Table 1 – Mechanisms of Pediatric CRS1

• Non-eosinophilic/Infectious CRS
• Eosinophilic CRS +/- NP
• Allergic Fungal Sinusitis
• Aspirin-Exacerbated Respiratory Disease
• Primary Immunodeficiency Syndromes and Sinus Disease
• Cystic Fibrosis, Ciliary Dysmotility Disorders, and Sinusitis

Abbreviations: NP – nasal polyps

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Table 2 – Medical Evaluation Components1

Component Comments
History • Determine symptoms and longevity, infections, antibiotic use, nutritional status, presence/control of asthma, NSAID exposure, ability to smell/taste
• Anosmia, dysgeusia – sign of NP
Physical Examination • Reveals rhinorrhea, nasal turbinate swelling/edema, erythematous nasal mucosa, allergic sensitization
• Consider allergy testing (i.e. perennial, seasonal aeroallergens) if allergic rhinitis is suspected in conjunction with CRS
Imaging Non-contrasted CT scan:
• Gold standard for uncomplicated CRS refractory to medical therapy

• Superior resolution of bone and soft tissue; reveals information about anatomy alterations

• Other imaging options recommended for sensitive areas due to radiation exposure

• Superior soft tissue imaging
• Lacks bone detail required for surgical intervention
Nasal Endoscopy:
• Aids in confirming a CRS diagnosis
• Provides direct cultures for infection work-ups
• Reveals posterior pharyngeal drainage, edema, and purulent discharge past the nasal vestibule
• Aids in diagnosing adenoiditis, adenoid hyperplasia/hypertrophy, NP, mucosal edema, and septal deviation
Not Recommended:
• Plain radiographs
• Ultrasound imaging
Additional tests
(For patients who do not respond to appropriate medical management or present with NP)
• For CF: Sweat chloride and genetic testing
• For PCD: Nasal and bronchial biopsy with genetic testing
• Tests for allergic fungal sinusitis as well as aspirin-exacerbated respiratory disease

Abbreviations: CF – cystic fibrosis; CT – computed tomography; MRI – magnetic resonance imaging; NP – nasal polyps; PCD – primary ciliary dyskinesia

Table 3 – Medical Treatment Options for Pediatric CRS1

Therapy Comments
Antibiotics • Empiric antibiotics considered 1st line after initial CRS diagnosis

• 1st line agent: amoxicillin 90mg/kg

• Patients with penicillin allergy or concern for MRSA infection: clindamycin

• Duration of therapy debatable

• Studies: <10 days appears inadequate

• Providers: majority recommend 15-21 days.

• Culture-directed therapy considered if empiric therapy has failed
• May be used in combination with oral steroids

Nasal Saline Irrigation • Effective
• Low risk of adverse effects
Intranasal/Topical Steroids • Can be used as monotherapy or in combination therapy
• Sprays: decrease mucosal edema, improve symptoms
• Topical: quick resolution of symptoms; especially beneficial in patients with asthma or NP with eosinophilia of sinus tissues
Oral Steroids • Debatable role in the treatment of CRS
• Most useful in patients who require surgery (i.e. as postoperative therapy to decrease risk of disease recurrence)
• Use cautiously (significant risk of side effects with chronic use)
Combination Therapies • Antibiotics + oral steroids

• Decrease symptoms and sinus CT scores

• Antibiotics + intranasal steroid sprays
• Sinus rinses + topical steroids

• Decrease sinus surgery frequency, increase quality of life

• Sinus rinses + antibiotics

• Minimal statistical benefit observed

Allergen IT • Decrease medication requirements, improve symptoms, and increase quality of life in patients with defined environmental allergies
• 3-5 years of IT is recommended
• Empiric antibiotics considered 1st line after initial CRS diagnosis

• Decrease 
• Decrease 

Abbreviations: CT – computed tomography; IT – immunotherapy; MRSA – Methicillin-resistant Staphylococcus aureus; NP – nasal polyps