Functional endoscopic sinus surgery--a retrospective analysis of 115 children and adolescents with chronic rhinosinusitis

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

[Pediatric chronic rhinosinusitis]

Pediatric chronic rhinosinusitis (PCRS) differs from adult chronic rhinosinusitis (CRS) in several aspects. The confrontation with the environment takes place in the growing sinus system, and the immune system is also developing. The inflammatory mechanisms differ to some extent from those of adult CRS patients. The adenoid vegetations play an important role, particularly during the first 6 years of life. Other pathogenetic aspects are important (e.g., asthma, gastroesophageal reflux disease, immunodeficiency). Genetically determined systemic diseases such as cystic fibrosis cause specific challenges in diagnostics and treatment already in childhood. Consistent conservative therapy is often successful, but surgical procedures that have been proven to be effective and associated with few complications are also increasingly used.

The Relationship between Sphenoid Sinus, Carotid Canal, and Optical Canal in Paranasal Sinus Computed Tomography in Children

Objectives  The authors examined the structural differences in the paranasal sinus region at sphenoid sinus in the pediatric population. Methods  Paranasal sinus computed tomography (PNSCT) images of 86 pediatric subjects (30 males, 56 females) were included. In 13 to 15 years of age group ( n =34) and ≥16 years of age group ( n =52), sphenoid sinus pneumatization (SSP), optic canal and carotid canal classifications and dehiscence evaluation were performed. Results  In both sexes, type 1 and type 2 SS pneumatization were observed more frequently on both the right and left sides. On the right side, type 2> type 1; on the left side type 1> type 2 optic canals were detected in both gender. Type 3 optic canals were detected in 8.8 to 14.7% of the 13 to 15 years of age group; and 11.5 to 17.3% of ≥16 years of age group. Type 4 optic canals were detected in 2.9% of the 13 to 15 years of age group and 1.9% of the ≥16 years of age group bilaterally. Optic canal dehiscence was detected in 26.5% of the 13 to 15 years of age group and 17.3% of the ≥16 years of age group. Type 1 and type 2 carotid canals are most common in children, the percentages for type 3 carotid canals were 1.8 to 3.6% in children. Conclusion  In pneumatized SS, optic canal classifications got increased values which showed protrusion into the sphenoid sinus wall. Therefore, in children, the surgeons must be very careful for optic canal being nearer to the sphenoid sinus walls.

Mucocele in the maxillary sinus involving the orbit: A report of 2 cases

Mucocele of the paranasal sinuses is a benign, slow-growing, expansile lesion. Maxillary sinus mucoceles are usually associated with painless bulging of the cheek; however, orbital expansion is rarely observed. Maxillary sinus mucoceles can be classified as primary or secondary according to their etiology. An impediment to sinus ostium ventilation is thought to be the cause of primary mucocele, while sequestering of residual mucosa after surgery in the wound and long-term retention of tissue fluid have been suggested to lead to the formation of secondary mucocele. This report presents 2 cases of primary and secondary mucoceles, with a focus on radiographic features. As primary and superiorly positioned secondary maxillary sinus mucoceles are uncommon and their close proximity to the orbit predisposes the patient to significant morbidity, the authors expect that this report will contribute to a better understanding and diagnosis of maxillary sinus mucocele involving the orbit.

Nasal Polyps in Children: The Early Origins of a Challenging Adulthood Condition

Nasal polyps (NPs) are benign inflammatory masses causing chronic nasal obstruction, usually associated with underlying chronic rhinosinusitis (CRS), which are rarely reported in childhood. The interest in NPs has recently increased due to new therapeutic options, namely biological agents, such as dupilumab, and an update of the European position paper on this topic was released in 2020, providing a detailed classification for these lesions and also discussing diagnostic and therapeutic approaches also in children. In childhood, NPs usually represent red flags for systemic diseases, such as cystic fibrosis and immunodeficiencies. This review outlines the recent data on NPs in childhood, focusing on predisposing factors for CRS as well as on the potential endotypes in this particular age group, for which further studies are required in order to better clarify their pathogenesis and to identify molecular biomarkers that could help achieve more personalized treatments.

The Development of Dry Eye Disease After Surgery-Indicated Chronic Rhinosinusitis: A Population-Based Cohort Study

We aim to evaluate the risk of dry eye disease (DED) occurrence in patients with surgery-indicated chronic rhinosinusitis (CRS) via the national health insurance research database in Taiwan. After exclusion, patients with a diagnostic code of CRS and had received functional endoscopic sinus surgery (FESS) were regarded as having surgery-indicated CRS and enrolled in the study group, then each patient in the study group was age- and gender-matched to four non-CRS patients that served as the control group. The outcome was considered as the development of DED and Cox proportional hazard regression was used for the statistical analysis, which involved multiple potential risk factors of DED. A total of 6076 patients with surgery-indicated CRS that received FESS and another 24,304 non-CRS individuals were enrolled after exclusion. There were 317 and 770 DED events in the study group and the control group during the 16-year follow-up interval, and the study group demonstrated a significantly higher adjusted hazard ratio (1490, 95% confidence intervals (CI): 1.303-1.702) of DED development compared to the control group in the multivariable analysis. In addition, the cumulative probability analysis illustrated a positive correlation of DED occurrence and the disease period of surgery-indicated CRS (p < 0.0001). In the subgroup analysis, both genders revealed a higher but not significant incidence of developing DED in the study group. In conclusion, the existence of surgery-indicated CRS will increase the risk of developing DED, which correlated to the disease interval.

The Development of Glaucoma after Surgery-Indicated Chronic Rhinosinusitis: A Population-Based Cohort Study

This study investigates the development of glaucoma in subjects with surgery-indicated chronic rhinosinusitis (CRS) by the use of the National Health Insurance Research Database in Taiwan. Individuals that received the functional endoscopic sinus surgery (FESS) with a diagnostic code of CRS were regarded as surgery-indicated CRS and enrolled in the study group. Four non-CRS patients were age- and gender-matched to each patient in the study group. The exclusion criteria included legal blindness, ocular tumor, history of eyeball removal, and previous glaucoma. The outcome was regarded as the development of glaucoma, and conditional logistic regression was used for the statistical analysis, which involved multiple potential risk factors in the multivariate model. A total of 6506 patients with surgery-indicated CRS that received FESS and another 26,024 non-CRS individuals were enrolled after exclusion. The age and gender distributions were identical between the two groups due to matching. There were 108 and 294 glaucoma events in the study group and control group, respectively, during the follow-up period, and the study group had a significantly higher adjusted hazard ratio (1.291, 95% confidential interval: 1.031–1.615). The cumulative probability analysis also revealed a correlation between the occurrence of glaucoma and the CRS disease interval. In the subgroup analysis, the chance of developing open-angle glaucoma and normal-tension glaucoma was significantly higher in the study group than in the control group. In conclusion, the existence of surgery-indicated CRS is a significant risk factor for the development of glaucoma, which correlated with the disease interval.

The development of optic neuropathy after chronic rhinosinusitis: A population-based cohort study

Background

To evaluate the risk of developing optic neuropathy (ON) in patient with both non-surgery and surgery-indicated chronic rhinosinusitis (CRS) via the national health insurance research database in Taiwan.

Methodology/Principal findings

44,176 Patients with a diagnostic code of CRS was selected, which included 6,678 received functional endoscopic sinus surgery (FESS) regarded as the surgery-indicated CRS. Each individual in the study group was matched to two non-CRS patients by age and gender. The outcome was set as the occurrence of ON according to the diagnostic codes occurred after the index date. Poisson regression was used to calculate the adjusted relative risk (aRR) and conditional Cox proportional model was used to estimate the adjusted hazard ratio (aHR). There were 131 and 144 events of ON occurred in the study group and the control group respectively during the follow-up period. The whole study group, whether received FESS or not, demonstrated both significant aRR and aHR compared to the control group after adjusting demographic data, prominent ocular diseases, and systemic co-morbidities. In addition, both the aRR and aHR were higher in CRS patient received FESS than those with CRS but without FESS management.

Conclusion

The existence of CRS, especially the surgery-indicated CRS is a significant risk factor for the following ON using multivariable analysis.

Comparison of the efficiency and safety of endonasal and open rhinosurgery in children

OBJECTIVES/HYPOTHESIS

The objective of this study was to compare the efficiency and safety of endonasal endoscopic maxillary surgery and the Caldwell-Luc approach in children.

STUDY DESIGN

Case series.

METHODS

A total of 121 children aged 9 to 17 years with chronic rhinosinusitis were included in the study. The patients were operated on using Caldwell-Luc (n = 36) and endoscopic maxillary surgery (n = 85) procedures. Efficiency and safety of the surgeries were assessed using pre- and postoperative endoscopic evaluation of the mucosa of the nasal cavity, 20-item Sino-Nasal Outcome Test (SNOT-20), and subjective (both children's and parents') evaluation of the outcomes.

RESULTS

Endoscopic investigation of the mucosa of the nasal cavity demonstrated a significant improvement after both Caldwell-Luc and endoscopic surgery, although the Caldwell-Luc procedure did not result in significant improvement in mucosal color. However, no significant group difference was observed. Both techniques resulted in a significant improvement of mucosal edema and fluid characteristics. Based on the results of the SNOT-20, endoscopic maxillary surgery was characterized by a significant improvement in headache frequency, waking up at night, reduced concentration, ear pain, and emotional suppression as compared to Caldwell-Luc surgery. Although no significant group difference in efficiency between the Caldwell-Luc approach and endoscopic surgery was observed, the latter was characterized by a lower rate of scar formation, and reduced sensitivity, local painfulness, lacrimation, and psychologic discomfort.

CONCLUSIONS

The obtained data demonstrate the higher efficiency and safety of endoscopic sinus surgery as compared to the Caldwell-Luc approach in children.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1056-1063, 2020.

The Development of Keratopathy after Surgery-Indicated Chronic Rhinosinusitis: A Population-Based Cohort Study

The aim of the present study was to evaluate the risk of developing keratopathy in patients with surgery-indicated chronic rhinosinusitis (CRS) via the National Health Insurance Research Database in Taiwan. Patients with a diagnostic code of CRS and who received functional endoscopic sinus surgery (FESS) were considered to have surgery-indicated CRS. The exclusion criteria were legal blindness, an ocular tumor, eyeball removal or previous keratopathy, and each individual in the study group was matched to four non-CRS patients by age and sex. The outcome was set as the occurrence of keratopathy according to the diagnostic codes after the index date. Cox proportional hazard regression was used for statistical analysis. A total of 6053 patients with surgery-indicated CRS and another 24,212 non-CRS individuals were enrolled after exclusions. The age and sex distributions were identical between the two groups due to matching, while comorbidities, including hypertension, diabetes mellitus, and other cardiovascular disorders, were significantly higher in the study group. There were 231 episodes of keratopathy in the study group, and 695 episodes of keratopathy in the control group after the index date, for which study group showed a significantly higher rate of developing keratopathy with an adjusted hazard ratio of 1.208 and a higher cumulative probability. In subgroup analysis, female sex with surgery-indicated CRS showed a significantly greater risk of developing keratopathy. In conclusion, surgery-indicated CRS that needs FESS to relieve symptoms is a potential risk factor for keratopathy.

Results of endoscopic nasal surgery in the treatment of invasive fungal sinusitis in children with cancer and immunosuppression

BACKGROUND AND OBJECTIVE

to describe the results of the treatment of invasive fungal sinusitis with nasal endoscopic surgery in an immunocompromised paediatric oncological population.

METHODS

retrospective study of all patients diagnosed with invasive fungal sinusitis operated in the National Paediatric Oncology Unit between 2012 and 2016. Data taken from their medical history included: epidemiological characteristics, oncological diagnosis, haematological data, symptoms, tomographic studies, surgical interventions, results of pathology and cultures, medications received, complications, evolution and survival.

RESULTS

18 patients were identified, 7 male and 11 female. The average age was 12 years, 13 had a diagnosis of acute lymphocytic leukemia and 5 of acute myeloid leukemia. Seventeen patients presented severe neutropenia at the time of diagnosis. The most frequently identified aetiological agent was Aspergillus in 13 patients. In 16 patients (89%) the disease was controlled with nasal endoscopic surgery. Ten patients died due to unrelated causes throughout the study.

DISCUSSION AND CONCLUSIONS

Invasive fungal sinusitis should be considered a medical emergency due to its high mortality. The diagnosis is based on a high index of suspicion in patients with predisposing factors (leukaemia, neutropenia, persistent fever, nasogastric tube) and endoscopic nasal evaluation. Antifungal medical treatment and aggressive nasal endoscopic surgery is indicated regardless of the patient's condition to reduce the fungal burden and associated high mortality. The treatment must be provided by a multidisciplinary team that includes paediatrics, haemato-oncology, infectology and otorhinolaryngology.

Visualized ethmoid roof cerebrospinal fluid leak during frontal balloon sinuplasty

Balloon sinus dilation (BSD) is generally accepted as a safe alternative to traditional sinus surgery. It is a unique technique designed to potentially minimize complications associated with traditional functional endoscopic sinus surgery (FESS). We present a case in which a 65-year-old man experienced a cerebrospinal fluid (CSF) leak in the ethmoid roof that was visualized instantly after balloon dilation in a revision sinus surgery. In this case report, we discuss the causes of CSF leaks and explain in detail the immediate endoscopic repair with a collagen matrix. Also, literature is reviewed on the safety of BSD versus traditional FESS. Postoperatively, the patient has been without CSF leak and remains symptom free. CSF leak is a rare but major complication during both FESS and BSD. As BSD use increases, its complication profile will become clearer when used alone, in conjunction with FESS, and/or during revision surgery. Although BSD is considered a benign procedure, one should be cautious when using it in revision sinus surgery.

The Sinus and Nasal Quality of Life Survey (SN-5) in the Management of Pediatric Chronic Rhinosinusitis: A systematic review and meta-analysis

OBJECTIVES

Pediatric chronic rhinosinusitis (CRS) is a prevalent condition with quality of life (QoL) impacts that are seldom reported in the literature. We aimed to conduct a systematic review and meta-analysis on studies using the Sinus and Nasal Quality of Life Survey (SN-5), the only validated symptom questionnaire in pediatric CRS.

METHODS

A literature search was conducted to identify studies that used the SN-5 to measure QoL before and after medical or surgical interventions for pediatric CRS. Comparison of means and standard deviations was performed between pre- and post-intervention SN-5 scores.

RESULTS

A total of 10 studies, consisting of 13 separate treatment arms of either medical therapy, adenoidectomy, balloon catheter sinuplasty (BCS), or functional endoscopic sinus surgery (FESS) were identified. The vast majority (92.3%) of the treatment arms demonstrated minimal clinically important differences between baseline and post-intervention SN-5 scores. Rates of treatment success and minimal clinically important difference among all treatment arms ranged from 43.2% to 94.0%. Comparison of means showed an improvement in SN-5 score of 1.97 [95% CI, 1.18 to 2.76; p < 0.00001] for BCS, 1.83 [95% CI, 1.47 to 2.19; p < 0.00001] for FESS, and 1.15 [95% CI, 0.36 to 2.66; p = 0.13) for medical treatment.

CONCLUSION

There is a paucity of literature on QoL outcomes in pediatric CRS. More studies using the SN-5, particularly those controlling for baseline patient characteristics, are necessary to fully elucidate the impact of various interventions on QoL in pediatric CRS.

A Systematic Review of the Association between Cigarette Smoke Exposure and Chronic Rhinosinusitis

Objectives Cigarette smoking and passive smoke exposure have been associated with chronic rhinosinusitis (CRS). Our goal in this systematic review was to (1) determine if there was a strong correlative effect in large population studies between cigarette smoke exposure and the prevalence of CRS, (2) investigate pathogenic mechanisms of cigarette smoke in the upper airway, and (3) determine if a history of cigarette smoking affects the medical and surgical outcomes of CRS. Data Sources MEDLINE, Embase, Cochrane CENTRAL, Web of Science SCI and CPCI-S, and websites. Methods A comprehensive literature review and quantitative meta-analysis of studies based on the PRISMA protocol and examining the relationship between cigarette smoke exposure and CRS was performed. A search strategy was developed using various terms such as sinusitis, rhinitis, rhinosinusitis, and smoking. The articles were categorized by (1) epidemiology, (2) pathophysiology, and (3) outcomes. Data regarding study design, population/setting, methods, and bias were collected. Results The initial search generated 2621 titles/abstracts with 309 articles undergoing secondary review and 112 articles for final review. We determined that there is a strong correlation between active and passive cigarette smoke with the prevalence of CRS. Cigarette smoke challenge to sinonasal epithelia results in the release of inflammatory mediators and altered ciliary beat frequency. Pediatric patients exposed to secondhand smoke appear to have particularly poor outcomes. Conclusion There is clear evidence that cigarette smoke is related to CRS, but longitudinal and mechanistic studies are required to determine a causative effect. This information is critical for greater understanding of CRS health outcomes.

Clinical curative effect and safety of balloon sinuplasty in children with chronic rhinosinusitis

OBJECTIVE

Balloon Sinuplasty for the management of paranasal sinus inflammatory diseases was introduced in otolaryngology in 2005. Over the past decade, evidence strongly supports its safety and efficacy for the treatment of chronic rhinosinusitis (CRS) in adults. Because it requires no bone or tissue removal, this procedure could be suitable in children. We present our initial experience of its use for the treatment of CRS in children.

MATERIALS AND METHODS

A prospective study was performed of 30 children with failed medical therapy, who were scheduled for surgery. They underwent treatment by balloon sinuplasty of selected sinuses. Data were collected, including age, VAS score, CT score, and nasal endoscopy findings.

RESULTS

The procedure was successful in 61/65 sinuses (93.84%). Balloon sinuplasty improved sinus-related quality of life scores as well as computed tomography (CT) and endoscopic findings for up to 1 year after operation (p < 0.05).

CONCLUSION

In this initial study, balloon sinuplasty showed a clinical curative effect in the treatment of children with refractory CRS, and was relatively safe. Structural abnormalities in sinus ostia and hypoplastic sinuses may not be amenable to balloon catheter sinuplasty.

Functional endoscopic sinus surgery improves the quality of life in children suffering from chronic rhinosinusitis with nasal polyps

OBJECTIVE

To evaluate the impact of FESS in children with chronic rhinosinusitis with nasal polyps, regarding their overall postoperative quality-of-life (QoL) and constituent QoL domains. Potential differences between cystic fibrosis (CF) sufferers and non-sufferers, or cases with recurrent sinonasal polyposis versus single-operations were also explored.

METHODS

39 children were studied. The mean patient age was 10.9 years; four children suffered from cystic fibrosis. The children (or parents) completed the Glasgow Benefit Inventory for Children (GCBI) at least six months after their operation. The Mann-Whitney test compared the GCBI scores between non- and CF sufferers, as well as children with and without recurrent polyposis.

RESULTS

The median overall QoL score was 98. There were no statistically significant differences between CF sufferers and non-sufferers regarding their overall QoL, or the respective individual QoL domains, apart from their physical postoperative activity (p = 0.04). Twelve children demonstrated recurrent polyposis (30.7%); among them three were cystic fibrosis sufferers. No statistically significant differences were identified in the overall QoL score, or individual GCBI subscale scores between children with recurrent polyposis versus single-operations. Children with recurrent polyposis but not CF performed better regarding their overall QoL (p = 0.021) and medical status (p = 0.015), compared to their CF counterparts.

CONCLUSION

FESS performed for chronic rhinosinusitis with nasal polyps in children is associated with improved postoperative QoL, irrespective of the presence of CF (although the latter needs to be confirmed in larger patient cohorts). The absence of appreciable differences in the overall QoL, or its constituent domains, between single and re-operated children, indicate that the positive effect of FESS outweighed the burden of re-operation. Appropriate preoperative informed consent in cases of recurrent sinonasal polyposis necessitates acknowledging worse respective outcomes in CF sufferers.

Safety and Perioperative Adverse Events in Pediatric Endoscopic Sinus Surgery: An ACS-NSQIP-P Analysis

INTRODUCTION

This study describes safety outcomes of pediatric endoscopic sinus surgery (ESS) to identify risk factors for 30-day postoperative adverse events using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database.

METHODS

We performed a retrospective cohort study involving patients in the 2012-2015 NSQIP-P database who underwent ESS. Predictors included demographics, comorbidities and surgical acuity. Outcomes included 30-day complications, reoperations, and readmissions.

RESULTS

Among 2,061 ESS cases identified, 1,829 (88.7%) were elective and 232 (11.3%) were urgent/emergent. There were 92 (4.5%) readmissions, 54 (2.6%) unplanned reoperations, and 61 (3.0%) complications. On multivariate analysis, readmission was associated with urgent/emergent procedures (OR 2.31, CI 1.36-3.93, p<0.01) and history of bleeding disorder (OR 2.24, CI 1.12-4.44, p = 0.02), reoperation was associated with urgent/emergent procedures (OR 5.78, CI 3.24-10.34, p<0.01), and complications were associated with urgent/emergent procedures (OR 3.81, CI 2.13-6.82, p<0.01) and history of bleeding disorder (OR 5.30, CI 2.74-10.20, p<0.01). Bleeding requiring transfusion was associated with urgent/emergent procedures (OR 9.61, CI 2.90-31.80, p<0.01), history of bleeding disorder (OR 14.16, CI 4.41-45.45, p<0.01), and age <3 years (OR 3.92, CI 0.99-15.61, p = 0.05). Black children were significantly more likely to undergo urgent/emergent surgery than white children (19.7% vs. 9.6%, p<0.01).

CONCLUSIONS

This multi-institutional study confirms that while pediatric ESS is largely safe, urgent/emergent procedures carry the greatest risk of postoperative adverse events, and black children are significantly more likely to undergo higher acuity surgery than white children. Regardless of procedure acuity, young age and bleeding disorder are associated with higher risk of 30-day adverse events.

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.

Passive smoke exposure in chronic rhinosinusitis as assessed by hair nicotine

BACKGROUND

Prevalence of passive smoke exposure is relatively unknown in chronic rhinosinusitis (CRS). Previous studies have attempted to establish this relationship using subjective, questionnaire-based methodologies to assess smoke exposure, thus introducing the potential for error bias. The purpose of this study was to accurately determine the prevalence of passive smoke exposure in CRS and control patients using hair nicotine levels as a quantitative measure of cigarette smoke exposure.

METHODS

Hair samples were obtained at time of surgery from 569 patients: 404 undergoing surgery for CRS and 165 controls undergoing surgery for repair of cerebrospinal fluid leak, removal of pituitary tumors, or adenoidectomy from 2007 to 2013. Patient charts were reviewed for reported smoking status. Hair nicotine was quantified using reversed-phase high-performance liquid chromatography. Nonsmoking patients were classified as passive smoke exposed or smoke naïve according to the hair nicotine results. Statistical analysis was performed to test for differences in demographic information and smoke exposure prevalence between CRS, CRS subtypes, and controls.

RESULTS

The prevalence of passive smoke exposure in CRS as documented by hair nicotine was lower than previously reported subjective estimates. Passive smoke exposure rates were equivalent between those with CRS versus controls and significantly higher in children. Severity of passive smoke exposure was also equivalent between CRS subsets and controls. Annual passive smoke exposure prevalence did not change over time.

CONCLUSION

There is no clear evidence of avoidance of passive smoke exposure in the CRS population compared with controls. Passive smoke exposure also remained stable over time despite recent regional implementation of smoking bans. Given the constancy of exposure, it is critical that the impact of passive smoke on CRS exacerbation, outcomes, and pathophysiology be evaluated in large-scale clinical studies.

Functional Endoscopic Sinus Surgery Versus Balloon Sinuplasty with Ethmoidectomy: A 2-year Analysis in Pediatric Chronic Rhinosinusitis

To evaluate the 2-year post-operative outcomes of pediatric patients with chronic rhinosinusitis (CRS) treated with balloon catheter sinuplasty (BCS) and ethmoidectomy compared to functional endoscopic sinus surgery (FESS). Two-group, retrospective cohort study of 28 children with CRS was performed. Of these 28 participants, 15 were treated with traditional FESS (53.6 %) and 13 (46.4 %) underwent traditional ethmoidectomy with balloon sinuplasty. Pre-operative and 2-year postoperative total symptom scores and medications were compared. To examine the potential long-term differences in surgical outcomes and surgical procedure on symptom outcome, one-tailed Chi square analyses were employed. The mean age of the children examined was 9.3 (SD = SD = 4.1; range 3-18) and 61.9 % were male. Pre-operative symptomatology, medication and Lund Mackay scores were evaluated for both groups and no significant differences were identified. Overall, 73.3 % of children that underwent traditional FESS and 76.9 % of those who had BCS with ethmoidectomy reported significant long-term improvement in at least one of their pre-operative sinus complaints. Our data suggests that both BCS with ethmoidectomy and traditional FESS are effective treatment options for uncomplicated CRS and result in long-term alleviation of core sinus complaints, as well as decreased sinus related medication use. Larger prospective studies are needed to further evaluate these procedures.

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.

Functional endoscopic sinus surgery improves sinus-related symptoms and quality of life in children with chronic rhinosinusitis: a systematic analysis and meta-analysis of published interventional studies

AIM

To assess the current knowledge and evaluate the quality of evidence in the use of FESS for the treatment of chronic rhinosinusitis in children, regarding the respective changes in the quality-of-their-life (QoL) and the outcome that follows the operation.

MATERIALS/METHODS

Systematic literature review in Medline and other database sources and meta-analysis of pooled data.

RESULTS

15 studies were systematically analyzed. Four represented Level II, five Level III, and six Level IV evidence. The total number of treated patients was 1301. Thirteen research groups reported that pediatric FESS is an effective treatment for chronic rhinosinusitis; the respective positive outcome ranged between 71 and 100% of operated children. Five studies concluded that this treatment modality is associated with significant improvement in the children's postoperative QoL. Systemic diseases and environmental factors may have unfavourable prognostic effects; cystic fibrosis is associated with at least 50% recurrence rate. The rate of major complications following pediatric FESS is 0.6%, and the respective rate of minor complications 2%.

CONCLUSION

The surgical management in children with chronic rhinosinusitis, despite the reservations expressed by many clinicians, is effective when optimal medical treatment proves unsuccessful (grade B strength of recommendation), and is associated with improvement in the children's QoL (grade B strength of recommendation). FESS also improves the sinusitis-associated symptoms and QoL in children with cystic fibrosis (grade C strength of recommendation. Most complications of pediatric FESS reported in the literature are minor, and associated with difficulties in the postoperative assessment and care of pediatric patients.

Chronic rhinosinusitis in children

Chronic rhinosinusitis (CRS) affects nearly 37 million people in the United States each year and accounts for approximately $6 billion in direct and indirect health care costs. Despite its prevalence and significant impact, little is known about its exact cause and pathophysiology, and significant controversy remains regarding appropriate treatment options. Basic science research, however, has shown recent promise toward improving understanding of the innate and environmental factors underlying the pathophysiology of CRS. The hope is that this will also lead to advances in treatment for children adversely affected by this common yet complicated disease.

Acute sinusitis in children

Acute rhinosinusitis is a common illness in children. Viral upper respiratory tract infection is the most common presentation of rhinosinusitis. Most children resolve the infection spontaneously and only a small proportion develops a secondary bacterial infection. The proper choice of antibiotic therapy depends on the likely infecting pathogens, bacterial antibiotic resistance, and pharmacologic profiles of antibiotics. Amoxicillin-clavulanate is currently recommended as the empiric treatment in those requiring antimicrobial therapy. Isolation of the causative agents should be considered in those who failed the initial treatment. In addition to antibiotics, adjuvant therapies and surgery may be used in the management of acute bacterial rhinosinusitis.

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.

Impact of tobacco smoke on chronic rhinosinusitis: a review of the literature

BACKGROUND

Environmental factors such as inhaled pollutants like cigarette smoke may play a significant role in diseases of the upper airway including chronic rhinosinusitis (CRS). The objectives of this review are to summarize prior studies that describe the correlation between active smoking and secondhand smoke (SHS) on CRS. We also review the pathophysiologic effects of cigarette smoke on sinonasal mucosa and discuss its impact on surgical outcomes of endoscopic sinus surgery (ESS).

METHODS

A literature search was conducted of the PubMed database using the terms "sinusitis" or "rhinosinusitis" and "smoking." Additional search terms of "nasal epithelial" and "smoke" were used to find articles that discussed pathophysiologic effects of tobacco smoke, whereas "secondhand smoke" was added to identify articles analyzing the correlation of SHS and CRS. Finally "endoscopic sinus surgery" and "outcomes" were linked to "smoking" to find articles that analyzed the impact of smoking on surgical results.

RESULTS

We identified 204 articles in the initial search. An additional 72 articles were reviewed for their relevance to the pathophysiologic effects of tobacco smoke while 31 articles were analyzed to determine the correlation of SHS and CRS. Twenty-nine articles were reviewed to analyze the impact of smoking on surgical results.

CONCLUSION

There is clear evidence in the literature that cigarette smoke, either through active smoking or passive exposure to SHS, contributes to CRS. Recent prospective studies suggest that active smoking is not a contraindication to ESS, whereas the impact of smoking volume and long-term smoking after ESS has not been sufficiently evaluated.

Long-term improvements in quality of life after functional endoscopic sinus surgery for adolescents with chronic rhinosinusitis

CONCLUSIONS

The long-term quality of life of adolescents with chronic rhinosinusitis improved significantly after functional endoscopic sinus surgery (FESS), and endoscopic sinus surgery showed certain benefits for adolescent patients. The selection of appropriate patients may further improve the surgical outcomes and quality of life.

OBJECTIVE

To analyze the long-term quality of life in adolescents (12-18 years) with chronic rhinosinusitis after endoscopic sinus surgery, and to evaluate the value of endoscopic sinus surgery in adolescent patients.

METHODS

From 2003 to 2008, 729 adolescents with chronic sinusitis underwent endoscopic sinus surgery in our department; 270 of these patients were included in the study. Their quality of life was assessed before and within 3-8 years after the surgery using the SNOT-20 scale and was compared with that of healthy individuals of the same age.

RESULTS

The SNOT-20-based assessment showed that the overall quality of life differed significantly before and after surgery (p = 0.000) and that some symptoms (dizziness, sense of facial oppression, sleep difficulty, embarrassment, and fatigue) had no significant differences before and after surgery (p > 0.05). Preoperative and postoperative symptoms (dizziness, sense of facial oppression, sleep difficulty, embarrassment, and fatigue) showed no significant differences between the healthy population and treated patients (p > 0.05).

Long-term evaluation after endoscopic sinus surgery for chronic pediatric sinusitis with polyps

OBJECTIVE

Long-term retrospective evaluation was performed of computed tomography (CT) images and endoscopic findings after endoscopic sinus surgery for 88 cases of chronic pediatric sinusitis with nasal polyps. The objective was to determine the appropriate duration of such postoperative evaluation for children.

METHODS

Fifty-one patients had both sinusitis and nasal polyps (BSP group), and the surgical procedure was decided in consideration of each patient's age (for less than 10 years of age, polypectomy (n=12); for 10-13 years old, anterior ethmoidectomy plus opening of the fontanelle and nasofrontal duct (n=20); and for serious cases older than 13 years, total sinusectomy (n=19)). On the other hand, for cases of unilateral sinusitis with antrochoanal polyps (USP group), anterior ethmoidectomy plus opening of the fontanelle was performed regardless of the patient's age (n=37, 5-15 years old).

RESULTS

The postoperative endoscopic findings indicated that the polyps had been eliminated in approximately 91% of total patients. Good postoperative findings of CT images in most patients of USP group are observed at one year after the operation like the same of the postoperative course of adult chronic sinusitis. On the other hand CT images in BSP group evaluated one year after the operation were rated as unchanged or worsened in approximately half of the patients. However, at 4 years after the operation nearly all the patients were rated as improved or better. In addition, comparison of the age at final observation and the postoperative course found a striking decrease in the proportion of unchanged and worsened patients aged 12 and above.

CONCLUSION

Accordingly, it was concluded that there is difference of healing process after the operation between USP and BSP group. Postoperative evaluation of BSP group should be performed for 4 years and up to an age of at least 12 years although post-ESS following of USP group is similar to that of adult sinusitis.

Functional endoscopic sinus surgery in children: predictive factors of outcome

The main objective of this study is to assess the results of functional endoscopic sinus surgery in children and to determine which factors independently influence the postoperative results. It is a prospective study by Mansoura University Hospital. 87 patients with different applications of pediatric endoscopic sinus surgery (PESS) chronic rhinosinusitis (CRS) with nasal allergy (45 patients), CRS without nasal allergy (36 patients) and CRS with polypsis (6 patients) from 2005 to 2010 were included. All children underwent endoscopic sinus surgery. All patients were clinically, radiologically and endoscopically monitored. In this study, the overall success rate was 87.69%, the success rate for CRS with nasal allergy was 87.5%, the success rate for CRS without nasal allergy was 85.7% and the success rate for CRS with polyposis was 93%. Regarding the patients' age, it could affect the surgical score value (X(2) = 9.446 and P* = 0.009). There was significant relation between type of the preoperative disease extent, adenoidectomy, second look operation and postoperative improvement. There was no significant relation between type of the preoperative disease or previous surgery and postoperative improvement. In conclusion, postoperative improvement was significantly correlated with extent of preoperative disease, adenoidectomy and second look operation and not significantly correlated with type of the preoperative disease or previous surgery. The results of PESS are influenced by age group, a younger age group is associated with more adhesions and recurrences and an older age group is associated with blood loss and higher surgical score. All these variables are contributing in the outcome of PESS.