Brief History of Pediatric Sinusitis

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Before the 1980s, pediatric sinusitis, especially in the young child or infant, was rarely entertained as a distinct clinical entity. Most cases were apparently dismissed as an unimportant "allergy" or a "cold" and were rarely treated with anything beyond decon-gestants or antihistamines, or both, perhaps not an altogether bad approach. Through a series of well-designed and executed studies, Dr. Ellen Wald and her associates in Pittsburgh established a logical framework for diagnosing and treating children with sinus infections.1'2 These and other studies, many with pharmaceuticals industry support, demonstrated the efficacy of antimicrobial therapy.3,4

During the late 1980s the recognition of the value of coronal computed tomography (CT) and sinus telescopes led to the rise of "osteomeatal fundamentalism" as a predominant sinus doctrine, especially among rhinologic surgeons. Obstruction of the osteomeatal complex (OMC), recognized as being involved in selected cases of persistent or chronic sinusitis, was put forward as a unifying event in acute, recurrent, and chronic sinusitis. Initially focusing on adult disease, support for OMC doctrine proliferated, as did endoscopic sinus surgery courses and surgical cases.

During the early 1990s, several individuals and groups began performing and reporting hundreds of cases of pediatric endoscopic sinus surgery (mostly infants and young children).5-9 Applied enthusiasm for the procedure made more than a few pediatric otolaryngologists wealthy. The excitement for the procedure, among surgeons, was understandable—suddenly, the most common childhood illness (rhinitis/sinusitis) could be viewed as a surgical disease. The surgical indications were, in general, some type of sinus symptomatology, with rhinorrhea the most common, and CT evidence of mucosal disease, and sometimes simply an abnormal CT. This occurred before the nature of the "sinus disease" was defined or understood, in terms of etiology or pathogenesis. A number of otolaryngolo-gists went on record against this trend, and the topic was the subject of the 1994 Great Debate in Otolaryngology at the Annual Meeting of the American Academy of Otolaryngol-ogy10,11 Over the past 3 years, the number of pediatric and infantile cases has moderated substantially, and several of the busiest surgeons have withdrawn support for the operation, at least for nonmorbid indications.

The 1990s saw an explosion in the number of oral antimicrobial agents that might be used in sinusitis, but also a dramatic rise in resistance to those antimicrobials. This decade has seen an increase in our understanding of the pharmacokinetic and pharmacodynamic properties of antimicrobials that contribute to their clinical effectiveness in respiratory infections. Recent and forthcoming recommendations from consensus panels have reflected that understanding and the outcome from a few comparative trials—making a handful of antimicrobials "winners" and the rest either "also-rans" or losers. The array of antimicrobial choices, resistance issues, and selection considerations has complicated the selection process.12

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