Chronic Rhinosinusitis in Children: What are the Treatment Options?

Surgical Treatment of Paediatric Chronic Rhinosinusitis

Rhinosinusitis (RS) is a common disease in children, significantly affecting their quality of life. Chronic rhinosinusitis (CRS) is frequently linked to other respiratory diseases, including asthma. Children affected by CRS may be candidates for surgery in the case of failure of maximal medical therapy comprising three to six weeks of broad-spectrum systemic antibiotics with adjunctive therapies. Although endoscopic sinus surgery (ESS) is the surgical treatment of choice in adult patients with CRS, different surgical procedures are scheduled for refractory paediatric CRS and include adenoidectomy, paediatric ESS (PESS), and balloon catheter sinuplasty (BCS). The present paper discusses the indications and limitations of each treatment option in children with CRS. Given the amount of current evidence, it is reasonable to suggest that, in young and otherwise healthy children with refractory CRS, an adenoidectomy (eventually combined with BCS) should be offered as the first-line surgical treatment. Nevertheless, this approach may be considered ineffective in some patients who should be candidates for traditional ESS. In older children, those with asthma, or in the case of peculiar conditions, traditional ESS should be considered as the primary treatment.

Readmissions following ambulatory pediatric endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Endoscopic sinus surgery (ESS) is indicated in select pediatric patients with medically refractory sinus disease. Our objectives were to examine indications and rates of readmission following ambulatory pediatric ESS and identify specific subgroups that may benefit from inpatient admission.

STUDY DESIGN

Retrospective database review.

METHODS

The Pediatric Health Information Systems (PHIS) 2004-2016 database was retrospectively reviewed for patients age <18 years who underwent ambulatory ESS between January 2011 and December 2016 and were readmitted within 30 days postoperatively. Data regarding demographics, extent of surgery, comorbidities, adjunctive procedures, and cost were collected. A multivariable mixed-effects logistic regression model was employed for analysis.

RESULTS

We identified 3,669 unique pediatric ESS cases with 128 readmissions within 30 days (3.5%; 95% confidence interval [CI]: 2.9%-4.1%). Median cost of readmission was $980 (mean, $5,890; standard deviation, $13,421). The most common indication for readmission was epistaxis (17.2%), followed by nausea/abdominal pain (14.1%). Respiratory infection (13.3%) and sinusitis (10.2%) presented a combined readmission rate exceeding that of epistaxis alone. Multivariable analysis indicated age <3 years (odds ratio [OR]: 3.41, 95% CI: 1.96-5.93) and a prior diagnosis of asthma (OR: 2.88, 95% CI: 1.99-4.18) or cystic fibrosis (OR: 1.57, 95% CI: 1.00-2.44) significantly increased the risk of readmission. Extent of ESS and simultaneous adenoidectomy, septoplasty, or turbinate reduction had no significant impact on readmission rates.

CONCLUSIONS

ESS is a relatively safe outpatient surgical procedure in pediatric patients, with an overall readmission rate of 3.5%. Clinicians should consider careful preoperative evaluation of very young patients and those with cystic fibrosis or asthma to optimize perioperative management and determine if postoperative admission is warranted, given their significantly higher readmission rates.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2681-2686, 2019.

A cost-effectiveness analysis of the up-front use of balloon catheter dilation in the treatment of pediatric chronic rhinosinusitis

BACKGROUND

The treatment of pediatric sinusitis continues to be a controversial topic. It has been recommended to treat pediatric chronic rhinosinusitis (CRS) with adenoidectomy before proceeding to more invasive techniques. There are concerns regarding side effects of endoscopic sinus surgery in pediatric patients. With the advent of balloon catheter dilation (BCD) as a minimally invasive technique, some authors are recommending up front adenoidectomy with BCD in order to maximize disease resolution while minimizing risk.

PURPOSE

Our study examines the cost effectiveness of adenoidectomy alone versus adenoidectomy and upfront BCD for the management of pediatric CRS.

METHODS

A decision tree analysis was created to determine the cost effectiveness of treating a pediatric patient who has failed medical management, using adenoidectomy versus adenoidectomy with up-front BCD. Three separate decision trees were made. The incremental cost effectiveness ratio (ICER) was calculated for each scenario and a sensitivity analysis was done to determine how different values impacted our results.

RESULTS

Adenoidectomy as the sole first procedure was found to be more cost effective in all three decision trees. For tree 1, the adenoidectomy plus BCD arm was 0.03% more effective in the end, but with an $81, 431 incremental cost.

CONCLUSIONS

Costs in addition to outcomes must be considered when comparing treatment modalities in our current health care environment. This study found that adenoidectomy as a first intervention before proceeding to more advanced techniques is nearly as effective and is a much more cost-effective algorithm for the treatment of pediatric CRS. However, the physician must advocate the best treatment for his or her own patients.

Pediatric rhinosinusitis and asthma

Both asthma and rhinosinusitis are complex and heterogeneous diseases and, importantly, they often coexist: these diseases can be concomitant in 35-65% of affected children, according to different studies. Thus, evaluating this comorbidity in the clinical practice should be paramount. In this review, we focused our discussion on the multiple pathophysiological aspects that may link rhinosinusitis and asthma in the pediatric population. Although rhinosinusitis may exacerbate asthma through several mechanisms occurring by contiguity, actually this aspect seems to be only one component of the complex interplay between upper and lower airways. In particular, the onset of an important and persistent Th2-driven inflammatory process dominated by eosinophils presence at one site of the airways, may release into the bloodstream several cytokines; in their turn, those can lead to the stimulation of the bone marrow, which may function as a systemic amplifier of such an eosinophilic inflammation.

Post-adenoidectomy quality of life in children with refractory chronic rhinosinusitis

Objective:

This study aimed to evaluate post-adenoidectomy quality of life in children with refractory chronic rhinosinusitis.

Methods:

A prospective interventional study of children aged 4–12 years with chronic refractory rhinosinusitis was conducted. A total of 60 children completed follow up. Nasal endoscopy and non-contrast computed tomography of the paranasal sinuses were performed, and both symptoms and their effects on patient quality of life pre- and post-adenoidectomy were evaluated.

Results:

The most frequent symptoms were nasal obstruction, cough, fever and fatigue, which were experienced by 100 per cent, 90 per cent, 85 per cent and 81.7 per cent of children, respectively. Nasal endoscopy showed oedema and discharge were present in all children. A statistically significant post-operative improvement in sinus and nasal quality of life was seen in 53 children (88.3 per cent).

Conclusion:

Adenoidectomy is a simple, first-line surgical procedure for managing paediatric chronic rhinosinusitis refractory to maximal medical therapy and leads to an improved quality of life.

Quality of life after endoscopic sinus surgery in refractory pediatric chronic rhinosinusitis

OBJECTIVE

The present study aims to evaluate the role of Endoscopic Sinus Surgery (ESS) in refractory pediatric Chronic Rhinosinusitis (CRS) and to assess the change in quality of life after ESS.

MATERIALS AND METHODS

This prospective interventional study included 35 children (aged between 6 and 12 years) of refractory CRS, not responding to 4 weeks of maximal medical therapy attending the pediatric ENT clinic of a tertiary referral centre. Study period was from November 2013 to March 2016. This patient pool underwent Non Contrast Computed Tomography scan (NCCT) paranasal sinuses and diagnostic nasal endoscopy and those fulfilling the requisite inclusion criteria underwent Endoscopic sinus surgery. Global assessment of Rhinosinusitis Symptom severity score and SN-5 quality of life score of the patients was assessed preoperatively and 1 year after the surgery.

RESULTS

91.4% children showed an improvement in the total symptom score with a statistically significant (p value < 0.001) reduction in the mean total score postoperatively. Similarly 91.4% of the children showed an improvement in their quality of life with a statistically significant (p value < 0.001) difference seen in the average SN-5 scores after ESS. No major complications were encountered in any of the cases.

CONCLUSION

ESS is a safe and effective surgical management for children with CRS refractory to maximal medical therapy leading to an improvement in their quality of life.

Fifty Years of Chronic Rhinosinusitis in Children: The Accepted, the Unknown, and Thoughts for the Future

Chronic sinusitis is an often-used term in both lay and medical circumstances. In children, it has significant but largely undefined healthcare costs. Chronic rhinosinusitis (CRS) in children has well demarcated time periods and symptoms, although the actual pathway from normal sinus to CRS is not well understood. There is reasonable consensus as to the standards for diagnosis, the selection of a first-round antibiotic, and length of treatment. However, no recent prospective studies of antibiotics are available. Areas of continued speculation include the following: the microbiome of pediatric CRS, the best use of standard imaging, alternative antibiotic selection, ancillary therapy, and treatment of refractory CRS. In addition, older adolescents can present with a more adult-oriented CRS with or without polyps, suggesting a broader spectrum of disease than is commonly recognized. An accounting of the accepted elements of pediatric rhinosinusitis, as well as areas for future research, is emphasized in this review and, where appropriate, suggestions for potential investigations are offered.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

WITHDRAWN: Antibiotics for acute maxillary sinusitis in adults

Currently, two separate Cochrane reviews, ‘Antibiotics for acute maxillary sinusitis in adults ’ and ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’ describe the effect of antibiotics for acute rhinosinusitis. Although both Cochrane reviews study the same condition, they look at different populations (patients in which the diagnosis was based on clinical signs and symptoms and patients in which the diagnosis was confirmed by imaging). Because of this, the conclusions are different in these Cochrane reviews. This was confusing for clinicians who needed to read both Cochrane reviews to know which conclusions are most applicable to their patients.
 
 This review is being withdrawn and will be incorporated into the updated publication of ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’. This ‘merged’ review will still maintain the relevant distinction between the two populations. However, information on the effectiveness of antibiotics for rhinosinusitis will be published in the ‘merged’ Cochrane review. We will omit the comparison between antibiotics (as published in this Cochrane review) because the choice for certain antibiotics and/or doses differs according to the local antibiotic resistance patterns and therefore this comparison is less relevant.

The editorial group responsible for this previously published document have withdrawn it from publication.

Macroscopic findings during endoscopic sinus surgery for chronic rhinosinusitis in children

AIM

Endeavor to intraoperative macroscopic evaluation of changes in children with CRSs. Analysis of the type and incidence of pathological changes observed macroscopically during FESS was undertaken as well as an parallel attempt to correlate the level of inflammation markers with severity of disease.

MATERIALS AND METHODS

Retrospective analysis of case records of 153 patients of the Department of Pediatric Otolaryngology, Medical University of Warsaw, hospitalized between 2010 and 2013. During that time 106 patients with a diagnosis of chronic maxillary sinusitis required surgical intervention. 102 children (avg-aged 11.5 years) were qualified to functional endoscopic surgery. The youngest patient was 3 years old and the oldest 18. 26 patients presented the polypoid lesions of sinuses or nasals. At 19 confirmed the coexistence of sinus polyps with nasal polyps.

RESULTS

76 patients had oedematous-inflammatory lesions and 26 polypoid. Among the group of listed above 26 children, 19 had either sinuses or nasal polyps. 15% children with polyps were diagnosed with cystic fibrosis and 8.0% with asthma. A common deviation in the results of morphology in children with CRSs is higher level of monocytes. Inflammation markers within the population of FESS qualified children were low.

CONCLUSIONS

(1) Oedematous-inflammatory lesions are frequently intraoperatively identified. (2) The CRSs without polyps is the common type of chronic sinusitis in children. (3) Nasal polyps often coexist with sinus polyps. (4) If nasal polyps are found in pediatric population then diagnosis of CF, allergy and GERD should be considered. (5) Markers of inflammation in CRSs are low.

Characterization of aeroallergen sensitivities in children with allergic rhinitis and chronic rhinosinusitis

Allergic rhinitis is a common comorbid condition in pediatric chronic rhinosinusitis (CRS). Testing for aeroallergen sensitization should therefore be considered in the evaluation of children with CRS. At present the aeroallergen sensitivity profile of children with CRS remains uncharacterized. In this study, we retrospectively identify a consecutive series of children with CRS and allergic rhinitis who have undergone joint otolaryngology and allergy evaluation at a single tertiary care center. We describe the aeroallergen sensitivity profiles (based upon formal skin testing) of these children, stratifying them according to co-morbidity status: 1) CRS with cystic fibrosis (CF), 2) CRS with immune deficiency and 3) uncomplicated CRS (without co-morbid CF, immune deficiency or primary ciliary dyskinesia). We identify 208 children (average age 9.3 years, standard deviation 4.8 years) with CRS and allergic rhinitis meeting inclusion criteria, 140 with uncomplicated CRS, 64 with co-morbid immune deficiency and 4 with co-morbid CF. The prevalence of indoor aeroallergen sensitivities (62.9–100.0%) was more common than that of outdoor aeroallergen sensitivities (43.8–50.0%) in all three cohorts of children. In all three cohorts, the most common indoor aeroallergen sensitivity was to dust mites (50.0–75.0%) and the most common outdoor aeroallergen sensitivity was to tree pollens (43.8–50.0%). The aeroallergen sensitivity profile of children with CRS and allergic rhinitis appears to be similar to that of the general pediatric population with allergic rhinitis, and parallels the aeroallergen sensitivities previously described for adults with CRS and allergic rhinitis. Knowledge of the aeroallergen sensitivities in children with CRS and allergic rhinitis will enhance both diagnostic and treatment strategies.

Pediatric chronic rhinosinusitis: when should we operate?

PURPOSE OF REVIEW

The timing and role of surgery in the management of pediatric chronic rhinosinusitis (pCRS) remains unclear. This review attempts to summarize the existing literature regarding this topic.

RECENT FINDINGS

pCRS is a complex clinical syndrome that results from multiple potential causes. Multimodal medical therapy is the accepted primary treatment. Adenoidectomy continues to be the appropriate first-line surgical therapy, and the addition of antral lavage or balloon dilation to this procedure may improve outcomes. Functional endoscopic sinus surgery (FESS) in children is safe and effective in relieving symptoms in the majority of patients. Failure to respond to maximal medical therapy continues to be a commonly cited, although poorly defined, requisite for proceeding to surgery. Recent literature has been focused on the outcomes after FESS rather than specifically defining when this intervention should be considered. Nevertheless, the literature seems to continue to support FESS in children with persistent symptoms despite adenoidectomy and appropriate medical treatment for pCRS. As the symptoms of chronic rhinosinusitis (CRS) may result from multiple underlying causes, clinicians must understand that the role and timing of surgery may vary with particular patients' disease.

SUMMARY

Surgical management of CRS in children continues to be a frequent topic of study in the otolaryngology literature. As recent research tends to be focused on outcomes after surgery, further prospective studies comparing surgical versus nonsurgical treatment of CRS will likely be required to better define indications for proceeding to surgery at all.

Rhinosinusitis in children: a comparison of patients requiring surgery for acute complications versus chronic disease

BACKGROUND

Patient characteristics, risk factors, and microbiology are important to consider in the management of complications of acute bacterial sinusitis (ABS) in pediatric patients. This study evaluates this subset of patients and compares them to patients that undergo surgery for chronic rhinosinusitis (CRS).

METHODS

This study is a retrospective review of all pediatric patients from 2002 to 2011, who underwent sinus surgery at a tertiary hospital. Patients who underwent surgery for ABS complication were compared to patients who underwent surgery for CRS. Statistical analysis was completed using chi-square test or Fisher's exact test with a statistical significance set at p<0.05.

RESULTS

Twenty-seven patients with a complication of ABS and 77 patients with CRS were analyzed. The groups did not differ demographically. Patients with a complication were statistically less likely to have seasonal allergies, prior sinusitis, prior nasal steroid use, or adenoidectomy (p<0.05). In addition, they had more frequent involvement of ethmoid and frontal sinuses (p<0.05). The most common cultures results were no growth (30.8%), Streptococcus milleri (30.8%), and normal flora (19.2%) in ABS for the with a complication group, and normal flora (41.5%), coagulase negative Staphylococcus (22%), and Propionobacterium (19.5%) for the CRS group. Most prevalent complications were preseptal cellulitis (55.5%), orbital subperiosteal abscess (29.6%), subgaleal abscess (22%), and epidural abscess (22%). Five patients had simultaneous orbital and intracranial complications.

CONCLUSIONS

Patients who present with complications of ABS vary significantly from the CRS patients. Location of most commonly affected sinuses and microbiology also differ and is crucial for understanding the management of this disease process.

Current utilization of balloon dilation versus endoscopic techniques in pediatric sinus surgery

OBJECTIVES

To study the utilization of balloon catheter dilation (BCD) compared to traditional endoscopic surgery (ESS) in pediatric patients.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Hospital and freestanding ambulatory surgery centers in California, Florida, Maryland, and New York

SUBJECTS

Patients less than 18 years who underwent BCD(316) or ESS(2346), as identified by CPT codes from the State Ambulatory Surgery Databases 2011.

METHODS

Patient and facility demographics, mean charges, and operating room time were examined using bivariate and multivariate analyses.

RESULTS

A total of 2662 children underwent surgery, with BCD used in 10.6% of maxillary, 8.4% of sphenoid, and 11.8% of frontal procedures. Adjusted analysis found that children with asthma, allergic rhinitis (AR), GERD, or concomitant adenoidectomy were more likely to have BCD compared to patients without these comorbidities, asthma odds ratio (OR) = 1.94 (95% CI, 1.84-3.41), AR OR = 1.77 (95% CI, 1.03-3.07), GERD OR = 2.79 (95% CI, .59-4.90), or without adenoidectomy OR = 2.50 (95% CI, 1.84-3.41). Patients with cystic fibrosis were less likely to have BCD, OR = 0.33 (95% CI, 0.11-0.95). Median charges for patients undergoing maxillary antrostomy alone by BCD (P = .042) or with adenoidectomy (P < .001) were approximately $2100 and $4200 greater than the median of patients undergoing those procedures with ESS. However, operating room time was similar (P = .81) between patients undergoing maxillary antrostomy, regardless of whether BCD was used, but was longer (P < .001) in those undergoing maxillary antrostomy and adenoidectomy when BCD was utilized.

CONCLUSIONS

BCD was used in 11.9% of pediatric sinus surgery and had higher average charges with no decrease in OR time compared to procedures that only utilized ESS. Future research is necessary to evaluate whether BCD may lead to improved outcomes and eventually decreased operating room time for pediatric patients with chronic rhinosinusitis.

Antibiotics for acute maxillary sinusitis in adults

BACKGROUND

Sinusitis is one of the most common diagnoses among adults in ambulatory care, accounting for 15% to 21% of all adult outpatient antibiotic prescriptions. However, the role of antibiotics for sinusitis is controversial.

OBJECTIVES

To assess the effects of antibiotics in adults with acute maxillary sinusitis by comparing antibiotics with placebo, antibiotics from different classes and the side effects of different treatments.

SEARCH METHODS

We searched CENTRAL 2013, Issue 2, MEDLINE (1946 to March week 3, 2013), EMBASE (1974 to March 2013), SIGLE (OpenSIGLE, later OpenGrey (accessed 15 January 2013)), reference lists of the identified trials and systematic reviews of placebo-controlled studies. We also searched for ongoing trials via ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language or publication restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed trial quality. We calculated risk ratios (RRs) for differences between intervention and control groups in whether the treatment failed or not. All measures are presented with 95% confidence intervals (CIs). We conducted the meta-analyses using either the fixed-effect or random-effects model. In meta-analyses of the placebo-controlled studies, we combined data across antibiotic classes. Primary outcomes were clinical failure rates at 7 to 15 days and 16 to 60 days follow-up. We used GRADEpro to assess the quality of the evidence.

MAIN RESULTS

We included 63 studies in this updated review; nine placebo-controlled studies involving 1915 participants (seven of the studies clearly conducted in primary care settings) and 54 studies comparing different classes of antibiotics (10 different comparisons). Five studies at low risk of bias comparing penicillin or amoxicillin to placebo provided information on the main outcome: clinical failure rate at 7 to 15 days follow-up, defined as a lack of full recovery or improvement, for participants with symptoms lasting at least seven days. In these studies antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% CI 0.47 to 0.94, 1084 participants randomised, 1058 evaluated, moderate quality evidence). However, the clinical benefit was small. Cure or improvement rates were high in both the placebo group (86%) and the antibiotic group (91%) in these five studies. When clinical failure was defined as a lack of full recovery (n = five studies), results were similar: antibiotics decreased the risk of failure (pooled RR of 0.73, 95% CI 0.63 to 0.85, high quality evidence) at 7 to 15 days follow-up.Adverse effects in seven of the nine placebo-controlled studies (comparing penicillin, amoxicillin, azithromycin or moxicillin to placebo) were more common in antibiotic than in placebo groups (median of difference between groups 10.5%, range 2% to 23%). However, drop-outs due to adverse effects were rare in both groups: 1.5% in antibiotic groups and 1% in control groups.In the 10 head-to-head comparisons, none of the antibiotic preparations were superior to another. However, amoxicillin-clavulanate had significantly more drop-outs due to adverse effects than cephalosporins and macrolides.

AUTHORS' CONCLUSIONS

There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80% of participants treated without antibiotics improved within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population levels.

Prevalence of and associations with allergic rhinitis in children with chronic rhinosinusitis

OBJECTIVES

Chronic rhinosinusitis (CRS) in children has been associated with a variety of disorders including atopic disease, cystic fibrosis, immunologic disorders and ciliary dyskinesia. Although a strong association, or even cause and effect relationship, between allergic rhinitis (AR) and CRS is commonly assumed, the epidemiologic relationship between these disorders has not yet been defined in children.

METHODS

A retrospective review of all children diagnosed with CRS on otolaryngology or allergy office evaluation at a large tertiary-care pediatric hospital over a ten-year period was performed. Demographic data and concomitant diagnoses of AR, cystic fibrosis, immunologic disorders and primary ciliary dyskinesia were analyzed for relationships with CRS.

RESULTS

A total of 4044 children with an average age of 8.9 years and a slight male predominance (53.8%) with CRS were identified. Of these children, 0.2% had primary ciliary dyskinesia, 4.1% had cystic fibrosis, 12.3% had an immunologic disorder, and 26.9% had AR. A concomitant asthma diagnosis was positively associated with a diagnosis of AR (OR=6.24, 95% CI: 5.27-7.39, P<0.001), whereas a concomitant cystic fibrosis diagnosis was negatively associated (OR=0.12, 95% CI: 0.06-0.26, P<0.001).

CONCLUSIONS

AR is more prevalent than the other comorbidities combined in children with CRS, and is independently associated with the presence of asthma. Formal allergy testing, guided by clinical history and regional allergen sensitivity prevalence, should be strongly considered in all children with CRS, in particular those with reactive airway disease.

Compliance and efficacy of saline irrigation in pediatric chronic rhinosinusitis

OBJECTIVE

The objective of this study was to evaluate compliance with and effectiveness of nasal irrigation in children with chronic rhinosinusitis (CRS) and to assess its clinical course.

METHODS

Seventy-seven children with refractory CRS resistant to medical treatment including antibiotics and nasal corticosteroids were included. We evaluated patients' nasal symptom and Lund Mackay CT scores at baseline. All patients were educated about nasal irrigation and encouraged to perform nasal irrigation 1-3 times a day. After 1 month, patients were reevaluated regarding compliance with the protocol and improvement of CRS by assessing symptom score and endoscopic evaluation. The patients were followed up for at least two months to assess need for further treatment including surgery.

RESULTS

Mean age of patients was 8.3 years ranging from 4 to 13 years. Mean follow-up duration with nasal saline irrigation was 6.2 months (2-32 months). Forty nine patients (63.6%) successfully carried out nasal irrigation during follow-up (good compliance [GC] group) and 28 patients (36.4%) did not successfully carry out nasal irrigation (poor compliance [PC] group). There were no significant differences between GC and PC groups regarding clinical characteristics and baseline Lund-MacKay CT scores. Subjective and objective improvements were observed in 36 patients (73.5%) in the GC group and 14 patients (50.0%) in the PC group. Surgery including endoscopic sinus surgery and/or adenoidectomy was performed in 8 patients (16.3%) in the GC group and 12 patients (42.9%) in the PC group. The rate of surgical treatment was significantly different between the groups (p=0.019).

CONCLUSION

Nasal irrigation in children with long standing CRS is relatively well tolerated (63.6%) and effective. Nasal saline irrigation should be considered as a primary treatment tool in CRS even in pediatric age group.

Management of chronic rhinosinusitis

: Chronic rhinosinusitis (CRS) in children is difficult to treat, with resultant frequent recurrences and failures. There are controversies in the treatment, mirroring the debate over the exact etiology of this disorder. The available medical treatments are antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions; though, there is no general agreement on the efficacy of the latter. The new technique of balloon sinuplasty allows ventilation to the sinuses to be restored with minimal risk and trauma to the tissues, and initial outcome seems promising, being successful in most treated children. Concerning the surgical approach, adenoidectomy is among the most frequent surgical procedures performed on children, but its therapeutic effect is controversial, because randomized studies have failed to prove that adenoidectomy alone is sufficient in curing CRS. Instead, functional endoscopic sinus surgery is a minimally invasive technique which restores the sinus ostia patency and can re-establish ventilation and drainage through the natural pathways. It is important that the effectiveness of any treatment is also evaluated by patient-reported outcomes (PROs) that refer to all health-related reports coming from the patients, without any involvement or interpretations by physician or others. Among PROs, health-related quality of life (HRQL) is the one most widely known and used. HRQL can be measured by means of validated questionnaires, which provide scores proportional to the degree of well-being perceived by patients. Concerning diseases of the upper airway including RS, there are numerous instruments specifically designed for children and caregivers, which allow to assess the effects of treatments in a more extensive and complete manner.

Prenatal development of the maxillary sinus: a perspective for paranasal sinus surgery

OBJECTIVE

To review the prenatal development of the maxillary sinus under the perspective of the sinus surgery.

STUDY DESIGN

Cross-sectional study.

SETTING

Basic embryology laboratory.

SUBJECTS AND METHODS

Morphometry and morphology of the maxillary sinus and its ostium were studied under stereomicroscopy in 100 human fetuses from the 9th to the 37th week. Fetuses were obtained from the Fetal Collection of the School of Medicine of the Universidad Autónoma de Nuevo León. Approval was granted by the Ethics Committee. Statistics were applied.

RESULTS

The maxillary sinus begins its development at the 10th week. On the 37th week, the anterior-posterior diameter has a mean of 4.36 mm; ossification of the medial wall was absent, and the floor was located below the attachment of the inferior turbinate. Septa and recesses were temporarily observed. Some variations in shape were observed; however, only the oval shape persisted. Maxillary sinus hypoplasia was not found, although asymmetry was present in 30% of cases. The ostium was located at the anterior third of the ethmoid infundibulum; its final dimensions were 1.96 mm in length and 0.44 mm in width. The mean length between the ostium to the lamina papyracea and nasolacrimal duct was 1 mm. One case of double maxillary sinus was observed. Significant difference between the variables, in accordance with the age, was found (P = .02).

CONCLUSION

Knowledge of prenatal development of the maxillary sinus improves the perspective of the sinus surgeon and helps the understanding of postnatal anatomy, especially in children.

Mechanisms of mammalian ciliary motility: Insights from primary ciliary dyskinesia genetics

Motile cilia and flagella are organelles that, historically, have been poorly understood and inadequately investigated. However, cilia play critical roles in fluid clearance in the respiratory system and the brain, and flagella are required for sperm motility. Genetic studies involving human patients and mouse models of primary ciliary dyskinesia over the last decade have uncovered a number of important ciliary proteins and have begun to elucidate the mechanisms underlying ciliary motility. When combined with genetic, biochemical, and cell biological studies in Chlamydomonas reinhardtii, these mammalian genetic analyses begin to reveal the mechanisms by which ciliary motility is regulated.