role and it is this age group that is the focus of this article. In older children, the adenoid typically atrophies and is less important. At this stage, they are managed similar to adults with CRS.

Medical treatment:  Patients have often been treated with short term courses of oral antibiotics by their primary care physician, however current evidence does not support this practice. In fact, one study of 141 children compared 1) saline drops, 2) oral amoxicillin x 10 days with topical vasoconstrictor, 3) maxillary drainage under anesthesia with irrigation via indwelling catheter for 5 days, or 4) maxillary drainage/ catheter, oral amoxiciliin and topical vasoconstrictor. This study found no difference among any of the treatment arms with 26 week follow up. Evidence supports the efficacy of saline irrigation. Studies on the use of saline irrigation in pediatric patients found that only 23% of parents thought their children would tolerate it; however when attempted, 86% of children tolerated it and 84% of all patients thought saline irrigation improved their overall health. These findings were relatively consistent even in children below the age of 5 years (Jeffe et al Int J Pediatric ORL 2012). Oral steroids have not been studied versus placebo, however oral steroids did demonstrate benefit in PCRS when combined with oral antibiotics when compared to a group receiving antibiotics alone. Topical nasal steroid spray has not been studied in PCRS, hence it receives a grade D recommendation. However given strong evidence in all forms of adult CRS and efficacy in pediatric allergic rhinitis with limited harm, most clinicians would consider this first line therapy. Long term oral antibiotics and IV antibiotics have not been found to be effective in adult CRS and it does not appear as if there is support for these modalities in PCRS. GERD therapy is a level C recommendation based upon retrospective series and should probably be left to the discretion of the treating physician for each individual child. Anecdotal evidence for a variety of other therapies to include reflux treatment, leukotriene antagonists or mucolytics is anecdotal and not supported by high level evidence (Figure 1).