50 Pediatric Sinusitis Revision Surgery

Rodney P. Lusk

There remain significant controversies regarding the diagnosis and management of pediatric sinusitis. Pediatric sinusitis is estimated to complicate ~5 to 10% of upper respiratory infections in early childhood.1,2 Because children average six to eight upper respiratory illnesses per year, this makes sinusitis a very common problem. In a quality of life assessment, Cunningham found that sinusitis had a more significant impact on children and their families than asthma, juvenile rheumatoid arthritis, and other chronic disorders.³

Pathophysiology of Chronic Rhinosinusitis

Age is clearly one of the most significant factors in pediatric sinusitis.⁴ Children have an immature immune system; therefore, they are more likely to develop upper respiratory tract viral infections and associated acute sinusitis. There is a strong association between sinusitis and respiratory viral infections.⁵ The viral infections cause mucosal edema and ciliary disfunction, which obstructs the ostium and increases the chance of establishing a bacterial infection of the sinuses.^6,7 Because the infundibulum is one of the narrowest drainage sites, it would be expected that the adjacent anterior ethmoid sinuses and maxillary sinuses would be the most likely to be involved with sinusitis. Viral infections are thought to cause significant ciliary dysfunction by decreasing the ciliary beat frequency⁸ or destroying the ciliary blanket.⁹ This sets up the appropriate conditions for a bacterial infection. As the ciliary function improves, the sinuses clear, and the infection resolves. This likely accounts for the high incidence of spontaneous resolution of acute sinusitis.

One of the more dramatic discoveries in recent years has been the presence of biofilms within the crypts of the adenoid tissue. Biofilms have been noted to cover as much as 50% of the surface in children with chronic sinusitis and 2% in children with obstructive sleep apnea.¹⁰ Biofilms have been noted in the crypts of chronically infected tonsils and adenoids.¹¹ The infected adenoid tissue may be the nidus for recurrent or chronic sinusitis. Biofilms are independent of the size of adenoid tissue and this may account for the improvement in symptoms of sinusitis when even small adenoids are removed.

The role of allergy in chronic sinusitis remains controversial. Rachelefsky^12–14 was the first to point out an association between allergic symptoms and sinusitis in children. It is said that bacterial sinusitis occurs often in patients with allergic rhinitis, but this correlation has not yet been confirmed. Huang¹⁵ studied this issue for 5 years in children with perennial allergic rhinitis (PAR) and seasonal allergic rhinitis (SAR) and found that the prevalence of sinusitis was significantly higher among patients with PAR than among those with SAR regardless of age or season. The patients with mold allergy PAR had a higher risk than those with nonmold allergies. Huang concluded that mold allergy is an important risk factor for sinusitis. There does appear to be a strong correlation between the allergic response and fungal infections in some patients. This is commonly referred to as allergic fungal sinusitis. The presentation of pediatric patients with allergic fungal sinusitis is different from that in adults, because children have more malleable bones and therefore a greater incidence of obvious abnormalities of the facial skeleton; also, the disease appears to be more unilateral.¹⁶ Computed tomography (CT) scans show an equal amount of bony erosion.^4,17

There are numerous studies that show that ~50% of children with sinusitis also have allergies, but the cause and effect has not been definitively demonstrated.^18–20 There has been a long-standing association between asthma, allergies, and chronic sinusitis. Riccio et al, for example, found that allergic asthmatic children with chronic rhinosinusitis have a typical T helper type 2 (Th2) cytokine pattern, but also that nonallergic asthmatic children share a similar pattern.²¹ They indicated that these findings suggest the existence of a common pathophysiological mechanism shared by upper and lower airways, which is consistent with the concept of unified airways disease, and has been increasingly recognized.²²

Without a doubt, there is increasing resistance of bacteria to antibiotics, especially Streptococcus pneumoniae, which has made medical management of chronic sinusitis more difficult.²³ The aerobic pathogens in pediatric chronic sinusitis include bacteria typical of acute sinusitis as well as organisms more characteristic of chronic disease. Chronic sinus infections, however, have a significant role of antibiotic-resistant aerobes, including multiply resistant S. pneumoniae.

Gastroesophageal reflux (GER) may be associated with chronic sinusitis.²⁴ The incidence of GER in children is not known, but Bothwell et al maintain that GER is present in a majority of children with chronic sinusitis.25 Chambers et al found that GER was the only reliable historical symptom that predicted a bad outcome in adults.²⁶ There is, however, conflicting information in the literature. Phipps et al found a higher incidence of GER (63%) in children with sinusitis, and 79% improved their symptoms with medical management of GER.²⁷ Suskind et al studied patients undergoing antireflux surgery and who had failed medical management.²⁸ In this severe but very young group of patients (<2 years old), only two patients (14%) had severe chronic sinusitis and otitis media. Yellon et al also found an incidence of sinusitis in only 10% of patients with biopsy-proven esophagitis.²⁹ These two studies may lead one to conclude that sinusitis is not associated with GER. Without out a doubt, however, there are some children with sinusitis and GER. Reflux may be intermittent and not identified with a 24-hour pH probe study. If present, it should be treated with proton pump inhibitors, which could prevent surgery.

Imaging

It is now clear that plain films do not adequately image pediatric sinuses.³⁰ In the acute setting we would expect these studies to be positive, and therefore of little use, because the infection is not limited to the nasal cavity.⁷ Gwaltney’s and Glasier et al’s work showed a high incidence of opacification of the anterior ethmoid and maxillary sinuses with acute rhinovirus infections.^7,31 The coronal CT is currently the imaging method of choice for assessing the status of the sinuses. In general, sinusitis is a clinical diagnosis, and radiographic imaging is not necessary in children to confirm the diagnosis. CT scans should be obtained when both the parents and the surgeon feel surgical intervention is warranted. The CT scan is used primarily to look for anatomical abnormalities that would increase the risk of surgical complications. It should be obtained after a trial of maximum medical management that includes broad-spectrum antibiotics and topical nasal steroid sprays for at least 4 weeks. It is important not to be trapped, by an anxious or frustrated parent, into operating on a child with minimal disease on a CT.

Culture

In general, cultures of the nasal cavity have not been readily used in the pediatric population. The literature is mixed regarding the efficacy of directed cultures. Jiang et al³² showed that the bacteriology of the middle meatus was different from that found in the ethmoid bulla. They therefore concluded that the bacteriological findings in the middle meatus may not reflect the real bacteriology in chronic sinusitis and are therefore not valid. Other studies have shown a high correlation with antral punctures.^33,34 In the cooperative patient, endoscopically directed cultures of the middle meatus may be very useful, particularly in communities with increased resistance.

Medical Management

Because antibacterial therapy is most often empirically chosen to treat the disorder, knowledge of the typical etiologic agents and awareness of the antibacterial susceptibility profiles in a given community are of paramount importance. There is now recognition of the importance of nontypable Haemophilus influenzae that is unresponsive to first-generation cephalosporins, tetracyline-resistant gram-positive cocci, and the increasing emergence of β-lactamase-positive respiratory pathogens such as H. influenzae and Moraxella catarrhalis. These realities mandate the more conservative use of antibiotics in upper respiratory tract infections and the use of newer therapeutic agents for acute and chronic sinusitis.

There is much that is unknown about antibiotic therapy and chronic sinusitis. There is one subject in recent publications on pediatric sinusitis on which most authors agree, however, and that is that the public cannot continue to expect to receive antibiotics on demand solely because of purulent nasal discharge, and that clinicians cannot continue to prescribe broad-spectrum and expensive antibiotics for minimal indications. Antibiotics are often used to treat viral upper respiratory tract infections, even though they are usually ineffective. The inappropriate use of antibiotics contributes to the emergence of drug-resistant bacterial pathogens. It is frequently difficult to assess if the infection is viral or complicated by a bacterial infection that would be improved with antibiotic therapy. Reviews in the literature emphasize the need for primary medical management and not surgical intervention. In the most resistant cases, however, surgery can perform a significant therapeutic role, as subsequently outlined.

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