Pediatric sinusitis: when do we operate?

The role of surgery in the treatment of pediatric sinusitis is still in evolution. This review of recent literature highlights developments in the study of pediatric sinusitis, particularly as it pertains to surgical intervention. There is growing support in the literature for adenoidectomy as a first-line surgical intervention for chronic rhinosinusitis in children when maximal medical management fails. Maxillary sinus aspiration or middle meatal culture can be performed at the same sitting to facilitate directed antibiotic therapy. Intravenous antibiotics seem to be a promising alternative to functional endoscopic sinus surgery (FESS), especially in younger children. Current literature continues to support FESS as a safe and effective treatment for pediatric sinus disease. Previous notions that FESS may inhibit midfacial growth have been challenged by several recent studies. There is no clear consensus regarding timing of FESS for chronic rhinosinusitis. However, the current literature seems to support FESS when maximal medical therapy, adenoidectomy, and culture-directed systemic antibiotics have all failed with persistence of sinonasal disease, when anatomic abnormalities predispose to chronic rhinosinusitis by obstructing normal sinonasal drainage pathways, in sinonasal polyposis to facilitate application of topical steroids, as an adjunct to desensitization in aspirin-sensitive patients, when orbital or intracranial complications of sinonasal disease occur, and in selected cystic fibrosis patients to improve quality of life and facilitate application of topical antibiotics with activity against Pseudomonas aeruginosa. Although the current literature lends some additional clarity to the indications for surgical intervention in pediatric chronic rhinosinusitis, additional research is still needed to elucidate appropriate timing for surgery and more specific indications.