September 2019 HSC Section 1 Congenital and Pediatric Problems

International Journal of Pediatric Otorhinolaryngology 108 (2018) 163–167

L. Newton et al.

SinusiƟs Management: Imaging

Do not rouƟnely order sinus CT

Order a sinus xray before a sinus CT

Prior to ENT referral

UC PCP

To confirm sinusiƟs diagnosis

Worried about complicaƟon of sinusiƟs

0% 20% 40% 60% 80% 100%

Fig. 3. The majority of providers in primary or urgent care do not routinely order sinus CT.

care and urgent care follow this practice. Additionally, the ENT pro- viders are likely more familiar with the Clinical Consensus Statement on PCRS, which refers speci fi cally to more prolonged courses of anti- biotics with this patient population. This along with the complexity of the patients seen in specialty practice could be why ENT providers chose the longer courses of antibiotics. Perceptions on the length of antibiotic therapy needed may simply di ff er based on practice location and might deserve further investigation in the future. The use of adjuvant therapy also varies by specialty in our sample. The AAP guideline does not make speci fi c recommendations on the use of intranasal corticosteroids, nasal saline irrigation, decongestants, mucolytics, or antihistamines, however the PCRS consensus statement does recommend topical nasal steroids and nasal saline irrigation. In this survey, the majority of providers are recommending some form of nasal spray or irrigation. The other adjuvant therapies are not re- commended by a large number of providers, which is in accordance with the published AAP guideline. However, some of the ENT providers will recommend a short course of topical Afrin for symptom relief; a smaller number of all providers will also recommend nasal steroid. Perhaps with the increasing recognition and emergence of antibiotic stewardship programs, providers are opting to use some of these

adjuvant therapies either in place of antibiotic therapy or with the hopes of avoiding future antibiotic courses. Furthermore, with pressure from patients and families asking for antibiotics for sinusitis symptoms that can be similar to URI symptoms, recommending some of these adjuvant therapies instead of antibiotics may improve the overall pa- tient experience in that the provider is recommending some form of treatment for the patient's symptoms, even if it is not an antibiotic. While the 2013 AAP guidelines on ABRS do not re fl ect the routine use of nasal cultures, the majority of ENT providers obtain this test for patients with chronic or recurrent acute sinusitis and perceive that this is appropriate for PCPs. However, the majority of PCPs do not obtain cultures. While not speci fi cally elicited on this survey, pediatric ENT providers likely are using additional guidelines and consensus state- ments to guide their management of rhinosinusitis patients, including literature on the value of nasal culture in di ffi cult to treat sinusitis patients. Most of the patients who would meet criteria to have a sinus culture obtained likely have already been referred for ENT consultation and management based on the severity of their illness, thus the ENT providers would likely be the ones to obtain these cultures. Similarly, because PCPs simply do not see the high volume of PCRS patients that ENT providers do, they might lack the knowledge, training, and comfort

SinusiƟs Management: Adjuvant Therapies

100%

80%

60%

40%

20%

0%

Nasal saline

Afrin

Decongestant AnƟhistamine Nasal steroid

None

ENT PCP UC

Fig. 4. The most common adjuvant therapy recommended is nasal saline irrigation. ENT providers recommend afrin more commonly than primary care or urgent care providers.

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