Objective: To determine outcomes achieved by treating refractory pediatric rhinosinusitis with a stepped protocol of additional antibiotics, adenoidectomy, and functional endoscopic sinus surgery (FESS).
Design: Prospective cohort with follow-up at 2 to 3 months and at 10 to 12 months.
Setting: Hospital-based pediatric otolaryngology practice with community satellite offices.
Participants: Consecutive 10-month sample of 41 children aged 2 to 13 years who met the following criteria: (1) roentgenographically documented sinusitis, (2) at least one 3-week course of a beta-lactamase stable antibiotic, (3) 3 months or more of clinical symptoms or three or more annual recurrences, (4) no obstructive adenoid hyperplasia, and (5) no cystic fibrosis.
Interventions: Fifteen children (37%) received additional antibiotics alone. Nonresponders underwent adenoidectomy (n = 10) when adenoids were present or FESS (n = 16) when adenoids were scant or if adenoidectomy did not provide relief (n = 2).
Main outcome measures: Unblinded, oral survey of symptomatic response, caregiver expectations, and quality-of-life issues. Responses from the 12 survey questions were combined to produce a sinusitis response score.
Results: Caregiver expectations were met in 88% of children 1 year after treatment but were more often exceeded in patients undergoing FESS (50%) compared with those receiving antibiotics with or without adenoidectomy (13%). Functional endoscopic sinus surgery improved all major symptoms in 100% of children compared with 67% of those receiving antibiotics alone and 75% of those receiving antibiotics and undergoing adenoidectomy. In contrast, complete symptom resolution occurred in only 27% of patients, with no significant differences among groups. The median sinusitis response score of 84% was not associated with treatment level but was negatively associated with male gender.
Conclusions: A stepped treatment approach to refractory sinusitis can improve quality of life for children and caregivers. Additional antibiotic therapy and adenoidectomy should be considered before FESS, even if the adenoids are nonobstructing.