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

Surgical and medical management of chronic rhinosinusitis in pediatric cystic fibrosis patients: Impact on olfactory symptoms

BACKGROUND AND PURPOSE

Olfactory dysfunction (OD) commonly occurs in patients with sinonasal dysfunction, but the prevalence and severity of olfactory issues in adolescents with cystic fibrosis (AwCF) is unclear. OD may contribute to dietary deficiencies and exacerbate nutritional challenges. We sought to review literature on the effectiveness of medical and surgical management of sinonasal symptoms in AwCF and the associated impact on olfactory function.

METHODS

We performed a systematic literature search of PubMed, Embase, Web of Science, and Ebsco CINAHL from 1980 to 2022 per PRISMA-ScR protocols to conduct a scoping review in an effort to compile data on study design, patient demographics, clinical characteristics and outcomes, along with risk of bias.

RESULTS

Of 368 abstracts, 3 articles exclusively evaluated AwCF for a total of 34 patients. Two studies evaluated endoscopic sinus surgery (ESS) and dornase alfa. An additional 6 articles were included for mixed pediatric and adult CF populations totaling 313 patients. Interventions included ESS, elexacaftor-tezacaftor-ivacaftor (ETI), ivacaftor, saline, dornase alfa, hyaluronic acid, and hyaluronic acid-tobramycin combination. Outcome measures included subjective assessment of OD using non-validated (4/9) and validated (4/9) surveys, and psychophysical (1/9) smell testing. Studies evaluating ESS, FESS, dornase alfa, ivacaftor, and both hypertonic and isotonic saline reported statistically significant improvement in OD, whereas ETI failed to improve OD despite improvement in other quality of life measures.

CONCLUSIONS

There is limited data regarding the impact of medical and surgical interventions on olfaction for AwCF. Assessment of olfaction was often limited to subjective and qualitative self-report. We suggest that tracking of olfactory outcomes with psychophysical testing is critical in this population with dietary challenges and weight management issues.

[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.

Pediatric chronic rhinosinusitis

PURPOSE

An up-to-date overview of diagnosis, differential diagnosis, comorbidities, and current medical and surgical management of pediatric chronic rhinosinusitis (PCRS).

METHODS

Review of current evidence-based literature on PCRS.

RESULTS

Diagnosis of PCRS seems to be improving based on recent evidence using nasal endoscopy as well as computed tomography scanning. Recent literature supports the fact that chronic adenoiditis can be an independent etiology of symptoms of chronic sinusitis, that are very similar to chronic adenoiditis. Allergic rhinitis and immune deficiency play important roles in the management of PCRS. Surgery for PCRS has evolved significantly in the last 15-20 years to include adenoidectomy as well as endoscopic sinus surgery.

CONCLUSIONS

PCRS is very common in children causing poor QOL for these children. Medical management remains the main stay of treatment with attention to management of co-morbidities that may contribute to the disease severity. Making the correct diagnosis will help with the choice of surgical intervention if medical management fails.

Long-term Follow-up of Pediatric Chronic Rhinosinusitis After Surgical Treatment

OBJECTIVE

To study the long-term outcomes of pediatric chronic rhinosinusitis (CRS) after surgical treatment.

METHODS

Cross-sectional survey of patients who were treated surgically for CRS as children more than 10 years ago. Survey included SNOT-22 questionnaire, additional functional endoscopic sinus surgery (FESS) since last treatment, status of allergic rhinitis and asthma, and availability of any CT scan sinus/face for review.

RESULTS

About 332 patients were contacted by phone or email. Seventy-three patients filled the survey (22.5% response rate). Current age was 26 years (±+/-4.7, 15.3-37.8 years). Age at initial treatment was 6.8 years (+/-3.1, 1.7-14.7 years). Fifty-two patients (71.2%) had FESS and adenoidectomy, and 21 patients (28.8%) had adenoidectomy only. Follow-up since surgical treatment was 19.3 years (+/-4.1). SNOT-22 score was 34.5 (+/-22.2). None of the patients had any additional FESS for the duration of the follow-up, and only 3 patients had septoplasty and inferior turbinoplasty as adults. Twenty-four patients had CT scan sinuses/face available for review. Scans were obtained at an average of 14 years after surgical intervention (+/-5.2). CT LM score was 0.9 (+/-1.9), compared to 9.3 at time of their surgery (+/-5.9) (P < .0001). Currently 45.8% and 36.9% of patients have asthma and AR, compared to 35.6% and 40.6% respectively as kids (P = .897 and P = .167).

CONCLUSION

Children who had surgery for CRS do not seem to have CRS as adults. However, patients continue to have active allergic rhinitis that may affect their quality of life.

Impact of Prolonged Operative Time on Complications Following Endoscopic Sinonasal Surgery

OBJECTIVE

To determine how prolonged operative time (POT) impacts 30-day outcomes in patients undergoing endoscopic sinonasal surgery (ESNS).

STUDY DESIGN

Retrospective study.

METHODS

Data from patients who underwent ESNS (nonsinus, sinus, and extended sinus) between 2005 to 2018 were collected from the American College of Surgeons National Surgical Quality Improvement database. Univariate and multivariate analyses were performed to evaluate the effect of POT on postoperative outcomes.

RESULTS

Among 1,994 ESNS cases, 495 nonsinus procedures, 1,191 sinus procedures, and 308 extended sinus procedures were identified. Median OT was 90 minutes (interquartile range [IQR], 51-165 minutes) for nonsinus procedures, 113 minutes (IQR, 66-189 minutes) for sinus procedures, and 187 minutes (IQR, 137-251 minutes) for extended sinus procedures. Other than older age (P = .008), POT was not significantly associated with baseline demographics and comorbidities for patients undergoing non-sinus procedures. Older age (P < .001), White and Black race (P < .001), ASA physical classifications III or IV (P < .001), and several preoperative comorbidities, including obesity (P = .045), and hypertension (P < .001) were associated with POT for sinus procedures. Older age (P = .030), male sex (P = .010), and lower body mass index (P = .004) were associated with POT for extended sinus procedures. After risk-adjustment, POT was independently associated with prolonged hospital stay (LOS) for all procedure categories, and associated with overall surgical complications and postoperative bleeding for sinus and extended sinus procedures specifically.

CONCLUSION

POT is independently associated with several adverse outcomes following ESNS, including prolonged LOS, overall surgical complications, and bleeding. Preoperative planning should include optimizing modifiable patient risk factors for POT and identifying surgeon-specific factors to enhance surgical efficiency.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:51-58, 2023.

Cystic fibrosis exacerbations treated with medical therapy with and without concurrent sinus surgery

OBJECTIVE

This analysis investigates any potential differences in pulmonary function test (PFT) outcomes among pediatric patients with cystic fibrosis (CF) receiving both medical management (MM) and functional endoscopic sinus surgery (FESS) versus MM alone for CF exacerbation.

STUDY DESIGN

Prospective cohort.

SETTING

Pediatric tertiary care facility.

METHODS

The data was prospectively collected from July 2011 to March 2020. Diagnosis of CF and age ≤ to 18 were required. All patients were hospitalized and treated for CF exacerbations with both FESS with MM and MM alone at variable time intervals, although the order of initial treatment received differed. Two-way ANOVA with repeated measures were used to determine the effect of receiving FESS with MM versus MM alone on PFT outcomes over time (during admission, at discharge, at 3 months, at 6 months, and at 12 months).

RESULTS

13 pediatric patients, 7 of which had FESS with MM initially and 6 who had MM alone initially, and 20 events of both FESS and MM were included for analysis. For PFT outcomes, there was no statistically significant two-way interaction between treatment type and time following treatment, p = 0.492. The main effect of treatment did not show a statistically significant difference in FEV1 between treatment types, p = 0.737. There was no statistically significant association between treatment type and time between hospital readmission in months, p = 0.111.

CONCLUSION

There was no significant difference between PFT outcomes in pediatric patients hospitalized for CF exacerbation treated with MM with or without FESS at any time interval.

Chronic and Recurrent Sinusitis in Children, as Manifestation of Immune Dysfunction and Atopic Background

Rhinosinusitis in children, as in adults, can be classified by duration (acute, recurrent, and chronic) and by cause (viral, bacterial, and inflammatory) and needs to be treated accordingly after careful investigation which include through clinical history, laboratory tests, and, if necessary, nasal endoscopy and imaging studies.

Complications of primary pediatric endoscopic sinus surgery for chronic rhinosinusitis: A 25-year single surgeon experience

Objective

To report our experience on the complications of primary pediatric endoscopic sinus surgery (ESS).

Methods

Case series of pediatric ESS performed from 1991 to 2016 on children who failed maximal medical therapy and/or adenoidectomy. Inclusion criteria were children (age <12 years old) who underwent primary ESS with or without adenoidectomy for chronic rhinosinusitis (CRS) after failed maximal medical therapy and/or adenoidectomy. All patients underwent maxillary antrostomy ± partial or total ethmoidectomy. Patients with complicated acute rhinosinusitis were excluded. Complications reviewed included: skull base injury and CSF leak, orbital injuries (blindness, orbital hemorrhage, emphysema, periorbital swelling and bruising, fat exposure), and bleeding requiring intervention.

Results

A total of 352 patients underwent ESS between 1991 and 2016. There were no blindness or orbital hematoma reported, and no major nasal bleeding requiring intervention. The total number of complications was 31 (8.8%): 1 (0.3%) CSF leak, 3 (0.85%) orbital emphysema, 5 (1.4%) periorbital ecchymosis, and 22 (6.3%) lamina papyracea violation with orbital fat exposure.

Conclusions

Complications of primary pediatric ESS can be rare dependent on surgeon's experience, the most common being orbital injury.Level of evidence: 4.

Pediatric Rhinosinusitis

Rhinosinusitis is a common diagnosis encountered by providers of all disciplines. Pediatric acute and chronic rhinosinusitis account for up to 2% of the total annual visits to the outpatient clinics and emergency departments. Once correct diagnosis is made, appropriate treatment measures can be initiated. It is important to recognize rhinosinusitis in children due to the potential serious complications and the impact it may have on quality of life of those children. Medical management is the mainstay of treatment, and, fortunately, it is successful in most of those children. When medical management fails, or a complication occurs, surgery may be required.

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 management of paediatric rhinosinusitis

Paediatric rhinosinusitis (PDRS) is commonly used as a synonym for rhinitis within healthcare. Although they may share common symptoms, the pathophysiology does differ; PDRS is the inflammation of the nasal mucosa in addition to the sinuses whereas rhinitis is the inflammation of just nasal mucosa. This review provides a comprehensive overview of the epidemiology, pathophysiology, symptoms, diagnosis and management of PDRS. There is a greater emphasis on the diagnosis and management of PDRS within this review due to a lack of clear guidelines, which can lead to the common misconception that PDRS can be treated indifferently to rhinitis and other upper respiratory conditions. PDRS has detrimental effects on children's current health, long-term health into adulthood and education. Therefore, having a comprehensive guide of PDRS would provide a greater understanding of the condition as well as improved diagnosis and management. This article primarily focuses on the position of Europe and the United Kingdom; however, the recommendations can be applied to other countries as the causes and treatments would not differ significantly.

Detecting epidemiological relevance of adenoid hypertrophy, rhinosinusitis, and allergic rhinitis through an Internet search

Purpose

This study aimed to detect the epidemiological relevance between adenoid hypertrophy (AH) and rhinosinusitis, and AH and allergic rhinitis (AR) through an Internet search.

Methods

Internet search query data from January 2011 to December 2019 in China were retrieved from the Baidu Index (BI). Spearman’s correlation coefficients were used to detect the correlation among the search volumes of AH, rhinosinusitis, and AR. We also collected search data from the first 5 months of 2020, when quarantine was implemented in China due to the coronavirus disease 2019 epidemic. Then, we compared the search data to those obtained during the same period in 2019 to assess the effects of isolation on AH and AR.

Results

Statistically significant relevance was found between the search variations of AH and rhinosinusitis during 2011–2019 (R = 0.643, P < 0.05). However, the relationship between AH and AR was weak (R =  − 0.239, P < 0.05) and that between rhinosinusitis and AR (R =  − 0.022, P > 0.05) was not relevant. The average monthly search volume of AH and rhinosinusitis had a strong correlation (R = 0.846, P < 0.01), but AH and AR and rhinosinusitis and AR were not correlated (R = – 0.350, P > 0.05; R = – 0.042, P > 0.05, respectively). AH and rhinosinusitis search volumes decreased consistently during the first 5 months of 2020 (isolation), whereas that for AR increased during January–February.

Conclusion

AH had an epidemiological relationship with rhinosinusitis, which was not consistent with AR. The decrease in public gathering effectively reduced the morbidities of AH and rhinosinusitis but not those of AR.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

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.

[Features and effectiveness of endoscopic sinus surgery in children]

The concept of modern functional endonasal sinus surgery in the pediatric population is based on sparing, minimally invasive interventions within the middle nasal passage, mainly the ostiomeatal complex, performed taking into account modern knowledge of the physiology of the nasal cavity and paranasal sinuses, as a result of which normal can be restored as soon as possible aerodynamics in the nasal cavity; respiratory and other functions of the nasal cavity and paranasal sinus are restored. The article presents the history, modern principles and indications for pediatric sinus surgery. The features of preparation, management of the postoperative period and the effectiveness of sinus surgery in the age aspect are described.

Pediatric Versus Adult Chronic Rhinosinusitis

PURPOSE OF REVIEW

Pediatric and adult chronic rhinosinusitis (CRS) have some similarities but a number of differences. This article reviews the similarities and differences between pediatric and adult CRS.

RECENT FINDINGS

Rhinosinusitis is an inflammatory disease of the nose and the paranasal sinuses. In adults, inflammation in CRS without polyps (CRSsNP) mainly manifests with T-helper 1 lymphocytes while in CRS with polyps (CRSwNP) manifests with T-helper 2 lymphocytes and eosinophilic inflammation. In children, CRS inflammation manifests with neutrophils, macrophages, and lymphocytes. The associations between the ostiomeatal complex occlusion and CRS are revealed in adults but are not so evident in children. Although the relationship between the CRS and allergic rhinitis is still controversial, recent findings have shown an association between allergen sensitization and a specific group of adults with rhinosinusitis. Intranasal corticosteroids and saline constitute the first-line of medical treatment for both pediatric and adult rhinosinusitis. Low-dose macrolides are used for immunomodulatory activities and beneficial effects to adult patients with CRSsNP were demonstrated by recent meta-analyses. For surgical treatment, adenoidectomy is a key strategy to eradicate mature biofilms in pediatric CRS and effective in treating children with CRS regardless of the adenoid size. Although endoscopic sinus surgery has been proven to improve quality of life outcomes in adult CRS, it should be only considered in the pediatric CRS after failure of adenoidectomy. Pediatric and adult CRS are different in many aspects, including immunopathogenesis and management. Investigations should be considered in specific cases. After failure of medical treatments, endoscopic sinus surgery is recommended for adults, while adenoidectomy is primarily considered for children.

Chronic rhinosinusitis in patients with cystic fibrosis-Current management and new treatments

OBJECTIVES

The purpose of this article is to provide a state-of-the-art review of the literature and summarize the latest publications on medical and surgical treatment of cystic fibrosis (CF) chronic rhinosinusitis (CRS), with an emphasis on describing recent advancements in cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies.

METHODS

A comprehensive literature review was conducted utilizing the PubMed database with search phrases detailed within the body of the article. Abstracts were reviewed to include publications detailing medical, surgical, and CFTR modulating therapies for CF CRS. Findings from studies not previously reviewed and publications regarding CFTR modulators were emphasized.

RESULTS

No clear guidelines for treatment of CF CRS are available. Nasal saline rinses, topical steroids, topical antibiotics, and topical dornase alfa are reported medical therapies. Ivacaftor has some sinonasal symptomatic benefit. A new triple therapy CFTR modulator, elexacaftor/tezacaftor/ivacaftor, is capable of treating 90% of patients with CF and has shown the greatest FEV1 improvement of any CFTR modulator yet. There is no clear consensus on surgical indications or technique, though aggressive surgery in recalcitrant disease has shown some symptomatic benefit. Endoscopic sinus surgery after lung transplantation may benefit some patients in whom the sinuses serve as a reservoir for recurrent pulmonary infections by decreasing rates of bronchiolitis obliterans syndrome and improving 5 year survival.

CONCLUSION

As lifespan increases for patients with CF, further investigation into medical therapy, CFTR modulator sinonasal outcomes, and surgical technique and outcomes for CF CRS is needed.

LEVEL OF EVIDENCE

5.

[Balloon sinuplasty in children - Russian first experience]

AIM

To evaluate and compare the clinical outcome and impact of balloon sinuplasty and functional endoscopic sinus surgery (FESS) on the quality of life of pediatric patients and adolescents suffering from chronic rhinosinusitis (CRS).

MATERIAL AND METHODS

A retrospective study was performed of 47 children with failed medical therapy, who were scheduled for surgery. The first one pediatric balloon sinuplasty was performed by Ilya Zyabkin in Filatov Children's City Hospital on the 30-th of August 2012.They underwent treatment by balloon sinuplasty of selected sinuses in 553% (n=26) cases and hybrid FESS with BSP - in 44.7% (n=21). Data were collected, including perioperative CT Lund-Mackay score and SN-5 quality of life findings.

RESULTS

Compared with preoperative values, Lund-Mackay scores were significantly lower at 1 year (p<0.05) in 92,3% (n=12) patients after surgery. Moreover, balloon sinuplasty improved sinusrelated quality of life score in 93.3% (n=42) patients for up to 1 year after operation (p<0.05).

CONCLUSION

Balloon sinuplasty showed a clinical curative effect in the treatment of children and adolescents with refractory CRS, and was relatively safe by itself. BSP allows to postpone, if necessary, FESS or avoid circular mucosal trauma and infundibulotomy in hybrid FESS with balloon sinuplasty technique.

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 and Analysis of Research Trends in Surgical Treatment of Pediatric Chronic Sinusitis

Background

Chronic sinusitis is a common otolaryngologic complaint with a significant impact on patients’ quality of life. There is current debate and differences in quality of evidence regarding the best surgical management approach to pediatric chronic sinusitis.

Objective

To investigate changes in publishing trends over time in surgical management of pediatric chronic sinusitis.

Methods

A systematic literature review was conducted in January 2019 using Embase, PubMed, and Web of Science, of all articles that included surgical treatments for pediatric chronic sinusitis. Publications were grouped into 3 time periods: pre-1998, 1999–2008, and 2009–2018. In addition, a subgroup of publications pertaining to endoscopic sinus surgery, balloon sinuplasty, and adenoidectomy were grouped into 2-year periods since 1988 to compare the number of publications on each topic and to examine overall trends.

Results

A total of 327 abstracts were included in the data collection and analysis. There was an overall significant increase in total number of publications ( P < .0001), total number of authors ( P = .001), and comparison studies ( P = .003) from pre-1989 to 2018. Relative number of prospective studies, systemic review, and case studies/expert opinions have not significantly increased over time when comparing decades ( P > .05). Among the surgery types, functional endoscopic sinus surgery has the most amount of publications regardless of year despite a statistically significant increase in publications pertaining to balloon sinuplasty in the pediatric literature from 1999–2008 to 2009–2018 ( P = .001).

Conclusions

Studies on pediatric chronic sinusitis have increased significantly during each of the last 2 decades with an increase in the concomitant number of authors and comparison studies. Although most publications are still Level C or D evidence, there has been a nonsignificant increase in Level A evidence in the past decade. Endoscopic sinus surgery still remains the most studied procedure despite the recent increase in publications on balloon sinuplasty.

Innovations in Endonasal Sinus Surgery in Children

Although there have been many advances in new tools and procedures for endonasal sinus surgery in children, the management and care for pediatric chronic rhinosinusitis has remained relatively unchanged. However, there have been advances in skull base surgery and tumor removal and new knowledge about perioperative concerns in children. This article discusses the role and risks of endoscopic sinus surgery, the use of balloon sinuplasty in children, management of complicated rhinosinusitis, and advances in skull base tumors and choanal atresia repair.

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.

Endoscopic sinus surgery for pediatric patients: Prognostic factors related to revision surgery

OBJECTIVES

In the past two decades, endoscopic sinus surgery (ESS) has been performed frequently in children with medically recalcitrant chronic rhinosinusitis (CRS). However, surgical success rates vary according to age. The causes of failure and prognostic factors for revision ESS remain unclear. The aims of the present study were to evaluate prognostic factors related to revision surgery after ESS, and to determine the most optimal timing for surgery in the pediatric population.

METHODS

This was a retrospective review in a tertiary medical center. Children who underwent ESS for CRS between 2004 and 2017 were enrolled. Demographics, sinonasal examination findings, previous operation history, laboratory data, comorbidities, and computed tomography (CT) results were collected from medical records. Prognostic factors for revision surgery were analyzed.

RESULTS

A total of 188 pediatric patients were enrolled in this study. Twenty-four patients (12.8%) required revision surgery. Multivariate logistic regression analysis identified patients with nasal allergy (OR = 6.258; P = .010) and higher Lund-Mackay score on preoperative sinus CT (OR = 1.658; P = .043) had worse outcomes, while older age was a positive prognostic factor (OR = 0.702; P = .018). A cut-off point of 15.68 years of age and mean Lund-Mackay score of 10.5 showed the best predictive power for revision surgery.

CONCLUSION

Because ESS is performed with increasing frequency in children, knowledge of prognostic factors for revision surgery is important. In this study, patients with younger age, nasal allergy, and higher Lund-Mackay score on preoperative sinus CT had worse outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1051-1055, 2020.

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.

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.

Chronic Rhinosinusitis in Children

Purpose of review

Pediatric chronic rhinosinusitis (CRS) is a common condition that is often misdiagnosed and can be challenging to treat. This review aims to 1) Review definitions, presentation, complications, and management of CRS in children. 2) Highlight the paucity of evidence in the management of pediatric CRS.

Recent findings

There are few studies supporting the usual recommended medical therapy for pediatric CRS (antibiotics, nasal saline irrigations, intranasal steroid). Adenoidectomy remains a mainstay of surgical treatment, but recent evidence demonstrates the utility of balloon sinuplasty and functional endoscopic sinus surgery (FESS) for patients who fail adenoidectomy alone.

Summary

Pediatric CRS is distinct from ARS and adult CRS. It is a common problem that is poorly studied, in part because of significant symptomatic overlap with related conditions. Recent evidence supports the use of surgical treatment in children who fail medical management. However, further outcome studies are needed to better evaluate the effectiveness of current medical and surgical management protocols.

Update on pediatric sinus surgery: indications and outcomes

PURPOSE OF REVIEW

To review the recent literature of pediatric endoscopic sinus surgery (ESS).

RECENT FINDINGS

Sinus balloon catheter dilation is an important addition to the surgical treatment tools for pediatric chronic rhinosinusitis (PCRS). ESS is a safe and effective therapeutic modality for uncomplicated PCRS. For PCRS complicated by comorbidities including cystic fibrosis and primary ciliary dyskinesia, ESS and adjuvant medical therapy confers significant sinus, pulmonary, and quality of life benefits to pediatric patients.

SUMMARY

ESS is a safe and effective treatment modality in the management of pediatric acute and chronic sinus disorders.

Sinus and Upper Airway Surgery in Children

PURPOSE OF REVIEW

Chronic sinus and upper airway disease in children is a common health problem encountered every day. Its pathophysiology is complicated which leads to different treatment options and approaches. We seek to review the current literature and evidence to surgical treatments.

RECENT FINDINGS

Medical treatment with antibiotics and topical nasal sprays continues to be the first-line treatment. Surgical interventions include adenoidectomy, balloon catheter sinuplasty (BCS), and endoscopic sinus surgery (ESS). Each modality has proven to be safe; however, its effectiveness is widely variable. More research with higher level of evidence is needed to help in choosing the right surgical treatment with optimal benefit.

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.

Practice patterns in pediatric chronic rhinosinusitis: A survey of the American Rhinologic Society

BACKGROUND

The management of pediatric chronic rhinosinusitis (PCRS) is evolving.

OBJECTIVE

To assess current practice patterns of members of the American Rhinologic Society (ARS) in managing PCRS.

METHODS

A 27-item Web-based survey on treatment of PCRS was electronically distributed to the ARS membership.

RESULTS

The survey was completed by 67 members, 40% of whom had completed a rhinology fellowship. The most frequently used medical therapies as part of initial treatment for PCRS were nasal saline solution irrigation, (90%), topical nasal steroids (93%), oral antibiotics (52%), and oral steroids (20%). For initial surgical therapy, 90% performed adenoidectomy; in addition, 31% also performed sinus lavage, 17% performed balloon catheter dilation (BCD), and 17% performed endoscopic sinus surgery (ESS). Sixty percent performed adenoidectomy before obtaining computed tomography imaging. When initial surgical treatment failed, 85% performed traditional ESS. In patients with pansinusitis, 50% of the respondents performed frontal sinusotomy and 70% performed sphenoidotomy. BCD was not frequently used; overall, 66% never or rarely used it, 20% sometimes used it, 12% usually used it, and 3% always or almost always used BCD.

CONCLUSIONS

Most aspects of PCRS management among ARS members were aligned with published consensus statements. Adenoidectomy was almost always included as part of first-line surgical treatment but was also combined with adjunctive surgical procedures with moderate frequency. ESS was performed by a minority of rhinologists as a primary procedure for medically refractory PCRS but was favored when previous surgery failed. BCD was uncommonly used in PCRS.

Problem-based learning discussion: Medical treatment of pediatric chronic rhinosinusitis

This problem-based learning case focused on the approach to evaluation and management of a 5-year old girl who was "always sick" with sinus infections. The discussion unfolds in a "real life" scenario, i.e., based on information available to the clinician initially and after the acquisition of laboratory data, and, ultimately, after sinus surgery. Emphasis is placed on the differential diagnosis of the patient's symptoms, discussion of the initial management strategy for chronic rhinosinusitis (CRS), evolution from acute rhinosinusitis to CRS, the prevalence of and differential diagnosis of nasal polyps in children, treatment considerations specific for CRS with nasal polyps, the significance of Pseudomonas aeruginosa sinus infection, the significance of an abnormal sweat chloride test in a young child with nasal polyposis, special considerations in children with CRS who have cystic fibrosis, treatment considerations after endoscopic sinus surgery, and, finally, prognostic factors that impact the outcomes of endoscopic sinus surgery. This problem-based learning case highlights many facets of managing refractory CRS in children.

Pediatric Rhinosinusitis

Rhinosinusitis, is defined as an inflammation of the paranasal and nasal sinus mucosae. Chronic rhinosinusitis (CRS)is a common problem in the pediatric age group and the diagnosis and treatment are challenging due to the chronicity and similarity of symptoms with allergic rhinitis and adenoid hypertrophy. Although it is less common than acute rhinosinusitis, CRS is becoming more frequent and significantly affects the quality of life in children and can substantially impair daily function. CRS is characterized by sinus symptoms lasting more than 3 months despite medical therapy. Many factors are involved in the pathogenesis of this disease and include a primary insult with a virus followed bybacterial infection and mucosal inflammation, along with predisposition to allergies. The standard treatment of pediatricacute bacterial rhinosinusitis (ABRS) is nasal irrigation and antibiotic use. Medical treatment of pediatric CRS includes avoidance of allergens in allergic patients (environmental or food) and therapy with nasal irrigation, nasal corticosteroids sprays, nasal decongestants, and antibiotics directed at the most common sinonasalorganisms (Haemophilusinfluenzae, Streptococcus pneumoniae, and Moraxella catarrhalis). Surgical therapy is rarely needed after appropriate medical therapy. Referral to an otolaryngologist and allergy specialist is recommended in case of failure of medical treatment.

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.

Clinical consensus statement: pediatric chronic rhinosinusitis

OBJECTIVE

To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS).

METHODS

A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus.

RESULTS

After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty.

CONCLUSION

Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Hepatocyte Growth Factor Gene-Modified Mesenchymal Stem Cells Augment Sinonasal Wound Healing

This study was designed to investigate the effects of hepatocyte growth factor (HGF) transgenic mesenchymal stem cells (HGF-MSCs) on wound healing in the sinonasal mucosa and nasal epithelial cells (NECs). We also sought to determine whether HGF-MSCs and MSCs can migrate into the injured mucosa and differentiate into ciliated cells. Human HGF-overexpressing umbilical cord MSCs (hHGF-UCMSCs) were established, and upregulation of hHGF expression was confirmed by real-time PCR (RT-PCR) and enzyme-linked immunosorbant assay (ELISA). To investigate the paracrine effect of human MSCs (hMSCs) on nasal epithelial repair, hMSC- and HGF-MSC-conditioned media (CM) were used in NEC proliferation assays and in an in vitro scratch-wound repair model. The in vivo sinonasal wound-healing model was established, and all enrolled rabbits were randomly assigned to four groups: the GFP-MSC group, the HGF-MSC group, the Ad-HGF group, and the surgery control group. The average decreased diameter was recorded, and the medial wall of the maxillary sinus was removed for histological analysis and scanning electron microscopy. Collagen deposition in the wound tissue was detected via Masson trichrome (M&T) staining. The distribution of MSCs and HGF-MSCs was observed by immunofluorescence. MSCs improved nasal wound healing both in vivo and in vitro. HGF overexpression in MSCs augmented the curative effects. Reduced collagen deposition and transforming growth factor beta1 (TGF-β1) expression were detected in the HGF-MSC group compared with the MSC-, Ad-HGF-, and phosphate-buffered saline-treated groups based on M&T staining and ELISA. The enhanced therapeutic effects of HGF-MSCs were accompanied by decreased level of the fibrogenic cytokine TGF-β1. In addition, both HGF-MSCs and MSCs can migrate to the injured mucosa and epithelial layer.

Inter-hospital variation in the frequency of sinus surgery in children with cystic fibrosis

BACKGROUND

Chronic rhinosinusitis and nasal polyposis are common conditions in cystic fibrosis (CF). Approximately 2-3% of pediatric CF patients per year have sinus disease requiring surgery. The purpose of this study was to evaluate the variation of sinus surgery rates in pediatric CF patients across multiple US pediatric hospitals.

METHODS

The Pediatric Health Information System (PHIS) compiles inpatient administrative data from 42 pediatric hospitals. We conducted a retrospective analysis of PHIS for the period January 1, 2008 to January 1, 2011 to evaluate frequency of sinus surgery at each hospital. We identified CF patients and sinus surgery during inpatient encounters using ICD-9 codes. Demographic data and data for each hospital on hospital size, number of pediatric otolaryngologists, average FEV1, and percentage of patients meeting minimum care guidelines were collected. Twenty-nine hospitals were included in analysis using mixed-effects logistic regression models for occurrence of sinus surgery.

RESULTS

We identified 5,194 CF patients, accounting for 18,788 unique encounters among 29 hospitals. 880 patients underwent 1,397 sinus operations. Total number of CF patients at each institution ranged from 39 to 364 and total number of sinus surgeries ranged from 4 to 205, over the 3-year period. Variation in the rate of sinus surgery with hospital encounter was observed (1-24%). Hospital-average lung function (P = 0.56), number of otolaryngologists (P = 0.65) were not found to be predictors of sinus surgery. The size of the CF center (P = 0.01), hospital size (P = 0.05), and age at admission (P ≤ 0.0001) were associated with an increased frequency of sinus surgery. However, with multivariable analysis, only size of the CF center and age of admission remained statistically significant predictors of surgery with admission.

CONCLUSIONS

There is large variation in the incidence of sinus surgery for CF in 29 of the largest freestanding pediatric hospitals. This study highlights remarkable variation in clinical practice and underscores the need for further research into the indications and benefits of sinus surgery in pediatric patients with CF. Pediatr Pulmonol. 2015; 50:231-235. © 2014 Wiley Periodicals, Inc.

Management of the upper airway in cystic fibrosis

PURPOSE OF REVIEW

Upper airway disease engenders significant morbidity for patients with cystic fibrosis and is increasingly recognized as having a much greater role in pulmonary outcomes and quality of life than originally believed. Widespread disparate therapeutic strategies for cystic fibrosis chronic rhinosinusitis underscore the absence of a standardized treatment paradigm. This review outlines the most recent evidence-based trends in the management of upper airway disease in cystic fibrosis.

RECENT FINDINGS

The unified airway theory proposes that the sinuses are a focus of initial bacterial colonization which seeds the lower airway and may play a large role in maintaining lung infections. Mounting evidence suggests more aggressive treatment of the sinuses may confer significant improvement in pulmonary disease and quality of life outcomes in cystic fibrosis patients. However, there is a lack of high-level evidence regarding medical and surgical management of cystic fibrosis chronic rhinosinusitis that makes generalizations difficult.

SUMMARY

Well designed clinical trials with long-term follow-up concerning medical and surgical interventions for cystic fibrosis sinus disease are required to establish standardized treatment protocols, but increased interest in the sinuses as a bacterial reservoir for pulmonary infections has generated considerable attention.