Why The Maxillary Sinus

Although the frontal and sphenoid sinuses have long been recognized as occasional sites of clinically important disease, the maxillary sinus has traditionally been the focus for defining bacterial sinusitis. Emphasis on the OMC has only recently shifted new attention to the importance of the eth-moidal cells. In retrospect, it was our ability to "image" the maxillary sinuses satisfactorily with standard radiographic equipment, that led to that site as the gold standard for assessing the microbiology and efficacy issues surrounding sinusitis. The insistence by established sinus investigators and regulatory agencies, such as Food and Drug Administration (FDA), that sinusitis primarily be considered by maxillary investigations is not consistent with our current understanding. In all likelihood, for most cases of symptomatic acute sinusitis, mucosal disease in the ethmoids and nasal cavity accounts for more symptoms than what transpires in the maxillary sinus, especially in children.

failure to differentiate accurately between the various clinical types of sinusitis and the failure to understand the real pathophysiologic basis of pediatric rhinosinusitis.

Most cases of pediatric endoscopic sinus surgery are performed after a period of chronicity or multiple sinus infections. Some clinicians have advocated protocols in which sinus surgery was recommended after failure of an adenoidectomy to control the disease.13 But what is the definition of failure, and what is the process responsible for these clinical failures? Is it persistent bacterial infection? Perhaps—but that, we believe, can be completely eliminated as a problem by effective antimicrobial use, even considering today's resistance problems (see Treatment Issues, below). Is it uncontrolled allergic disease? I am not aware of anyone admitting to recommending pediatric sinus surgery for allergic disease (without polyps). Most chronic disease actually represents the reemergence of symptoms related to intercurrent new viral and bacterial respiratory infections. Perhaps just as important as a determinant of which child receives aggressive sinus management is the presence of a family member who is uncommonly focused on, and intolerant of, sinus symptoms. Those symptoms and associated findings are typically identical to those of thousands of other children who are receiving no specific care for their rhinosinusitis.

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