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Definitions of pediatric rhinosinusitis. The solid line corresponds with the evolution in time of intensity of symptoms and signs of rhinosinusitis. This intensity is compared with a baseline situation (dashed line) in which symptoms and signs are absent.

Definitions of pediatric rhinosinusitis. The solid line corresponds with the evolution in time of intensity of symptoms and signs of rhinosinusitis. This intensity is compared with a baseline situation (dashed line) in which symptoms and signs are absent.

Table 1. 
Symptoms and Signs of Pediatric Rhinosinusitis
Symptoms and Signs of Pediatric Rhinosinusitis
Table 2. 
History and Physical Examination Results Suggestive of Allergy
History and Physical Examination Results Suggestive of Allergy
Table 3. 
Recommended Antimicrobial Management
Recommended Antimicrobial Management
1.
Poole  MD Pediatric endoscopic sinus surgery: the conservative view. Ear Nose Throat J. 1994;73221- 227
2.
Otten  FWAVan Aarem  AGrote  JJ Long-term follow-up of chronic maxillary sinusitis in children. Int J Pediatr Otorhinolaryngol. 1991;2281- 84Article
3.
Parsons  DS Pediatric sinusitis: preface. Otolaryngol Clin North Am. 1996;29III- XIII
4.
Setliff  RC Minimally invasive sinus surgery: the rationale and the technique. Otolaryngol Clin North Am. 1996;29115- 129
5.
van Buchem  FLPeeters  MFKnottnerus  JA Maxillary sinusitis in children. Clin Otolaryngol. 1992;1749- 53Article
6.
Gwaltney  JMPhilips  CDMiller  RDRiker  DK Computed tomographic study of the common cold. N Engl J Med. 1994;33025- 30Article
7.
Manning  SCBiavati  MJPhillips  DL Correlation of clinical sinusitis signs and symptoms to imaging findings in pediatric patients. Int J Pediatr Otorhinolaryngol. 1996;3765- 74Article
8.
Wald  ER Rhinitis and acute and chronic sinusitis. Bluestone  CDStool  SEKenna  MAeds.Pediatric Otolaryngology Philadelphia, Pa WB Saunders Co1996;1843- 858
9.
Kennedy  DW Sinus Disease: Guide to First-Line Management.  Deerfield Beach, Fla Health Communications Inc1994;12
10.
Riding  KHIrvine  R Sinusitis in children. J Otolaryngol. 1987;16239- 243
11.
Cools  GHEClement  PAR The use of rigid nasal endoscope in children with special interest in the middle meatus. Acta Otorhinolaryngol Belg. 1991;45399- 404
12.
Muntz  HRLusk  RP Signs and symptoms of chronic sinusitis. Lusk  RPed.Pediatric Sinusitis New York, NY Raven Press1992;1- 5
13.
Parsons  DSWald  ER Otitis media and sinusitis: similar diseases. Otolaryngol Clin North Am. 1996;2911- 25
14.
Wald  ERReilly  JSCasselbrant  M  et al.  Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor. J Pediatr. 1984;104297- 302Article
15.
Arruda  LKMimica  IMSole  D  et al.  Abnormal maxillary sinus radiographs in children: do they represent bacterial infection? Pediatrics. 1990;85553- 558
16.
Orobello  PWPark  RIBelcher  LJ  et al.  Microbiology of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg. 1991;117980- 983Article
17.
Lusk  RPMuntz  HR Endoscopic sinus surgery in children with chronic sinusitis: a pilot study. Laryngoscope. 1990;100654- 658Article
18.
Wald  ERChiponis  DLedesma-Medina  J Comparative effectiveness of amoxicillin and amoxicillin-clavulate potassium in acute paranasal sinus infections in children: a double-blind, placebo-controlled trial. Pediatrics. 1986;77795- 800
19.
Otten  FWAGrote  JJ The diagnostic value of transillumination for maxillary sinusitis in children. Int J Pediatr Otorhinolaryngol. 1989;189- 11Article
20.
Wald  ERMilmoe  GJBowen  A  et al.  Acute maxillary sinusitis in children. N Engl J Med. 1981;304749- 754Article
21.
Shapiro  GGFurukawa  CTPierson  WEGilbertson  EBierman  CW Blinded comparison of maxillary sinus radiography and ultrasound for diagnosis of sinusitis. J Allergy Clin Immunol. 1986;7759- 64Article
22.
Lusk  RPMcAlister  Bel Fouley  A Anatomic variation in pediatric chronic sinusitis: a CT study. Otolaryngol Clin North Am. 1996;2975- 91
23.
Manning  SC Pediatric sinusitis. Otolaryngol Clin North Am. 1993;26623- 638
24.
Van Der Veken  PJVClement  PARBuisseret  TH  et al.  CAT scan study of the incidence of sinus involvement and nasal anatomic variations in 196 children. Rhinology. 1990;28177- 184
25.
Parsons  DS Chronic sinusitis: a medical or surgical disease? Otolaryngol Clin North Am. 1996;291- 9
26.
Van Der Veken  PJClement  PARBuisseret  TH  et al.  Age-related CT-scan study of the incidence of sinusitis in children. Am J Rhinol. 1992;645- 48Article
27.
Iwens  PClement  PAR Sinusitis in allergic patients. Rhinology. 1994;3265- 67
28.
Yaniv  EOppenheim  DFuchs  C Chronic rhinitis in children. Int J Pediatr Otorhinolaryngol. 1992;2351- 57Article
29.
Polmar  SH Sinusitis and immune deficiency. Lusk  RPed.Pediatric Sinusitis New York, NY Raven Press1992;53- 58
30.
Lusk  RP Chronic sinusitis: surgical management. Bluestone  CDStool  SEKenna  MAeds.Pediatric Otolaryngology Philadelphia, Pa WB Saunders Co1996;859- 865
31.
Otten  FWAGrote  JJ Treatment of chronic maxillary sinusitis in children. Int J Pediatr Otorhinolaryngol. 1988;15269- 278Article
32.
Brook  I Bacteriological features of chronic sinusitis in children. JAMA. 1981;246967- 969Article
33.
Rachelefsky  GSKatz  RMSiegel  SC Chronic sinusitis in the allergic child. Pediatr Clin North Am. 1988;351091- 1101
34.
Roujeau  JCKelly  JPNaldi  L  et al.  Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;3331600- 1607Article
35.
Verbist  LDhoore  F In vitro susceptibility of recently isolated respiratory tract pathogens to minocycline and comparable antibiotics: a multicenter study. Acta Clin Belg. 1994;49268- 273
36.
Takahashi  HFujita  AHonjo  I Effect of adenoidectomy on otitis media with effusion, tubal function, and sinusitis. Am J Otolaryngol. 1989;10208- 213Article
37.
Rosenfeld  RM Pilot study of outcomes in pediatric rhinosinusitis. Arch Otolaryngol Head Neck Surg. 1995;121729- 736Article
38.
Wang  DClement  PARKaufman  LDerde  MP Fiberoptic examination of the nasal cavity and nasopharynx in children. Int J Pediatr Otorhinolaryngol. 1992;2435- 44Article
39.
Maes  JJClement  PA The usefulness of irrigation of the maxillary sinus in children with maxillary sinusitis on the basis of the Water's X-ray. Rhinology. 1987;25259- 264
40.
Lusk  RPLazar  RMuntz  HR The diagnosis and treatment of recurrent and chronic sinusitis in children. Pediatr Clin North Am. 1989;361411- 1421
41.
Younis  RTLazar  RH Criteria for success in pediatric functional endonasal sinus surgery. Laryngoscope. 1996;106869- 873Article
Original Article
January 1998

Management of Rhinosinusitis in ChildrenConsensus Meeting, Brussels, Belgium, September 13, 1996

Author Affiliations

From the Department of ENT, Head and Neck Surgery (Dr Clement), and the Pediatric ENT Department, Children's Hospital (Dr Gordts), Free University of Brussels (Vrije Universiteit Brussel), Brussels, Belgium; University of Pittsburgh School of Medicine and the Department of Pediatric Otolaryngology (Dr Bluestone), and the Division of Allergy, Immunology and Infectious Diseases, Department of Pediatrics (Dr Wald), Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatric Otolaryngology, St Louis Children's Hospital of Washington University, St Louis, Mo (Dr Lusk); the Department of Otorhinolaryngology, Diaconessenziekenhuis, Leiden (Dr Otten), and the Throat, Nose and Ear Department, St Elisabeth Hospital, Tilburg (Dr van Buchem), the Netherlands; the Department of Microbiology (Universitaire Instelling Antwerpen), Antwerp, Belgium (Dr Goossens); Consultant Physician in Clinical Immunology, Allergy and Rhinology, Royal National Throat Nose & Ear Hospital, London, England (Dr Scadding); the Department of Hearing and Speech Science (Department of Otolaryngology), Graduate School of Medecine, Kyoto, Japan (Dr Takahashi); and the ENT Clinic, Department of Otolaryngology, University Hospital Ghent (Universiteit Gent), Ghent, Belgium (Dr Van Cauwenberge).

Arch Otolaryngol Head Neck Surg. 1998;124(1):31-34. doi:10.1001/archotol.124.1.31
Abstract

Objectives  To (1) provide definitions for the different forms of pediatric rhinosinusitis, with an enumeration of the main symptoms and signs; (2) provide indications for microbiological, allergic, and immunologic assessment as well as for imaging studies; (3) suggest standard medical management with judicious use of antimicrobial agents; and (4) discuss indications for surgery.

Data Sources  Clinical studies and literature data relevant to the different topics of pediatric rhinosinusitis.

Conclusions  Rhinosinusitis in children is a multifactorial disease in which the importance of several predisposing factors changes with increasing age. Continued study to obtain a better understanding of the disease and carefully controlled comparative evaluations of medical and surgical therapies are suggested.

THE MANAGEMENT of rhinosinusitis in children is a controversial and rapidly evolving issue. Opinions regarding treatment vary from no therapy to extensive sphenoethmoidectomy. Those who favor minimal or no intervention argue that spontaneous resolution of chronic rhinosinusitis in the young child is the norm.1,2 At the opposite end of the therapeutic spectrum, surgeons are abandoning the more aggressive surgical techniques in favor of a concept of minimally invasive sinus surgery.3,4 Even the use of antibiotics, still the mainstay in the medical management of rhinosinusitis, has to be questioned. The combination of emerging antibiotic resistance of the microorganisms commonly involved in rhinosinusitis plus the infrequency of complications in children treated without antibiotics5 has prompted some authors to encourage limiting antibiotic therapy to highly selected patients.1

With these and other controversies in mind, the members of the Consensus Panel discussed the following topics of rhinosinusitis: definitions, symptoms and signs, diagnosis, medical management, and surgery.

DEFINITIONS

The members of the Consensus Panel prefer to speak of rhinosinusitis since rhinitis and sinusitis in children are often a continuum of disease.6,7 Also, it is not possible to differentiate rhinitis from sinusitis on clinical grounds alone.5 Be aware, however, that isolated rhinitis (ie, allergic or specific) does exist.8 Isolated sinusitis can also occur but is rare.

The participants of the Consensus Panel have tried to maintain the definitions of sinusitis that evolved from the International Conference on Sinus Disease held in Princeton, NJ, in July 1993.9 According to these definitions, a computed tomographic (CT) scan is required for the diagnosis of chronic sinusitis. The members of the Consensus Panel believe, however, that CT scanning in all children with suspected chronic rhinosinusitis is not feasible and therefore suggests the following definitions:

  1. Acute rhinosinusitis is a sinus infection in which complete resolution of symptoms (judged on a clinical basis only) without intermittent upper respiratory tract infection may take up to 12 weeks. Acute rhinosinusitis is subdivided into severe and nonsevere forms (see "Symptoms and Signs").

  2. Chronic rhinosinusitis is defined as a sinus infection with low-grade symptoms and signs that persist for longer than 12 weeks.

    The members of the Consensus Panel note that (1) medical treatment (such as with antibiotics and nasal steroids) may modify symptoms and signs of acute and chronic rhinosinusitis and (2) it is sometimes difficult to differentiate infectious rhinosinusitis from allergic rhinitis on clinical grounds alone.

  3. Recurrent acute rhinosinusitis consists of multiple acute episodes in which symptoms and signs resolve completely between episodes. In contrast, in patients with acute exacerbations of chronic rhinosinusitis, symptoms and signs do not resolve completely between episodes (Figure 1).

SYMPTOMS AND SIGNS

The symptoms and signs5,1013 of acute rhinosinusitis can be divided into nonsevere and severe forms (Table 1). The symptoms and signs of chronic rhinosinusitis are the same as those of nonsevere acute rhinosinusitis; however, duration exceeds 12 weeks (see "Definitions"); also, fetor oris is a common complaint of parents and caretakers.

DIAGNOSIS

The diagnosis of acute and chronic rhinosinusitis in children is usually made on clinical grounds alone. In selected patients, imaging of the sinuses may be indicated, or it may be necessary to obtain a specimen of sinus secretions for microbiological assessment.

Microbiology

Microbiological assessment is usually not necessary in children with uncomplicated acute or chronic rhinosinusitis. Indications for sinus puncture are (1) a severe illness or a toxic condition in a child, (2) acute illness in a child that does not improve with medical therapy in 48 to 72 hours, (3) an immunocompromised host, and (4) the presence of suppurative (intraorbital or intracranial) complications (orbital cellulitis excepted).

There was no consensus regarding whether middle meatal cultures can substitute for sinus punctures.5,8,14,15 Culture specimens obtained from the middle meatus or from the ethmoidal bulla16,17 are more often likely to show positive results than are culture specimens obtained from the maxillary antrum.

Imaging

Imaging is not necessary to confirm a diagnosis of rhinosinusitis in children. Transillumination of the sinuses is difficult to perform and unreliable in children.18,19 The value of ultrasound is controversial.5,20,21 Plain radiographs (only for assessment of maxillary or frontal sinuses) are an alternative if CT scans are not available.2224 A CT scan is indicated if sinus surgery is considered. The other indications for CT scan are identical to those for sinus puncture (see "Microbiology").

Additional Investigations

In the presence of recalcitrant rhinosinusitis, underlying conditions such as allergy, immunodeficiency, cystic fibrosis, ciliary immotility disorders, and gastroesophageal reflux have to be considered.

Of these, respiratory allergy is perhaps the most frequent.2528 Therefore, in children with chronic or recurrent acute rhinosinusitis with a suggestive history and/or physical examination findings (Table 2), allergic assessment (skin prick testing, nasal smear, radioallergosorbent testing, or trial of treatment) should be performed for patients who continue to have clinical difficulties despite avoidance and simple pharmacological measures. Also, immunologic assessment (complete blood cell count, quantitative immunoglobulin levels, immunoglobulin G subclass levels in serum, and antipneumococcic antibody titers) is advised.8,29

MEDICAL MANAGEMENT
Antimicrobial Therapy
Acute Rhinosinusitis

According to the members of the Consensus Panel, indications for antimicrobial therapy are (1) a severe illness or a toxic condition in a child with suspected or proven suppurative complications (parenteral antibiotics are preferred), (2) severe acute rhinosinusitis, and (3) nonsevere acute rhinosinusitis in a child with protracted symptoms to whom antibiotics can be given on an individualized basis (presence of asthma, chronic bronchitis, acute otitis media, etc).

Regarding the duration of antimicrobial therapy,1,8,30 the Consensus Panel suggests at least 10 to 14 days of treatment for acute rhinosinusitis. Treatment can be prolonged to 1 month if the symptoms have improved but have not resolved completely. However, if symptoms are unchanged at 72 hours or worsen at any time, reevaluation is necessary; the clinician should either change antibiotics or obtain a specimen of sinus secretions for culture.

Chronic Rhinosinusitis

For chronic rhinosinusitis—especially with frequent exacerbations—an initial course of 2 weeks of oral antimicrobial treatment is advised. If there is no response within 5 to 7 days, the antibiotic should be changed. If there is again no response within 5 to 7 days, a specimen of sinus secretions should be obtained for culture or a noninfectious condition should be considered (see "Additional Investigations"). If, however, the patient responds rather slowly, a second 2-week course can be prescribed. In rare cases with clear-cut improvement but persisting symptoms, a third course can be given before surgery is considered. Parenteral antimicrobial therapy may be appropriate if oral antimicrobial therapy is ineffective.

For the empiric choice of antibiotics,8,14,3133 refer to Table 3. The following antibiotics are not recommended as first choice for the treatment of rhinosinusitis: combination of sulfamethoxazole and trimethoprim, clarithromycin, cefixime, ceftibuten, doxycycline monohydrate, and cefaclor (if there is a known low resistance in the community, cefaclor can be an alternative for amoxicillin; however, the pleasant taste of cefaclor must be weighted against the risk of serum sickness and its low intrinsic activity against some pathogens).8,3335 These agents have known serious adverse effects or are not effective against antimicrobial-resistant bacterial pathogens, or both.

Additional Medical Therapy

Several members of the Consensus Panel recommend treatment with intranasal steroids30 for children with chronic, nonpurulent rhinosinusitis, especially those with an established diagnosis or a strong suspicion of allergic (specific) rhinitis.

SURGERY
Adenoidectomy

The effect of adenoidectomy on chronic rhinosinusitis has been shown to be effective in some patients in at least 2 clinical trials,36,37 but since these trials were limited in size, definite conclusions cannot be drawn. Adenoidectomy is recommended by some members of the Consensus Panel in the presence of moderate-to-severe nasal obstruction secondary to adenoid hyperplasia.38

Antral Lavage

Antral aspiration and lavage requires general anesthesia in children and is indicated in the presence of a severe, unresponsive, or complicated condition. The indications for antral lavage are the same as those for sinus puncture (see "Microbiology"). According to the literature, antral lavage seems to be ineffective for chronic rhinosinusitis in the younger child.31,39,40

Endoscopic Sinus Surgery

Extensive sphenoethmoidectomy is usually not necessary in children. Anterior ethmoidectomy (with removal of the uncinate process with or without maxillary antrostomy, opening of the bulla, no dissection posterior to the basal lamella) is often sufficient.3,4,17,25,30

The members of the Consensus Panel prefer to divide indications for sinus surgery into absolute and possible indications.

Absolute indications are as follows: (1) complete nasal obstruction in cystic fibrosis due to massive polyposis or closure of the nose by medialization of the lateral nasal wall; (2) antrochoanal polyp; (3) intracranial complications; (4) mucoceles and mucopyoceles; (5) orbital abscess; (6) traumatic injury in the optic canal (decompression); (7) dacryocystorhinitis due to sinusitis and resistant to appropriate medical treatment; (8) fungal sinusitis; (9) some meningoencephaloceles; and (10) some neoplasms.

Possible indications are as follows: (1) in chronic rhinosinusitis that persists despite optimal medical management and after exclusion of any systemic disease, endoscopic sinus surgery is a reasonable alternative to continuous medical treatment; and (2) optimal medical management includes 2 to 6 weeks of adequate antibiotics (intravenous or oral) and treatment of concomitant diseases.

The participants of the Consensus Panel stressed that children who are eligible for sinus surgery represent only a small fraction of all children suffering from chronic rhinosinusitis.

CONCLUSIONS

There is more to pediatric rhinosinusitis than anatomical abnormalities and ostiomeatal complex obstruction.41 Rhinosinusitis in children is a multifactorial disease in which the importance of several predisposing factors changes with increasing age.26,28

The members of the Consensus Panel believe that more research is needed, especially in the areas of epidemiology and natural history, etiology, pathogenesis, and diagnosis of rhinosinusitis. The members of the Consensus Panel endorse and encourage continued study in these fields as well as carefully controlled comparative evaluations of medical and surgical therapies to determine the most safe and effective methods to prevent and treat rhinosinusitis in children.

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Article Information

Accepted for publication August 15, 1997.

Reprints: Frans Gordts, MD, ENT Department, Laarbeeklaan 101, B-1090 Brussels, Belgium (e-mail: knoctp@az.vub.ac.be).

References
1.
Poole  MD Pediatric endoscopic sinus surgery: the conservative view. Ear Nose Throat J. 1994;73221- 227
2.
Otten  FWAVan Aarem  AGrote  JJ Long-term follow-up of chronic maxillary sinusitis in children. Int J Pediatr Otorhinolaryngol. 1991;2281- 84Article
3.
Parsons  DS Pediatric sinusitis: preface. Otolaryngol Clin North Am. 1996;29III- XIII
4.
Setliff  RC Minimally invasive sinus surgery: the rationale and the technique. Otolaryngol Clin North Am. 1996;29115- 129
5.
van Buchem  FLPeeters  MFKnottnerus  JA Maxillary sinusitis in children. Clin Otolaryngol. 1992;1749- 53Article
6.
Gwaltney  JMPhilips  CDMiller  RDRiker  DK Computed tomographic study of the common cold. N Engl J Med. 1994;33025- 30Article
7.
Manning  SCBiavati  MJPhillips  DL Correlation of clinical sinusitis signs and symptoms to imaging findings in pediatric patients. Int J Pediatr Otorhinolaryngol. 1996;3765- 74Article
8.
Wald  ER Rhinitis and acute and chronic sinusitis. Bluestone  CDStool  SEKenna  MAeds.Pediatric Otolaryngology Philadelphia, Pa WB Saunders Co1996;1843- 858
9.
Kennedy  DW Sinus Disease: Guide to First-Line Management.  Deerfield Beach, Fla Health Communications Inc1994;12
10.
Riding  KHIrvine  R Sinusitis in children. J Otolaryngol. 1987;16239- 243
11.
Cools  GHEClement  PAR The use of rigid nasal endoscope in children with special interest in the middle meatus. Acta Otorhinolaryngol Belg. 1991;45399- 404
12.
Muntz  HRLusk  RP Signs and symptoms of chronic sinusitis. Lusk  RPed.Pediatric Sinusitis New York, NY Raven Press1992;1- 5
13.
Parsons  DSWald  ER Otitis media and sinusitis: similar diseases. Otolaryngol Clin North Am. 1996;2911- 25
14.
Wald  ERReilly  JSCasselbrant  M  et al.  Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor. J Pediatr. 1984;104297- 302Article
15.
Arruda  LKMimica  IMSole  D  et al.  Abnormal maxillary sinus radiographs in children: do they represent bacterial infection? Pediatrics. 1990;85553- 558
16.
Orobello  PWPark  RIBelcher  LJ  et al.  Microbiology of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg. 1991;117980- 983Article
17.
Lusk  RPMuntz  HR Endoscopic sinus surgery in children with chronic sinusitis: a pilot study. Laryngoscope. 1990;100654- 658Article
18.
Wald  ERChiponis  DLedesma-Medina  J Comparative effectiveness of amoxicillin and amoxicillin-clavulate potassium in acute paranasal sinus infections in children: a double-blind, placebo-controlled trial. Pediatrics. 1986;77795- 800
19.
Otten  FWAGrote  JJ The diagnostic value of transillumination for maxillary sinusitis in children. Int J Pediatr Otorhinolaryngol. 1989;189- 11Article
20.
Wald  ERMilmoe  GJBowen  A  et al.  Acute maxillary sinusitis in children. N Engl J Med. 1981;304749- 754Article
21.
Shapiro  GGFurukawa  CTPierson  WEGilbertson  EBierman  CW Blinded comparison of maxillary sinus radiography and ultrasound for diagnosis of sinusitis. J Allergy Clin Immunol. 1986;7759- 64Article
22.
Lusk  RPMcAlister  Bel Fouley  A Anatomic variation in pediatric chronic sinusitis: a CT study. Otolaryngol Clin North Am. 1996;2975- 91
23.
Manning  SC Pediatric sinusitis. Otolaryngol Clin North Am. 1993;26623- 638
24.
Van Der Veken  PJVClement  PARBuisseret  TH  et al.  CAT scan study of the incidence of sinus involvement and nasal anatomic variations in 196 children. Rhinology. 1990;28177- 184
25.
Parsons  DS Chronic sinusitis: a medical or surgical disease? Otolaryngol Clin North Am. 1996;291- 9
26.
Van Der Veken  PJClement  PARBuisseret  TH  et al.  Age-related CT-scan study of the incidence of sinusitis in children. Am J Rhinol. 1992;645- 48Article
27.
Iwens  PClement  PAR Sinusitis in allergic patients. Rhinology. 1994;3265- 67
28.
Yaniv  EOppenheim  DFuchs  C Chronic rhinitis in children. Int J Pediatr Otorhinolaryngol. 1992;2351- 57Article
29.
Polmar  SH Sinusitis and immune deficiency. Lusk  RPed.Pediatric Sinusitis New York, NY Raven Press1992;53- 58
30.
Lusk  RP Chronic sinusitis: surgical management. Bluestone  CDStool  SEKenna  MAeds.Pediatric Otolaryngology Philadelphia, Pa WB Saunders Co1996;859- 865
31.
Otten  FWAGrote  JJ Treatment of chronic maxillary sinusitis in children. Int J Pediatr Otorhinolaryngol. 1988;15269- 278Article
32.
Brook  I Bacteriological features of chronic sinusitis in children. JAMA. 1981;246967- 969Article
33.
Rachelefsky  GSKatz  RMSiegel  SC Chronic sinusitis in the allergic child. Pediatr Clin North Am. 1988;351091- 1101
34.
Roujeau  JCKelly  JPNaldi  L  et al.  Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;3331600- 1607Article
35.
Verbist  LDhoore  F In vitro susceptibility of recently isolated respiratory tract pathogens to minocycline and comparable antibiotics: a multicenter study. Acta Clin Belg. 1994;49268- 273
36.
Takahashi  HFujita  AHonjo  I Effect of adenoidectomy on otitis media with effusion, tubal function, and sinusitis. Am J Otolaryngol. 1989;10208- 213Article
37.
Rosenfeld  RM Pilot study of outcomes in pediatric rhinosinusitis. Arch Otolaryngol Head Neck Surg. 1995;121729- 736Article
38.
Wang  DClement  PARKaufman  LDerde  MP Fiberoptic examination of the nasal cavity and nasopharynx in children. Int J Pediatr Otorhinolaryngol. 1992;2435- 44Article
39.
Maes  JJClement  PA The usefulness of irrigation of the maxillary sinus in children with maxillary sinusitis on the basis of the Water's X-ray. Rhinology. 1987;25259- 264
40.
Lusk  RPLazar  RMuntz  HR The diagnosis and treatment of recurrent and chronic sinusitis in children. Pediatr Clin North Am. 1989;361411- 1421
41.
Younis  RTLazar  RH Criteria for success in pediatric functional endonasal sinus surgery. Laryngoscope. 1996;106869- 873Article
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