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This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media (AOM) guideline from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated AOM.In 2009, the AAP convened a committee composed of primary care physicians and experts in the fields of pediatrics, family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the new literature related to AOM since the initial evidence report of 2000. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations.The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific, stringent definition of AOM. It addresses pain management, initial observation versus antibiotic treatment, appropriate choices of antibiotic agents, and preventive measures. It also addresses recurrent AOM, which was not included in the 2004 guideline. Decisions were made on the basis of a systematic grading of the quality of evidence and benefit-harm relationships.The practice guideline underwent comprehensive peer review before formal approval by the AAP.This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

Ramadan HH, Tiu J. Laryngoscope. 2007;117(6):1080–1083 PURPOSE OF THE STUDY. To determine which children who undergo adenoidectomy for chronic rhinosinusitis will subsequently undergo endoscopic sinus surgery. STUDY POPULATION. Children who had adenoidectomy for treatment of refractory chronic rhinosinusitis over a 10-year period at a tertiary pediatric facility were included in the study. Excluded children were those with immunodeficiency, cystic fibrosis, or previous sinus surgery. All patients had an extensive preoperative workup to rule out allergy, immunodeficiency, and cystic fibrosis. METHODS. Charts were reviewed, and data were collected retrospectively. All patients underwent adenoidectomy via the suction electrocautery technique. Children were followed monthly for 3 months after adenoidectomy and then every 3 months. Data collected included age, presence of allergy or asthma, severity of sinusitis as indicated on computed tomography (CT) scans, and dates of adenoidectomy and subsequent sinus surgery. Endoscopic sinus surgery was performed for persistent symptoms despite adenoidectomy and medical management with radiographic evidence of sinusitis on CT scans. RESULTS. A total of 143 children had adenoidectomy for sinusitis, and follow-up data were available for 121 children. Adenoidectomy failed for 61 (50%) children, with data available from 55 who had subsequent endoscopic sinus surgery. The mean time between adenoidectomy and endoscopic sinus surgery was 24 months (range: 4.4–77.4 months). Children with asthma had a mean of 19 months between surgeries, whereas those without asthma had an interval of 28 months (P = .04). Children younger than 7 years of age had sinus surgery a mean of 15 months after adenoidectomy, compared with an interval of 27.5 months between surgeries for children ≥7 years (P = .01). The presence of allergy, severity of sinusitis as indicated by CT scans, and gender did not seem to affect the time of failure of adenoidectomy. CONCLUSIONS. At least 50% of children with rhinosinusitis will benefit from an adenoidectomy without the need for subsequent sinus surgery. Children who have persistent sinusitis that requires endoscopic sinus surgery after adenoidectomy tend to be younger children and/or children with asthma, with a mean of 24 months between surgeries. REVIEWER COMMENTS. Adenoidectomy is a simple procedure that is effective for treating children with rhinosinusitis whose conditions fail medical therapy, but a number of children do go on to have more extensive surgical procedures. The retrospective nature of this study and limited information on how sinusitis symptoms were stratified, as well as how treatment failure was defined, affect our ability to generalize the conclusions of this study. The shorter interval between adenoidectomy and endoscopic sinus surgery in children with asthma may reflect a more aggressive approach to surgical management of sinusitis in the presence of pulmonary disease rather than an actual difference in the natural history of sinusitis in these children. The shorter interval between adenoidectomy and endoscopic sinus surgery in the younger children suggests more severe sinus symptoms in this group, although it may just reflect the natural history of sinusitis and upper respiratory infections in children, with eventual resolution expected for many older children regardless of treatment.

Ramadan HH, Cost JL. Laryngoscope. 2008;118(5):871–873 PURPOSE OF THE STUDY. To compare the outcomes of adenoidectomy with adenoidectomy combined with maxillary sinus wash for the treatment of children with medically refractory sinusitis. STUDY POPULATION. Studied were children treated at a tertiary otolaryngology referral center with chronic (>6 months) or recurrent (>6 episodes) rhinosinusitis diagnosed by both clinical criteria and computed tomography (CT) who did not improve with 6 months of treatment with oral antibiotics, decongestants, and allergy management when appropriate. Children with cystic fibrosis, immunoglobulin deficiency, ciliary dysfunction, or a history of previous adenoid or sinus surgery were excluded. METHODS. Patients were assigned to adenoidectomy alone or adenoidectomy in combination with maxillary sinus wash in a nonrandomized manner on the basis of surgeon and parental preference. A questionnaire was administered 12 months after surgery to evaluate changes in symptoms of nasal obstruction/congestion, purulent drainage, cough, and headache after surgery. Univariate and multivariate analyses were performed to compare results of the 2 procedures. RESULTS. Sixty patients were enrolled in this study: 32 (53%) underwent adenoidectomy with sinus wash, and 28 (47%) had adenoidectomy alone. The adenoidectomy/wash group had more severe sinus disease on the basis of the Lund-Mackay scoring of CT scans (mean score: 7.9 vs 3.0; P = .001) and had more boys (P = .04). Overall, 87.5% of the patients who had adenoidectomy/sinus wash were improved on the basis of questionnaire results, compared with 60.7% of the subjects who had adenoidectomy alone (P = .017). Children with more severe sinusitis on the basis of CT scans were more likely to improve with both adenoidectomy/sinus wash than with adenoidectomy alone (93% vs 60%; P = .03). CONCLUSIONS. This study demonstrates a benefit of maxillary sinus wash at the time of adenoidectomy for refractory sinusitis, particularly for children with more extensive sinus disease as indicated on preoperative CT scans. REVIEWER COMMENTS. The role of surgery for treatment of children with sinusitis remains controversial. Who should have surgery, and which child should have adenoidectomy, endoscopic surgery, or maxillary lavage? The role of maxillary sinus wash or nasoantral windows for children has been discouraged in the past 2 decades with the recognition of key anterior ethmoid disease that might best be treated by endoscopic surgery when medical treatments fail. This article shows a benefit of maxillary wash when added to adenoidectomy, particularly for severe disease. This benefit may be from the method of irrigation through the natural ostium of the maxillary sinus rather than via the inferior meatus or the canine fossa. Unfortunately, this article is sparse with the details of measured outcomes criteria and the definition of improvement of symptoms. Although statistical analysis was used to control for nonrandom assignment of treatment, unrecognized bias may still exist. With these limitations, maxillary sinus wash through the middle meatus seems to be a conservative surgical option in the treatment of refractory childhood sinusitis, a disease with a favorable natural history.

Germiller JA, Monin DL, Sparano AM, Tom LWC. Arch Otolaryngol Head Neck Surg. 2006;132:969–976 PURPOSE OF THE STUDY. To evaluate the presentation, imaging, microbiology, treatment, and outcome of intracranial complications of sinusitis in children. STUDY POPULATION. The study included 25 consecutive children and adolescents treated for intracranial complications of sinusitis over a 5-year period. METHODS. This was a retrospective chart review of patients who were identified by screening admission diagnoses for central nervous system infections including intracranial abscesses, meningitis, encephalitis, and dural sinus thrombophlebitis. These records were cross-referenced for both procedure codes for external and endoscopic sinus surgery and diagnosis of acute or chronic sinusitis. RESULTS. Twenty-five consecutive patients were identified, with ages ranging from 4 to 18 years; 19 patients were male and 6 were female. There were 35 intracranial complications: 13 epidural abscesses, 9 subdural empyemas, 6 meningitis, 2 dural sinus thromboses, and 1 middle cerebral artery ischemia. Nine patients (36%) had >1 intracranial complication. Ten patients (44%) also had at least 1 extracranial complication: 5 with orbital cellulites, 4 with orbital/periorbital abscess, 1 with forehead abscess, and 1 with forehead edema. Seventy percent of the patients with extracranial complications had epidural abscess as their intracranial complication. In addition, 12 patients (48%) presented with neurologic signs and symptoms, most commonly change in mental status (9 patients) or hemiparesis (5 patients). Of the 13 who presented without neurologic signs and symptoms, 9 (69%) had epidural abscess as their only intracranial complication. Fifteen patients had computed tomography imaging with contrast, identifying 12 (63%) of 19 complications in those patients. MRI was performed in 19 patients, identifying 26 (93%) of 28 complications in those patients. Cultures grew multiple organisms in more than one half of the patients, 53% of which were Streptococcus species. Outcomes were divided into 3 groups. No patient in group 1 (14 patients) had neurologic deficits or events. All the patients in group 1 underwent endoscopic sinus surgery (100%), and 7 (50%) underwent a neurosurgical procedure. By definition, there were no short-term or long-term sequelae for the children in group 1. Group 2 included 8 patients who experienced short-term neurologic sequelae only. Seven patients of group 2 underwent endoscopic sinus surgery (88%), and 5 (63%) underwent a neurosurgical procedure. Group 3 included 3 patients who experienced permanent neurologic deficits (bilateral sensorineural hearing loss for one and hemiparesis, expressive aphasia, and seizures for the other) or death. Two patients in group 3 underwent endoscopic sinus surgery (67%), and 1 (33%) underwent a neurosurgical procedure. CONCLUSIONS. Intracranial complications of sinusitis in children present diagnostic challenges, because many patients lack a history of sinusitis and present with vague, nonlocalizing signs and symptoms. Aggressive medical and surgical management may limit morbidity and improve outcomes. Early imaging is crucial to diagnosis, and MRI is the most useful test. REVIEWER COMMENTS. Intracranial complications of sinusitis remain uncommon; even in this review from a tertiary pediatric center only 5 patients per year were identified. A high index of clinical suspicion, particularly in adolescent boys, should lead to early imaging for diagnosis. Medical therapy combined with neurosurgical and otolaryngological surgical interventions may improve outcomes and reduce short-term and long-term sequelae.

Purpose of the Study. To compare the outcomes of children treated for refractory chronic sinusitis with adenoidectomy, endoscopic sinus surgery (ESS), or adenoidectomy with ESS. Study Population. Children, 2 to 13 years old, with sinusitis that persisted after 6 months of medical treatment (eg, antibiotics, nasal steroids, decongestants, reflux medications). These children had surgery (adenoidectomy, ESS, or both) over the 10-year study period. Methods. This was a nonrandomized study in which children were followed prospectively every 3 months after the surgical approaches. Each child was evaluated preoperatively for allergy, immunodeficiency, and cystic fibrosis and had a sinus computed tomography (CT) scan to assess disease severity. Parents filled out a questionnaire to assess improvement every 6 months for 1 year. Improvement based on questionnaire reports and need for more surgery were the principal outcome measures. Results. A total of 222 children had surgery for sinusitis during the study period (11% of children referred for evaluation of sinusitis), and 183 had adequate follow-up. The 3 surgical groups were similar with regard to gender, asthma, allergy, smoke exposure, and day care attendance. The children who had adenoidectomy alone were younger and had less severe sinus disease on CT scan than those in the other groups. Children who had adenoidectomy/ESS showed the greatest rate of improvement (87%) and lowest need for more surgery (7%). Seventy-five percent of children after ESS alone were improved, and 13% of the children in this group needed revision surgery. The adenoidectomy group had improvement in 52% of its subjects, and more surgery was needed for 25%. Younger children (aged ≤6) had lower rates of improvement and needed revision surgery more than older children, with no difference in results between surgical groups. Children older than 6 years had the greatest improvement rate with adenoidectomy/ESS (96%). Children with asthma had lower rates of surgical success than those without (62% vs 80%); there was no difference in surgical success in children with and without allergies. For patients with asthma, adenoidectomy/ESS was superior. When CT scans showed mild disease, no differences were seen in the 3 surgical groups. With more severe disease on CT scan, adenoidectomy/ESS improved more patients (87%) than did ESS (72%) or adenoidectomy (46%) alone. Conclusions. Surgery is recommended for children with chronic sinusitis refractory to medical therapy, and improvement is seen in most children. Adenoidectomy alone is recommended for children who are 6 years old or younger with mild sinus disease on CT scan. Adenoidectomy/ESS should be considered for older children, those with severe sinusitis, and those with asthma. Reviewer Comments. Children with chronic sinusitis usually do not need surgery. For those whose conditions fail medical treatment, the choice of initial surgery (adenoidectomy, ESS, or both) remains problematic. This comparison of postsurgical results has several limitations. The patients were not randomly assigned to the groups, which was most evident in the adenoidectomy group; the children in this group were younger and had less severe disease than those in the other 2 groups. It is not surprising that the children in the adenoidectomy group would have a higher rate of additional surgery, because the threshold to perform ESS in a child after adenoidectomy alone failed is certainly lower than that of performing additional surgery on one in whom ESS failed. The postoperative survey was not validated, and objective measures of improvement (school days missed, number of antibiotic courses, etc) were not included. A comparable group treated without surgery was not studied. Despite these shortcomings, this study provides clinical indicators to assign appropriate surgery for the child with refractory sinusitis.

Bhattacharyya N, Jones DT, Hill M, Shapiro NL. Arch Otolaryngol Head Neck Surg . 2004;130:1029–1032 To determine the accuracy of computed tomography (CT) in the diagnosis of pediatric chronic rhinosinusitis (CRS). The sinus CT scans of 2 cohorts of children were evaluated and compared prospectively. The “diseased” cohort consisted of 66 children (mean age: 8 years) who were scheduled to undergo endoscopic sinus surgery for medically refractory CRS. The second “nondiseased,” control cohort consisted of 192 children (mean age: 9 years) who were undergoing CT scans for reasons other than sinusitis. Sinus CT scans were scored according to the Lund-MacKay system. The Lund-MacKay staging system scores each sinus (anterior ethmoid, posterior ethmoid, maxillary, frontal, and sphenoid sinuses) …

Koltai PJ, Solares CA, Koempel JA, et al. Otolaryngol Head Neck Surg . 2003;129:532–538 To compare the safety and efficacy of intracapsular tonsillar reduction (partial tonsillectomy) with those of conventional tonsillectomy for treating obstructive sleep-disordered breathing among children. The authors reviewed the medical records for a total of 350 children who underwent either partial (243 children) or standard (107 children) tonsillectomy for treatment of obstructive sleep-disordered breathing. The diagnosis of sleep-related obstruction was made on the basis of history findings. This was a retrospective chart review of patient records for all children with obstructive sleep-disordered breathing who underwent either partial or standard tonsillectomy, performed by 1 of 3 primary surgeons. The choice of surgical technique was made by the parents, who were told that the new partial tonsillectomy might be …

Brietzke SE, Brigger MT. Int J Pediatr Otorhinolaryngol . 2008;72(10):1541–1545 PURPOSE OF THE STUDY. The objective of this study was to evaluate the available medical literature for evidence that adenoidectomy is an effective procedure for treating children with medically refractory rhinosinusitis. STUDY POPULATION. Articles were obtained by using database searches and manual searches. These articles studied children, ≤18 years of age, who underwent adenoidectomy alone for management of medically refractory rhinosinusitis. The mean of the mean age of patients for each included series was 5.8 years, with a range of means …

Ramadan HH, Hinerman RA. Am J Rhinol. 2006;20:438–440 PURPOSE OF THE STUDY. To compare results of endoscopic sinus surgery for treatment of chronic rhinosinusitis in children with and without documented allergy. STUDY POPULATION. One hundred forty-one children (aged 3–13 years) with chronic rhinosinusitis who were followed for at least 12 months after endoscopic sinus surgery and had symptoms assessed by caregiver questionnaire were included in this study. All children were evaluated for allergy, immunoglobulin deficiency, and cystic fibrosis before surgery. A total of 77 children had documented allergy, and 64 had negative allergy evaluations. The allergic and nonallergic children were similar with regard to gender distribution, tobacco exposure, and disease severity, but asthma was more than twice as prevalent in the allergic group (56% vs 23%). Children with cystic fibrosis, immunodeficiency, fungal infection, or previous sinus surgery were excluded from the study. Surgery usually consisted of middle meatal antrostomy and anterior ethmoidectomy. METHODS. Symptoms were evaluated by the caregiver using a nonvalidated questionnaire before surgery and every 3 months for at least 12 months after surgery. The results of the questionnaire 12 months after surgery were used to create 2 groups: (1) cured or improved subjects were categorized as successful, and (2) subjects with unchanged or worsened symptoms and those who required additional surgery were categorized as treatment failures. Medical treatment for sinusitis included long-term antibiotics, intranasal steroids, decongestants, antireflux treatment, systemic steroids, and allergy management. Allergy management consisted of antihistamines and intranasal steroids in all allergic children and immunotherapy in 25%. One third of allergic patients underwent endoscopic sinus surgery before initiation of allergy treatment. RESULTS. The overall success rate for endoscopic sinus surgery was 80%. The allergic group had a 77% success rate after sinus surgery, whereas the nonallergic group had an 84% success rate, a difference that was not statistically significant. Multivariate analysis was performed, and the presence of allergy did not predict a poorer outcome. Allergic children who underwent sinus surgery without preoperative allergy treatment had a 62% success rate, compared with a success rate of 84% for children who were treated for allergy before surgery. CONCLUSIONS. The presence of allergy does not predict poorer outcomes after sinus surgery in children. Preoperative treatment of such allergy improves surgical results. REVIEWER COMMENTS. This article demonstrated that endoscopic sinus surgery can effectively treat refractory sinusitis in children even when allergy is documented. The standard practice of allergy evaluation and treatment before sinus surgery in children was also supported, although the details of such evaluation were not addressed in this article. Because this was a cohort study, not a randomized, controlled trial, we cannot assess the effects of allergy management alone on children with chronic sinusitis. It is curious that the group of children who had allergy treatment before surgery had better surgical results at a 12-month follow-up than the others with allergy, because we would suspect that all children diagnosed with allergy would be treated for allergy at some point before or after surgery. The indications for endoscopic sinus surgery in children, and the extent of such surgery, remain debated. This article adds to evidence that such surgery is effective for refractory sinusitis, even in allergic children.

van Staaij BK, van den Akker EH, Rovers MM, Hordijk GJ, Hoes AW, Schilder AG. BMJ . 2004;329:651–658 To evaluate the effectiveness of adenotonsillectomy in children with a small number of recurrent sore throat infections or with mild obstructive symptoms from adenotonsillar hypertrophy. Three hundred otherwise healthy children in the Netherlands, aged 2 to 8 years, who were being considered for adenotonsillectomy to treat recurrent throat infections or obstructive symptoms. Excluded from the study were children with frequent throat infections (≥7 in the past year, ≥5 in each of the past 2 years, or ≥3 in each of the past 3 years), children with suspected …