My two-year-old has been diagnosed with a chronic sinus infection. After two weeks on antibiotics, nothing has changed. Her ENT has put her on Cleocin, Nasacort spray, a decongestant, Benadryl and saline for three weeks. She also said we will most likely have to remove her adenoids. She has no runny nose or drainage. She doesn't snore and is not a mouth breather. She does not cough or sneeze or have breathing trouble. She does have cheek pain. Is surgery necessary, and do these medications sound appropriate?

A.

You've asked me a tricky one. Bear in mind that I have not had the benefit of examining your daughter, so it is thus impossible for me to answer your first question, "Is surgery necessary?"

I can, however, make a few comments that should guide future conversations with your daughter's ear, nose and throat doctor (ENT):

• Is your daughter having fevers, facial swelling or bad breath? If she lacks these and all of the other symptoms of sinusitis (such as purulent runny nose -- meaning a runny nose containing pus -- and/or postnasal drainage), the decision to do anything -- even whether to treat with antibiotics -- depends largely on the question of how much your daughter's cheek pain is bothering her.
  
• Usually, adenoids that are large enough to cause sinusitis cause other symptoms, too. You have already mentioned several of these symptoms: habitual mouth-breathing, chronic nasal congestion or runny nose, snoring and a "hyponasal" voice (the sort of voice you have when your nose is stuffed). Your daughter apparently lacks these symptoms.
  
• Adenoidectomy can be a bloody operation. The ability to tolerate blood loss depends greatly on the child's weight; smaller children cannot endure as much blood loss as larger children. For me, if a child weighs less than 40 pounds, I REALLY need to feel that the benefits of surgery outweigh the risk of significant blood loss.
  

My advice: Run this one by your daughter's pediatrician. Pediatricians tend to be very conservative when it comes to recommending surgery -- perhaps too conservative. If your daughter's pediatrician feels that an adenoidectomy is warranted, then it probably is. On the other hand, if your daughter's ENT can explain her reasoning to your satisfaction, then by all means, proceed with surgery.

You also asked me to comment on your daughter's medications. First, let me say this: The principle is correct. Assuming that there is a problem that must be fixed, treat it aggressively with medications before resorting to surgery. On to the meds:

Cleocin: This is the trade name for the antibiotic clindamycin. This is not a "first-line" drug for sinusitis, but it is often used in stubborn cases.

Nasacort: This is a nasal corticosteroid spray used to decrease nasal inflammation in hopes of promoting sinus drainage. Nasal steroid sprays are fairly safe; the newer ones are approved for usage in children as young as three or four. This does not mean that it is "unsafe" to use such a spray in a two-year-old, only that the spray was not tested on children this young.

Decongestants: If she is not congested, why use a decongestant? The idea is similar to the use of nasal corticosteroids: reduce swelling and thereby promote sinus drainage. Decongestants tend to thicken mucus, however, and this is often counterproductive. Also, they can cause hyperactivity or sedation.

Benadryl: This is an antihistamine (generic name diphenhydramine) and is almost always sedating, but it could be helpful if allergies are contributing to your daughter's symptoms. However, if this is true, then cromolyn sodium nasal spray could be more effective and certainly less sedating. Cromolyn is not approved for use in two-year-olds, so you should certainly discuss this drug with your daughter's ENT and/or pediatrician before using it.

Saline: salt water, in other words. Saline nasal spray helps "loosen" mucus and can help clear a stuffy nose. It is safe and well-tolerated by children. Great stuff.

Once again, please take this column as food for thought, NOT gospel! Remember that a "Web doc" lacks many advantages of an in-person practitioner and is thus prone to error.