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Pediatric
Rhinosinusitis
Hassan H. Ramadan
Fuad M. Baroody
Editors
123
Pediatric Rhinosinusitis
Hassan H. Ramadan • Fuad M. Baroody
Editors
Pediatric Rhinosinusitis
Editors
Hassan H. Ramadan Fuad M. Baroody
Department of Otolaryngology Section of Otolaryngology–Head and Neck
West Virginia University Surgery
School of Medicine The University of Chicago Medicine and
Morgantown, WV The Comer Children’s Hospital
USA Chicago, IL
USA
ISBN 978-3-030-22890-3 ISBN 978-3-030-22891-0 (eBook)

https://doi.org/10.1007/978-3-030-22891-0
© Springer Nature Switzerland AG 2020

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
Part I Definitions and Basics

1 Definitions and Clinical Signs and Symptoms�� 3
Andrea Shogan and Fuad M. Baroody
2 Burden and Health Impact of Pediatric Rhinosinusitis �� 9
Aimee A. Kennedy and Mark E. Gerber
3 Pathogenesis of Pediatric Rhinosinusitis�� 17
Lyuba Gitman and Maria Peña
4 Imaging in Pediatric Rhinosinusitis �� 41
Phillip R. Purnell, Abdul Rahman Tarabishy,
and Johnathan E. Castaño
5 Microbiology of Pediatric Sinusitis�� 57
Phillip R. Purnell and Michele M. Carr
Part II Sinusitis and Other Pediatric Issues

6 The Role of Adenoids in Pediatric Sinusitis�� 73
Max April and Sara C. Gallant
7 Allergy and Sinusitis�� 85
Sidrah M. Ahmad and Ahmad R. Sedaghat
8 Rhinosinusitis and Asthma in Children �� 95
Ahmad Salaheddine Naja, Ahmad R. Sedaghat,
and Wanda Phipatanakul
9 Chronic Rhinosinusitis in Children with Cystic Fibrosis�� 107
Nour Akil and Austin S. Rose
10 Sinusitis and Immunodeficiency in Children�� 129
Randa Barazi and Zeina Korban
v
vi Contents
11 Pediatric Rhinosinusitis and Gastroesophageal Reflux�� 139

Lauren Sowa and Fuad M. Baroody
12 Pediatric Sinusitis and Adenoiditis�� 149
Angela M. Donaldson
Part III Medical Treatment of Rhinosinusitis

13 Antibiotics: Intranasal and Systemic for Treatment
of Sinusitis in Children�� 159
Zachariah K. Chandy, Elisabeth H. Ference, and Jivianne T. Lee
14 Saline Irrigation in Pediatric Rhinosinusitis �� 171
Friederike S. Luetzenberg and Julie L. Wei
15 Medical Treatment of Pediatric Rhinosinusitis:
Focus on Intranasal and Systemic Corticosteroids�� 189
Fuad M. Baroody
Part IV Surgical Treatment of Rhinosinusitis

16 Adenoidectomy and Sinus Lavage�� 203
Habib G. Zalzal, Chadi A. Makary, and Hassan H. Ramadan
17 Balloon Sinuplasty in Children�� 211
Elisabeth H. Ference and Hassan H. Ramadan
18 Endoscopic Sinus Surgery for Pediatric Patients�� 227
Judd H. Fastenberg, Michael S. Weinstock, and John P. Bent
19 Septoplasty and Turbinate Reduction in Children �� 241
Christian P. Soneru, Charles A. Riley, and David A. Gudis
20 Postoperative Management of Pediatric Sinusitis�� 253
Jason R. Rudman, Douglas M. Nguyen, Mikhaylo Szczupak,
and Ramzi T. Younis
21 Failure of Surgical Treatment in Children
with Chronic Rhinosinusitis�� 267
Anne S. Lowery and Frank W. Virgin
Part V Complications
22 Pediatric Intracranial Complications from Sinusitis�� 279
Osama Hamdi, Connor M. Smith, Caitlin E. Fiorillo, and Diego
Preciado
Index�� 291
Contributors
Sidrah M. Ahmad, MD Department of Surgery, Division of Otolaryngology,

Stony Brook University Hospital, Stony Brook University School of Medicine,
Stony Brook, NY, USA
Nour Akil, MD Division of Pediatric Pulmonary, University of North Carolina
School of Medicine, Chapel Hill, NC, USA
Max April, MD Department of Otolaryngology–Head and Neck Surgery, NYU
Langone Medical Center, New York, NY, USA
Randa Barazi, MD Department of Otolaryngology Head and Neck Surgery,
American University of Beirut Medical Center, Beirut, Lebanon
Fuad M. Baroody, MD Section of Otolaryngology–Head and Neck Surgery and
Department of Pediatrics, The University of Chicago Medicine and The Comer
Children’s Hospital, Chicago, IL, USA
John P. Bent, MD Department of Otolaryngology–Head and Neck Surgery,
Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
Department of Otolaryngology, Children’s Hospital at Montefiore, Bronx, NY, USA
Michele M. Carr, DDS, MD, PhD Department of Otolaryngology–Head and
Neck Surgery, West Virginia University School of Medicine, Morgantown, WV,
USA
Johnathan E. Castaño, MD Department of Otolaryngology–Head and Neck
Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
Zachariah K. Chandy, MD Department of Head and Neck Surgery, David Geffen
School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
vii
viii Contributors
Angela M. Donaldson, MD Department of Otorhinolaryngology Head and Neck

Surgery, Mayo Clinic Jacksonville, Jacksonville, FL, USA
Judd H. Fastenberg, MD Department of Otorhinolaryngology–Head and Neck
Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx,
NY, USA
Elisabeth H. Ference, MD, MPH Rick and Tina Caruso Department of
Otolaryngology–Head and Neck Surgery, Keck School of Medicine of the University
of Southern California, Los Angeles, CA, USA
Caitlin E. Fiorillo, MD Department of Pediatric Otolaryngology, Children’s
National Medical Center, Children’s National Health System, Washington, DC,
USA
Sara C. Gallant, MD Department of Otolaryngology–Head and Neck Surgery,
NYU Langone Medical Center, New York, NY, USA
Mark E. Gerber, MD Otolaryngology, Head and Neck Surgery, Phoenix
Children’s Hospital, Phoenix, AZ, USA
Lyuba Gitman, MD Division of Otolaryngology, Children’s National Medical
Center, and the Department of Otolaryngology, George Washington University,
Washington, DC, USA
David A. Gudis, MD Department of Otolaryngology - Head and Neck Surgery,
Columbia University Irving Medical Center, New York, NY, USA
Osama Hamdi, BS Division of Pediatric Otolaryngology, Children’s National
Health System, Washington, DC, USA
Aimee A. Kennedy, MD Otolaryngology, Head and Neck Surgery, Children’s
Hospital Medical Center, Cincinnati, OH, USA
Zeina R. Korban, MD Department of Otolaryngology Head and Neck Surgery,
American University of Beirut Medical Center, Beirut, Lebanon
Jivianne T. Lee, MD, FACS Department of Head and Neck Surgery, University of
California Los Angeles Medical Center and David Geffen School of Medicine at the
University of California Los Angeles, Los Angeles, CA, USA
Anne S. Lowery, BA Vanderbilt University School of Medicine, Nashville, TN,
USA
Surgical Outcomes Center for Kids, Vanderbilt University Medical Center,
Nashville, TN, USA
Friederike S. Luetzenberg, BS University of Central Florida College of Medicine,
Orlando, FL, USA
Contributors ix
Chadi A. Makary, MD Department of Otolaryngology–Head and Neck Surgery,

West Virginia University School of Medicine, Morgantown, WV, USA
Ahmad Salaheddine Naja, MD Department of Surgery, American University of
Beirut Medical Center, Beirut, Lebanon
Douglas M. Nguyen, BS Department of Otolaryngology, University of Miami
Miller School of Medicine, Miami, FL, USA
Maria Peña, MD, FACS, FAAP Division of Otolaryngology, Children’s National
Medical Center, and the Department of Otolaryngology, George Washington
University, Washington, DC, USA
Wanda Phipatanakul, MD, MS Department of Pediatrics, Harvard Medical
School, Boston, MA, USA
Division of Allergy and Immunology, Boston Children’s Hospital, Boston, MA,
USA
Diego Preciado, MD, PhD Department of Pediatric Otolaryngology, Children’s
National Health System, The George Washington University School of Medicine,
Washington, DC, USA
Phillip R. Purnell, MD, PhD Department of Otolaryngology–Head and Neck
Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
Hassan H. Ramadan, MD Department of Otolaryngology, West Virginia
University, School of Medicine, Morgantown, WV, USA
Charles Alexander Riley, MD Department of Otolaryngology - Head and Neck
Surgery, Columbia University Irving Medical Center, New York, NY, USA
Austin S. Rose, MD, FARS Department of Otolaryngology–Head and Neck
Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
Jason R. Rudman, MD Department of Otolaryngology–Head and Neck Surgery,
University of Miami Miller School of Medicine, Miami, FL, USA
Ahmad R. Sedaghat, MD, PhD Department of Otolaryngology–Head and Neck
Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
Andrea Shogan, MD Section of Otolaryngology–Head and Neck Surgery, The
University of Chicago Medicine and The Comer Children’s Hospital, Chicago, IL,
USA
Connor M. Smith, BA Division of Pediatric Otolaryngology, Children’s National
Health System, Washington, DC, USA
Christian P. Soneru, MD Department of Otolaryngology - Head and Neck
Surgery, Columbia University Irving Medical Center, New York, NY, USA
x Contributors
Lauren Sowa, MD Section of Otolaryngology–Head and Neck Surgery,

The University of Chicago Medicine and The Comer Children’s Hospital, Chicago,
IL, USA
Mikhaylo Szczupak, MD Department of Otolaryngology–Head and Neck
Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
Abdul Rahman Tarabishy, MD Department of Radiology, Department of
Interventional Neuroradiology, West Virginia University School of Medicine,
Morgantown, WV, USA
Frank W. Virgin, MD Department of Otolaryngology-Head and Neck Surgery,
Vanderbilt University Medical Center, Nashville, TN, USA
Surgical Outcomes Center for Kids, Vanderbilt University Medical Center,
Nashville, TN, USA
Julie L. Wei, MD Pediatric Otolaryngology/Audiology, Department of Surgery,
Nemours Children’s Hospital, Orlando, FL, USA
Otolaryngology-Head Neck Surgery, University of Central Florida College of
Medicine, Orlando, FL, USA
Michael S. Weinstock, MD Department of Otolaryngology–Head and Neck
Surgery, Montefiore Medical Center, Albert Einstein Medical School, Bronx, NY,
USA
Ramzi T. Younis, MD, FACS, FAAP Department of Otolaryngology–Head and
Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
Habib G. Zalzal, MD Department of Otolaryngology–Head and Neck Surgery,
West Virginia University School of Medicine, Morgantown, WV, USA
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Part I
Definitions and Basics
Chapter 1
Definitions and Clinical Signs
and Symptoms
Andrea Shogan and Fuad M. Baroody
Rhinosinusitis (RS) in pediatric patients can be difficult to diagnose due to its

similarity with other common conditions such as allergic rhinitis, viral upper
respiratory infections, and adenoiditis. It is more broadly defined as inflammation of
the nose and paranasal sinuses and has a negative impact on the quality of life of
patients and can substantially impair their daily function [1]. The study by
Cunningham et al. in 2000 demonstrates that parents of children diagnosed with RS
perceived their children to have more bodily pain and to have more limited physical
activity than other children with chronic diseases such as asthma or juvenile
rheumatoid arthritis [1].
Current guidelines state that a clinical diagnosis of RS can be made in children if
they have two or more of the following symptoms, with one of them being either
nasal blockage, obstruction, congestion, or nasal discharge and either facial pain or
cough [2]. The clinical symptoms have to be accompanied with objective signs that
are determined by either nasal endoscopy, with signs of nasal polyps, mucopurulent
discharge from the middle meatus, or edema/mucosal obstruction from middle
meatus, or computed tomography (CT) of the sinuses demonstrating mucosal
changes within the ostiomeatal complex and/or sinuses [2, 3].
RS is further classified, based on the duration of the illness itself. Acute
rhinosinusitis (ARS) lasts less than 4 weeks with complete resolution of symptoms,
and chronic rhinosinusitis (CRS) is defined as inflammation of the nose and
paranasal sinuses with symptoms that last greater than 12 weeks without complete
resolution. Recurrent acute rhinosinusitis is defined as four of more episodes of
ARS per year with resolution of symptoms between each episode.
A. Shogan · F. M. Baroody (*)

Section of Otolaryngology-Head and Neck Surgery and Department of Pediatrics, The
University of Chicago Medicine and The Comer Children’s Hospital, Chicago, IL, USA
e-mail: [email protected]
© Springer Nature Switzerland AG 2020 3

H. H. Ramadan, F. M. Baroody (eds.), Pediatric Rhinosinusitis,
https://doi.org/10.1007/978-3-030-22891-0_1
4 A. Shogan and F. M. Baroody
Acute Rhinosinusitis
Acute rhinosinusitis (ARS) often occurs after a viral upper respiratory illness (URI).
Pediatric patients can experience up to seven to ten URIs per year and approxi-
mately 5–13% of viral URIs will progress to acute bacterial rhinosinusitis [4]. The
peak age of occurrence of bacterial rhinosinusitis is between 3 and 6 years which
correlates with the peak incidence of viral upper respiratory infections [5]. A study
by Marom et al. also found that girls more frequently developed acute bacterial
rhinosinusitis (ABRS) and had more recurrent bouts of ABRS [6]. ARS is defined
as the sudden onset of two or more of the following symptoms: nasal blockage/
obstruction/congestion, discolored nasal drainage, and/or cough [2].
ARS can be further subdivided into acute viral rhinosinusitis, acute post viral
rhinosinusitis, and acute bacterial rhinosinusitis. Patients with acute viral rhinosi-
nusitis have the signs and symptoms of acute rhinosinusitis that commonly last for
5–7 days but less than 10 days, just as do the symptoms of a URI [7–9]. An impor-
tant point in this context is that the paranasal sinuses are involved even during rou-
tine URIs, thus the term, rhinosinusitis, to describe this clinical entity. Kristo and
colleagues investigated 60 children (mean age = 5.7 years) who had acute URI
symptoms for an average of 6 days before MRI scanning [10]. Approximately 60%
of the children had abnormalities in their maxillary and ethmoid sinuses, 35% in the
sphenoid sinuses, and 18% in the frontal sinuses. In 26 children with major abnor-
malities, a follow-up MRI scan taken 2 weeks later showed a significant reduction
in the extent of abnormalities irrespective of resolution of clinical symptoms.
Similarly, sinus involvement occurs in over 50% of adults evaluated during a URI
with spontaneous improvement after symptom resolution [11]. These studies rein-
force the notion that every upper respiratory tract infection is essentially a self-
limited episode of rhinosinusitis with common involvement of the paranasal sinuses
by the viral process. A few of these episodes will evolve into acute bacterial rhino-
sinusitis as outlined above and those will usually require more than expectant man-
agement (Fig. 1.1).
Acute post-viral rhinosinusitis is seen when there is worsening of symptoms
after 5 days or persistent symptoms longer than 10 days (Fig. 1.2). ABRS is defined
as a persistent illness for more than 10 days, worsening course, double sickening
(deterioration after an initial milder phase of illness or a new fever after the sixth or
seventh day of illness) [7], or severe onset of fever and purulent nasal discharge for
at least 3 consecutive days [8]. The symptoms of ABRS include purulent anterior or
posterior nasal discharge, nasal congestion, or and daytime or nighttime cough [9].
ABRS is the fifth most common condition for which an antibiotic is prescribed in
the United States [12]. The most common pathogens involved in acute bacterial
rhinosinusitis are Streptococcus pneumonia, Haemophilus influenzae, and Moraxella
catarrhalis [13].
1 Definitions and Clinical Signs and Symptoms 5
Fever
Cough
Sore throat
Intensity of symptoms
Drainage
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Days of illness
Fig. 1.1 Chronology of symptoms during viral upper respiratory tract infections. Fever and sore
throat peak earliest and are the shortest lasting. Cough and nasal drainage peak later in the course
of a viral URI and last longer. In uncomplicated URIs, most symptoms resolve within 10–12 days
of onset
Acute viral rhinosinusitis

ABRS (persistent symptoms)
ABRS (double-sickening)
Intensity of symptoms
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Days of illness
Fig. 1.2 Symptom chronology in viral URI and acute bacterial rhinosinusitis (ABRS). Most of
the symptoms of a viral URI resolve within 10 days of illness. Two scenarios justify making the
clinical diagnosis of ABRS: symptoms of an URI lasting longer than the typical 10 days and the
double-sickening scenario where symptoms of a viral illness start to resolve only to
re-exacerbate
Recurrent Acute Rhinosinusitis
Recurrent acute rhinosinusitis (RAR) is defined as multiple episodes of acute

sinusitis in which the signs and symptoms of infection resolve completely in
between episodes. It is most commonly four or more episodes of ARS per year with
episodes separated by at least 10 days. During these periods of at least 10 days, the
patient is asymptomatic with no signs and symptoms of ARS. The episodes
themselves must meet the definition of ARS [14]. Factors that seem to predispose
patients to RAR are older pediatric patients, allergy, atopy, and asthma. These
factors are also associated with an increase chance of developing chronic
rhinosinusitis [15]. A study by Brooks et al. in 2004 found that the most common
pathogens identified in patients with RAR were the same as those isolated in
individuals with ARS, Streptococcus pneumonia, Haemophilus influenzae, and
Moraxella catarrhalis, yet there was an increase in antimicrobial resistance [16].
Treatment for RAR can be both medical as well as surgical. A literature review
by Michalowski and Kacker found that patients with four to six episodes of acute
sinusitis that last for 4 weeks or less would benefit from surgical intervention [14].
They recommended that the patients be seen in the office during one of these epi-
sodes to confirm the diagnosis and be treated with both intranasal and oral steroids
and have a CT scan done prior to proceeding with endoscopic sinus surgery. The
extent of the surgery can be limited to bilateral maxillary antrostomies as well as
anterior ethmoidectomies and addressing any additional abnormalities identified on
the CT scan [14].
Chronic Rhinosinusitis
Chronic rhinosinusitis (CRS) in pediatric patients can often be mistaken for other
common clinical entities just like ARS. It is defined as at least 90 days of two or
more symptoms of purulent rhinorrhea, nasal obstruction, facial pressure/pain, or
cough. You must also have either endoscopic signs of mucosal edema, purulent
drainage, or nasal polyposis and/or CT scan showing mucosal changes within the
ostiomeatal complex and/or sinuses [4]. Patients with immune deficiency, cystic
fibrosis, ciliary dyskinesia, and anatomic abnormalities often have chronic rhinosi-
nusitis [17]. After obtaining either endoscopic and/or CT scan findings, CRS can be
further subdivided into chronic rhinosinusitis with nasal polyposis or chronic rhino-
sinusitis without nasal polyposis. Polyps are not a common occurrence in children
in the United States and prompt further evaluation to rule out cystic fibrosis or
allergic fungal rhinosinusitis. They do sometimes occur in the context of severe
asthma. The most common clinical symptoms of pediatric CRS are cough, rhinor-
rhea, nasal congestion, and postnasal drip.
It is often difficult to distinguish chronic rhinosinusitis from adenoiditis based on
symptoms and physical exam findings only. CT scan findings have been shown to
1 Definitions and Clinical Signs and Symptoms 7
be useful and a Lund Mackay score of 4 or more is considered more consistent with
CRS [18]. In a chart review from a tertiary care facility with pediatric patients who
presented with symptoms consistent with CRS, Purnell and colleagues identified
those with CRS vs those with adenoiditis based on their CT scores as mentioned
above [19]. They then analyzed the symptoms to see if any specific symptom com-
plex was likely to differentiate the two entities. Of the 99 pediatric patients included,
22 patients had a diagnosis of adenoiditis and 77 had a diagnosis of CRS. When
purulent rhinorrhea was present with facial pain, CRS was statistically more preva-
lent than chronic adenoiditis. Other symptoms including cough, rhinorrhea, and
facial pressure were not predictive of one diagnosis over the other. The authors
concluded that purulent rhinorrhea in the presence of facial pain is more indicative
of CRS versus chronic adenoiditis.
The age when a patient develops CRS helps to determine contributing factors as
well as their management. For example, adenoiditis is a prominent factor in CRS in
younger pediatric patients while allergic rhinitis is more important in older children.
Unlike ABRS, a study by Brooks et al. identified that CRS is most commonly
caused by anaerobic organisms in adult patients. However, aerobic organisms that
cause ABRS can appear in some acute exacerbations of CRS [20]. Studies to deter-
mine the microbiology of chronic sinusitis have been done in adult patients and
have yet to be reproduced in the pediatric population.
The clinical consensus statement on pediatric CRS states that medical treatment
consists of 20 days of an appropriate broad-spectrum antibiotic (culture-directed
choice is encouraged when possible) in addition to daily intranasal steroids and
saline irrigations. For patients who fail medical therapy, adenoidectomy should
be considered the first-line surgical treatment in patients up to 12 years of age and
then endoscopic sinus surgery should be considered [4]. Clearly individualized
care decisions are guided by the treating otolaryngologist within these general
guidelines.
Being able to correctly identify and categorize a patient’s RS will help the
clinician to better treat both the patient and their family. ARS responds well to
conservative management and antibiotic treatment once it becomes bacterial. For
CRS, culture-directed antibiotic treatment as well as daily intranasal steroids and
irrigations are first-line treatment. Identifying any underlying medical problems that
are contributing to a patient’s RS will help to guide treatment as well.
References
1. Cunningham MJ, Cunningham JM, Chiu EJ, Landgraf JM, Gliklich RE. The health
impact of chronic recurrent rhinosinusitis in children. Arch Otolaryngol Head Neck Surg.
2000;126(11):1363–8.
2. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European position paper
on rhinosinusitis and nasal polyps 2012. Rhinol Suppl. 2012;23(3):1–298.
3. Leo G, Mori F, Incorvaia C, Barni S, Novembre E. Diagnosis and management of acute
rhinosinusitis in children. Curr Allergy Asthma Rep. 2009;9(3):232–7.
4. Brietzke SE, Shin JJ, Choi S, Lee JT, Parikh SR, Pena M, et al. Clinical consensus statement:
pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014;151(4):542–53.
5. Conrad DA, Jenson HB. Management of acute bacterial rhinosinusitis. Curr Opin Pediatr.
2002;14(1):86–90.
6. Marom T, Alvarez-Fernandez PE, Jennings K, Patel JA, McCormick DP, Chonmaitree T. Acute
bacterial sinusitis complicating viral upper respiratory tract infection in young children. Pediatr
Infect Dis J. 2014;33(8):803–8.
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establishing definitions for clinical research and patient care. J Allergy Clin Immunol.
2004;114(6 Suppl):155–212.
8. Wald ER, Applegate KE, Bordley C, Darrow DH, Glode MP, Marcy SM, et al. Clinical practice
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years. Pediatrics. 2013;132(1):e262–80.
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practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis.
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10. Kristo A, Uhari M, Luotonen J, Koivunen P, Ilkko E, Tapiainen T, et al. Paranasal sinus
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11. Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the
common cold. N Engl J Med. 1994;330(1):25–30.
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Pract. 2012;29(6):706–12.
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quiz 437.
14. Michalowski A, Kacker A. Is sinus surgery indicated for recurrent acute rhinosinusitis?
Laryngoscope. 2017;127(6):1255–6.
15. Choi S-H, Han M-Y, Ahn Y-M, Park Y-M, Kim C-K, Kim H-H, et al. Predisposing factors
associated with chronic and recurrent rhinosinusitis in childhood. Allergy Asthma Immunol
Res. 2012;4(2):80–4.
16. Brook I, Frazier EH. Microbiology of recurrent acute rhinosinusitis. Laryngoscope.
2004;114(1):129–31.
17. Principi N, Esposito S. New insights into pediatric rhinosinusitis. Pediatr Allergy Immunol.
2007;18(Suppl 1):7–9.
18. Bhattacharyya N, Jones DT, Hill M, Shapiro NL. The diagnostic accuracy of computed
tomography in pediatric chronic rhinosinusitis. Arch Otolaryngol Head Neck Surg.
2004;130:1029–32.
19. Purnell PR, Ramadan JH, Ramadan HH. Can symptoms differentiate between chronic adenoiditis
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https://doi.org/10.1177/0145561319840133. [Epub ahead of print].
20. Brook I. Bacteriology of chronic sinusitis and acute exacerbation of chronic sinusitis. Arch
Otolaryngol Head Neck Surg. 2006;132(10):1099–101.
Chapter 2
Burden and Health Impact of Pediatric
Rhinosinusitis
Aimee A. Kennedy and Mark E. Gerber
Prevalence of Pediatric Rhinosinusitis
The exact prevalence of pediatric rhinosinusitis is difficult to estimate. The reason for
this difficulty is twofold. First, many episodes of rhinosinusitis will resolve without
the patient seeking medical attention, and therefore, these cases will not be captured
by reviews of office- or emergency-based visits. Secondly, for the patients who do
present for medical care, there is a high potential for misdiagnosis as the signs and
symptoms of rhinosinusitis mimic other common pediatric conditions such as aller-
gic rhinitis, adenoiditis, and other upper respiratory tract infections. According to
the consensus statement from the American Academy of Otolaryngology, in order
to definitively diagnose chronic rhinosinusitis, there must be 90 consecutive days
with 2 or more subjective symptoms (nasal congestion, nasal discharge, facial pres-
sure/pain, or cough) and objective evidence of inflammation either on endoscopy or
computed tomography (CT) scan [1]. Differentiating between recurrent upper respi-
ratory infections and persistent sinusitis symptoms over 90 days in duration can be
difficult in children. In addition, depending on the healthcare setting in which the
patient presents, obtaining objective evidence of inflammation may not be possible.
In these cases, the diagnosis of rhinosinusitis must be made on symptoms and other
exam findings alone.
Most episodes of acute rhinosinusitis (ARS) develop from an upper respiratory
tract infection (URI). The average child will experience between 6 and 8 URIs per
A. A. Kennedy
Otolaryngology, Head and Neck Surgery, Children’s Hospital Medical Center,
Cincinnati, OH, USA
M. E. Gerber (*)
Otolaryngology, Head and Neck Surgery, Phoenix Children’s Hospital,
Phoenix, AZ, USA

10 A. A. Kennedy and M. E. Gerber
year, of which 5–13% will be complicated by acute sinusitis [2]. Numerous factors
increase the likelihood of developing rhinosinusitis either through increased expo-
sure to pathogens or disruption of normal immune functions. One factor consis-
tently linked with increased risk in young children is daycare attendance. Children
in daycare have a 2.2 times higher likelihood of being diagnosed with acute sinus-
itis, which is significant considering that at least 65% of children in the United
States attend some form of daycare [3, 4]. Cigarette smoke exposure has also been
linked to the development of both ARS and chronic rhinosinusitis (CRS) [5, 6].
Smoke exposure increases local inflammatory mediators, alters the ciliary beat in
sinonasal epithelium [3], and aids in the formation of robust biofilms [7]. Many
studies have sought to find a link between allergic rhinitis and development of
acute and chronic rhinosinusitis; however, no consistent increased risk has been
found. Recent cohort studies have concluded that a history of atopy does not pre-
dict an increased risk of ARS or CRS development [8, 9]. For CRS, a positive fam-
ily history can significantly increase a patient’s risk for developing the disease. The
likelihood of developing CRS is approximately 57.5-fold higher if a sibling has
been diagnosed, 5.6-fold higher if a parent has been diagnosed, and ninefold higher
if a first cousin has been diagnosed [10]. Several other risk factors have been exam-
ined as likely contributors to development of sinusitis and chronic rhinosinusitis,
including anatomic abnormalities, gastroesophageal reflux, and systemic medical
conditions such as cystic fibrosis, primary ciliary dyskinesia, and immune defi-
ciency [11].
Several large database and cohort-based studies have sought to quantify the prev-
alence of ARS in the pediatric population. In a prospective cohort study following
over 3000 children at a primary care pediatric practice, 9.3% of children over 5 years
old and 7.2% of children less than 5 years old were noted to develop ARS [6].
Similarly, a separate cohort study which screened over 1300 patients presenting to
a primary care clinic for sinonasal symptoms found that 10% of children between 1
and 5 years of age met clinical criteria for sinusitis, and of the patients presenting
specifically with URI symptoms, 17% of those patients had sinusitis [12]. A Swedish
cohort survey of 13–14-year-olds found a 12% prevalence of current ARS symp-
toms [13]. With respect to databases, both the National Ambulatory Medical Care
Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey
(NHAMCS) have been used. Both are comprised of large surveys administered
annually by the National Center for Health Statistics. The NAMCS includes data
related to ambulatory care visits to office-based physicians, while the NHAMCS
includes data on visits to hospital- and outpatient-based emergency centers. A
review of these databases from 2005 to 2012 found an average of 1.6 million visits
per year for ARS, which comprised approximately 0.6% of the total visits for all
pediatric encounters [14]. For comparison, the visit rate for other common pediatric
conditions were 2.6% for allergic rhinitis, 8% for upper respiratory infections, and
6.7% for otitis media [14]. In summary, despite the difficulty with estimating preva-
lence of ARS, based on the literature, the rate falls somewhere between 7% and
12%, with a lower annual visit burden when compared to other more common pedi-
atric conditions.
2 Burden and Health Impact of Pediatric Rhinosinusitis 11
For patients with ARS, if the symptoms persist for over 12 weeks, they are con-
sidered to have chronic rhinosinusitis (CRS). The prevalence of CRS is well docu-
mented in the adult literature, with estimates between 8% and 10% of adults being
affected [15, 16]. In the pediatric literature, a prospective cohort study following
3112 Swedish children from birth until 16 years of age, found 1.5% of patients had
symptoms of CRS on self-reported survey [17]. At the time of follow-up, only 0.8%
had continued symptoms of CRS, and of those patients, endoscopic evidence of
CRS was seen in 0.3% [17]. Despite the overall low prevalence of CRS, findings
from the NAMCS and NHAMCS database review found between 3.7 and 7.5 mil-
lion visits per year, which comprised 2.1% of all pediatric ambulatory encounters
[14]. Visits for CRS were more common than for ARS across all age groups and
became more common than visits for otitis media in the 15–20-year-old age groups.
In a study of children with chronic respiratory complains, 63% of them were noted
to have sinus disease on CT imaging, with lower age being the most significant
predictor of positive CT findings [18]. Similarly, a review of CT scans performed on
196 children with sinonasal symptoms showed that the severity and number of
involved sinuses decreased with increasing age [19]. In summary, while CRS is less
prevalent than ARS, with less than 1.5% of children meeting criteria, the number of
ambulatory visits and healthcare utilization is higher.
Quality of Life Impact
Rhinosinusitis is an inflammatory disease of the nose and paranasal sinuses which

may present with purulent nasal discharge, cough, headache, irritability, facial pain,
fevers, and/or postnasal drip. In younger patients, the predominant symptoms tend
to be purulent rhinorrhea and congestion, whereas in older patients, congestion,
postnasal drip, and sore throat related to chronic drainage tend to predominate. Even
with adequate treatment of an acute episode, these symptoms can last up to 3 weeks.
For patients with CRS, these symptoms can last for years. For patients with rhinosi-
nusitis, particularly CRS, they can have a significantly impaired health-related qual-
ity of life. In a study by Cunningham et al. in 2000, the Child Health Questionnaire
(CHQ) was given to patients with CRS and their caregivers [20]. These responses
were then compared to previously reported healthy controls. The caregivers reported
significant reductions in the child’s ability to participate in physical activities, per-
ception of overall health, bodily pain, limitations in personal time due to the condi-
tion, guardian distress regarding the child’s condition, and mental health problems.
The children with CRS reported significantly worse body pain scores and limita-
tions in school-related activities and activities with friends. The differences between
the CHQ data for the caregivers versus the patients indicates that there is a discrep-
ancy in perception of how significantly CRS is affecting the health-related quality
of life. Interestingly, when CRS was compared to other common chronic pediatric
conditions such as attention-deficit/hyperactivity disorder (ADHD), psychiatric dis-
orders, juvenile rheumatoid arthritis, epilepsy, and asthma, the CRS children and
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their caregivers reported more physical limitations in school- and play-related activ-
ities and more bodily pain than what was reported for these other conditions. In the
cross-sectional cohort study of 13–14-year-olds in Sweden, 45% of the responders
reported severe symptoms in which 35% had sleep disturbances and 54% had limi-
tations in daily activities [13]. Objectively, many patients with CRS have olfactory
dysfunction, with mean olfactory thresholds in the hyposmia range, which may also
impact quality of life [17].
For those patients who require surgical intervention, adenoidectomy and endo-
scopic sinus surgery (ESS) are the most commonly performed procedures. Rudnik
and Mitchell performed a quality of life assessment for patients undergoing these
surgical interventions using the Sinus and Nasal Quality of Life Survey (SN-5) and
found that surgical intervention led to improvement in all measured domains, with
the greatest improvement in the “emotional distress” category and least improve-
ment in the “allergy symptoms” [21].
Quality of Life Surveys
In adults, there are many different validated tools for assessing quality of life related
specifically to sinonasal disease. These surveys include the Sinonasal Outcomes
Test (SNOT-22), Chronic Sinusitis Survey (CSS), and the Rhinosinusitis Disability
Index (RSDI). Measuring quality of life outcomes in the pediatric population is
distinctly different due to the difficulty of extracting subjective data from young
children and ensuring that the survey includes the health topics that are important to
children, adolescents, and teenagers. These additional topics could address issues
such as family relations, self-esteem, and physical/emotional development. Various
health-related quality of life surveys have been developed for the pediatric popula-
tion, such as the Child Health and Illness Profile (ages 11–17 years) and the Child
Health Questionnaire (ages 5–18 years). With regard to quality of life specific to
pediatric sinonasal disease, currently the only validated symptom questionnaire is
the Sinus and Nasal Quality of Life Survey (SN-5) [22]. This tool has been shown
to have good test-retest reliability, validity, and responsiveness. It measures symp-
tom severity across five domains of sinus infections, nasal obstruction, allergy
symptoms, emotional distress, and activity limitations, as well as an overall quality
of life score [22].
Social Disparities
Disparities among access to healthcare, quality of healthcare, diagnosis rates, use of

ancillary testing/imaging, and drug prescribing habits have been documented in a
variety of pediatric conditions [23, 24]. In a large-scale analysis of primary care
pediatricians treating upper respiratory tract infections, Gerber et al. found that
African American children were less likely to be diagnosed with otitis media, sinus-
itis, or group A streptococcal infection [25]. Additionally, African American chil-
dren were 25% less likely to receive an antibiotic prescription, even on an individual
clinician basis [25]. Using the 2008 National Emergency Department Sample
Database, Sedegahat et al. found that emergency rooms in the northeast and south,
particularly metropolitan hospitals, were three to six times more likely to use imag-
ing in the workup of acute sinusitis [26]. Additionally, patients with private health
insurance and higher socioeconomic status were more likely to have imaging per-
formed in their workup, especially CT scan. These differences in access, workup,
and treatment also extend into differences seen among the complications related to
sinusitis. Another study by Sedaghat et al. reported a dichotomy between the chil-
dren with orbital complications versus those with intracranial complications—find-
ings that orbital complications were associated with higher income and private
insurance, whereas intracranial complications were associated with Medicaid or no
insurance [27]. While the exact cause of these disparities is difficult to pinpoint, it is
an area that warrants further investigation in order to better understand and correct
these inequities.
Financial and Societal Burden
There are both direct and indirect costs related to the diagnosis and treatment of
ARS and CRS. Direct costs include money spent on office visits, emergency room
or urgent care visits, imaging, treatments, and medications. In 1996, these costs
were estimated at 5.8 billion, with 1.8 billion spent on children under 12 years of
age [28]. A more updated figure from 2007 estimated that the direct expenditures
were around 8.6 billion [29]. The indirect costs of ARS and CRS are more difficult
to quantify but are numerous. In addition to missed school for children and missed
work for the caregivers, it is important to also consider things such as risks associ-
ated with imaging, side effects related to treatments, and rising resistance of micro-
organisms related to antibiotic overuse.
CT scan is the gold standard imaging modality for visualizing sinus inflamma-
tion/infection. While this is primarily obtained for patients with CRS as opposed to
ARS, thoughtful consideration regarding the utility of the study and which patients
would benefit from it should be given since CT scans involve radiation exposure.
This is especially important in the case of younger children in whom 25–30% of the
bone marrow is located in the skull. In order to minimize radiation risk, it is impor-
tant to be judicious in deciding to proceed with imaging and to use the lowest pos-
sible dose of radiation.
Once the determination of ARS and CRS have been made, the majority of
patients will then proceed with some form of antibiotic therapy. A variety of differ-
ent antimicrobials are used including beta-lactams, fluoroquinolones, macrolides/
azalides, lincosamides, and sulfonamides/trimethoprim. In addition to the direct
monetary cost of these medications, there is great concern regarding overprescrib-
ing. Antibiotic-resistant organisms have been increasing and are a great public
health concern. The development of antibiotic resistance is primarily driven by anti-
biotic use. In order to cut back on inappropriate antibiotic use, both the Centers for
Disease Control and the White House have launched campaigns targeted at reducing
unnecessary or inappropriate use. In the pediatric population, the top three condi-
tions associated with antibiotic prescriptions are sinusitis, suppurative otitis media,
and pharyngitis [30]. While antibiotics for true bacterial infections constitutes
appropriate use, up to 50% of the antibiotics prescribed in a primary care pediatric
setting for upper respiratory infections are inappropriately prescribed [30]. The high
rate of inappropriate prescriptions highlights the importance of accurate diagnosis
and antimicrobial stewardship.
Conclusion
ARS and CRS will affect approximately 7–12% and 1–2% of children, respectively.
While these conditions are less prevalent than other conditions such as URIs, otitis
media, and pharyngitis, they both carry significant quality of life impacts and result
in high direct and indirect healthcare expenditures. A better understanding of how
quality of life (QOL) is impacted across the various age groups is essential in order
to mitigate these negative effects. While many sinonasal specific and validated QOL
questionnaires exist for adults, there is currently only one for the pediatric popula-
tion—the SN-5. Additionally, ARS and CRS are both diseases entities in which
improvements can be made in correcting healthcare disparities and decreasing inap-
propriate antibiotic usage.
References
1. Brietzke SE, Shin JJ, Choi S, et al. Clinical consensus statement: pediatric chronic rhinosinus-
itis. Otolaryngol Head Neck Surg. 2014;151:542–53.
2. Wald ER, Guerra N, Byers C. Upper respiratory tract infections in young children: duration of
and frequency of complications. Pediatrics. 1991;87:129–33.
3. Celedon JC, Litonjua AA, Weiss ST, et al. Day care attendance in the first year of life and
illnesses of the upper and lower respiratory tract in children with a familial history of atopy.
Pediatrics. 1999;104:495–500.
4. West J, Wright D, Hausken EG. Child care and early education program participation of
infants, toddlers, and preschoolers. Washington, DC: US Department of Education; Statistics
in Brief; 1995.
5. Christensen DN, Franks ZG, McCrary HC, Saleh AA, Chang EH. A systematic review of the
association between cigarette smoke exposure and chronic rhinosinusitis. Otolaryngol Head
Neck Surg. 2018;158(5):801–16.
6. Kakish KS, Mahafza T, Batieha A, et al. Clinical sinusitis in children attending primary care
centers. Pediatr Infect Dis J. 2000;19(11):1071–4.
7. Goldstein-Daruech N, Cope EK, Zhao KQ, et al. Tobacco smoke mediated induction of sino-
nasal microbial biofilms. PLoS One. 2011;6(1):e15700.
8. Leo G, Incorvaia C, Cazzavillan A, Consonni D, Zuccotti GV. Could seasonal allergy be a risk
factor for acute rhinosinusitis in children? J Laryngol Otol. 2018;132(2):150–3.
9. Sedaghat AR, Phipatanakul W, Cunningham MJ. Atopy and the development of chronic rhino-
sinusitis in children with allergic rhinitis. J Allergy Clin Immunol Pract. 2013;6(1):689–91.
10. Orb Q, Curtin K, Oakley GM, et al. Familial risk of pediatric chronic rhinosinusitis.
Laryngoscope. 2016;126(3):739–45.
11. Rose AS, Thorp BD, Zanation AM, et al. Chronic rhinosinusitis in children. Pediatr Clin N
Am. 2013;60(4):979–91.
12. Aitken M, Taylor JA. Prevalence of clinical sinusitis in young children followed up by primary
care pediatricians. Arch Pediatr Adolesc Med. 1998;152:244–8.
13. Sterner T, Uldahl A, Svensson Å, et al. The Southern Sweden Adolescent Allergy-Cohort:
prevalence of allergic diseases and cross-sectional associations with individual and social fac-
tors. J Asthma. 2018;5:1–9.
14. Gilani S, Shin JJ. The burden and visit prevalence of pediatric chronic rhinosinusitis.
Otolaryngol Head Neck Surg. 2017;157(6):1048–52.
15. Ahn JC, Kim JW, Lee CH, Rhee CS. Prevalence and risk factors of chronic rhinosinusitus,
allergic rhinitis, and nasal septal deviation: results of the Korean National Health and Nutrition
Survey 2008–2012. JAMA Otolaryngol Head Neck Surg. 2016;142(2):162–7.
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17. Westman M, Stjarne P, Bergstrom A, et al. Chronic rhinosinusitis is rare but bothersome in ado-
lescents from a Swedish population-based color. J Allergy Clin Immunol. 2015;136(2):512–4.
18. Nguyen KL, Corbett ML, Garcia DP, et al. Chronic sinusitis among pediatric patients with
chronic respiratory complaints. J Allergy Clin Immunol. 1993;92:824–30.
19. Van der Veken P, Clement PA, Buisseret T, et al. CAT-scan study of the prevalence of sinus dis-
orders and anatomical variation in 196 children. Acta Otorhinolaryngol Belg. 1989;43(1):51–8.
20. Cunningham MJ, Chiu EJ, Landgraf JM, et al. The health impact of chronic recurrent rhinosi-
nusitis in children. Arch Otolaryngol Head Neck Surg. 2000;126:1363–8.
21. Rudnick EF, Mitchell RB. Long-term improvements in quality-of-life after surgical therapy for
pediatric sinonasal disease. Otolaryngol Head Neck Surg. 2007;137(6):873–7.
22. Kay DJ, Rosenfeld RM. Quality of life for children with persistent sinonasal symptoms.
Otolaryngol Head Neck Surg. 2003;128:17–26.
23. Shay S, Shapiro NL, Bhattacharyya N. Pediatric otolaryngologic conditions: racial and socio-
economic disparities in the United States. Laryngoscope. 2017;127(3):746–52.
24. Flores G. Technical report--racial and ethnic disparities in the health and health care of chil-
dren. Pediatrics. 2010;125(4):979–1020.
25. Gerber JS, Prasad PA, Localio AR, et al. Racial differences in antibiotic prescribing by primary
care pediatricians. Pediatrics. 2013;131(4):677–84.
26. Sedaghat AR, Cunningham MJ, Ishman SL. Regional and socioeconomic disparities in emer-
gency department use of radiographic imaging for acute pediatric sinusitis. Am J Rhinol
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of acute bacterial sinusitis complications in children. Laryngoscope. 2014;124(7):1700–6.
28. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996:
contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol.
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30. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic pre-
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Chapter 3
Pathogenesis of Pediatric Rhinosinusitis
Lyuba Gitman and Maria Peña
Rhinosinusitis (RS) is an inflammatory process of the mucosal lining of the parana-

sal sinuses and the nasal cavities with a complex and multifactorial pathogenesis
that is partially impacted by clinical presentation and duration of symptoms [1–5]
(Table 3.1). RS presenting for less than 12 weeks is classified as acute RS [1, 2]. The
2012 European Position Paper on Rhinosinusitis and Nasal Polyps further subdi-
vides pediatric acute RS into acute viral RS, acute postviral RS, and acute bacterial
RS depending on etiology, in addition to duration of symptoms [1]. Pediatric chronic
rhinosinusitis (CRS) is characterized by sinonasal mucosal inflammation for more
than 90 consecutive days of sinonasal symptoms. Current consensus is that objec-
tive criteria based on nasal endoscopy and/or CT scan should support the diagnosis
of CRS [1, 2, 5]. CRS can be further delineated depending on whether patients have
NP, which are outgrowths of the sinonasal mucosa. Recurrent acute bacterial RS is
defined as four or more episodes per year of acute bacterial RS without signs or
symptoms of RS between episodes [1, 2].
Normal Paranasal Sinuses Physiology
Normal sinonasal physiology is dependent on effective mucociliary clearance

(MCC). It is the primary physical defense of the respiratory tract, complementing
the epithelial layer mechanical barrier, and relies on both mucus production and
transport [6, 7].
Each of the paranasal sinuses are each lined with respiratory epithelium com-
posed of pseudostratified columnar ciliated epithelial cells joined by tight junctions
L. Gitman · M. Peña (*)

Division of Otolaryngology, Children’s National Medical Center, and the Department of
Otolaryngology, George Washington University, Washington, DC, USA

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Sift flour once, measure, add baking powder and salt, and sift again.
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Novelty Rolls
Muffin-rolls. Use recipe for Calumet Pocketbook Rolls (page 21).
Shape dough into l-inch balls and place in small greased muffin
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Knots. Use recipe for Calumet Pocketbook Rolls (page 21). Roll
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Quick Cinnamon Rolls

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½ cup sugar
1 egg, well beaten
½ cup milk
1½ tablespoons melted butter

4 tablespoons sugar
1 tablespoon flour
again. Cut in shortening. Combine egg and milk; add to flour
mixture, stirring until mixture is blended. Turn into greased 9-inch
layer pan, spreading dough evenly. Brush top with melted butter.
Sprinkle with mixture of sugar, flour, and cinnamon. Bake in hot oven
(400°F.) 25 to 30 minutes.
Sandwich Nut Bread

3 cups sifted flour
1 teaspoon salt
¾ cup sugar
1 cup chopped nut meats
2 eggs, well beaten
1¼ cups milk
again. Add nuts and mix well. Combine eggs and milk; add to dry
ingredients and blend. Add shortening. Bake in greased loaf pan, 8
× 4 × 3 inches, in moderate oven (350°F.) 1¼ hours.
Southern Spoon Bread
¾ cup yellow corn meal
1 teaspoon salt
3 tablespoons melted butter
1 cup boiling water
1 cup milk
2 eggs, well beaten
Combine corn meal, salt, and butter. Stir in boiling water slowly and
beat until smooth. Add milk, eggs, and baking powder. Mix well. Turn
into greased casserole or pan, 8 × 8 × 2 inches, and bake in
moderate oven (350°F.) 40 to 50 minutes, or until firm.
24
No tunnels, no humps in
CALUMET MUFFINS
Nine kinds of muffins from one recipe
Calumet Muffins
2 cups sifted flour
2 tablespoons sugar
½ teaspoon salt
1 egg, well beaten
1 cup milk
again. Combine egg, milk, and shortening. Add to flour, beating only
enough to dampen all flour. Bake in greased muffin pans in hot oven
(425°F.) 25 minutes, or until done. Makes 12 muffins.
Nut Muffins. Use recipe for Calumet Muffins, adding ½ cup broken
nut meats to the sifted flour mixture.
Raisin Spice Muffins. Use recipe for Calumet Muffins, sifting ¾

teaspoon cinnamon with flour, baking powder, sugar, and salt. Add
¾ cup chopped raisins to the sifted flour mixture.
Currant Muffins. Use recipe for Calumet Muffins, adding ½ cup

currants to the sifted flour mixture.
Apricot Muffins. Use recipe for Calumet Muffins, adding ½ cup

cut, dried apricots to the sifted flour mixture.
Prune Muffins. Use recipe for Calumet Muffins, adding ⅔ cup

finely cut prunes to sifted flour mixture.
Date Muffins. Use recipe for Calumet Muffins, adding ⅔ cup finely
cut dates to the sifted flour mixture.
Surprise Muffins. Use recipe for Calumet Muffins. Drop a scant

teaspoon of currant jelly on each muffin before baking.
Bacon Muffins. Use recipe for Calumet Muffins, adding ½ cup

crushed, crisp bacon to flour mixture. Bacon drippings may be used
for part of butter.
25
Blueberry Muffins
2½ teaspoons Calumet Baking Powder
⅓ cup sugar
½ teaspoon salt
1 cup fresh blueberries
1 egg, well beaten
1 cup milk
again. Combine berries with ⅓ cup of flour mixture. Combine egg,
milk, and shortening. Add to flour, beating only enough to dampen
all flour. Fold in berries. Bake in greased muffin pans in hot oven
Cranberry Muffins
½ teaspoon salt
½ cup sugar
1 cup coarsely chopped cranberries
2 eggs, well beaten
1 cup milk
again. Combine berries with ⅓ cup of flour mixture. Combine eggs,
milk, and shortening. Add to flour, beating only enough to dampen
all flour. Fold in berries. Bake in greased muffin pans in hot oven
Corn Muffins
2 tablespoons sugar
¾ teaspoon salt
¾ cup yellow corn meal
2 eggs, well beaten
1 cup milk
again. Add corn meal and mix well. Combine eggs, milk, and
shortening; add to flour, stirring only enough to dampen all flour.
Bake in greased muffin pans in hot oven (425°F.) 25 minutes, or
until done. Makes 12 muffins.
Grape-Nuts Orange Muffins

2 cups sifted flour
⅔ cup sugar
½ teaspoon salt
2 eggs, well beaten
¾ cup orange juice
1 tablespoon grated orange rind
1 cup Grape-Nuts
again. Combine eggs, orange juice and rind, and shortening. Add to
flour, beating only enough to dampen all flour. Add Grape-Nuts. Bake
in hot, greased muffin pans in hot oven (425°F.) 20 to 25 minutes.
Makes 12 muffins.
Bran Muffins
1 cup sifted flour
3 tablespoons sugar
¼ teaspoon salt
¾ cup milk
1 cup Post’s Whole Bran
1 egg, well beaten
again. Pour milk over Post’s Whole Bran. Add egg and butter to bran
mixture. Add flour, beating as little as possible. Bake in greased
muffin pans in hot oven (425°F.) 25 minutes. Makes 10.
Fruited Bran Gems

1 cup finely cut dates
⅔ cup boiling water
1 cup sifted flour
¼ teaspoon salt
1 egg, well beaten
⅓ cup molasses
Combine dates and water. Let stand 5 minutes. Add Post’s Whole
Bran. Sift flour once, measure, add salt and baking powder, and sift
again. Add egg, butter and molasses to bran mixture. Add flour,
beating as little as possible. Bake in greased muffin pans in hot oven
(425°F.) 25 minutes, or until done. Makes about 12 gems.
26
New lightness and tenderness in
WAFFLES & GRIDDLE CAKES
Serve pancakes at once on hot plates
Waffles
2 cups sifted flour
½ teaspoon salt
3 egg yolks, well beaten
1¼ cups milk
3 egg whites, stiffly beaten
Combine egg yolks and milk; add gradually to flour, beating only
until smooth. Add shortening. Fold in egg whites. Bake in hot waffle
iron. Serve with butter and Log Cabin Syrup. Makes four thick 4-
section waffles.
Cheese Waffles
Use the recipe for Waffles, adding 1 cup grated American cheese to
batter just before folding in egg whites. These waffles may be
served with fresh or broiled tomatoes and broiled bacon, as a
luncheon or supper dish.
Ham Waffles
Use recipe for Waffles, sprinkling ¼ cup finely cut boiled ham over
batter just before closing waffle iron.
Orange Waffles
½ teaspoon salt
¼ cup sugar
1½ teaspoons orange rind
⅔ cup milk
again. Add orange rind to egg yolks and mix well; combine with milk
and add to flour mixture, beating only until smooth. Add butter and
blend. Fold in egg whites. Bake in hot waffle iron. Serve hot with
butter and orange marmalade or orange sauce. Makes four thick 4-
section waffles.
27
Chocolate Dessert Waffles

1½ cups sifted Swans Down Cake Flour
½ teaspoon salt
¾ cup sugar
½ cup milk
½ cup melted butter
2 squares Baker’s Unsweetened Chocolate, melted
½ teaspoon vanilla
again. Combine egg yolks and milk; add to flour mixture, heating
until smooth. Combine butter and chocolate, add to batter, and
blend. Add vanilla. Fold in egg whites. Bake in hot waffle iron. Serve
hot with whipped cream, or Luscious Orange Sauce (page 18).
Makes four 4-section waffles.
Griddle Cakes
1 cup sifted flour
1 teaspoon Calumet Baking Powder
½ teaspoon salt
1 tablespoon sugar
1 egg, well beaten
¾ cup milk
again. Combine egg and milk. Add gradually to flour, beating only
until smooth. Add shortening. Bake on hot, greased griddle. Makes
12 to 15 griddle cakes.
Bran Griddle Cakes

¾ teaspoon salt
2 teaspoons sugar
1¾ cups milk
1 cup Post’s 40% Bran Flakes
1 tablespoon melted butter or other shortening
again. Combine egg yolks and milk; add gradually to flour, beating
only until smooth. Add Flakes and shortening. Fold in egg whites.
Bake on hot, greased griddle. Makes 2 dozen griddle cakes.
Corn Griddle Cakes

2 tablespoons sugar
1 teaspoon salt
1 cup yellow corn meal
2 eggs, well beaten
1⅓ cups milk
again. Add corn meal and mix well. Combine eggs and milk; add to
dry ingredients, mixing well. Add shortening. Bake on hot, greased
griddle. Serve hot with Log Cabin Syrup. Makes 20 to 24 griddle
cakes.
Grape-Nuts Flakes Griddle Cakes

1 cup sifted flour
½ teaspoon salt
1 tablespoon sugar
1 egg, well beaten
1¼ cups milk
1 cup Grape-Nuts Flakes
again. Combine egg and milk; add gradually to flour, beating only
until smooth. Add Grape-Nuts Flakes and shortening. Bake on hot,
greased griddle. Serve hot with Log Cabin Syrup. Makes 15 to 20
griddle cakes.
Rolled Pancakes
1 cup sifted flour
1 teaspoon Calumet Baking Powder
½ teaspoon salt
1 teaspoon sugar
2 egg yolks, slightly beaten
1 cup milk
again. Combine egg yolks and milk; add gradually to flour, beating
only until smooth. Add shortening. Fold in egg whites. Bake on hot,
greased griddle. Roll and serve with broiled sausages or bacon.
Makes six 7-inch pancakes.
28
Extra quality ... sure success for
OTHER FAVORITES
Calumet pie crust, golden brown and flaky
Chocolate Coronet Pudding

1 cup sifted flour
½ teaspoon salt
⅛ teaspoon cinnamon
½ cup sugar
1 egg, well beaten
¾ cup raisins
2 squares Baker’s Unsweetened Chocolate, melted
⅓ cup milk
Sift flour once, measure, add baking powder, salt, and cinnamon,
and sift together three times. Cream butter thoroughly, add sugar
gradually, and cream together until light and fluffy. Add egg and
raisins and beat well; then chocolate and blend. Add flour,
alternately with milk, beating only enough to blend. Turn into
greased tube pan; cover with waxed paper and tie securely. Steam
about 2 hours. Serve hot with Butterscotch Hard Sauce (page 18) or
with Fluffy Chocolate Sauce (page 18). Serves 10.
Doughnuts
4 cups sifted flour
½ teaspoon salt
¼ teaspoon nutmeg
1 cup sugar
2 eggs, well beaten
¼ teaspoon lemon extract
1 cup milk
Sift flour once, measure, add baking powder, salt, and nutmeg, and
sift together three times. Add sugar to eggs, beating thoroughly;
then lemon extract and shortening. Add flour, alternately with milk,
mixing well after each addition. Knead lightly on slightly floured
board. Roll ⅓ inch thick; cut with floured 1¾-inch doughnut cutter.
Fry in deep fat (385°F.) until golden brown, turning frequently. Drain
on unglazed paper. Sprinkle powdered or fine granulated sugar over
doughnuts, if desired. Makes 4 dozen small doughnuts.
29
Individual Strawberry Shortcakes

1 teaspoon salt
½ cup butter or other shortening
¾ cup milk
2 quarts strawberries, washed and hulled
Cut in shortening; add milk all at once and stir carefully until all flour
and follows spoon around bowl. Turn out immediately on slightly
floured board and knead 30 seconds. Roll ¼ inch thick and cut with
floured 3-inch biscuit cutter. Place half of circles on ungreased
baking sheet; brush with melted butter. Place remaining circles on
top and butter tops well. Bake in hot oven (450°F.) 15 to 20 minutes.
Cut strawberries in small pieces and sweeten slightly. Reserve 8
whole berries for garnish. Separate halves of hot biscuits, spread
bottom halves with soft butter and some of sweetened strawberries.
Place other halves on top, crust-side down. Spread with butter and
remaining berries. Garnish with whipped cream and whole berries.
Serves 8.
Dough may be rolled ½ inch thick, cut, and baked; split shortcakes
after baking.
Delicious Cottage Pudding

½ teaspoon salt
1 cup sugar
1 cup milk
½ teaspoon vanilla
Cream butter, add sugar gradually, and cream together well. Add
flour, alternately with milk, a small amount at a time, beating after
each addition until smooth. Add vanilla. Bake in greased pan, 8 × 8
× 2 inches, in moderate oven (350°F.) about 1 hour. Serve hot with
Chocolate Sauce (page 18).
Plum Rolls
2 cups sifted flour
½ teaspoon salt
¾ cup milk (about)
1½ cups canned red plums, seeded and drained
Cut in shortening; add milk gradually, stirring until soft dough is
formed. Turn out on slightly floured board and knead 30 seconds, or
enough to shape. Roll ¼ inch thick. Cover with plums and roll as for
jelly roll. Moisten edge and press against roll. Cut in 1½-inch slices.
Place in pan, cut-side down and pour Plum Sauce over them. Bake in
hot oven (425°F.) 30 minutes or until done, basting often. Serve hot
with a tablespoon of whipped cream on each slice, if desired. Serves
6.
Plum Sauce for Plum Rolls

1 cup sugar
1 tablespoon flour
¼ teaspoon salt
1 cup plum juice
1 cup water
1 tablespoon butter
1 tablespoon lemon juice
Combine sugar, flour, and salt. Add fruit juice and water and boil 3
minutes. Add butter and lemon juice. Serve hot.
Chicken Pot Pie

2½ tablespoons Minute Tapioca
¼ teaspoon salt
Dash of pepper
Dash of paprika
2 cups cooked chicken, cut in pieces
1¼ cups milk or chicken stock
6 to 8 unbaked baking powder biscuits, rolled ¼ inch thick
Combine ingredients in order given. Turn into greased casserole and

bake in hot oven (425°F.) 25 minutes, stirring mixture twice during
first 10 minutes of baking. Place biscuits on top of chicken mixture
after it has baked 10 minutes; return to oven and bake 12 to 15
minutes longer, or until browned. Serves 4.
30
Calumet Pie Crust

¼ teaspoon Calumet Baking Powder
½ teaspoon salt
⅔ cup cold shortening
⅓ cup cold water (about)
Cut in shortening until pieces are about size of small peas. Add
water (preferably ice water), a small amount at a time, mixing lightly
with fork. Handle as little as possible. Wrap in waxed paper; chill
thoroughly. Roll out on slightly floured board. Bake in hot oven
(450°F.). Makes enough pastry for 9-inch two-crust pie, or two 9-
inch pie shells.
Pie Shell. Line a 9-inch pie plate with ½ of pastry rolled ⅛ inch
thick, allowing pastry to extend 1 inch beyond edge; fit loosely. Fold
edge back to form standing rim; flute with fingers. Prick with fork, or
line with waxed paper and fill with rice or beans to hold shape. Bake
in hot oven (450°F.) 15 minutes, removing rice after first 10 minutes
of baking.
Lemon Meringue Pie

1¼ cups sugar
½ cup Swans Down Cake Flour
Dash of salt
1½ cups water
½ cup lemon juice
1 tablespoon grated lemon rind
1 baked 9-inch pie shell
3 egg whites
6 tablespoons sugar
Combine sugar, flour, and salt in top of double boiler; add water and
egg yolks, mixing thoroughly. Place over rapidly boiling water and
cook 10 minutes, stirring constantly. Remove from boiling water; add
lemon juice and rind. Cool. Turn into pie shell. Beat egg whites until
foamy throughout; add sugar, 2 tablespoons at a time, beating after
each addition until sugar is blended. Then continue beating until
mixture will stand in peaks. Pile lightly on filling. Bake in moderate
oven (350°F.) 15 minutes, or until browned.
Chocolate Cream Pie
3 squares Baker’s Unsweetened Chocolate
2½ cups milk
1 cup sugar
6 tablespoons flour
½ teaspoon salt
1 teaspoon vanilla
1 baked 9-inch pie shell
2 egg whites
4 tablespoons sugar
Add chocolate to milk and heat in double boiler. When chocolate is

melted, beat with rotary egg beater until blended. Combine sugar,
flour, and salt; add gradually to chocolate mixture and cook until
thickened, stirring constantly; then continue cooking 10 minutes,
stirring occasionally. Pour small amount of mixture over egg yolks,
stirring vigorously; return to double boiler and cook 2 minutes
longer. Remove from boiling water; add butter and vanilla. Cool.
Turn into pie shell. Beat egg whites until foamy; add sugar, 2
tablespoons at a time, beating after each addition until sugar is
blended. Then continue beating until mixture will stand in peaks. Pile
lightly on filling. Bake in moderate oven (350°F.) 15 minutes.
Red Cherry Pie

2½ tablespoons Minute Tapioca
1 cup sugar
⅛ teaspoon salt
1 tablespoon melted butter
2½ cups canned, sour red cherries, pitted and drained
1 cup cherry juice
1 recipe Calumet Pie Crust
Combine Minute Tapioca, sugar, salt, butter, cherries, and cherry
juice; let stand while pastry is being made. Line a 9-inch pie plate
with pastry rolled ⅛ inch thick. Fill with cherry mixture and moisten
edge of crust. Make several slits in top crust for escape of steam,
then adjust on filled crust. Bake in hot oven (450°F.) 15 minutes;
then decrease heat to moderate (350°F.) and bake 30 minutes
longer, or until filling is cooked and crust is browned.
31
Deep-dish Apple Pie

1 recipe Calumet Pie Crust (page 30)
4 to 6 apples, thinly sliced
1 cup sugar
¼ teaspoon cinnamon
⅛ teaspoon nutmeg
¼ cup water
1 tablespoon butter
Line sides only of deep baking dish with a strip of pastry rolled ¼
inch thick, adjusting it so that pastry comes within ½ inch of bottom
and extends over rim of dish as for pie. Fill with apples. Combine
sugar, cinnamon, and nutmeg, and sprinkle over apples. Add water
and dot with butter. Roll remaining pastry ¼ inch thick; cut several
slits to allow escape of steam, and place over filled dish. Press edges
together. Bake in hot oven (450°F.) 15 minutes; then decrease heat
to moderate (350°F.) and bake 45 minutes longer, or until apples are
tender. Serves 8.
Cherry Cobbler
3 tablespoons Minute Tapioca
¾ cup sugar
3 cups canned, sour red cherries, pitted and drained
1 cup cherry juice
2 cups sifted flour

½ teaspoon salt
¾ cup milk (about)
Combine Minute Tapioca, sugar, cherries, cherry juice, and butter,

and let stand while crust is being made. Sift flour once, measure,
add baking powder and salt, and sift again. Cut in shortening. Add
milk gradually, stirring until soft dough is formed. Turn out on slightly
floured board and knead 30 seconds, or enough to shape. Roll ⅔ of
dough in strip, 2 inches wide and ¼ inch thick; fit into 8 × 8 × 2-
inch pan, lining sides well. Fill with cherry mixture. Roll remaining ⅓
of dough ¼ inch thick; with sharp knife make slits to permit escape
of steam. Fit over cherries, pressing edges together. Bake in hot
oven (450°F.) 15 minutes; reduce heat to moderate (350°F.); bake
20 minutes longer.
Christmas Plum Pudding

2 cups sifted flour
½ teaspoon soda
½ teaspoon salt
¼ teaspoon allspice
½ teaspoon nutmeg
¼ cup chopped figs
½ cup raisins
½ cup currants
¼ cup sliced citron
¼ cup candied cherries, quartered
1 tablespoon candied orange peel, chopped
¼ cup blanched and chopped almonds
½ cup chopped apple
½ cup chopped suet
½ cup molasses
2 eggs, well beaten
½ cup milk
Sift flour once, measure, add baking powder, soda, salt, and spices,
and sift together three times. Sift ½ cup of flour mixture over dried
and preserved fruits and nuts, and mix well. Combine apple, suet,
molasses, eggs, and milk; add to flour mixture and beat thoroughly.
Add fruit and nuts. Turn into greased molds, filling them ⅔ full;
cover tightly. Steam about 3 hours. Serve hot with Butterscotch Hard
Sauce (page 18). Serves 12.
Steamed Bran Pudding

1 cup sifted flour
½ teaspoon salt
⅓ cup brown sugar, firmly packed
1 cup raisins, finely cut
1 egg, well beaten
¼ cup molasses
⅓ cup melted butter or other shortening
1 cup milk
Add Post’s Whole Bran, sugar, and raisins; mix well. Combine egg,
molasses, shortening, and milk; add to flour mixture and beat
thoroughly. Turn into greased molds, filling them ⅔ full; cover
tightly. Steam 2 to 3 hours, depending upon size of mold; steam
individual molds 1 hour and 20 minutes. Serve hot with fruit sauce
or Butterscotch Hard Sauce (page 18), as desired. Serves 8 to 10.
32
Get this book—
“All About Home Baking”
Learn the whole art of baking in 23 easy picture-lessons!
Almost like a movie ... these step-by-step

pictures!
1 Chocolate is melted over water to prevent scorching
2 Beat egg; add to creamed mixture and mix well

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ISBN 978-3-030-22890-3 ISBN 978-3-030-22891-0 (eBook)

© Springer Nature Switzerland AG 2020

Part I Definitions and Basics

Part II Sinusitis and Other Pediatric Issues

11 Pediatric Rhinosinusitis and Gastroesophageal Reflux������������������������ 139

Part III Medical Treatment of Rhinosinusitis

Part IV Surgical Treatment of Rhinosinusitis

Sidrah M. Ahmad, MD Department of Surgery, Division of Otolaryngology,

Angela M. Donaldson, MD Department of Otorhinolaryngology Head and Neck

Chadi A. Makary, MD Department of Otolaryngology–Head and Neck Surgery,

Lauren Sowa, MD Section of Otolaryngology–Head and Neck Surgery,

Andrea Shogan and Fuad M. Baroody

Rhinosinusitis (RS) in pediatric patients can be difficult to diagnose due to its

A. Shogan · F. M. Baroody (*)

© Springer Nature Switzerland AG 2020 3

Acute viral rhinosinusitis

Recurrent Acute Rhinosinusitis

Recurrent acute rhinosinusitis (RAR) is defined as multiple episodes of acute

Aimee A. Kennedy and Mark E. Gerber

Prevalence of Pediatric Rhinosinusitis

© Springer Nature Switzerland AG 2020 9

Quality of Life Impact

Rhinosinusitis is an inflammatory disease of the nose and paranasal sinuses which

Quality of Life Surveys

Disparities among access to healthcare, quality of healthcare, diagnosis rates, use of

Financial and Societal Burden

Lyuba Gitman and Maria Peña

Rhinosinusitis (RS) is an inflammatory process of the mucosal lining of the parana-

Normal Paranasal Sinuses Physiology

Normal sinonasal physiology is dependent on effective mucociliary clearance

L. Gitman · M. Peña (*)

© Springer Nature Switzerland AG 2020 17

Swedish Tea Rolls

Caraway seeds may be sprinkled over rolls instead of poppy seeds, if

Quick Cinnamon Rolls

Whole Bran Brown Bread

Quick Coffee Cake

1½ tablespoons melted butter

Sandwich Nut Bread

Nine kinds of muffins from one recipe

Raisin Spice Muffins. Use recipe for Calumet Muffins, sifting ¾

Currant Muffins. Use recipe for Calumet Muffins, adding ½ cup

Apricot Muffins. Use recipe for Calumet Muffins, adding ½ cup

Prune Muffins. Use recipe for Calumet Muffins, adding ⅔ cup

Surprise Muffins. Use recipe for Calumet Muffins. Drop a scant

Bacon Muffins. Use recipe for Calumet Muffins, adding ½ cup

Grape-Nuts Orange Muffins

Fruited Bran Gems

Part I Definitions and Basics

Part II Sinusitis and Other Pediatric Issues

11 Pediatric Rhinosinusitis and Gastroesophageal Reflux�� 139

Part III Medical Treatment of Rhinosinusitis

Part IV Surgical Treatment of Rhinosinusitis

Recurrent Acute Rhinosinusitis

Prevalence of Pediatric Rhinosinusitis

Quality of Life Impact

Quality of Life Surveys

Financial and Societal Burden

Normal Paranasal Sinuses Physiology