Cr sw np in children.compressed

Christos Georgalas DLO FRCS(ORL-HNS) Academic Medical Centre, Amsterdam

Pediatric Rhinosinusitis: when to operate?

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”

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EPOS 2012 POSITION PAPER

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

w Center for Applied Genomics, Children’s Hospital of Philadelphia, PA, USA

x Division of Otorhinolaryngological Clinic at Clinical Hospital of the University of São Paulo, Brazil

y Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

z Department of Surgery-Otolaryngology, Head and Neck Surgery, Adelaide and Flinders Universities, The Queen Elizabeth Hospital, Woodville, South Australia, Australia

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.

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.


Chronic sinusitis in childrenchildren 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

Innate ImmunityMucus → cystic fibrosis

→ other

Cilia → 1o dyskinesia

→ 2o dyskinesia

Other factors:

Interferon neutrophils

Lysozyme defensins macrophages

Mucus abnormalities

Cystic fibrosis- heterozygotes overrepresented in CRS population

Young’s syndrome- ? Cilia abnormal

? Others- no evidence for milk allergy

Ciliary Dyskinesia

Primary

Secondary – Infection –Pollution –allergy

SECONDARY IMMUNODEFICIENCY

Malnutrition - Fe ?, Zn, vit A

Infection - viral,bacterial,mycobacterial

Iatrogenic - steroids, immunosuppressants,phenytoin, antibiotics

Hyposplenism- CHO coated bacteria, tuftsin

Metabolic disorders- diabetes

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

Evidence based treatment for Children with chronic

Rhinosinusitis


220

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.

8.6.2. Evidence based management for children with Chronic Rhinosinusitis 8.6.2.1. DiagnosisSymptoms present equal or 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;

± cough;

Additional diagnostic information

questions on allergy should be added and, if positive,

allergy testing should be performed.

ENT examination, endoscopy if available;

Not recommended: plain x-ray or CT-scan (unless surgery is

considered)

8.6.2.2. TreatmentFor treatment evidence and recommendations for Chronic

Rhinosinusitis in children see Table 8.7.

This management scheme is for young children. Older children

(in the age that adenoids are not considered important) can be

treated as adults. See Figure 8.7.

Acute exacerbations of CRS should be treated like acute

rhinosinusitis.

Treatment should be based on severity of symptoms.

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

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.

219

Supplement 23

8.5.4.2. Treatment For treatment evidence and recommendations for CRSwNP see

Table 8.5 and 8.6.

Treatment should be based on severity of symptoms

Decide on severity of symptomatology using VAS and

endoscope. See Figure 8.6.

8.6. Evidence based management for children with Chronic Rhinosinusitis

8.6.1. Definitions8.6.1.1. Chronic Rhinosinusitis (with or without NP) in children is defined as:presence of two or more symptoms one of which should be

either nasal blockage/obstruction/congestion or nasal discharge

(anterior/posterior nasal drip):

± facial pain/pressure;

± cough;

for ≥12 weeks;

with validation by telephone or interview.

Questions on allergic symptoms (i.e. sneezing, watery

rhinorrhea, nasal itching, and itchy watery eyes) should be

included.

Chronic rhinosinusitis with nasal polyps (CRSwNP): Chronic

rhinosinusitis as defined above and bilateral, endoscopically

visualised polyps in middle meatus.

Figure 8.7. Management scheme for young children with chronic rhinosinusitis.

Irritant AvoidanceE.g. cigarette smoke, chlorine, sulphur dioxide, NO etc.

Decreases symptoms

Consider douching

Nasal neglect

The same girl 2 months later

•Rinsing with normal saline

• Training in Nasal Breathing

• Topical Steroids after rinsing

• 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?

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

Absolute and relative indication for surgery:

14 year old girl with mucocele 14 year old girl with antrochoanal polyp

10 year old girl pre- and postoperative

Preoperative

Postoperative

ORIGINAL CONTRIBUTION

Long-term results of functional endoscopic sinus surgery in children with chronic rhinosinusitis with nasal polyps*

Summary Background: Chronic rhinosinusitis with nasal polyps (CRSwNP) is rare in children and has a major impact on Quality of Life (QoL).

Functional endoscopic sinus surgery (FESS) has proven to be an effective treatment, but it is still unclear what long-term outco-

mes are in children with CRSwNP. The objective of this study was to assess long-term results of FESS in children with CRSwNP.

Methodology: We performed a combined prospective and retrospective study. A QoL questionnaire was send to all children with

CRSwNP who received FESS between the year 2000-2010. Almost half of these children also filled in this questionnaire preoperati-

vely.

Results: Forty-four Children underwent FESS. From 18 patients, we also prospectively collected preoperative QoL questionnaires.

The mean follow-up period was 4.0 years (± 2.9). The mean age at surgery was 13 years (±2.9). Of these children, 9 had CF and 10

children asthma. R-SOM scores showed a significant improvement both in general symptoms as well as several different domains

when comparing pre- and postoperative questionnaires. Only 5 of 44 patients needed a subsequent intervention. In children with

CF this was 3 of 9.

Conclusion: This study demonstrates that long-term results of FESS in children with CRSwNP are good. QoL has improved signifi-

cantly, especially in nasal symptoms, showing that FESS is a good treatment in children with CRSwNP. Furthermore, even children

with CF show good results.

Key words: endoscopic sinus surgery, children, nose, paranasal sinuses, quality of life, nasal polyps

Marjolein E. Cornet, Christos Georgalas, Susanne M. Reinartz, Wytske J. Fokkens

Department of Otorhinolaryngology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands

Rhinology 51: 328-334, 2013

DOI:10.4193/Rhino13.079

*Received for publication:

May 30, 2013

Accepted: July 14, 2013

328

IntroductionCRS with nasal polyps (CRSwNP) is rare in children and has a

major impact on the Quality of Life (QoL) of paediatric patients

and their parents (1). Because of the physical and psychological

consequences of CRSwNP in children, a thorough treatment is

needed.

In adults with CRSwNP functional endoscopic sinus surgery

(FESS) is considered to be the treatment of choice when maxi-

mum medical treatment fails (2,3). Several studies have shown

that most patients benefit from this approach and that there is

a revision rate of 20% (4,5). In children with CRSwNP on the other

hand, surgical success rates are not known.

Until now there are some studies published describing the

results of FESS in children, but they mainly focus on the results

in children with CRS without nasal polyps (CRSsNP) and they

report contradictory outcomes (6-13). A meta-analysis performed

by Hebert and Bent showed positive outcome in 88.7% of 832

children with CRSsNP who underwent FESS with an average fol-

low up of 3.7 years (8). Also several studies indicate that there is

significant improvement in QoL after FESS in children with CRS-

sNP (6,11). Besides, overall safety of FESS in children with CRSsNP

has been established in some case series (14,15).

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

Questionnaires1. 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


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)

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


Long term improvement of nasal symptoms after FESS by self assessment.

worsea little worsethe samebettermuch better


Post-operative Nasal RSOM score

GroupMean nasal

R-SOM scoreLevel 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 groupNPCF

Prospective comparison

• 18 children

• Pre-operative RSOM scores

• Collected during the years

• Separate analysis comparing pre- and postoperative RSOM scores.

Prospective comparison different domains of RSOM

Pre-opPost-op

Pre-opPost-op

Pre-opPost-op

*

* *

* = p<0.05

Prospective Nasal specific RSOM scores

Pre-opPost-op

* = p<0.05

*

*

* *

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

• .pdf

41

Rhinology and Skull Base SurgeryFrom the Lab to the Operating Room – An Evidence-based Approach

Christos GeorgalasWytske Fokkens

DVD included

Cr sw np in children.compressed

Health & Medicine

Transcript of Cr sw np in children.compressed