By the time a child arrives in the otolaryngologist's office for evaluation of "chronic" sinusitis, someone in the family will have raised the issue that "this is all due to allergy." In many situations, the nature of the rhinorrhea and congestion does resemble that seen in atopic patients. However, microscopic and immunologic analyses of the secretions are not consistent with what is seen in IgE-mediated rhinitis. Rather, the findings are those of acute infectious inflammation. Whereas some reports report a higher incidence of sinusitis in atopic children, concerns about reporting biases and biases in the allergy practices reporting such findings raise concerns about the validity of the reports. The primary risk factors for such disease are primarily related to exposure to other children, as in day care. The prompt response to effective antimicrobials also weighs against allergy being of primary importance. As a child grows beyond 3-5 years of age, the incidence of IgE-mediated disease rises and becomes more important in the differential diagnosis. Although the rationale for atopic mucosa increasing the likelihood of bacterial infection appears sound, many of our adults with the worst allergic rhinitis are never affected by bacterial sinusitis.
Some allergists maintain that the main culprit is an IgG-mediated allergy or food allergy. Although that may occasionally be the case, the scientific evidence for food allergy contributing to pediatric sinusitis is weak.
The role of testing for immunodeficiencies in patients with problematic pediatric sinusitis is controversial. Mild age-related immunodeficiency is common, but a specific therapy for this is not currently available or practical. The same applies for IgG subclass deficiencies. We do not generally order such tests unless a child is severely affected or shows evidence of chronic infections elsewhere.
Reflux esophagitis is said to be an underlying cause of chronic pediatric sinusitis with a frequency ranging from almost always to rarely.15'16 Testing or empirical therapy for reflux may be appropriate in children with associated symptoms of reflux or in cases in which other forms of medical therapy have not been successful.
In approaching the child with "chronic sinusitis," we find it useful to try to classify the patients as having one or more of the common sinus "syndromes" (in the approximate order of frequency):
1. Relatively normal rhinosinusitis with an excessively concerned family
2. Frequently recurrent rhinosinusitis (day-care syndrome)
3. Purulent rhinosinusitis unresponsive to empirically selected oral antimicrobials
4. Rhinosinusitis associated with posterior nasal obstruction (adenoid enlargement)
5. Sinusitis with reflux
6. Significant component of IgE-mediated rhinitis/sinusitis
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