This episode of Rhinology Roundtable, the podcast of the American Rhinologic Society, hosted by Dr. Ashleigh Halderman breaks down pediatric sinusitis from the first diagnostic crossroads to surgical decision-making. The conversation focuses on how children differ from adults, why adenoids matter so much, and how to sort out chronic symptoms, recurrent infections, and the cases where an immune or systemic workup is needed. Joining the discussion are Dr. Chadi Makary Professor, Vice Chair of Clinical Services, and Chief of Rhinology at West Virginia University, and Dr. Sarah Maurrasse Assistant Professor, Assistant Program Director, and Pediatric otolaryngologist at Yale School of Medicine. Our experts share practical, age-specific guidance on diagnosis, imaging, antibiotics, surgery, and long-term management. Key topics Pediatric sinusitis is not just adult sinusitis in smaller faces: Younger children often have a more infectious, adenoid-driven disease process rather than the inflammatory endotypes seen in adults.Adenoids are central to the pediatric story: Enlarged or infected adenoids can cause obstruction, mucus stasis, bacterial colonization, and biofilms.Chronic sinusitis is relatively uncommon in kids: What looks like chronic disease is often back-to-back viral infections that never fully clear. True chronic sinusitis is harder to diagnose because kids have fewer reliable symptoms.Cough matters more in children than facial pain: Day and night cough is highlighted as a major diagnostic clue in pediatrics. Headache and facial pain are less reliable, especially in younger kids who may not verbalize them well.Age changes the algorithm: Around ages 12 to 13, the disease starts to look more adult-like, and adenoidectomy may be less of a default first step.CT is used selectively: Imaging is more likely when symptoms and endoscopy do not match, when older children have more adult-like disease, or when a FESS decision is on the table.Polyps trigger a broader workup: If polyps are seen, the discussion shifts toward cystic fibrosis, allergy, immune evaluation, and possibly other systemic disease.Medical therapy is still first-line: Intranasal steroids, saline sprays, and rinses are used frequently.Surgery is usually stepwise: In younger children, adenoidectomy is typically the first operation. FESS is reserved for selected casesImmune workup should be considered in refractory cases: CBC, immunoglobulins, vaccine titers, allergy testing, and targeted referral to immunology. Many patients improve after addressing under-response to pneumococcal vaccination.Quality of life is a major outcome: Even when surgery does not eliminate viral infections, it can shorten illnesses and reduce severity, which the guests describe as a meaningful win for families. Timestamps 02:38 - Guest introductions: Dr. Chadi McCary and Dr. Sarah Maras 04:12 - Why adenoids are a major confounder 06:56 - Pediatric disease is more infectious than adult CRS 11:45 - Why cough is a core pediatric symptom 16:35 - Objective evidence and why scope comes before CT 19:11 - When to image 27:28 - Polyps in kids 32:14 - Saline rinses, sprays, and realistic compliance 37:45 - Antibiotic choice and duration for acute exacerbations 40:11 - When to consider surgery 42:11 - Immune workup 48:03 - Goals of surgery 51:53 - Post-op expectations 56:14 - Antibiotics in immunodeficient children 58:21 - Surgery in immune deficiency
