Empower your child's health: tailored strategies to prevent rhinosinusitis

Bernardi, Francesca De; Zeroli, Chiara; Coecke, Sandra; Landi, Massimo; Gallo, Stefania; Castelnuovo, Paolo; Nosetti, Luana

doi:10.1016/j.jped.2024.02.005

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Review article • J. Pediatr. (Rio J.) 101 (5) • 2025 • https://doi.org/10.1016/j.jped.2024.02.005 linkcopy

Empower your child's health: tailored strategies to prevent rhinosinusitis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective This review explores preventive strategies for pediatric rhinosinusitis and examines their potential impact on children's mental well-being, advocating for a comprehensive holistic approach that includes medical disciplines and government policies to support EU and global prevention strategies.

Sources A comprehensive search encompassed Medline, Embase, PubMed, and the Cochrane Library for English-language articles from January 2010 to December 2023. Inclusion criteria involved papers on pediatric rhinosinusitis prevention in the pediatric population, published in peer-reviewed journals. Following the removal of duplicates and exclusion of irrelevant studies, 20 unique titles were included in the review.

Summary of the findings The review underscores the challenges posed by the similarity of symptoms between pediatric rhinosinusitis and other common childhood illnesses. It emphasizes the interconnected nature of upper and lower airways, illustrating the potential impact on both physical and mental well-being in children. The findings highlight the necessity for a multifaceted prevention approach, supported by individualized prevention plans, medical professional involvement, and government policies.

Conclusions The holistic research and clinical approach proposed in this review contribute valuable insights into the global efforts aimed at reducing the incidence of pediatric rhinosinusitis while promoting the mental well-being of children. The article serves as an informative resource for readers seeking a deeper understanding of pediatric rhinosinusitis prevention strategies. The review emphasizes the necessity of a multidisciplinary approach, involving pediatricians, otolaryngologists, pneumologists, and allergologists, in PRS prevention. Government prioritization of preventive measures is essential. Precision medicine and integrative approaches are recommended for tailored treatment plans.

Keywords
Prevention; Rhinosinusitis; Sinusitis; Upper respiratory tract infections; Mental health; Depression

Primary Prevention
First Author (year)	Type of Study (n. of patients)	Results
Veskitkul J. (2017)⁶	Randomized, double-blind, placebo-controlled study (40 children,5-15 years)	- Azithromycin prophylaxis can reduce the number of rhinosinusitis episodes and medication score and improve nasal symptoms in nonallergic rhinitis children with recurrent acute rhinosinusitis.
Bellussi L.M. (2019)⁷	Review	- The existing microbial ecosystem have a central role in the pathogenesis of respiratory disease; - New therapeutic approaches include the implantation and persistence within the normal microflora of relatively innocuous "effector" bacteria that can competitively exclude or prevent the outgrowth of potentially disease-causing bacteria; - Bacteriotherapy in children have beneficial effects in the prevention of upper respiratory tract infections.
Chen J. (2017)⁸	Randomized control study (96 children, 4-12 years)	- Bacterial lysate used in the remission period of rhinosinusitis in children was shown to provide long-term prophylaxis; - Bacterial lysate can reduce the frequency of rhinosinusitis attacks and ameliorate attack symptoms.
Cingi C. (2015)⁹	Review	- Antileukotrienes are a promising treatment for upper airway diseases as evidenced by a detailed literature review. Specifically, montelukast treatment following sinus surgery has been found to significantly reduce eosinophilic cationic protein levels in the bloodstream and improve nasal and pulmonary symptoms and antileukotrienes have been shown to effectively treat allergic rhinitis
Ciprandi G. (2020)¹⁰	Review	- Local Bacteriotherapy significantly reduced the number of respiratory infections, their severity, the use of antibiotics, and school absences; - Local Bacteriotherapy is a promising approach in preventing respiratory infections and could be a routine strategy to contrast infections in the future.
Chiappini E. (2021)¹¹	Consensus document	- The panel agrees that it is necessary to assesses and contains environmental risk factors, to support the administration of vaccines and to improve the best practices to reduce respiratory infections, such as hand washing.
Passali D. (2019)¹²	Prospective observational study (202 children, median age 7,5 years)	- Prophylactic bacteriotherapy by administration of Streptococcus salivarius 24SMB and Streptococcus oralis 89a in children with a history of recurrent upper respiratory tract infection could reduce the number of episodes of otolaryngologic infections. - Bacteriotherapy can be even more clinically important due to increasing difficulty in finding new effective antibiotic compounds. - New alternative therapeutic approaches must be found with, in comparison to antibiotics, greater specificity and safety with respect to patients' native beneficial flora; lack of drug interactions; the ability to leverage complementary systemic modes of action; and drastically reduced risk of developing resistance within the patient population and the environment.
Piqué N. (2018)¹³	Review	- In clinical trials, xyloglucan has been seen to reduce symptoms of nasal disorders. - Xyloglucan, endowed with film-forming protective barrier properties, is a safe non-pharmacological alternative for the management of different diseases, such as gastrointestinal and nasal disorders.
Principi N. (2017)¹⁴	Review	- Methods for performing nasal irrigation have to be standardized to determine which solution, device, and duration of treatment are adequate to obtain favorable results. This seems particularly important for children that suffer from a great number of sinonasal problems and might benefit significantly from an inexpensive and simple preventive and therapeutic measure such as NI.
Tarantino V. (2019)¹⁵	Prospective observational study (80 children, mean age 5.26±2.52 years)	- Bacteriotherapy using Streptococcus salivarius 24SMB and Streptococcus oralis89a nasal spray could prevent recurrent UI in children.
Fokkens W.J. (2020)¹⁶	Guidelines	- Occupational and environmental factors are of increasing importance in primary prevention and the effects of global warming carefully monitored. - Co-morbidities such as allergy, asthma and GORD should be considered. - Genetic and microbiological factors will likely become of greater importance.

Secondary Prevention
First Author (year)	Type of Study	Results
Fokkens W.J. (2020)¹⁶	Guidelines	- Early diagnosis and selection of the optimal treatment is central in URTI secondary prevention; - Optimizing medical treatment and consideration of the timing and extent of surgery can improve outcomes.
Kucuksezer U.C. (2018)¹⁷	Review	- The exploration of disease endotypes and introduction of novel agents are important advancements in underlying CRS pathogenesis and disease-contributing factors. - Prior studies performed without disease-endotyping resulted in the inefficiency of certain drugs and insignificant results. - The identification of biomarkers, development of personalized approaches, and utilization of disease algorithms are required for CRS therapy success.
Hamilos DL (2015)¹⁸	Review	- Differences in the microbiome could be a cause of the substantial differences in the symptoms of and treatment options for adult and pediatric patients with chronic rhinosinusitis and using microbiome analysis to understand the pathogenesis of CRS in adults and children is crucial; - Actinobacteria had a significantly higher relative abundance in the adult group than in the pediatric group at the phylum level. - At the genus level, Corynebacterium showed significantly higher relative abundance in the adult group than in the pediatric group.
Abzug M.J. (2014)¹⁹	Review	- Antibiotics probably do have a role in the treatment of pediatric ABS - The most compelling rationale is prevention of serious complications, but proof for this rationale is lacking.
Babar-Craig H. (2010)²⁰	Review	- Complications which require surgical treatment are similar in both a “prior antibiotic treated group” and a “no prior antibiotic group”, suggesting limited benefit of oral antibiotics in the Primary Care setting.

Tertiary Prevention
First Author (year)	Type of Study	Results
Cantone E. (2022)²¹	Systematic Review	- In children aged over 9 years, large subperiosteal orbital abscesses,impaired vision, ophthalmoplegia, proptosis, elevated C-reactive protein and absolute neutrophil counts, hemodynamic compromise, no clinical improvement after 48/72 h of antibiotic therapy, and a Chandler III score or higher are clinical markers of the need for surgery (criticalities: most of the studies are observational and retrospective, and further studies are needed to identify reliable and repeatable clinical markers of the need for surgery).
Fokkens W.J. (2020)¹⁶	Guidelines	- In tertiary prevention, a careful review of ongoing treatment, technique and compliance with medication should be undertaken. - Growth in digital healthcare and patient apps may encourage self-management and increase compliance.
Rohde R.L. (2022)²²	Review	- Determination of the optimal approach depends on patient clinical features including age, history of prior endoscopic sinus surgery, and presence of intracranial involvement on presentation. - An individualized, targeted, and interdisciplinary approach to the treatment of Pott's Poffy Tumor is critical for successful disease resolution
Hansen F.S. (2012)²³	Retrospective cohort study (47 patients of which 26 children, total mean age 35.9 years)	- Antibiotic treatment of acute rhinosinusitis in general practice does not play a role in preventing complications.

Symptoms	Pathology/(Frequency)	Subtypes
Periorbital oedema/erythema Displaced globe Double vision Ophthalmoplegia Reduced visual acuity	Orbital complication/(60-80 %)	preseptal cellulitis, orbital cellulitis, subperiosteal, intraorbital abscess
Severe headache Signs of meningitis Neurological signs Ophthalmoplegia	Endocranial complication/(15-20 %)	epidural empyema, subdural empyema, brain abscess, meningitis, encephalitis, superior sagittal and cavernous sinus thrombosis.
Frontal swelling	Osseous complications/(5 %)	osteomyelitis and may present as a subperiosteal frontal bone abscess (Potts Puffy tumour) or a frontocutaneous fistula.
Unilateral symptoms Bleeding Crusting Cacosmia	Neoplasm

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