Endoscopic Sinus Surgery

When prolonged maximal medical therapy and adenoidectomy both fail to provide adequate relief in a child with at least 6 months of severe symptoms of chronic rhinosinusitis, the child may be a potential candidate for functional endoscopic sinus surgery (FESS).78,85 The Caldwell-Luc procedure is essentially contraindicated in young children due to the potential for damage to unerupted teeth.29,44 Indications for FESS in pediatric rhinosinusitis remain poorly defined and shrouded in controversies. The Consensus Meeting in Brussels defined their indications in the context of "absolute" and "possible" and are as follows.17

Absolute indications

Complete nasal obstruction in cystic fibrosis due to massive polyposis or medialization of the lateral nasal wall Antrochoanal polyp Intracranial complications Mucoceles and mucopyoceles Orbital abscess

Traumatic injury in the optic canal (decompression) Dacryocystorhinitis due to sinusitis resistant to appropriate medical management Fungal sinusitis Some meningoencephaloceles Some neoplasms

Possible indications

Chronic rhinosinusitis that persists despite optimal medical management, and after exclusion of systemic disease (optimal medical management includes 2 to 5 weeks of appropriate antibiotics and treatment of concomitant diseases)

Patients with cystic fibrosis and other systemic disorders are more likely to require surgery; thus, the indications for these children are unique. The details are beyond the scope of this chapter.

To evaluate the potential surgical candidate, coronal CT scans are necessary.44 The scans should be obtained while the child is still receiving treatment, yet nearing the completion ofat least 4 weeks of appropriate antibiotic therapy48 with concurrent treatment of associated conditions. This approach is necessary to minimize false-positive readings secondary to edema or untreated acute infection. Based on the scans, anatomic abnormalities and mucosal derangements identified in the paranasal sinuses help direct the surgical management plans.

The goals of FESS are to open the osteomeatal complex (OMC), eliminate ethmoid disease, and open the occluded natural sinus ostia when appropriate, in order to reestablish normal mucociliary clearance of the sinuses.86 Frontal and sphenoid sinuses are rarely entered in children.2 According to Lusk,78 dissection into the frontal recess is not performed unless there is extensive disease. Although the appropriate extent of surgery is controversial, a limited procedure is usually all that is necessary in pediatric rhinosinusitis patients. The maxillary and anterior ethmoid sinuses are the primary sites of disease in children; accordingly, the most common FESS procedures in these cases are anterior ethmoidectomy with removal of the entire unci-nate process, and possibly maxillary antrostomy with conservative enlargement of the natural ostium.2 Tissue biopsies and cultures are also obtained at surgery to guide continued medical therapy. Currently, gelatin film stenting of the ethmoid cavity is commonly performed to decrease synechiae and granulation tissue and is removed 2 weeks later under a general anesthesia for a second-look procedure. Few studies have addressed the role for the second-look procedure, although some investigators conclude that this procedure may not offer any advantages.87'88 Postoperatively, antibiotics and adjunctive medical management are commonly continued for at least 2 to 3 weeks.

Technically, endoscopic sinus surgery in children is potentially more challenging than in adults because of the relatively restricted anatomy. Because the nasosinal structures are still developing, preservation of unaffected structures is very important, and every attempt must be made to preserve normal mucosa. Also, concerns have been raised that surgery on the middle meatus could lead to possible disturbances of midface growth; thus far, no studies confirm these concerns.89 However, the risk-to-benefit ratio must always be carefully considered when embarking on pediatric FESS.

Various studies have reported good FESS outcomes in children, with success rates in the 80% range.2'66'78'90'91 A recent meta-analysis of pediatric FESS outcomes reports an 88.4% positive outcome with a 0.6% major complication rate in patients with chronic rhinosinusitis refractory to appropriate medical therapy.91 There are no standardized criteria for defining success, however, and more long-term prospective studies are needed for an effective assessment of the outcomes of this surgical approach in children.

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