Efficacy of a stepwise protocol that includes intravenous antibiotic therapy for the management of chronic sinusitis in children and adolescents

Background: Recent concern regarding interference with facial skeletal grow th and the risk of complications after endoscopic sinus surgery (ESS) has l ed to interest in exploring other treatment options for the management of c hronic sinusitis in children. Objective: To present the use of a stepwise protocol that includes intraven ous (IV) antibiotic therapy as a therapeutic alternative to pediatric ESS. Design: Retrospective analysis of pediatric patients with chronic sinusitis treated from January 1, 1993, to July 1, 1998, with a stepwise protocol th at includes the use of IV antibiotics. Settings Academic tertiary care children's hospital. Patients: Seventy patients, aged 10 months to 15 years, with the diagnosis of chronic sinusitis as defined by symptomatic disease for at least 12 week s. All patients had persistent symptoms and radiographic evidence of sinus disease by computed tomographic scan after a minimum 3- to 4-week course of oral antibiotics. Interventions: Patients were treated with maxillary sinus aspiration and ir rigation with selective adenoidectomy, followed by a 1- to 4-week course of a culture-directed IV antibiotic. Most patients also underwent placement o f a long-arm IV catheter. Outcome Measures: Medical charts were reviewed for clinical response to IV antibiotics, complications from IV antibiotic therapy, need for ESS, and re current episodes of sinusitis. Results: Of the 70 patients studied, 62 (89%) had complete resolution of sy mptoms following IV therapy with selective adenoidectomy. Eight patients (1 1%) failed IV therapy and required ESS. Thirty-seven patients (53%) underwe nt concurrent adenoidectomy. Patients treated with concurrent adenoidectomy had equivocal response rates compared with patients treated with IV antibi otic therapy alone. Follow-up data were available for 52 patients (range, 6 -62 months; mean, 25 months). All recurrent episodes resolved with oral ant ibiotic therapy. Complications from IV therapy included superficial thrombo phlebitis in 6 patients (9%) and dislodgement of a catheter guidewire durin g placement in I patient (1%), requiring venotomy. Antibiotic-related compl ications also occurred in 3 patients (4%) and included serum sickness, pseu domembranous colitis, and drug fevers. Conclusion: A stepwise protocol that includes IV antibiotic therapy is a sa fe and efficacious mode of therapy for the management of chronic sinusitis in children and adolescents and may be a reasonable alternative to pediatri c ESS.