Clinical bottom line
Pediatric chronic rhinosinusitis (CRS) remains a challenging diagnosis with significant impact on quality of life and healthcare utilization. Recent advances emphasize a multifactorial pathophysiology involving mucosal inflammation, microbial dysbiosis, and allergic comorbidities. Updated diagnostic approaches integrate nasal endoscopy with clinical criteria, while evolving management strategies prioritize targeted medical therapy including intranasal corticosteroids and adjunctive treatments guided by biomarkers. Surgical intervention is reserved for refractory cases. Emerging evidence highlights the importance of individualized treatment plans considering allergic status and comorbid conditions to optimize outcomes (Romano et al., 2025; Sousa-Pinto et al., 2026).
What the evidence shows
Pediatric CRS is characterized by persistent sinonasal inflammation lasting more than 12 weeks, often associated with nasal obstruction, mucopurulent discharge, and cough. Diagnosis relies on a combination of clinical history, nasal endoscopy, and imaging when indicated. Nasal endoscopy has been reaffirmed as a critical tool for direct visualization of mucosal edema, purulence, and anatomical abnormalities, improving diagnostic accuracy beyond symptom-based criteria alone (The Role of Nasal Endoscopy, 2007).
Recent guidelines underscore the role of allergic rhinitis as a common comorbidity exacerbating CRS symptoms. The ARIA-EAACI 2024-2025 revision highlights intranasal corticosteroids as first-line therapy for allergic inflammation contributing to CRS, with evidence supporting their efficacy in reducing mucosal edema and improving nasal airflow (Sousa-Pinto et al., 2026). Adjunctive therapies such as saline irrigation and antihistamines may provide symptomatic relief, although data in pediatric populations remain limited.
Biomarker research is advancing understanding of CRS endotypes, with studies identifying inflammatory mediators and cytokine profiles that may predict treatment response. Ogulur et al. (2021) discuss emerging biomarkers in allergic diseases that could inform personalized management strategies, although clinical application in pediatric CRS is still investigational.
Medical management remains the cornerstone of therapy, focusing on controlling inflammation and addressing contributing factors such as allergies and environmental exposures. Romano et al. (2025) emphasize a stepwise approach starting with medical therapy and reserving surgery—typically functional endoscopic sinus surgery (FESS)—for children who fail maximal medical treatment or have complications such as orbital involvement.
Caveats and uncertainty
Despite advances, pediatric CRS diagnosis and management face several uncertainties. Symptom overlap with other upper airway conditions, including adenoid hypertrophy and allergic rhinitis, complicates clinical assessment. The sensitivity and specificity of nasal endoscopy can vary with operator experience, and its availability may be limited in some settings (The Role of Nasal Endoscopy, 2007).
Evidence for many adjunctive therapies remains extrapolated from adult studies or based on small pediatric cohorts, limiting definitive recommendations. Biomarker-guided therapy is promising but not yet validated for routine clinical use in children (Ogulur et al., 2021).
Surgical indications and timing in pediatric CRS lack consensus, with variable outcomes reported. Long-term safety data on repeated corticosteroid use and potential effects on growth are also areas requiring further study (Romano et al., 2025).
How this may change practice
Clinicians should incorporate nasal endoscopy more routinely in the evaluation of pediatric CRS to improve diagnostic precision and guide management. Recognizing and treating allergic rhinitis as a key comorbidity can enhance symptom control and reduce disease burden, supported by updated ARIA-EAACI guidelines recommending intranasal corticosteroids (Sousa-Pinto et al., 2026).
Personalized treatment approaches based on emerging biomarker profiles may become feasible as research matures, enabling targeted anti-inflammatory therapies and reducing unnecessary interventions (Ogulur et al., 2021).
A cautious, stepwise management strategy prioritizing medical therapy with vigilant monitoring for surgical indications remains prudent. Multidisciplinary collaboration including allergy and immunology specialists may optimize outcomes in complex cases.