Topical treatment of rhinosinusitis

Rhinosinusitis is a multifactorial condition whichposes a diagnostic and management challenge toinfection and ENT specialists as well as topediatricians (1, 2). Topical treatment modalitiesare frequently used in pediatrics; however, theseoptions have not been thoroughly tested on anylarge scale for effectiveness. Topical treatmentchoice depends on a differential workup thatmust cope with conditions of widely differentetiology, such as recurrent viral upper respiratoryinfections, allergic and non-allergic rhinitis, gas-troesophageal reflux, ciliary dyskinesia, cysticfibrosis, allergic and non-allergic fungus-induceddisease and immunodeficiency (3). Anatomicalvariation per se does not determine the develop-ment of chronic rhinosinusitis but can influencethe choice of a topical treatment (4). PediatricENT specialists manage 95% of their patientswith chronic rhinosinusitis with antibiotics whiletopical steroids are used by 90% and use salinesprays by 68% of specialists (5). Thus topicaltreatments are widespread and include saline atdifferent osmotic pressures, nasal decongestantsand topical steroids, antibiotics, antihistaminesand fungicides. However, published evidence ofefficacy is lacking, when clinicians are faced withthe indication or request for the topical treatmentof rhinosinusitis, and searching for studies toapply ones patients may be frustrated by thequality of reporting. Experience in a universityhospital pediatric department suggested thatimproving practice and implementation of prac-tice parameters needed a reappraisal of theprimary evidence for this therapeutic modality.The 2001 American Academy of Pediatrics Clin-ical Practice Parameter on the management of(bacterial) rhinosinusitis (6) is remarkably terseon the topic of local treatment modalities.