Clinical practice guidelines for the management of acute sinusitis in children have been published by the American Academy of Pediatrics. Of note is that in this document, a brief discussion of chronic disease concluded that the bacterial pathogens causing disease, pathogenesis and management are essentially unknown. Although there are insufficient data in the literature to develop evidence-based clinical guidelines, a careful review of the literature and clinical experience of experts who manage pediatric chronic sinusitis is presented in an effort to develop specific recommendations and to offer practical treatment options. It is apparent that anaerobic bacteria play a major role in this infection thereby influencing the natural history of disease and directing, to a great degree, medical management.