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Cr sw np in children.compressed
1. Christos Georgalas DLO FRCS(ORL-HNS)
Academic Medical Centre, Amsterdam
Pediatric Rhinosinusitis:
when to operate?
2. When do we operate a child
with rhinosinusitis?
• What does rhinosinusitis
mean in children and
how do we recognize it?
• Therapeutic options
• Absolute and relative
indications for surgery
• The role of “nasal
neglect”
4. European Position Paper on Rhinosinusitis and Nasal Polyps
2012
Wytske J. Fokkens, chair a
, Valerie J. Lund, co-chair b
, Joachim Mullol, co-chair c
,
Claus Bachert, co-chair d
, Isam Alobid c
, Fuad Baroody e
, Noam Cohen f,
Anders
Cervin g
, Richard Douglas h
, Philippe Gevaert d
, Christos Georgalas a
, Herman
Goossens i
, Richard Harvey j
, Peter Hellings k
, Claire Hopkins l
, Nick Jones m
,
Guy Joos n
, Livije Kalogjera o
, Bob Kern p
, Marek Kowalski q
, David Price r
, Herbert
Riechelmann s
, Rodney Schlosser t
, Brent Senior u
, Mike Thomas v
, Elina Toskala
w
, Richard Voegels x
, De Yun Wang y
, Peter John Wormald z
Rhinology supplement 23 :
1-299, 2012
a Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, the Netherlands
b Royal National Throat, Nose and Ear Hospital, London, United Kingdom
c Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic – IDIBAPS, Barcelona, Catalonia, Spain
d Upper Airway Research Laboratory, Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
e Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medical Center, and the Pritzker School of Medicine, University of Chicago,
Chicago, IL, USA
f Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, PA, USA
g Department of Otorhinolaryngology, Head and Neck Surgery, Lund University, Helsingborg Hospital, Helsingborg, Sweden
h Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
i Department of Microbiology, University Hospital Antwerp, Edegem, Belgium
j Rhinology and Skull Base Surgery, Department of Otolaryngology/Skull Base Surgery, St Vincents Hospital, University of New South Wales & Macquarie University, Sydney,
Australia
k Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven Belgium
l ENT Department, Guy’s and St Thomas’Hospital, London, United Kingdom
m Department of Otorhinolaryngology, Head and Neck Surgery, Queens Medical Centre, Nottingham, United Kingdom
n Department of Respiratory Medicine, Ghent University, Gent, Belgium
o Department of Otorhinolaryngology/Head and Neck Surgery, Zagreb School of Medicine, University Hospital“Sestre milosrdnice”, Zagreb, Croatia
p Department of Otolaryngology-Head and Neck Surgery Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
q Department of Immunology, Rheumatology and Allergy, Medical University of Łódź, Łódź, Poland
r Academic Centre of Primary Care, University of Aberdeen, Foresterhill Health Centre, United Kingdom
s Department of Otorhinolaryngology, Medicial University Innsbruck, Innbruck, Austria
t Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
u Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology, University of North Carolina at Chapel Hill, NC, USA
v Primary Care Research, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, Southampton, United Kingdom
5. Rhinosinusitis: Clinical
Definition
The definition of Rhinosinusitis:
Inflammation of the nasal airway and sinus which is characterized by two symptoms, nasal obstruction or rhinorrhea (posterior or
anterior)
± Pain/ Pressure behind the face
± hypo- or anosmia
AND/ OR
Endoscopy
– Polyposis and/ or
– Mucopuruleny discharge primarily in middle meatus and/or
– Oedema / obstruction of mucosa at middle meatus
AND/ OR
CT
– Changes of mucosa in paranasal sinuses and osteomeatal complex
Fokkens W, Lund V, Mullol J, on behalf of the EP3OS group. Rhinology. 2012;45(suppl 20):1-136.
At: http://www.rhinologyjournal.com.
6. Rhinosinusitis: severity and
duration
Severity
• Mild = VAS 0-3
• Moderate = VAS 3-7
• Severe = VAS 7-10
Duration
• Acute
– <12 weeks
– Complete resolution of
symptoms
• Chronic
– >12 weeks
– Not complete resolution
of symptoms
– With or withoiut
exacerbations
Not at all
bothersome
Most
bothersome
imaginable
10 cm
How bothersome are the symptoms of
Rhinosinusitis?
VAS = visual analogue scale.
Fokkens W, Lund V, Mullol J, on behalf of the EP3OS group. Rhinology. 2012;45(suppl 20):1-136.
At: http://www.rhinologyjournal.com.
7. Chronic sinusitis in children
children adults
Immune system
Immature : incomplete reaction to
some antigens (IgG2, IgA)
Mature, some exceptions
Adenoids Present, often inter-dependent Normally absent
History
Commonly improves (after the age
of 6-8 years)
Does not improve by itself after a
certain age.
Histology Mainly neutrophils Mainly eosinophils
Endoscopy Rarely polypoid, except of CF Frequent polypoid
Associated
disorder
CF, immunodeficiencies, ciliary
dysmotility
Rarely
CT More diffuse, often pansinusitis
Frontal and sphenoid more rarely
affected
13. SECONDARY
IMMUNODEFICIENCY
Malnutrition -
Fe ?, Zn, vit A
Infection -
viral,bacterial,mycobacte
rial
Iatrogenic -
steroids,
immunosuppressants,phe
nytoin, antibiotics
Hyposplenism-
CHO coated bacteria,
tuftsin
Metabolic
disorders- diabetes
14. Diagnosis of Children With
Chronic Rhinosinusitis
Symptoms present longer than 12 weeks
– Two or more symptoms, one of which should be
either nasal blockage/obstruction/congestion or
nasal discharge (anterior/posterior nasal drip):
• ± Facial pain/pressure
• ± Reduction/loss of smell
Additional diagnostic information
– Questions on allergy should be added and, if
positive, allergy testing should be performed
– Other predisposing factors should be
considered: immune deficiency (innate,
acquired, gastro-oesophageal reflux disease
Imaging
– Plain x-ray not recommended
– CT scan is also not recommended unless
additional problems (very severe disease,
immunocompromised patients, signs of
complications) are present
– (Note : MRI can also be used)
Treatment should be based on severity of
symptoms
Examination (if applicable)
– Nasal: swelling redness, pus
– Oral: posterior discharge
– Exclude dental infection
– ENT examination should include nasal endoscopy
15. Evidence based treatment for
Children with chronic
Rhinosinusitis
Fokkens W, Lund V, Mullol J, on behalf of the EP3OS group. Rhinology. 2012;45(suppl 20):1-136.
At: http://www.rhinologyjournal.com.
European Position Paper on Rhinosinusitis and Nasal Polyps 2012
Chronic Rhinosinusitis without nasal polyps (CRSsNP): Chronic
Rhinosinusitis as defined above and no visible polyps in middle
meatus, if necessary following decongestant.
This definition accepts that there is a spectrum of disease in CRS
which includes polypoid change in the sinuses and/or middle
meatus but excludes those with polypoid disease presenting in
the nasal cavity to avoid overlap.
ENT examination, endoscopy if available;
Not recommended: plain x-ray or CT-scan (unless surgery is
considered)
8.6.2.2. Treatment
For treatment evidence and recommendations for Chronic
Table 8.7. Treatment evidence and recommendations for children with chronic rhinosinusitis.
Therapy Level Grade of recommendation Relevance
nasal saline irrigation Ia A yes
therapy for gastro-oesophageal reflux III C no
topical corticosteroid IV D yes
oral antibiotic long term no data D unclear
oral antibiotic short term <4 weeks Ib(-)#
A(-)* no
intravenous antibiotics III(-)##
C(-) ** no
#
Ib (-): Ib study with a negative outcome
*
A(-): grade A recommendation not to use
##
III(-): level III study with a negative outcome
**
C(-): grade C recommendation not to use
16. Treatment Scheme for Children
With Chronic Rhinosinusitis
Fokkens W, Lund V, Mullol J, on behalf of the EP3OS group. Rhinology. 2012;45(suppl 20):1.
At: http://www.rhinologyjournal.com.
Supplement 23
8.5.4.2. Treatment
For treatment evidence and recommendations for CRSwNP see
Table 8.5 and 8.6.
8.6. Evidence based management for
children with Chronic Rhinosinusitis
Figure 8.7. Management scheme for young children with chronic rhinosinusitis.
19. The same girl 2 months later
•Rinsing with
normal saline
• Training in Nasal
Breathing
• Topical Steroids
after rinsing
20. • Very rarely !!!
• Relative indications:
– > 8 years of age
– significant QOL impairment ζωής
– following maximal medical treatment
– be aware of nasal neglect
• Always sandwich treatment
medical
medical
surgical
When do we operate a child
with rhinosinusitis?
21. Absolute and relative
indication
• Complete nasal obstruction (eg CF due to massive polyposis)
• Inverted papilloma/neoplasias
• Orbital abscess
• Endocranial complications
• Antrochoanal polyp
• Mucoceles/mucopyoceles
• Fungal rhinosinusitis
30. Pediatric FESS operations –
our experience
• Inclusion: 44 children with CRSwNP (<18 years)
• Undergoing FESS between 2005-2010 in the
AMC
• Exclusion: antrochoanal polyps, inverted
papilloma
1) Retrospective analysis using postal questionnaires
2) Prospective analysis: using pre-operative identical
questionnaires collected during the years
Cornet M, Reinartz S, Fokkens W, Georgalas C: Long-term results of functional endoscopic
sinus surgery in children with chronic rhinosinusitis with nasal polyps.: Rhinology , 2013
31. Questionnaires
1. How are your nasal symptoms now compared to before surgery?
(5 point scale)
2. R-SOM 31 (= disease specific QoL questionnaire)
- 6 nasal symptoms, 25 other symptoms (non-nasal, sleep-
disorders, emotional, practical, general)
- score 1-5
3. SF-36 (=general QoL questionnaire)
- 36 items, 8 dimensions
- score 0-100
Cornet M, Reinartz S, Fokkens W, Georgalas C: Long-term results of functional endoscopic
sinus surgery in children with chronic rhinosinusitis with nasal polyps.: Rhinology , 2013
32. Results
• Patients
- response rate: 82%
- 36 children (16 boys and 20 girls)
- mean age: 13 years old (± 2.9)
- 27 children without CF (sweattest/DNA)
- 9 children with CF
• Follow-up:
- total group: 4.0 yrs (1-12 yrs)
- NP: 3.0 yrs (1-9 yrs)
- CF: 6.0 yrs (3-12 yrs)
33. Results
• Predisposing factors:
• No complications
• Revision surgery:
- total: 5 children (14%)
- CF: 3 (33%)
- NP: 2 (7%)
Factors Percentage (%)
Asthma 28
Allergy 25
CF 25
Aspirine intolerance 3
Smoking 6
Cornet M, Reinartz S, Fokkens W, Georgalas C: Long-term results of functional endoscopic
sinus surgery in children with chronic rhinosinusitis with nasal polyps.: Rhinology , 2013
34. Long term improvement of nasal symptoms
after FESS by self assessment.
worse
a little worse
the same
better
much better
Cornet M, Reinartz S, Fokkens W, Georgalas C: Long-term results of functional endoscopic
sinus surgery in children with chronic rhinosinusitis with nasal polyps.: Rhinology , 2013
35. Post-operative Nasal
RSOM score
Group
Mean nasal
R-SOM score
Level of complaints
All children
(n=36)
CF
(n=9)
NP
(n=27)
I 0 and 1 No or little 15 (41%) 5 (56%) 10 (37%)
II 2 Little to moderate 11 (31%) 2 (22%) 9 (33%)
III 3 Moderate to severe 9 (25%) 2 (22%) 7 (26%)
IV 4 and 5 Severe to extreme 1 (3%) 0 1 (4%)
Total group
NP
CF
36. Prospective
comparison
• 18 children
• Pre-operative RSOM scores
• Collected during the years
• Separate analysis comparing pre- and
postoperative RSOM scores.
39. Conclusions from
this study
• Most of the children with nasal polyps do
not have CF (only 9 out of 36)
• The results of FESS in children with
CRSwNP are very good.
• Children with CF do well after surgery,
although revision surgery is not uncommon.
Cornet M, Reinartz S, Fokkens W, Georgalas C: Long and short term outcomes of FESS in
children non-CF children with nasal polyps: Rhinology , 2013
40.
41. • .pdf
41
Rhinology and
Skull Base Surgery
From the Lab to the Operating Room – An Evidence-based Approach
Christos Georgalas
Wytske Fokkens
DVD included
