2017 Sec 1 Green Book

Z. Farhood et al. / International Journal of Pediatric Otorhinolaryngology 89 (2016) 149 e 153

Con fl icts of interest

tonsillectomy was not shown to be an effective treatment modality for PANDAS except in small anecdotal settings, and those who did improve were also subject to other treatments including neuro- psychiatric medications and/or antibiotics, confounding the true results of tonsillectomy. Therefore, it is suggested that practitioners continue to offer tonsillectomy per the current American Academy of Otolaryngology-Head & Neck Surgery guidelines [9] . Antibiotic therapy has two strategies: prophylaxis and treat- ment. By preventing infection or rapidly treating with antibiotics, one would expect a reduction in symptom severity. In this sys- tematic review, prophylaxis did not appear bene fi cial but acute episodes did seem to resolve when treated with antibiotics. Based on this we can conclude that antibiotic therapy remains an option in the management of PANDAS, but ef fi cacy is uncertain. Due to the proposed autoimmune component of PANDAS, IVIG has been considered as a possible treatment option. It has previ- ously been studied in patients with rheumatic fever and was sug- gested to improve symptoms associated with Sydenham's chorea [24,25] . Although there may be bene fi t from IVIG for exacerba- tions and recurrences, it is not a benign treatment and the potential risks and complications should be weighed when deciding to employ it. It is worth noting that while adverse events were frequent in these studies, all were considered mild. Steroids are unlikely to be used in this population as they may worsen the neuropsychiatric symptoms [14,26] . CBT confronts PANDAS from a psychiatric standpoint and due to the minimal risk involved in receiving therapy, it can be recom- mended for management of symptoms. Unlike traditional OCD, the symptoms of PANDAS have an abrupt onset and resolution which manifest at an earlier age [27] . Only one case report utilizing SSRIs was identi fi ed, but not included in this systematic review [28] . This treatment caused behavioral activation in the patient consisting of mood instability and suicidality. A substantial obstacle in evaluating treatment modalities is that most have received multiple treatments, leaving interpretation susceptible to confounding factors. Furthermore, the pathophysi- ology is still poorly de fi ned/understood. Finally, this is a rare disease with an uncertain prevalence [29] . Antibiotics, SSRIs, and IVIG may continue to be studied as there is currently a Phase 2 clinical trial registered on clinicaltrials.gov [30] . In spite of these limitations, the current study summarizes the evidence for treatment strategies in the PANDAS population and can serve as a reference for otolaryn- gologists who may be less familiar with the disease. Assessing treatment strategies for PANDAS remains dif fi cult, as it is a rare disease with few published high quality studies. Many of these studies are retrospective in nature and consist of small pop- ulations. Furthermore, patients often undergo multiple treatment modalities, leaving room for confounding. Adenotonsillectomy does not seem to clearly bene fi t this patient population. Antibiotics may prove to be useful in preventing or treating infections and therefore neuropsychiatric exacerbation, but there is limited evi- dence to recommend it. Though IVIG proved to be effective in certain patient populations, it is not without serious risk and should be reserved for the immunocompromised or most severe cases. Finally, traditional psychiatric therapy for PANDAS may be effective and is of minimal risk to the patient. 5. Conclusion

None.

References

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Funding

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