Frequency of otitis media based on otoendoscopic evaluation in preterm infants.

OBJECTIVE: This study was conducted to determine the frequency of otitis media in preterm neonates using otoendoscopy and tympanometry. STUDY DESIGN: Prospective study. SETTING: Wayne State University, Hutzel Women's Hospital Neonatal Intensive Care Unit. SUBJECTS AND METHODS: Eighty-six preterm infants were included (gestational age <36 weeks). Otoendoscopy and tympanometry were performed to detect the presence of otitis media. Kappa statistic and logistic regression were used for statistical analysis. RESULTS: Otoendoscopy was performed in 85 patients. The frequency of otoendoscopy-diagnosed otitis media was 72.9% (62/85). Tympanometry could be performed on 69.76% of the ears. There was 73.5% agreement between the findings of tympanometry and those of otoendoscopy. The association between the presence of otitis media and gestational age at birth was statistically significant. The lower the gestational age, the higher the frequency of otoendoscopy-diagnosed otitis media (P = .001). CONCLUSION: Otoendoscopically diagnosed otitis media is frequent in preterm neonates. There was agreement between the results of tympanometry and those of otoendoscopy. The frequency of otitis media increased with lower gestational age.

Protecting the most vulnerable: litigation from pediatric otolaryngologic procedures and conditions.

OBJECTIVES/HYPOTHESIS: To identify allegations raised in litigation stemming from pediatric otolaryngologic procedures and conditions. STUDY DESIGN: Retrospective analysis of a legal database. METHODS: The authors reviewed jury verdict and settlement reports on the WestlawNext database from 1994 to 2013 for cases involving pediatric plaintiffs and alleged negligence in otolaryngologic procedures and conditions. RESULTS: Of the 78 cases included, 52.6% were resolved with a payment; aggregate payments exceeded $69 million, and median jury-awarded damages and settlements were $874,190 and $250,000, respectively. Adenotonsillectomy was the most commonly litigated procedure. Otolaryngologists were defendants in 42 (53.8%) cases, with pediatricians and anesthesiologists the next most commonly named defendants. Forty-six (59.0%) cases involved alleged negligence in operative management, whereas other factors included permanent injury (44.9%), misdiagnosis/failure to diagnose in a timely manner (41.0%), death (35.9%), and requiring additional surgery. Airway-related complications and allegedly permanent injuries significantly increased the size of payments. Awards were highest in cases with plaintiffs at 1 to 5-years of age and lowest among children older than 10 years of age. CONCLUSIONS: Unique considerations specific to pediatric patients are involved in malpractice litigation, and damages awarded were considerable. By including the specific factors listed in this analysis in a comprehensive informed consent process, and recognizing concerns specific to this patient population, practitioners in multiple specialties may potentially reduce liability. Clear communication with parents is a critical component of this process.

Demonstration of the role of an implantable bioscaffold in airway reconstruction: a pilot study utilizing an animal model.

INTRODUCTION: Laryngotracheal reconstruction is a common procedure to repair subglottic stenosis. Despite a success rate upwards of 85%, this procedure has significant morbidity associated with it, specifically with the site of the graft harvest and recurrence of stenosis. We propose that a recently described cellular bioscaffold xenograft may be useful in reducing these complications. METHODS AND MATERIALS: 10 Sprague Dawley rats were divided into 2 groups of 5. One group underwent incision through the cricoid and the first two tracheal rings followed by primary closure (G1); the second group underwent incision through the cricoid and the first two tracheal rings followed by placement of the xenograft (G2); additionally, a specimen was harvested from an animal which did not undergo any surgical procedure to compare to the two surgical groups. Specimen harvest occurred on post-operative days 1, 7, 14, 21, and 28. RESULTS: 6 of 10 animals provided usable data. All animals receiving the xenograft survived until the time of specimen harvest. Only 1 animal undergoing primary closure survived beyond post-operative day one. On histology review, the xenograft animals showed a progressive decrease in fibrosis relative to the animals that underwent primary closure. On POD 28, restoration of the respiratory epithelium and intact basement membrane was noted in the xenograft group. CONCLUSION: We believe that this pilot study shows the potential of utilizing bio-implantable biomaterials, specifically a cellular bioscaffold which encourages the ingrowth of native tissue instead of fibrosis. Histologic analysis shows that use of the xenograft can initiate the proliferation of native tissues decreasing the amount of fibrosis present post-operatively, although significant further analysis is needed before definitively concluding that this approach is superior to utilization of a graft.

Potential role of biofilms in deep cervical abscess.

OBJECTIVES: Deep neck abscesses are complex head & neck problems that can lead to significant complications including life threatening infections. It is understood that the pathology of these infections is primarily polymicrobial. Although broad spectrum antibiotics can be effective for small abscesses, larger abscesses can be recalcitrant and difficult to treat with antibiotics. It has been demonstrated for several infectious diseases, including some of head & neck, that biofilm phenotypes present a unique model for recurrence and chronicity of infectious diseases. It is suspected that biofilm phenotypes could play a crucial role in the recalcitrance of large deep neck abscesses. This study presents initial evidence indicating the presence of polymicrobial biofilms in deep neck space infections. METHODS: Fourteen samples obtained via biopsy of abscess walls from deep neck spaces of patients undergoing surgical drainage. Eight patients were male and 6 were female. All but one patient were pediatric with ages ranging from 18 months to 32 years. All samples were processed and analyzed with scanning electron microscopy. RESULTS: Electron micrographs of 12 out of 14 specimens showed discrete biofilm architecture with individual bacteria, both rods and cocci, embedded within the matrix. This was starkly different from tissue surfaces devoid of biofilms. CONCLUSIONS: This initial evidence suggests that biofilm phenotypes could play a role in the pathogenesis and recalcitrance of deep neck infections, particularly in larger abscesses.

Incidence of gastroesophageal reflux disease and positive maxillary antral cultures in children with symptoms of chronic rhinosinusitis.

OBJECTIVES: Studies have shown that gastroesophageal reflux disease occurs more frequently than expected in children with chronic rhinosinusitis. The objective of this study is to further understand the relationship of pediatric chronic rhinosinusitis and gastroesophageal reflux disease in children with symptoms of rhinorrhea, nasal congestion, and chronic cough. METHODS: A retrospective chart review of 63 children, ages 6 months to 10 years old with rhinorrhea, nasal congestion, and chronic cough. The patients underwent maxillary cultures, adenoidectomy, and distal third esophageal biopsies. Children with esophageal biopsies showing esophagitis were classified as positive for gastroesophageal reflux disease, and maxillary antral swabs growing a high density of bacteria were classified as positive for chronic rhinosinusitis. RESULTS: Six months to 5 years old children (n=43), 6 (14%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 11 (26%) had positive esophageal biopsies alone, 23 (53%) had positive maxillary antral cultures alone, and 3 (7%) had neither. Six to 10 years old children (n=20), 9 (45%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 1 (5%) patient had positive esophageal biopsies alone, 3 (15%) patients had positive maxillary antral cultures alone, and 7 (35%) patients had neither. Twenty-seven (42%) of the patients from the whole study had gastroesophageal reflux positive biopsies. The younger children were statistically likely to have chronic rhinosinusitis and gastroesophageal reflux disease independently of each other (p=0.0002). A direct group comparison found the younger group to have independent chronic rhinosinusitis and gastroesophageal reflux disease and the older group to have simultaneous chronic rhinosinusitis and gastroesophageal reflux disease (p=0.0006). CONCLUSION: In children with the presenting symptoms of rhinorrhea, nasal congestion, and chronic cough, younger children tend to have either chronic rhinosinusitis or gastroesophageal reflux disease, whereas older children tend to have a more complicated etiology of chronic rhinosinusitis and gastroesophageal reflux disease or other. In all of these patients gastroesophageal reflux disease plays an important role, as over 40% of all patients had gastroesophageal positive biopsies.

Utility of two-stage laryngotracheal reconstruction in the management of subglottic stenosis in adults.

OBJECTIVES: We examined a retrospective case series to evaluate the utility of two-stage laryngotracheal reconstruction (LTR) in the management of subglottic stenosis (SGS) in adults. Operative correction of SGS with LTR has been practiced successfully in the pediatric population. However, in the adult population, cricotracheal resection has been a more common alternative. METHODS: We reviewed the medical records at the Wayne State University Department of Otolaryngology-Head and Neck Surgery. We included all adult patients with SGS who underwent LTR and completed the recommended procedures between December 24, 2003, and October 1,2010. RESULTS: Twelve of the 14 patients identified were decannulated (86%). Of the 12 decannulated patients, 1 required a salvage operation, eventually achieving decannulation after cricotracheal resection. Therefore, although our overall decannulation rate was 86%, the rate with LTR alone was 79%. The majority of our patients (71%) had high-grade (grade III or IV) stenosis. CONCLUSIONS: We conclude that LTR is a viable option for adult patients with SGS. In children, LTR is a relatively safe and often-performed procedure. With use of modern techniques, it has the potential to be applicable to adults, as well. It has the added benefit of avoiding the pitfalls and complications associated with cricotracheal resection.

New paradigms in the pathogenesis of otitis media in children.

Acute otitis media (AOM) is a multifactorial disease with a significant socioeconomic impact. The pathogenesis of AOM is attributed to a variety of well-established internal and extrinsic factors. Recent evidence strongly points to bacterial biofilm formation as an important contributor to this disease entity. The nasopharynx is a likely reservoir for infection with subsequent seeding of pathogens to the middle ear via planktonic shedding. Various modalities have been used to directly detect biofilm formation in the middle ear mucosa of children with AOM. Further insights into this disease may lead to new strategies for prevention and treatment.

Fat graft myringoplasty using umbilical fat.

BACKGROUND: Myringoplasty is a common procedure performed by otolaryngologists, particularly in the pediatric population. Tympanic membrane (TM) perforations can be caused by a variety of factors including retained tympanostomy tubes, infection and trauma. First described in 1878, myringoplasty has evolved to include many different materials for repair. Current materials used for myringoplasties include fascia, perichondrium, gelfoam, fat and paper. Multiple studies have looked at the success rates for these different materials. Fat graft myringoplasties in particular offer the advantage of a high success rate commonly reported in the range between 80% and 90%. Fat graft is classically harvested from ear lobe or post-auricular subcutaneous tissue. PURPOSE: In this study, we described the techniques and results of harvesting umbilical fat for the use in pediatric myringoplasty. METHOD: Twenty-eight cases of umbilical fat-graft myringoplasty performed between June 2008 and January 2011 was retrospectively reviewed and studied for rate of successful TM closure. RESULTS: Average length of follow up was 8 months ranging from 3 months to 26 months. Overall rate for successful TM closure of 100% was achieved. Literature review was performed to compare our results with those of studies using auricular fat graft. Furthermore, a review of existing literature on various properties of fat graft was done to explain the potential advantages of using umbilical fat for myringoplasty. CONCLUSION: Fat patch myringoplasty using umbilical fat is a safe and successful procedure for TM repair.

Comparison of two minimally invasive techniques for treating chronic rhinosinusitis in the pediatric population.

OBJECTIVE: To compare two minimally invasive techniques for the treatment of chronic rhinosinusitis in young children. BACKGROUND: Chronic rhinosinusitis (CRS) is a common diagnosis in young children. Maxillary sinus aspiration & irrigation with adenoidectomy (MSI) followed by an extended course of oral antibiotics has been shown to be an alternative to functional endoscopic sinus surgery. However, since MSI is not performed under direct visualization, it has inherent risk. This study analyzes the techniques of MSI and endoscopically guided middle meatus cultures & antral biopsy with adenoidectomy (EGC) in the (1) diagnosis of bacterial infection by culture, (2) time to resolution using double antibiotic therapy, and (3) associated morbidity of the two procedures. METHODS: The medical records at Wayne State University, Department of Otolaryngology Head & Neck Surgery were reviewed from 2004 to 2010. All children who presented with CRS who underwent MSI or EGC were included in this retrospective case series. RESULTS: Patients presented with a history of cough, nasal discharge, and congestion. The mean age was 3.7 years. Symptom duration prior to treatment was 7.4 months in the 64 patients who underwent MSI and 9.1 months in the 46 patients who underwent EGC. MSI identified bacteria in 80% of patients compared to 73% in EGC patients (p=0.45). The MSI group underwent antibiotic treatment for 8.7 weeks and achieved symptom resolution in 8.7 weeks compared to 6.9 weeks and 4.9 weeks respectively in the EGC group (p=0.08 and 0.01). However, if patients presented with snoring or cough, time to resolution of symptoms was significantly lower in patients undergoing EGC versus MSI (p=0.02 and p=0.01, respectively). One patient who underwent MSI experienced epistaxis requiring nasal packing, and two patients had pseudoproptosis following irrigation that resolved spontaneously shortly thereafter. No complications were reported in the EGC group. CONCLUSION: EGC is an effective treatment for young children with CRS. EGC and MSI are equally effective in obtaining diagnostic cultures. EGC decreases time to symptom resolution, and it lowers the risk of complication when compared to MSI.

Systematic review of endoscopic airway findings in children with gastroesophageal reflux disease.

OBJECTIVES: We performed a systematic review of published literature correlating findings on endoscopic evaluation of the larynx and trachea in the pediatric population with the incidence of gastroesophageal reflux disease. METHODS: Eight articles were identified through a structured PubMed search of English-language literature using the key terms laryngopharyngeal reflux, extraesophageal reflux, and gastroesophageal reflux. A systematic review was performed relating the presence of reflux in the pediatric population to findings on endoscopic airway evaluation. A covariant analysis was performed, and each study was weighted according to the number of available samples in that study as a fraction of the total. Overall odds ratios and confidence intervals were computed for each endoscopic finding on the basis of the documented absence or presence of gastroesophageal reflux disease. RESULTS: A correlation was seen between the endoscopic findings and the presence of reflux. CONCLUSIONS: Arytenoid, postglottic, and vocal fold edema and erythema, lingual tonsil hypertrophy, laryngomalacia, and subglottic stenosis are among the endoscopic findings most frequently identified in patients with gastroesophageal reflux disease. Certain findings commonly encountered on endoscopic evaluation of the larynx and trachea in children who present with respiratory symptoms do indeed demonstrate a correlation with the presence of laryngopharyngeal reflux disease and may indicate the need for antireflux therapy.

Auditory testing profiles of Pelizaeus-Merzbacher disease.

To characterize the auditory manifestations of patients diagnosed with Pelizaeus-Merzbacher Disease (PMD), a rare X-linked disorder of myelin classically characterized by nystagmus, spastic quadriparesis, ataxia, and cognitive delay in early childhood or progressive disease in adulthood. A prospective case study of 5 pediatric and 3 adult patients diagnosed with PMD who demonstrate varying degrees of abnormal auditory function. These patients underwent comprehensive audiological evaluations (audiometry, tympanometry, otoacoustic emissions), auditory processing tests (Dichotic Listening, Frequency Pattern Test, Duration Pattern Test), and electrophysiological measures (Auditory Brainstem Response). Abnormal electrophysiological findings with normal cochlear function were found in all test subjects. Further testing completed on adult subjects revealed further central auditory dysfunction via auditory processing tests. All the adult test subjects had abnormal results on auditory processing tests including significant left ear deficits on dichotic digits and poor duration pattern test scores. Auditory processing test results indicated strong right ear advantages for all adult PMD test subjects in Dichotic Digit testing. The degree of audiological central dysfunction findings was more severe in subjects with greater symptoms of the disease. Our findings indicate the need for a full audiological test battery on all patients with Pelizaeus-Merzbacher disease and other severe neurological disorders.

Biofilms and chronic otitis media: an initial exploration into the role of biofilms in the pathogenesis of chronic otitis media.

PURPOSE: The aim of the study was to compare the extent of biofilm infection in percentage of mucosal surface area of adenoids removed from children with otitis media with effusion (OME) vs those with recurrent acute otitis media (RAOM) and obstructive sleep apnea (OSA). MATERIALS AND METHODS: Comparative microanatomical investigation of adenoid mucosa using scanning electron microscopy obtained from 30 children with OME, RAOM, and OSA was used in this study. Seventeen males and 13 females ranging in age from 9 months to 10 years were included in this study. Percentage of biofilm surface area involvement was the main measure. RESULTS: Adenoids removed from patients with OME had moderately dense mature biofilms covering the mucosal surface with a mean of 27.7% of their mucosal surface covered with mature biofilms. These results were distinct from results obtained from patients diagnosed with RAOM and OSA with means of 97.6% and 0.10% of their mucosal surfaces covered with mature biofilms, respectively. These differences were statistically significant at P < .0001. CONCLUSIONS: Adenoids removed from patients with OME were characterized by distinctly different percentage of biofilm mucosal surface area coverage, with significantly more biofilm presence than OSA patients but significantly less biofilm presence than RAOM patients. Although previous investigations have supported a dominant role of nasopharyngeal biofilms in RAOM pathogenesis, these results suggest nasopharyngeal biofilms may play a different role in the pathogenesis of OME and that this clinical entity may be more multifactorial in nature.

Biofilm density in the pediatric nasopharynx: recurrent acute otitis media versus obstructive sleep apnea.

OBJECTIVES: We compared the biofilm surface density of adenoids removed from children with recurrent acute otitis media (RAOM) to that of adenoids removed from children with a diagnosis of obstructive sleep apnea (OSA). METHODS: We performed a comparative microanatomic study of adenoid mucosa using scanning electron microscopy in patients with diagnoses of RAOM and OSA (27 female and 41 male; age range, 3 months to 15 years). RESULTS: The adenoids removed from patients with RAOM had dense, mature biofilms covering nearly their entire mucosal surfaces. More specifically, the adenoids removed from patients with RAOM had an average of 93.53% of their mucosal surface covered, versus an average of 1.01% coverage on the adenoids removed from patients with OSA. These differences were statistically significant (p < 0.0001). CONCLUSIONS: The adenoids removed from patients with RAOM had almost their entire mucosal surface covered with biofilms, versus scant coverage for patients with OSA. Recurrent acute otitis media is notoriously resistant to antibiotic treatment, and aspirates of middle ear fluid repeatedly yield negative cultures. It is these properties that have led biofilms to become increasingly implicated in the pathogenesis of RAOM. Thus, the resistance of biofilms to antimicrobials, together with their planktonic shedding of organisms, may be an important mechanism in the development of RAOM.

Identification of adenoid biofilms with middle ear pathogens in otitis-prone children utilizing SEM and FISH.

OBJECTIVES: Biofilms have been implicated in the development of several chronic infections. We sought to demonstrate middle ear pathogens in adenoid biofilms using scanning electron microscopy (SEM) and fluorescent in situ hybridization (FISH) with confocal laser scanning microscopy (CLSM). METHODS: Comparative micro-anatomic investigation of adenoid mucosa using SEM and FISH with confocal scanning laser microscopic (CLSM) imaging from patients with recurrent acute otitis media (RAOM). RESULTS: All otitis-prone children demonstrated biofilm surface area presence greater than 85% by SEM. FISH accompanied by CLSM imaging also demonstrated patchy biofilms All biofilms contained middle ear pathogens and were frequent in polymicrobial distributions: 4 of 6, 4 of 6 and 3 of 6 samples contained Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis, respectively. CONCLUSIONS: Dense adenoid biofilms may act as a reservoir for reinfection of the tubotympanum. Aspiration of planktonic middle ear pathogens existing in resistant adenoid biofilms during a viral upper respiratory tract infection may be an important event in the development of RAOM.

Demonstration of nasopharyngeal and middle ear mucosal biofilms in an animal model of acute otitis media.

OBJECTIVES: We performed this study to determine the role of nasopharyngeal and middle ear (ME) biofilms in acute otitis media (AOM). METHODS: Sixty female 6-month-old chinchillas, free of ME disease, were utilized. Experimental animals were inoculated with influenza A followed by Streptococcus pneumoniae 7 days later. Control animals were inoculated with Sorensen's phosphate buffer. Daily otoscopy and tympanometry was performed, and the animals were painlessly sacrificed on days 1, 2, 5, 8, and 14. All mucosae were harvested and prepared for scanning electron microscopy. RESULTS: The ME inflammation, initially detected on day 2 after bacterial inoculation, peaked on day 8. Eight percent of the dually inoculated chinchillas displayed type B tympanograms, and 40% displayed type C. Otoscopic evaluation of tympanic membrane inflammation was rated from 0 to 4 (0 = normal and 4 = severe drainage and/or inflammation) according to an otoscopic grading system. Ten percent of the experimental chinchillas had a grade 2 score, 20% had grade 3, and 6.7% had grade 4. The controls demonstrated no abnormal tympanometric or otoscopic findings. Scanning electron microscopic imaging showed dense biofilms on 83% of the nasopharynges and 67% of the MEs on day 8 in the experimental animals. All animals with ME biofilms had biofilms in the nasopharynx. The controls did not demonstrate biofilm formation. CONCLUSIONS: The study parallels the natural pathogenesis of AOM in humans. The demonstration of mucosal biofilms in both the nasopharynx (58%) and the ME (47%) of animals with ME inflammation and/or infection lends further support to the importance of mucosal biofilms in the pathogenesis of AOM.

Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome.

OBJECTIVE: First objective was to review cases of craniocervical necrotizing fasciitis (CCNF) at Wayne State University/Detroit Medical Center (Detroit, MI) for the last 18 years. Second was to analyze patients with and without thoracic extension for contributing factors. METHODS: Retrospective review of 660 patients with necrotizing fasciitis treated at WSU/DMC from January 1989 to January 2007 was conducted. Data regarding source/extent of infection, presenting signs/symptoms, computed tomography, microbiology, antibiotics, comorbidities, number/type of operations, hyperbaric oxygen (HBO) therapy, hospital duration, complications, and overall outcome were compared/analyzed between patients with and without thoracic extension. RESULTS: Twenty patients with CCNF for the past 18 years met the inclusion criteria. Ten patients had thoracic extension, and 10 patients did not have. Individuals in the thoracic extension group were likely to be older, had increased comorbidity, required more surgical debridement, experienced increased postoperative complications, and had lower overall survival. Three patients with thoracic extension underwent HBO therapy and 66% survived. CONCLUSION: This is the largest single institutional review of CCNF comparing patients with and without thoracic extension. Patients with thoracic extension have a poorer outcome as follows: 60% (6/10) survival vs 100% (10/10) for those without thoracic extension (P < .05). The CCNF patients without thoracic extension treated at our institution all survived after prompt medical and surgical intervention. Overall survival of CCNF patients without thoracic extension may be attributed to rigorous wound care, broad spectrum intravenous antibiotics, aggressive surgical debridement, and vigilant care in surgical intensive care unit. The HBO therapy should be included if the patient can tolerate it.

Correlating the clinical course of recurrent croup with endoscopic findings: a retrospective observational study.

OBJECTIVES: We sought to correlate endoscopic findings with the clinical course of recurrent croup. METHODS: Children were classified as having recurrent croup if they had had 2 or more episodes of barky cough, inspiratory stridor, and hoarseness. All study participants underwent direct laryngoscopy and bronchoscopy and were started on an antireflux regimen. A telephone questionnaire assessed the child's symptoms and treatment response. RESULTS: Forty-seven children with recurrent croup were seen in our otolaryngology outpatient clinic. Demographics included a male-to-female ratio of 1.6 to 1 and an age range of 1 month to 11 years (median, 20 months). Thirty patients (63.8%) had a medical history of asthma, and 10 (21.3%) came with a prior diagnosis of gastroesophageal reflux. Gastroesophageal reflux-related laryngopharyngeal changes were seen during direct laryngoscopy and bronchoscopy in 87.2%. Of those with survey follow-up, 87.5% had improvement of respiratory symptoms after a 6- to 9-month course of antireflux medications. This finding was further reflected in a decreased number and duration of episodes (p < .0001). CONCLUSIONS: The underlying narrowing process of recurrent croup can be attributed to gastroesophageal reflux and should be considered in any child with persistent barky cough, inspiratory stridor, and hoarseness. To confirm the diagnosis, diagnostic methods should be correlated with symptom progression after treatment initiation.

Pediatric chronic rhinosinusitis: a retrospective review.

PURPOSE: Chronic rhinosinusitis (CRS) is a major cause of morbidity in the pediatric population and a difficult entity to treat with a poorly defined pathophysiology and diagnostic criteria. Functional endoscopic sinus surgery (FESS) has proven to be effective for these patients, but concerns remain regarding its possible interference with facial growth. Recently, stepwise treatment protocols, which include maxillary sinus irrigation followed by long-term intravenous (IV) antibiotics, have been demonstrated to be effective alternatives to FESS. However, long-term IV therapy is inconvenient and not without complications. The purpose of this study is to review one institution's experience in treating medically refractory pediatric CRS, specifically to describe the epidemiology of the affected population and estimate the success of a stepped treatment protocol using long-term double oral antibiotic therapy for its treatment. MATERIALS AND METHODS: A retrospective review of the medical records of 23 patients who received treatment. RESULTS: Mean age was 2.3 years. Clinical resolution was achieved in 96% of patients and in 78% without the use of IV antibiotics. Four patients who required IV antibiotics subsequently tested positive for immune deficiency. Long-term resolution rate was 78% overall and 86% for those that did not require IV antibiotics. No complications were reported, and no patients required FESS. CONCLUSIONS: A stepwise protocol that includes concurrent adenoidectomy and bilateral maxillary sinus irrigation followed by long-term double oral antibiotic therapy is safe and effective for the treatment of pediatric CRS. Patients with immunodeficiency may require long-term IV therapy to achieve symptom resolution.