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Pediatric rhinosinusitis 1997-otolaryngology---head-and-neck-surgery

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Pediatric rhinosinusitis 1997-otolaryngology---head-and-neck-surgery

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Pediatric rhinosinusitis 1997-otolaryngology---head-and-neck-surgery

  1. 1. Pediatric rhinosinusitis RODNEYP.LUSK,MD,and JAMESA. STANKIEWICZ,MD,St. Louis, Missouri, and Chicago, IlLinois Pediatric rhinosinusitis is often misdiagnosed and inappropriately treated. On the one hand, all upper res- piratory viral infections may be considered acute rhi- nosinusitis and therefore treated with antibiotics. On the other hand, some physicians and parents view puru- lent rhinorrhea as part of "growing up" and do not inter- vene with medical management. Over the past several decades much has been learned about chronic rhinosinusitis in children. II is now rec- ognized that infections of the nasal mucosa and sinuses are actually a continuum of disease, that rhinitis or rhi- nosinusitis rarely occurs in isolation, and that most pediatric sinus infections begin with an upper respirato- ry tract viral infection and progress to a bacterial sinus infection. The natural history of pediatric chronic rhinosinusi- tis is not well understood. Rhinosinusitis is a multifac- torial disease, and predisposing factors change in importance over time. For example, the maturing immune system and enlarging anatomy of the sinuses may be factors that separate pediatric chronic rhinosi- nusitis from adult chronic rhinosinusitis. 13 Other spe- cial conditions yet to be defined as predisposing factors for chronic rhinosinusitis in children are allergy,4 air pollution, 5 gastroesophageal reflux,6-8 day care set- tings, and enlarged tonsils and adenoids. Although sig- nificant growth retardation does not seem to occur after surgery, it remains a concern. DIAGNOSIS Definition Rhinosinusitis, which is the preferred term, acknowledges that most sinus infections start in the nasal passages as part of a continuum of disease. 9 Viral From the Department of Pediatric Otolaryngology, St. Louis Children's Hospital (Dr. Lusk), and the Department of Otolaryngology-Head and Neck Surgery, Loyola University, Chicago,Ill.(Dr.Stankiewicz). Reprint requests: Rodney R Lusk, MD, Department of Pediatric Otolaryngology, St. Louis Children's Hospital, One Children's Place, St. Louis,MO 63110. OtolaryngolHeadNeck Surg 1997;117:$53-$57. Copyright © 1997 by the AmericanAcademy of Otolaryngology- Head and NeckSurgeryFoundation,Inc. 0194-5998/97/$5.00+ 0 23/0/83511 rhinitis cannot be differentiated from rhinosinusitis on clinical grounds alone. Isolated rhinitis probably exists, but isolated sinusitis is rare. I° Signs and Symptoms The diagnosis of rhinosinusitis is usually based on the clinical evidence and the duration of symptoms. In the first 7 to 10 days of illness it is virtually impossible to tell the difference between an upper respiratory tract infection and rhinosinusitis. In some circumstances, however, an acute infection may rapidly progress to complicated rhinosinusitis. In acute rhinosinusitis the signs and symptoms last longer than 10 days. Chronic rhinosinusitis is associated with low-grade symptoms that persist more than 12 weeks, although acute exacer- bations can occur in chronic infection. Recurrent acute rhinosinusitis consists of repeated acute episodes, with the signs and symptoms resolving completely between episodes. In patients who are being treated with antibi- otics, it is often difficult to differentiate chronic rhino- sinusitis from acute rhinitis on the basis of the signs and symptoms alone, because the clinical features may be masked by the drugs. The signs and symptoms of pediatric rhinosinusitis are listed in Table 1.11-t4 Severe symptoms and compli- cations are usually associated with acute rhinosinusi- tis. I5 The signs and symptoms associated with chronic rhinosinusitis include nasal congestion, rhinorrhea, headaches, irritability, day and night cough, postnasal discharge, and halitosis. 3,t2-14,16 Testing Cultures may be necessary if infections do not respond to conventional treatment (i.e., antibiotics that cover ~3-1actamase-prodncing bacteria) or if symptoms return within 1 week after antibiotic therapy is stopped. There is no consensus on whether middle meatal cul- tures can substitute for sinus punctures. 10,17,18Cultures from the middle meatus or the ethmoid bulla appear to give the best results in chronic rhinosinusitis. 19-21 Cultures are necessary in the following situations: when a child is severely ill or toxic, when symptoms progress despite appropriate medical management, when the child is immunocompromised, and when sup- purative complications are present. The most likely S53
  2. 2. S54 LUSKand STANKIEWICZ Otolaryngology- Head and Neck Surgery September 1997 Table 1. Signs and symptoms of pediatric rhinosinusitis Rhinosinusitis Sign/symptom Nonsevere Severe Rhinorrhea Yes Yes: frank, purulent Nasal congestion Yes Yes Headaches, facial pain May be present Yes Fever None or low grade High grade Frequent cough Yes Yes Postnasal discharge Mild Mild Data from Wald ER. N Engl J Med 1992;326:319-23; Wald ER. Ann Oto/Rhinol Laryngol Supp11992;155:37-41; Muntz HR et al. In: Lusk RP, editor. Pediatric sinusitis. New York: Raven Press; 1992. p. 1-5;Parsons DS et al. Otolaryn9ol Clin North Am 1996;29:11-25. Table 2. Indications for endoscopic sinus surgery Absolute indications Complete nasal obstruction caused by the following: Cystic fibrosis Allergic fungal sinusitis Antrochoanal polyps Other causes of nasal polyps Intracranial complications Cavernous sinus thrombosis Mucoceles and mucopyoceles Subperiosteal or orbital abscess Traumatic injury to optic canal (decompression) Dacryocystorhinitis from rhinosinusitis Allergic or invasive fungal rhinosinusitis Meningoencephaloceles Cerebrospinal fluid leaks Tumors of the nasal cavity or sinuses Relative indications Subacute rhinosinusitis after failure of optimal medical therapy Chronic rhinosinusitis after failure of optimal medical therapy Recurrent acute rhinosinusitis occurring frequently enough that patient takes antibiotics most of the time causes of infection are Staphylococcus aureus, Streptococcus pneumoniae, Moraxella (Branhamella) catarrhalis, and Haemophilus influenzae. 15,20-22 Imaging is not needed to make the diagnosis of rhi- nosinusitis in all children. Controversy exists concern- ing the value of diagnostic ultrasound examination, but this modality appears to be of little use in children. 23-28 Transillumination is of no value in diagnosing rhinosi- nusitis in children. 24Although sinus radiographs are of little use in assessing the ethmoid sinuses or the sphe- noid and frontal sinuses in small children, they can be helpful in diagnosing acute maxillary sinusitis in older children. 29-32 Computed tomographic scanning is indi- cated if endoscopic sinus surgery is being considered or if symptoms indicate that medical management has failed.33-37 The workup should also include investigations for allergy,38-43immune deficiency, 38'4°'44-47cystic fibrosis, 48- 51 ciliary disorders,52-54and gastroesophageal reflux.8 MEDICAL MANAGEMENT Antibiotics and nasal steroids may mask the signs and symptoms of acute and chronic rhinosinusitis. It is also important to remember that the current practice of using broad-spectrum antibiotics for less well-docu- mented infections is likely to increase resistant strains of bacteria.55 Antibiotics may be given for bronchitis and acute otitis media as necessary. The severely ill or toxic child with symptoms of purulent rhinorrhea, nasal obstruc- tion, cough, and headache should be treated with oral antibiotics, whereas the severely ill or toxic child with evidence of suppurative complications should be treat- ed with intravenously administered antibiotics that are effective against H. influenzae, S. pneumoniae, and M. catarrhalis.10,17,56-59 Nonsevere acute rhinosinusitis may be treated with amoxicillin. If no improvements occur in 48 to 78 hours, the antibiotic should be changed to a ~}-lacta- mase stable agent. An oral ~-lactamase stable agent should be used for the initial therapy of severe acute rhinosinusitis and for the treatment of prolonged symp- tomatic chronic rhinosinusitis. For chronic rhinosinusitis a 4- to 6-week course of antibiotics is appropriate. 1°,6°-62 For acute rhinosinusi- tis 10 to 14 days of antibiotic therapy is appropri- ate. 10,63,64If symptoms continue or recur within 5 to 7 days after antibiotic therapy is stopped, the infection should be considered persistent. However, the infection should be considered a new one in a child who was free of symptoms for 2 or more weeks and who was not tak- ing antibiotics. If the symptoms progress after 72 hours of antibiotic therapy, it is appropriate to reevaluate the patient, to change to a broader spectrum antibiotic, or to obtain a culture from the middle meatus. SURGICAL MANAGEMENT Complications of acute rhinosinusitis such as subpe- riosteal abscess, orbital cellulitis, or intracranial abscess must receive aggressive surgical management.
  3. 3. Otolaryngology- Head and Neck Surgery Volume 117 Number 3 Part 2 LUSKand STANKIEWICZ $55 Adenoidectomy In children with rhinosinusitis characterized by moderate to severe nasal obstruction caused by adenoid hypertrophy, adenoidectomy has been shown to be ben- eficial, although not statistically valid, as the cause of resolution.65-69 The degree of symptomatic improve- ment is greatest when the adenoid pads are large.7° Therefore adenoidectomy should be considered as a first-line treatment in a child with rhinosinusitis symp- toms and an obstructive adenoid pad. The size of the adenoid is best assessed with flexible endoscopy of the nasopharynx, but the degree of obstruction can also be documented on a lateral radi- ograph. The lateral tomogram on the sinus computed tomography scan will show good definition of the nasopharynx and allow evaluation of the adenoids. Antral Lavage As a diagnostic corollary of fluid in the maxillary sinus, air-fluid levels on radiographs or computed tomography scans are the only reliable predictors of retrievable fluid.7°-72 Most of the literature discussing lavage was published in the early 1980s; r.hese studies related the procedure to the diagnostic criteria for rhi- nosinusitis, the bacteriology of the illness, and the effi- cacy of sinusitis treatment. 72 Antral lavage is not a viable therapeutic modality for the treatment of rhinosinusitis, because it involves only the maxillary sinus and not the ethmoid sinuses.73-75 Although lavage is no longer used as a therapeutic modality, it remains a valuable diagnostic tool in the immunocompromised patient. An accepled use for lavage is where disease is primarily maxillary. Nasal Antrol Window The nasal antral window (inferior antrostomy) was popularized as a less aggressive and more effective method of treating rhinosinusitis than the Caldwell-Luc procedure. 75 In 1941 Hilding76 cited the nasal antral window as a safer and better procedure than antrostomy of the natural maxillary sinus ostium, because it was less likely to cause infection of the maxillary sinus in a rabbit animal model. Kennedy et al.77,78 cited Proetz79 as being concerned about the possibility of traumatizing the natural ostium with this procedure. Wilkerson8° repopularized the nasal antral window, and it is now frequently used with endoscopic sinus surgery]v,78 The inferior antrostomy has not been a successful modality for treating rhinosinusitis. 81-83 One reason is that the cilia continue to beat toward the obstructed nat- ural ostium. In addition, the diseased ethmoid sinuses are not addressed. Exceptions for placing an inferior antros- tomy include cilial dysfunction and cystic fibrosis. Endoscopic Sinus Surgery Pediatric endoscopic surgery became a viable option after success was demonstrated with adult endoscopic sinus surgery77,84-87 and special instruments were developed for use in children. 19Because of the smaller anatomy, pediatric sinus procedures are thought to require greater technical skill and more meticulous surgery than the same procedures in adults. Frontal and sphenoid sinuses are rarely entered in children. 19,62,88 Because pediatric rhinosinusitis in chil&en is usual- ly located in the anterior ethmoid and maxillary sinus- es, extensive surgery usually is not necessary. Instead, children generally require only a limited procedure con- sisting of anterior ethmoidectomy and possibly maxil- lary antrostomy. In an anterior ethmoidectomy the entire uncinate process is removed. The dissection is carried through the bulla and posteriorly to the basal lamella. The lateral dissection goes to the lamina papyracea. If a maxillary antrostomy is neces- sary,19,64,88-91 a conservative enlargement of the natur- al ostium seems effective. Generally, the ostium remains patent and appears to function well most of the time.78 Absolute and relative indications for endoscopic sinus surgery are listed in Table 2. Children with under- lying immune deficiency, cystic fibrosis, allergy, asth- ma, and mncociliary dyskinesia are more likely to require surgical intervention. Only a small number of children with rhinosinusitis will actually require surgery. In the authors' practice each pediatrician refers an average of one or two patients per year for the eval- uation of chronic rhinosinusitis. Approximately one third of these referred children will require surgery. Good outcomes occur in a large percentage of chil- dren who undergo endoscopic procedures. 19,64,92,93 Most parents who have realistic expectations (i.e., who understand that their children will continue to have viral upper respiratory tract infections) believe that their children are significantly improved after the surgery. CONCLUSION More research is necessary to examine the patho- physiology of pediatric rhinosinusitis and its medical and surgical treatment. Prospective controlled trials are also needed to evaluate the available surgical modali- ties. REFERENCES 1. Van der VekenPJ, ClementPA, BuisseretT, et al. Age-related CT-scanstudyof the incidenceof sinusitis in children.Am J Rhinol 1992;45-8.(gradeA) 2. GrossCW.The diagnosisand managementof sinusitisin chil- dren. Surgicalmanagement:an otolaryngologist'sperspective. PediatrInfectDis 1985;4:$67-72. (gradeB)
  4. 4. S56 LUSK and STANKIEWICZ Otolaryngology- Head and Neck Surgery September 1997 3. Wald ER, Gue~TaN, Byers C. Upper respiratory tract infections in young children: duration of and frequency of complications. Pediatrics 1991;87:129-33. (grade B) 4. Manning SC, Vuitch F, Weinberg AG, et al. Allergic aspergillo- sis: a newly recognized form of sinusitis in the pediatric popula- tion. Laryngoscope 1989;99:681-5. (grade B) 5. Koltai PJ. Effects of air pollution on the upper respiratory tract of children. Otolaryngol Head Neck Surg 1994;111:9-11. (grade B) 6. Hamilos DL. Gastroesophageal reflux and sinusitis in asthma. Clin Chest Med 1995;16:683-97. (grade B) 7. Holinger LD, Sanders AD, Chronic cough in infants and chil- dren: an update. Laryngoscope 1991;101:596-605. (grade A) 8. Barbero GJ. Gastroesophageal reflux and upper airway disease: a commentary. Otolaryngol Clin North Am 1996;29:27-38. (grade B) 9. Gwaltney JM Jr, Phillips CD, Miller RD, et al, Computed tomo- graphic study of the common cold. N Engl J Med 1994;330:25- 30. (grade A) 10. Wald ER. Rhinitis and acute and chronic sinusitis. In: Bluestone CD, editor. Pediatric otolaryngology. 3rd ed. Philadelphia: WB Saunders; 1996. p. 845-6. (grade B) 11. Wald ER. Sinusitis in children. N Engl J Med 1992;326:319-23. (grade B) 12. Wald ER. Sinusitis in infants and children. Ann Otol Rhinol Laryngol Suppl 1992;155:37-41. (grade B) 13. Muntz HR, Lusk RR Signs and symptoms of chronic sinusitis. In: Lusk RP, editor. Pediatric sinusitis. New York: Raven Press; 1992. p. 1-5. (grade B) 14. Parsons DS, Wald ER. Otitis media and sinusitis: similar dis- eases. Otolaryngol Clin North Am 1996;29:11-25. (grade B) 15. Weizman Z, Mussaffi H. Ethmoiditis-associated periorbital cel- lulitis. Int J Pediatr Otorhinolaryngol 1986;11:147-51. (grade B) 16. Fireman R Diagnosis of sinusitis in children: emphasis on the history and physical examination. J Allergy Clin lmmunol 1992;90:433-6. (grade B) 17. Wald ER, Reilly JS, Casselbrant M, et al. Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxi- cillin and cefaclor. J Pediatr 1984;104:297-302. (grade A) 18. Arruda LK, Mimica IM, Sole D, et al. Abnormal maxillary sinus radiographs in children: do they represent bacterial infection? Pediatrics 1990;85:553-8, (grade C) 19. Lusk RR Muntz HR. Endoscopic sinus surgery in children with chronic sinusitis: a pilot study. Laryngoscope 1990;100:654-8. (grade B) 20. Orobello PW Jr, Park RI, Belcher LJ, et al. Microbiology of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg 1991;117:980-3. (grade A) 21. Muntz HR, Lusk RE Bacteriology of the ethmoid bullae in chil- dren with chronic sinusitis. Arch Otolaryngol 1991;117:179-81. (grade A) 22. Gittelman PD, Jacobs JB, Lebowitz AS, et al. Staphylococcus aureus nasal carriage in patients with rhinosinusitis. Laryngoscope 1991;101:733-7. (grade B) 23. Wald ER, Milmoe GJ, Bowen A, et al. Acute maxillary sinusitis in children. N Engt ] Med 1981;304:749-54. (grade A) 24. Wald ER, Chiponis D, Ledesma-Medina J. Comparative effec- tiveness of amoxicillin and amoxicillin-clavulanatepotassium in acute paranasal sinus infections in children: a double-blind, placebo-controlled trial. Pediatrics 1986;77:795-800. (grade A) 25. Shapiro GG, Furukawa CT, Pierson WE, et al. Blinded compar- ison of maxillary sinus radiography and ultrasound for diagnosis of sinusitis. J Allergy Clin Immunol 1986;77:59-64. (grade A) 26. Reil!y JS, Hotaling AJ, Chiponis D, et al. Use of ultrasound in detection of sinus disease in children. Int J Pediatr Otorhinolaryngol 1989;17:225-30. (grade B) 27. Druce HM. Emerging techniques in the diagnosis of sinusitis. Ann Allergy 1991;66:132-6. (grade B) 28. Hussein A, Koch I, Nordwall H. Comparison of sonographic and roentgenologic findings in the paranasal sinuses in children [German]. Monatsschrift Kinderheilkunde 1988;136:686-9. (grade B) 29. McAlister WH, Lusk RR Muntz HR. Comparison of plain radi- ographs and coronal CT scans in infants and children with recur- rent sinusitis. Am J Roentgenol 1989;153:1259-64. (grade A) 30. Lusk RP, McAlisterWH, Fouley A. Anatomic variations in pedi- atric chronic sinusitis [Abstract]. Otolaryngol Clin North Am 1996;29:75-6. (grade A) 31. Manning SC. Pediatric sinusitis. Otolaryngol Clin North Am 1993;26:623-38. (grade B) 32. van der Veken PJ, Clement PA, Buisseret T, et al. CT- scan study of the incidence of sinus involvement and nasal anatomic varia- tions in 196 children. Rhinology 1990;28:177-84. (grade B) 33. Sonkens JW, Harnsberger HR, Blanch GM, et al. The impact of screening sinus CT on the planning of functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 1991;105:802-13. (grade B) 34. Saxton VJ, Boldt DW, Shield LK. Sinusitis and intracranial sep- sis: the CT imaging and clinical presentation. Pediatr Radiol 1995;25(Suppl 1):$212-$217. (grade B) 35. Calhoun KH, Waggenspack GA, Simpson CB, et al. CT evalua- tion of the paranasal sinuses in symptomatic and asymptomatic populations. Otolaryngol Head Neck Surg 1991;104:480-3. (grade C) 36. Lazar RH, Younis RT, Parvey LS. Comparison of plain radi- ographs, coronal CT, and intraoperative findings in children with chronic sinusitis. Otolaryngol Head Neck Surg 1992;107:29-34. (grade B) 37. Zinreich SJ, Kennedy DW, Rosenbaum AE, et al. Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology 1987;163:769-75. (grade C) 38. Shapiro GG. Role of allergy in sinusitis. Pediatr Infect Dis 1985;4:$55-$59. (grade B) 39. Rachelefsky GS, Katz RM, Siegel SC. Chronic sinusitis in the allergic child. Pediatr Clin North Am 1988;35:1091 -101. (grade A) 40. Asakura K, Kojima T, Shirasaki H, et al. Evaluation of the effects of antigen specific immunotherapy on chronic sinusitis in children with allergy. Auris Nasus Larynx 1990;17:33-8. (grade B) 41. Richards W, Roth RM, Church JA. Underdiagnosis and under- treatment of chronic sinusitis in children. Clin Pediatr (Phila) 1991;30:88-92. (grade B) 42. Evans R. Environmental control and immunotherapy for allergic disease. J Allergy Clin Immunol 1992;90:462-8. (grade C) 43. Furukawa CT. The role of allergy in sinusitis in children. J Allergy Clin Immunol 1992;90:515-7. (grade C) 44. Petty RE, Cassidy JT, Sullivan DB. Reversal of selective IgA deficiency in a child with juvenile rheumatoid arthritis after plasma transfusions. Pediatrics 1973;51:44-8. (grade B) 45. Lusk RP, Polmar SH, Muntz HR. Endoscopic ethmoidectomy and maxillary antrostomy in immunodeficient patients. Arch Otolaryngol Head Neck Surg 1991;117:60-3. (grade B) 46. Shapiro GG, Virant FS, Furukawa CT, et al. Immunologic defects in patients with refractory sinusitis. Pediatrics 199l;87:311-6. (grade B) 47. Kurono Y, Fujiyoshi 3", Mogi G. Secretory IgA and bacterial adherence to nasal mucosal cells. Ann Otol Rhinol Laryngol 1989;98:273-7. (grade A) 48. Hui Y, Gaffney R, Crysdale WS. Sinusitis in patients with cystic fibrosis. Eur Arch Otorhinolaryngol 1995;252:191-6. (grade B) 49. Ramsey B, Richardson MA. Impact of sinusitis in cystic fibro- sis. J Allergy Clin Immunol 1992;90:547-52. (grade B) 50. Drake-Lee AB, Morgan DW. Nasal polyps and sinusitis in chil- dren with cystic fibrosis. J Laryngol Otol 1989;103:753-5. (grade B)
  5. 5. Otolaryngology- Head and Neck Surgery Volume 117 Number 3 Part 2 LUSKand STANKIEWICZ $5,7 51. Cepero R, Smith RJ, Catlin FI, et al. Cystic fibrosis--an oto- laryngologic perspective. Otolaryngol Head Neck Surg 1987;97:356-60. (grade B) 52. Fontolliet C, Terrier G. Abnormalities of cilia and chronic sinusitis. Rhinology 1987;25:57-62. (grade B) 53. Karja J, Nuutinen J. Immotile cilia syndrome in children. Int J Pediatr Otorhinolaryngol 1983;5:275-9. (grade B) 54. Scheeren RA, Keehnen RM, Meijer CJ, et al. Defects in cellular immunity in chronic upper airway infections are associated with immunosuppressive retroviral pl5E-like proteins. Arch Otolaryngol Head Neck Surg 1993;119:439-43 (grade A) 55. McCaig LF, Hughes JM. Trends in antimicrobial drug prescrib- ing among office-based physicians in the United States. JAMA 1995;273:214-9. (grade C) 56. Otten FW, Grote JJ. Treatment of chronic max:llary sinusitis in children. ~[ntJ Pediatr Otorhinolaryngol 1988;15:269-78. (grade C) 57. Bluestone CD. Medical and surgical therapy of sinusitis. Pediatr Infects Dis 1984;3:S13-S18. (grade C) 58. Aijmand EM, Lusk RR Management of recuE:ent and chronic sinusitis in children. Am J Otolaryngol 1995;16:367-82. (grade B) 59. Finch RG. Epidemiological features and chemotherapy of corn- munity-acquired respiratory tract infections. J Antimicrob Chemother 1990;26(Suppl E):53-61. (grade B) 60. Wald ER. Sinusitis. Pediatr Rev 1993;14:345-51. (grade B) 6t. Wald ER. Antimicrobial therapy of pediatric patients with sinusitis. J Allergy Clin Immunol 1992;90:469-'73. (grade B) 62. Lusk RP. Endoscopic approach to sinus disease. J Allergy Clin Immunol 1992;90:496-505. (grade B) 63. Poole MD. Pediatric endoscopic sinus surgery: abe conservative view. Ear Nose Throat J 1994;73:221-7. (grade C) 64. Lusk RR Chronic sinusitis: surgical management. In: Bluestone CD, editor. Pediatric otolaryngology, 3rd ed. Philadelphia: WB Saunders; 1996. p. 859-65. (grade B) 65. Takahashi H, Fujita A, Honjo I. Effect of adenoidectomy on oti- tis media with effusion, tubal function, and sinusitis. Am J Otolaryngol 1989;10:208-13. (grade A) 66. Lusk RR Surgical modalities other than etl~moidectomy. J Allergy Clin Immunol 1992;90:538-42. (grade B) 67. Fujita A, Takahashi H, Honjo I. Etiological role of adenoids upon otitis media with effusion. Acta Otolaryngol Suppl (Stockh) 1988;454:210-3. (grade B) 68. Paul D. Sinus infection and adenotonsillitisin pediatric patients. Laryngoscope 1981;91:997-1000. (grade B) 69. Merck W. Relationship between adenoidal enlargement and maxillary sinusitis. HNO 1974;6:198-9. (grade B) 70. Kay NJ, Setia RN, Stone J. Relevance of conventional radiogra- phy in indicating maxillary antral lavage. Ann Otol Rhinol Laryngol 1984;93:37-8. (grade B) 71. Decreton SJ, Clement PA. Comparative study ot standard x-ray of the maxillary sinus and sinuscopy in children. Rbinotogy 1981;19:155-9. (grade B) 72. PfleidererAG, Drake-Lee AB, Lowe D. UltrasouM of the sinus- es: a worthwhile procedure? A comparison of ultrasound and radiography in predicting the findings of proof puncture on the maxillary sinuses, Clin Otolaryngol 1984;9:335-!}. (grade B) 73. Bertrand B, Eloy R Temporary nasosinusal drainage and lavage in chronic maxillary sinusitis. Statistical study on 847 maxillary sinuses. Ann Otol Rbinol Laryngol 1993;102:858- 62. (grade B) 74. Maes JJ, Clement PA. The usefulness of ilrigation of the maxil- lary sinus in children with maxillary sinusitis on the basis of the Water's x-ray. Rhinology 1987;25:259-64. (grade B) 75. Hempstead BE. End results ofinternasal operation for maxillary sinusitis. Arch Otolaryngol 1939;30:711-5. (grade B) 76. Hilding AC. Experimental sinus surgery: effects of operative windows on normal sinuses. Ann Otol Rhinot Laryngot 1941;50:379-92. (grade C) 77. Kennedy DW, Zinreich SJ, Rosenbaum AE, et al. Functional endoscopic sinus surgery. Theory and diagnostic evaluation. Arch Otolaryngot 1985;111:576-82. (grade B) 78. Kennedy DW, Zinreich SJ, Shaalan H, et al. Endoscopic middle meatal antrostomy: theory, technique, and patency. Laryngoscope 1987;97: 1-9. (grade B) 79. Proetz AW. Essays on the applied physiology of the nose. St Louis: Annals Publishing Co.; 1941. p. 356. (grade C) 80. Wilkerson WWI Antral window in the middle meatus. Arch Ophthalmol 1949;49:463-89. (grade B) 81. Muntz HR, Lusk RP. Nasal antral windows in children: a retro- spective study. Laryngoscope 1990;100:643-6. (grade B) 82. Lund VJ. Fundamental considerations of the design and function of intranasal antrostomies. Rhinology 1985;23:231-6. (grade B) 83. Lund VJ. Inferior meatal antrostomy. Fundamental considera- tions of design and function. J Laryngol Otol Suppl 1988;15:1- 18. (grade A) 84. Kennedy DW. Functional endoscopic sinus surgery. Technique. Arch Otolaryngol 1985;111:643-9. (grade B) 85. Stammberger H. Endoscopic surgery- for mycotic and chronic recurring sinusitis. Ann Otol Rhinol Laryngol 1985;119:1-I 1, (grade B) 86. Stammberger H. Nasal and paranasal sinus endoscopy. A diag- nostic and surgical approach to recurrent sinusitis. Endoscopy 1986;18:213-8. (grade B) 87. Stammberger H. Endoscopic endonasal surgery: concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and patho- physiologic considerations. Otolaryngol Head Neck Surg 1986;94:143-7. (grade B) 88. Lusk RE Surgical management of chronic sinusitis. In: Lusk RR editor. Pediatric sinusitis. New York: Raven Press; 1992. p. 77- 126. (grade B) 89. Settlif RC. Minimally invasive sinus surgery: the rationale and the technique. Otolaryngol Clin North Am t996;29:115-29. (grade B) 90. Parsons DS. Chronic sinusitis: a medical or surgical disease? Otolaryngol Clin North Am i996;29:1-9. (grade B) 91. Stankiewicz JA, Pediatric endoscopic nasal and sinus surgery. Otolaryngol Head Neck Surg 1995;113:204-10. (grade B) 92. Lazar RH, Younis RT, Gross CW. Pediatric functional endonasal sinus surgery: review of 210 cases. Head Neck 1992;14:92-8. (grade B) 93. Manning SC, Wasserman RL, Silver R, et al. Results of endo- scopic sinus surgery in pediatric patients with chronic sinusitis and asthma. Arch Otolaryngol Head Neck Surg 1994;120:1142- 5. (grade A)

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