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Giving clinicians the option to wait up to 3 days before treating the most common presentation of acute bacterial sinusitis is among the changes to the American Academy of Pediatrics’ updated clinical practice guidelines for treating these infections.
About 5%-10% of upper respiratory tract infections in children develop into acute bacterial sinusitis, according to the new guidelines, published in Pediatrics.
Other changes include a new presentation, and discouraging the use of x-rays to confirm diagnosis. The guidelines published online were written by Dr. Ellen R. Wald, chair of pediatrics at the University of Wisconsin, Madison, and her associates (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1071]). The guidelines incorporated data from an accompanying systematic review of the research published since the last guidelines were issued in 2001.
The added presentation is a worsening course, defined as "worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement." This presentation joins the existing severe onset (a fever of at least 39° C [102.2° F] with at least 3 days of a purulent nasal discharge) and, most common, persistent illness lasting more than 10 days without improvement.
For those with symptoms of nasal discharge, daytime cough, or fever lasting more than 10 days, clinicians may discuss with the parent whether to treat right away or wait a few days. For severe onset and worsening symptoms, clinicians should prescribe antibiotic therapy right away. First-line treatment is amoxicillin with or without clavulanate, followed by a reassessment of initial management if the symptoms worsen or do not improve within 72 hours.
The guidelines do not recommend adjuvant therapies, including intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines.
Among the four major changes to the guidelines, including the updated evidence, the option for delayed treatment in nonsevere cases and the recommendation not to use imaging are especially relevant for clinical practice, according to Dr. Wald, a pediatric infectious disease specialist.
"When the AAP writes about this, they’re talking about it as joint decision making," Dr. Wald said in an interview. "If the parent really wants treatment at that time, I think the doctor’s going to want to do it. It’s being a little bit more permissive in tolerating the symptoms for a few more days. The clinician is given the option to treat immediately or, with the parents’ consent, they can wait a few days to see if the child gets better spontaneously."
Dr. Wald noted that the decision to treat can involve a trade-off, so these guidelines offer the clinicians more latitude in making the cost-benefit analysis with the parent, taking into account the illness severity, the child’s quality of life, and the parents’ values and concerns.
"The reason we like to treat it is that kids get better faster," Dr. Wald said. "On the one hand, we want the kid to get better faster, but on the other hand, we don’t want to use the antibiotic if we don’t have to because we want to avoid side effects or, from a public health perspective, the increased antibiotic resistance for the population." The most common side effect of antibiotics is diarrhea, she said; fewer patients may experience a rash.
The guideline discouraging imaging stems from findings that imaging offers little clinical benefit. "In the past, a diagnostician would get a set of x-rays to see if the sinuses were cloudy and confirm the diagnosis if they found cloudy sinuses," Dr. Wald said. "However, x-rays are frequently abnormal even in children with uncomplicated colds, so the x-rays are not a help. Therefore, we’re encouraging people to make the diagnosis only on clinical grounds."
However, the guidelines do encourage clinicians to get a "contrast-enhanced CT scan of the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or central nervous system complications of acute bacterial sinusitis" because discovered abscesses may require surgical intervention.
The systematic review, conducted by Dr. Michael J. Smith, a pediatric infectious disease specialist at the University of Louisville (Ky.), included evidence from 17 randomized controlled trials in the treatment of sinusitis in children (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1072]. All published since 2001, these trials add to the evidence base from the 21 studies published between 1966 and 1999 that were used in the previous guidelines.
Among the 17 new trials, 4 were randomized, double-blind, placebo-controlled trials of antimicrobial therapy used on a combined 392 children, but they were too heterogenous in criteria and results (2 favored treatment and 2 found no significant difference between treatment and control) to use in conducting a formal meta-analysis. Comparisons were further complicated by the long time span over which they were conducted, the introduction of universal conjugate pneumococcal vaccination, the increase in prevalence of other bacterial infections, and the variance in placebo group clinical improvement, ranging from 14% to 79% across the studies.
Five other trials that compared antimicrobial therapies lacked placebo controls, three dealt with subacute sinusitis rather than acute, and six tested various ancillary treatments. These ancillary treatments included steroids, nasal spray, saline irrigation, and mucolytic agents, but with small study populations and mostly equivocal results.
"Greater severity of illness at the time of presentation seems to be associated with increased likelihood of antimicrobial efficacy," Dr. Smith said.
Dr. Smith identified several clinical questions that require additional research: definitions of acute, subacute, and recurrent acute sinusitis; the epidemiology of sinusitis in the pneumococcal conjugate vaccine era; the effectiveness of antimicrobial prophylaxis; accurate estimates for duration of symptoms; and clinical utility of various imaging types.
The guidelines and systematic review did not identify any external funding used. Dr. Smith has received research funding from Sanofi Pasteur and Novartis. Dr. Nelson is employed by McKesson Health Solutions. Dr. Wald, Dr. Shaikh, and Dr. Rosenfeld have published research related to sinusitis. No other disclosures were reported.
In the revised Clinical Practice Guideline on
management of acute sinusitis endorsed by the American Academy of Pediatrics (Pediatrics
2013;132:e262-e280),http://pediatrics.aappublications.org/content/early/2013/06/19/peds.2013-1071
there are three changes from the previous guideline: (1) the addition of a
clinical presentation designated as “worsening course,” (2) an option to treat
immediately or observe children with persistent symptoms for 3 days before
treating, and (3) a review of evidence indicating that imaging is not necessary
in children with uncomplicated acute bacterial sinusitis.
The authors of the guideline are
authorities in the field and have done a good job under difficult
circumstances. The evidence on the best diagnosis and management of acute
bacterial sinusitis is limited and out-of-date, as shown by a companion
systematic review of the topic by Dr. Michael Smith in the same issue of Pediatrics.
Making guidelines without good evidence
is challenging and often leads to limited adoption by practitioners. Purulence
of nasal discharge is now accepted by most as a natural part of a viral upper
respiratory infection as the host immune system becomes activated, and
neutrophils and lymphocytes migrate to the nasopharynx to clear the infection. However,
waiting for 10 days of purulence before making the diagnosis is built on
methodology employed by Dr. Wald in her group’s seminal trials, but it was
empiric and not systematically investigated.
Treatment recommendations also are not
evidence based, but influenced greatly by the risks of unnecessary, excessive
antibiotic use for the common cold. Antibiotic selection now mirrors the
guideline for acute otitis media.
There have been no new data from
maxillary sinus punctures in children for over 30 years, and the microbiology
is reasonably presumed to be the same as that of AOM. Our group is the only
group in the United States
collecting tympanocentesis data from children with AOM, and those data are only
from children 6-36 months old. Prevnar 13 is changing the dynamics of the
bacterial pathogen mix of AOM and presumably sinusitis. In our work, we find
that only 30% of respiratory bacteria isolated from young children are
susceptible to amoxicillin – most of the Streptococcus
pneumoniae and about one-third of the Haemophilus
influenzae. Some authorities point to older literature that suggested a 50%
“spontaneous” cure rate with H. flu AOM
and an 80% “spontaneous” cure rate with Moraxella
catarrhalis infections. Our group has evidence that those rates do not
reflect the current virulence of H. flu
and M. catarrhalis, as we are seeing
many more tympanic membrane ruptures from those organisms than in years past
(Janet Casey, Legacy Pediatrics, Rochester, N.Y.,
personal communication).
Moreover, the speed of the
spontaneous cure is slower than occurs with antibiotics effective at eradication
of the causative pathogen. On that point, there is an ample evidence base. I
recommend and use amoxicillin/clavulanate with a high dose of amoxicillin.
Adding observation as an option to
match the AOM guideline is an interesting recommendation, and one I will watch
with interest. Practicing pediatricians will need to weigh the reaction of
parents and children to yet another 3 more days of waiting after persistence of
symptoms to begin a treatment that might speed resolution of the illness. What
would you do for your child?
Dr.
Michael E. Pichichero, a specialist in pediatric infectious diseases, is
director of the Rochester (N.Y.) General Hospital Research Institute. He is
also a pediatrician at Legacy Pediatrics in Rochester. He said he had no relevant
financial conflicts of interest to disclose.
In the revised Clinical Practice Guideline on
management of acute sinusitis endorsed by the American Academy of Pediatrics (Pediatrics
2013;132:e262-e280),http://pediatrics.aappublications.org/content/early/2013/06/19/peds.2013-1071
there are three changes from the previous guideline: (1) the addition of a
clinical presentation designated as “worsening course,” (2) an option to treat
immediately or observe children with persistent symptoms for 3 days before
treating, and (3) a review of evidence indicating that imaging is not necessary
in children with uncomplicated acute bacterial sinusitis.
The authors of the guideline are
authorities in the field and have done a good job under difficult
circumstances. The evidence on the best diagnosis and management of acute
bacterial sinusitis is limited and out-of-date, as shown by a companion
systematic review of the topic by Dr. Michael Smith in the same issue of Pediatrics.
Making guidelines without good evidence
is challenging and often leads to limited adoption by practitioners. Purulence
of nasal discharge is now accepted by most as a natural part of a viral upper
respiratory infection as the host immune system becomes activated, and
neutrophils and lymphocytes migrate to the nasopharynx to clear the infection. However,
waiting for 10 days of purulence before making the diagnosis is built on
methodology employed by Dr. Wald in her group’s seminal trials, but it was
empiric and not systematically investigated.
Treatment recommendations also are not
evidence based, but influenced greatly by the risks of unnecessary, excessive
antibiotic use for the common cold. Antibiotic selection now mirrors the
guideline for acute otitis media.
There have been no new data from
maxillary sinus punctures in children for over 30 years, and the microbiology
is reasonably presumed to be the same as that of AOM. Our group is the only
group in the United States
collecting tympanocentesis data from children with AOM, and those data are only
from children 6-36 months old. Prevnar 13 is changing the dynamics of the
bacterial pathogen mix of AOM and presumably sinusitis. In our work, we find
that only 30% of respiratory bacteria isolated from young children are
susceptible to amoxicillin – most of the Streptococcus
pneumoniae and about one-third of the Haemophilus
influenzae. Some authorities point to older literature that suggested a 50%
“spontaneous” cure rate with H. flu AOM
and an 80% “spontaneous” cure rate with Moraxella
catarrhalis infections. Our group has evidence that those rates do not
reflect the current virulence of H. flu
and M. catarrhalis, as we are seeing
many more tympanic membrane ruptures from those organisms than in years past
(Janet Casey, Legacy Pediatrics, Rochester, N.Y.,
personal communication).
Moreover, the speed of the
spontaneous cure is slower than occurs with antibiotics effective at eradication
of the causative pathogen. On that point, there is an ample evidence base. I
recommend and use amoxicillin/clavulanate with a high dose of amoxicillin.
Adding observation as an option to
match the AOM guideline is an interesting recommendation, and one I will watch
with interest. Practicing pediatricians will need to weigh the reaction of
parents and children to yet another 3 more days of waiting after persistence of
symptoms to begin a treatment that might speed resolution of the illness. What
would you do for your child?
Dr.
Michael E. Pichichero, a specialist in pediatric infectious diseases, is
director of the Rochester (N.Y.) General Hospital Research Institute. He is
also a pediatrician at Legacy Pediatrics in Rochester. He said he had no relevant
financial conflicts of interest to disclose.
In the revised Clinical Practice Guideline on
management of acute sinusitis endorsed by the American Academy of Pediatrics (Pediatrics
2013;132:e262-e280),http://pediatrics.aappublications.org/content/early/2013/06/19/peds.2013-1071
there are three changes from the previous guideline: (1) the addition of a
clinical presentation designated as “worsening course,” (2) an option to treat
immediately or observe children with persistent symptoms for 3 days before
treating, and (3) a review of evidence indicating that imaging is not necessary
in children with uncomplicated acute bacterial sinusitis.
The authors of the guideline are
authorities in the field and have done a good job under difficult
circumstances. The evidence on the best diagnosis and management of acute
bacterial sinusitis is limited and out-of-date, as shown by a companion
systematic review of the topic by Dr. Michael Smith in the same issue of Pediatrics.
Making guidelines without good evidence
is challenging and often leads to limited adoption by practitioners. Purulence
of nasal discharge is now accepted by most as a natural part of a viral upper
respiratory infection as the host immune system becomes activated, and
neutrophils and lymphocytes migrate to the nasopharynx to clear the infection. However,
waiting for 10 days of purulence before making the diagnosis is built on
methodology employed by Dr. Wald in her group’s seminal trials, but it was
empiric and not systematically investigated.
Treatment recommendations also are not
evidence based, but influenced greatly by the risks of unnecessary, excessive
antibiotic use for the common cold. Antibiotic selection now mirrors the
guideline for acute otitis media.
There have been no new data from
maxillary sinus punctures in children for over 30 years, and the microbiology
is reasonably presumed to be the same as that of AOM. Our group is the only
group in the United States
collecting tympanocentesis data from children with AOM, and those data are only
from children 6-36 months old. Prevnar 13 is changing the dynamics of the
bacterial pathogen mix of AOM and presumably sinusitis. In our work, we find
that only 30% of respiratory bacteria isolated from young children are
susceptible to amoxicillin – most of the Streptococcus
pneumoniae and about one-third of the Haemophilus
influenzae. Some authorities point to older literature that suggested a 50%
“spontaneous” cure rate with H. flu AOM
and an 80% “spontaneous” cure rate with Moraxella
catarrhalis infections. Our group has evidence that those rates do not
reflect the current virulence of H. flu
and M. catarrhalis, as we are seeing
many more tympanic membrane ruptures from those organisms than in years past
(Janet Casey, Legacy Pediatrics, Rochester, N.Y.,
personal communication).
Moreover, the speed of the
spontaneous cure is slower than occurs with antibiotics effective at eradication
of the causative pathogen. On that point, there is an ample evidence base. I
recommend and use amoxicillin/clavulanate with a high dose of amoxicillin.
Adding observation as an option to
match the AOM guideline is an interesting recommendation, and one I will watch
with interest. Practicing pediatricians will need to weigh the reaction of
parents and children to yet another 3 more days of waiting after persistence of
symptoms to begin a treatment that might speed resolution of the illness. What
would you do for your child?
Dr.
Michael E. Pichichero, a specialist in pediatric infectious diseases, is
director of the Rochester (N.Y.) General Hospital Research Institute. He is
also a pediatrician at Legacy Pediatrics in Rochester. He said he had no relevant
financial conflicts of interest to disclose.
Giving clinicians the option to wait up to 3 days before treating the most common presentation of acute bacterial sinusitis is among the changes to the American Academy of Pediatrics’ updated clinical practice guidelines for treating these infections.
About 5%-10% of upper respiratory tract infections in children develop into acute bacterial sinusitis, according to the new guidelines, published in Pediatrics.
Other changes include a new presentation, and discouraging the use of x-rays to confirm diagnosis. The guidelines published online were written by Dr. Ellen R. Wald, chair of pediatrics at the University of Wisconsin, Madison, and her associates (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1071]). The guidelines incorporated data from an accompanying systematic review of the research published since the last guidelines were issued in 2001.
The added presentation is a worsening course, defined as "worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement." This presentation joins the existing severe onset (a fever of at least 39° C [102.2° F] with at least 3 days of a purulent nasal discharge) and, most common, persistent illness lasting more than 10 days without improvement.
For those with symptoms of nasal discharge, daytime cough, or fever lasting more than 10 days, clinicians may discuss with the parent whether to treat right away or wait a few days. For severe onset and worsening symptoms, clinicians should prescribe antibiotic therapy right away. First-line treatment is amoxicillin with or without clavulanate, followed by a reassessment of initial management if the symptoms worsen or do not improve within 72 hours.
The guidelines do not recommend adjuvant therapies, including intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines.
Among the four major changes to the guidelines, including the updated evidence, the option for delayed treatment in nonsevere cases and the recommendation not to use imaging are especially relevant for clinical practice, according to Dr. Wald, a pediatric infectious disease specialist.
"When the AAP writes about this, they’re talking about it as joint decision making," Dr. Wald said in an interview. "If the parent really wants treatment at that time, I think the doctor’s going to want to do it. It’s being a little bit more permissive in tolerating the symptoms for a few more days. The clinician is given the option to treat immediately or, with the parents’ consent, they can wait a few days to see if the child gets better spontaneously."
Dr. Wald noted that the decision to treat can involve a trade-off, so these guidelines offer the clinicians more latitude in making the cost-benefit analysis with the parent, taking into account the illness severity, the child’s quality of life, and the parents’ values and concerns.
"The reason we like to treat it is that kids get better faster," Dr. Wald said. "On the one hand, we want the kid to get better faster, but on the other hand, we don’t want to use the antibiotic if we don’t have to because we want to avoid side effects or, from a public health perspective, the increased antibiotic resistance for the population." The most common side effect of antibiotics is diarrhea, she said; fewer patients may experience a rash.
The guideline discouraging imaging stems from findings that imaging offers little clinical benefit. "In the past, a diagnostician would get a set of x-rays to see if the sinuses were cloudy and confirm the diagnosis if they found cloudy sinuses," Dr. Wald said. "However, x-rays are frequently abnormal even in children with uncomplicated colds, so the x-rays are not a help. Therefore, we’re encouraging people to make the diagnosis only on clinical grounds."
However, the guidelines do encourage clinicians to get a "contrast-enhanced CT scan of the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or central nervous system complications of acute bacterial sinusitis" because discovered abscesses may require surgical intervention.
The systematic review, conducted by Dr. Michael J. Smith, a pediatric infectious disease specialist at the University of Louisville (Ky.), included evidence from 17 randomized controlled trials in the treatment of sinusitis in children (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1072]. All published since 2001, these trials add to the evidence base from the 21 studies published between 1966 and 1999 that were used in the previous guidelines.
Among the 17 new trials, 4 were randomized, double-blind, placebo-controlled trials of antimicrobial therapy used on a combined 392 children, but they were too heterogenous in criteria and results (2 favored treatment and 2 found no significant difference between treatment and control) to use in conducting a formal meta-analysis. Comparisons were further complicated by the long time span over which they were conducted, the introduction of universal conjugate pneumococcal vaccination, the increase in prevalence of other bacterial infections, and the variance in placebo group clinical improvement, ranging from 14% to 79% across the studies.
Five other trials that compared antimicrobial therapies lacked placebo controls, three dealt with subacute sinusitis rather than acute, and six tested various ancillary treatments. These ancillary treatments included steroids, nasal spray, saline irrigation, and mucolytic agents, but with small study populations and mostly equivocal results.
"Greater severity of illness at the time of presentation seems to be associated with increased likelihood of antimicrobial efficacy," Dr. Smith said.
Dr. Smith identified several clinical questions that require additional research: definitions of acute, subacute, and recurrent acute sinusitis; the epidemiology of sinusitis in the pneumococcal conjugate vaccine era; the effectiveness of antimicrobial prophylaxis; accurate estimates for duration of symptoms; and clinical utility of various imaging types.
The guidelines and systematic review did not identify any external funding used. Dr. Smith has received research funding from Sanofi Pasteur and Novartis. Dr. Nelson is employed by McKesson Health Solutions. Dr. Wald, Dr. Shaikh, and Dr. Rosenfeld have published research related to sinusitis. No other disclosures were reported.
Giving clinicians the option to wait up to 3 days before treating the most common presentation of acute bacterial sinusitis is among the changes to the American Academy of Pediatrics’ updated clinical practice guidelines for treating these infections.
About 5%-10% of upper respiratory tract infections in children develop into acute bacterial sinusitis, according to the new guidelines, published in Pediatrics.
Other changes include a new presentation, and discouraging the use of x-rays to confirm diagnosis. The guidelines published online were written by Dr. Ellen R. Wald, chair of pediatrics at the University of Wisconsin, Madison, and her associates (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1071]). The guidelines incorporated data from an accompanying systematic review of the research published since the last guidelines were issued in 2001.
The added presentation is a worsening course, defined as "worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement." This presentation joins the existing severe onset (a fever of at least 39° C [102.2° F] with at least 3 days of a purulent nasal discharge) and, most common, persistent illness lasting more than 10 days without improvement.
For those with symptoms of nasal discharge, daytime cough, or fever lasting more than 10 days, clinicians may discuss with the parent whether to treat right away or wait a few days. For severe onset and worsening symptoms, clinicians should prescribe antibiotic therapy right away. First-line treatment is amoxicillin with or without clavulanate, followed by a reassessment of initial management if the symptoms worsen or do not improve within 72 hours.
The guidelines do not recommend adjuvant therapies, including intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines.
Among the four major changes to the guidelines, including the updated evidence, the option for delayed treatment in nonsevere cases and the recommendation not to use imaging are especially relevant for clinical practice, according to Dr. Wald, a pediatric infectious disease specialist.
"When the AAP writes about this, they’re talking about it as joint decision making," Dr. Wald said in an interview. "If the parent really wants treatment at that time, I think the doctor’s going to want to do it. It’s being a little bit more permissive in tolerating the symptoms for a few more days. The clinician is given the option to treat immediately or, with the parents’ consent, they can wait a few days to see if the child gets better spontaneously."
Dr. Wald noted that the decision to treat can involve a trade-off, so these guidelines offer the clinicians more latitude in making the cost-benefit analysis with the parent, taking into account the illness severity, the child’s quality of life, and the parents’ values and concerns.
"The reason we like to treat it is that kids get better faster," Dr. Wald said. "On the one hand, we want the kid to get better faster, but on the other hand, we don’t want to use the antibiotic if we don’t have to because we want to avoid side effects or, from a public health perspective, the increased antibiotic resistance for the population." The most common side effect of antibiotics is diarrhea, she said; fewer patients may experience a rash.
The guideline discouraging imaging stems from findings that imaging offers little clinical benefit. "In the past, a diagnostician would get a set of x-rays to see if the sinuses were cloudy and confirm the diagnosis if they found cloudy sinuses," Dr. Wald said. "However, x-rays are frequently abnormal even in children with uncomplicated colds, so the x-rays are not a help. Therefore, we’re encouraging people to make the diagnosis only on clinical grounds."
However, the guidelines do encourage clinicians to get a "contrast-enhanced CT scan of the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or central nervous system complications of acute bacterial sinusitis" because discovered abscesses may require surgical intervention.
The systematic review, conducted by Dr. Michael J. Smith, a pediatric infectious disease specialist at the University of Louisville (Ky.), included evidence from 17 randomized controlled trials in the treatment of sinusitis in children (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1072]. All published since 2001, these trials add to the evidence base from the 21 studies published between 1966 and 1999 that were used in the previous guidelines.
Among the 17 new trials, 4 were randomized, double-blind, placebo-controlled trials of antimicrobial therapy used on a combined 392 children, but they were too heterogenous in criteria and results (2 favored treatment and 2 found no significant difference between treatment and control) to use in conducting a formal meta-analysis. Comparisons were further complicated by the long time span over which they were conducted, the introduction of universal conjugate pneumococcal vaccination, the increase in prevalence of other bacterial infections, and the variance in placebo group clinical improvement, ranging from 14% to 79% across the studies.
Five other trials that compared antimicrobial therapies lacked placebo controls, three dealt with subacute sinusitis rather than acute, and six tested various ancillary treatments. These ancillary treatments included steroids, nasal spray, saline irrigation, and mucolytic agents, but with small study populations and mostly equivocal results.
"Greater severity of illness at the time of presentation seems to be associated with increased likelihood of antimicrobial efficacy," Dr. Smith said.
Dr. Smith identified several clinical questions that require additional research: definitions of acute, subacute, and recurrent acute sinusitis; the epidemiology of sinusitis in the pneumococcal conjugate vaccine era; the effectiveness of antimicrobial prophylaxis; accurate estimates for duration of symptoms; and clinical utility of various imaging types.
The guidelines and systematic review did not identify any external funding used. Dr. Smith has received research funding from Sanofi Pasteur and Novartis. Dr. Nelson is employed by McKesson Health Solutions. Dr. Wald, Dr. Shaikh, and Dr. Rosenfeld have published research related to sinusitis. No other disclosures were reported.
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