Pediatric chronic rhinosinusitis: when should we operate?

Racial Disparities in Pediatric Endoscopic Sinus Surgery

OBJECTIVE

To determine the impact of race and ethnicity on 30-day complications following pediatric endoscopic sinus surgery (ESS).

STUDY DESIGN

Cross-sectional cohort study.

SUBJECTS AND METHODS

Patients ≤ 18 years of age undergoing ESS from 2015 to 2017 were identified in the Pediatric National Surgical Improvement Program-Pediatric database. Patient demographics, comorbidities, surgical indication, and postoperative complications were extracted. Patient race/ethnicity included non-Hispanic black, non-Hispanic white, Hispanic, and other. Multivariable logistic regression was performed to determine if race/ethnicity was a predictor of postoperative complications after ESS.

RESULTS

A total of 4,337 patients were included in the study. The median age was 10.9 (interquartile range: 14.5-6.7) years. The cohort was comprised of 68.3% non-Hispanic white, 13.9% non-Hispanic black, 9.7% Hispanic, and 2.1% other. The 30-day complication rate was 3.2%, and the mortality rate was 0.3%. The rate of reoperation was 3.8%, and readmission was 4.1%. Black and Hispanic patients had higher rates of urgent operations (P = .003 and P < .001, respectively), and black patients had a higher incidence of emergent operations (P < .001) compared to their white peers. For elective ESS cases, multivariable analysis adjusting for sex, age, comorbidities, and surgical indication indicated that children of Hispanic ethnicity had increased postoperative complications (odds ratio: 1.57, 95% confidence interval: 1.04-2.37).

CONCLUSION

This analysis demonstrated that black and Hispanic children disproportionately undergo more urgent and emergent ESS. Hispanic ethnicity was associated with increased 30-day complications following elective pediatric ESS. Further studies are needed to elucidate potential causes of these disparities and identify areas for improvement.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1369-E1374, 2021.

SYSTEMATIC REVIEW OF THE LITERATURE ON SURGICAL TREATMENT OF CHRONIC RHINOSINUSITIS IN CHILDREN: WHAT IS THE BEST APPROACH?

Objective:

To carry out a systematic literature review on the surgical treatment of chronic rhinosinusitis in the pediatric population.

Data sources:

A bibliographic review methodology was used, based on data from National Library of Medicine (Medline), PubMed, Latin American and Caribbean Health Sciences Literature (LILACS) and Scientific Electronic Library Online (SciELO), of the indexed works from 2006 to 2016, including the pediatric population from zero to 13 years of age. The search keywords according to Medical Subject Heading (MESH) and Health Sciences Descriptors (DeCS) were: child, surgery, sinusitis and chronic disease. A total of 318 articles were collected, five of which met the inclusion criteria and were used as a basis for this review. All articles were prospective cohort studies, level of evidence 2B, according to the criterion used by evidence-based medicine.

Data synthesis:

The literature agreed that the next step for the cases refractory to drug treatment in chronic rhinosinusitis in childhood would be surgery. Adenoidectomy would be the initial method, for the safety of the procedure and improvement in about 50% of the cases, although more significant results were found in patients who associated this procedure with facial sinus surgery.

Conclusions:

Surgical treatment should be indicated for chronic rhinosinusitis in childhood after treatment failure. The results pointed out that adenoidectomy, when associated with some type of approach to the facial sinus, present better results.

Review of Systemic Antibiotic Treatments in Children with Rhinosinusitis

Antibiotic treatment in paediatric rhinosinusitis is still a matter of debate, as the current guidelines have been drafted mainly based on clinical studies published before 2013. Recent modifications in the epidemiological basis of the disease might mean that current treatments are not completely adequate considering the evolving microbiological profile of the disease. The present paper reviews the role of systemic antibiotics in children with acute (ARS), chronic (CRS), recurrent (RARS), and complicated acute (CoARS) rhinosinusitis. A total of 14 studies (including 3 prospective non-randomised studies, 8 retrospective studies, and 3 prospective randomised studies) of the 115 initially identified papers were included in this review, corresponding to 13,425 patients. Five papers dealt with ARS, four papers with RARS or CRS, and five papers with CoARS; the remaining papers included patients with either ARS or CRS. Data about the effectiveness of antibiotic treatment in children with ARC, CRS, and CoARS is scarce, as only three randomised controlled trials have been published in the last decade, with contrasting results. There is an urgent need for dedicated controlled trials not only to test the actual clinical benefits deriving from the routine use of systemic antibiotics in different categories of patients but also to compare the effectiveness of various therapeutic protocols in terms of the type of antibacterial molecules and the duration of treatment.

Recurrent periorbital cellulitis associated with rhinosinusitis in children: Characteristics, course of disease, and management paradigm

BACKGROUND

Recurrent periorbital cellulitis (RPOC) associated with rhinosinusitis is rarely noted and scarcely discussed in the literature. The aim of our study was to analyze the characteristics and disease course of a group of pediatric patients with RPOC.

METHODS

The medical records of all pediatric patients with a diagnosis of RPOC treated in a tertiary children's hospital were retrieved. Included were patients with a history of two or more episode of RPOC.

RESULTS

A total of 14 children were included. Mean follow up was 3 years (SD ± 2.5). Median age of first POC episode was 12 months (range 5 months-12 years). Overall, 75 events of RPOCs were documented. A median of 3 events per patient was noted (range 2-16). Preseptal cellulitis was diagnosed in all but five patients, in whom orbital cellulitis or subperiosteal abscess were identified, one following failure of conservative treatment, and the remaining at first presentation or recurrence. Rhinorrhea was present in only five patients (35%). The majority of patients were treated with intra-venous antibiotics. Imaging studies were performed in all patients revealing ethmoidal sinusitis in all patients, with lamina papyracea dehiscence in two patients. Immune deficiency was diagnosed in one patient. Endoscopic sinus surgery was performed in seven patients, in four as preventive procedure and in three during an acute phase. Post-operative recurrent disease was noted in two patients that were operated during the acute phase.

CONCLUSIONS

RPOC is a rare entity. Rhinosinusitis should be suspected in events of recurrent preseptal cellulitis even in the absence of nasal symptoms. CT scan is diagnostic for sinus origin of disease and possible anatomical abnormalities. In the majority of patients no evident etiology was identified. Elective Surgery or prophylactic antibiotic treatment should be strongly considered in this subgroup of patients as it seems beneficial.

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.

Clinical Guidelines on Chronic Rhinosinusitis in Children

PURPOSE OF REVIEW

Pediatric chronic rhinosinusitis (CRS) is a prevalent problem that can elude diagnosis. In addition, given the burgeoning interest in pediatric sinonasal disease, treatment modalities are constantly evolving.

RECENT FINDINGS

The diagnosis of pediatric CRS is primarily based on clinical history and signs supported by objective findings (i.e., nasal endoscopy and/or computed tomography (CT) imaging). Cultures are indicated in patients who have not responded to medical therapy or have significant comorbidities. Nasal saline irrigation, nasal saline spray, and oral antibiotics are currently recommended for initial medical management. In children with CRS who have failed medical therapy, a stepwise approach to surgical intervention can lead to significant improvements in quality of life. This review provides an overview of the current guidelines and recent literature regarding the diagnosis, microbiology, and treatment options of CRS in the pediatric population.

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.

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.