PEDIATRIC RHINOSINUSITIS DANIEL W. TODD, MD, FACS MIDWEST ENT

“GET REAL” WHAT IS CHRONIC RHINOSINUSITIS VS THE NORMAL “SNOTTY NOSE” KID? MUST BALANCE THE SELF LIMITED NATURE OF THE DISEASE ITS SIGNIFICANT MORBITITY.

Rhinosinusitis A GROUP OF DISORDERS CHARACTERIZED BY INFLAMMATION OF THE MUCOSA OF THE NOSE AND PARANASAL SINUSES THERE IS NO CRITERIA BASED ON ETILOGY

RHINOSINUSITIS REALLY AN IMFLAMMATORY DISORDER NEED TO STOP THINKING OF IT AS SOLEY AN INFECTION (INFECTION IS REALLY THE RESULT)

Rhinosinusitis Rhinosinusitis is the preferred terminology as you DON’T get the sinusitis without the rhinitis. The term is then further defined by the duration of the inflammation ACUTE – LESS THAN 4 WEEKS RECURRENT ACUTE CHRONIC-MORE THAN 12 WEEKS

FORM AND FUNCTION FORM (ANATOMY)FUNCTION (PHYSIOLOGY)

ANATOMY (FORM) DEVELOPING SINUSES

PHYSIOLOGY (FUNCTION) NASAL PASSAGES BREATHING WARMING FILTERING HUMIDIFYING OLFACTION (SENSE OF SMELL) RESISTANCE SINUSES LIGHTEN THE SKULL MUCOUS PRODUCTION HUMIDIFICATION PROTECT FROM FALCIAL TRAUMA PROTECT NASAL BAROTRAUMA VOCAL RESONANCE ENHANCE OLFACTION

RHINOSINUSITIS---HOW DO YOU GET IT INFLAMMATION--- BLOCKING OF THE OSTIA—DIMINISHED PH---MUCOCILIARY DYSFUNCTION---- STAGNATION OF SECRECTIONS--- OVERGROWTH OF BACTERIA OR FUNGUS

RHINOSINUSITIS INFLAMMATION CAUSED BY: ? OMC: AREA OF RELATIVELY TIGHT ANATOMY

CAUSATIVE FACTORS: URI’S---CHILDREN CAN GET “COLDS” YEAR AND 5-10% CAN BE COMPLICATED BY ARS

CAUSATIVE FACTORS BACTERIAL PATHOGENS: BIOFILMS SUPERANTIGENS (RELATIONSHIP WITH ATOPIC DERMATITIS) HIGH MOLECULAR WEIGHT PYROGENIC PROTEINS ELICIT EXTREMELY POTENT STIMULATORY EFFECT ON T- LYMPHOCYTES

SUPERANTIGENS BACTERIA (staph aureus, pseudomas, H influenza) FUNGI (Molds, Candida, Bipolaris, Alternaria, Aspergillosis) Allergens (Conventional and Bacterial antigens) Irritants

CAUSATIVE FACTORS ALLERGIES: INHALANT AND INGESTANT % OF SURGICAL PTS HAVE SIGNIFICANT ALLERGIES ON SKIN TESTING

CAUSATIVE FACTORS ADENOIDITIS--- PHARYNGEAL TONSIL CAN OFTEN SERVE AS A BACTERIAL RESERVOIR 75% OF PEDIATRIC CRS IMPROVES WITH ADENOIDECTOMY (?TONSILLECTOMY)

CAUSATIVE FACTORS AIRWAY POLLUTANTS: MOST PROMINENTLY SECOND HAND SMOKE

CAUSATIVE FACTORS GERD: PROBABLY BY CAUSING ADENOIDITIS. RECENT STUDY BY PARSONS SUGGESTED SIGNIFICANT CAUSATION.

CAUSATIVE FACTORS STRUCTURAL ABNORMALITIES: DEVIATED SEPTUM MAXILLARY SINUS HYPOPLASIA LATERAL WALL ANOMALIES (HALLER CELL, CONCHA BULLOSA, PARADOXICAL MIDDLE TURBINATE)

CAUSATIVE FACTORS PRIMARY IMMUNO- DEFICIENCY (PID) TRANSIENT HYPOGAMMA GLOBULINEMIA IgG SUBCLASS DEFICIENCY OTHERS

CAUSATIVE FACTORS PCD (PRIMARY CILIARY DYSKINESIA)--- 50% HAVE KARTAGENER’S SYNDROME

CAUSATIVE FACTORS CYSTIC FIBROSIS- WITH NEWER GENETIC TESTING (CF MUTATION ANALYSIS) WE ARE ABLE TO DIAGNOSE MANY LESS SEVERE VARIANTS

RHINOSINUSITIS HOW DO YOU DIAGNOSE IT? HOW DO YOU TREAT IT?

DIAGNOSIS HISTORY PHYSICAL ENDOSCOPY CT SCAN

DIAGNOSIS MAJOR FACTORS FACIAL PAIN/PRESSURE NAO DISCHARGE HYPOSMIA PURULENCE FEVER MINOR FACTORS HEADACHE FEVER HALITOSIS FATIGUE DENTAL PAIN COUGH AURAL PAIN/FULLNESS

MAXIMAL MEDICAL THERAPY SALINE (SPRAY/IRRIGATIONS)— HYPERTONIC? DECONGESTANTS (TOPICAL/SYSTEMIC) MUCOLYTICS STEROIDS (TOPICAL/SYSTEMIC) ANTIHISTAMINES (TOPICAL/SYSTEMIC) REFLUX THERAPY?

MAXIMAL MEDICAL LEUKOTRIENE INHIBITORS ANTIBIOTICS (TOPICAL/SYSTEMIC) USUALLY START TREATMENT EMPIRICALLY---TREAT AT LEAST 1 WEEK PAST THE RESOLUTION OF SYMPTOMS (OFTEN 20 DAYS) SINUNEB—IRRIGATIONS CHRONIC---LOW DOSE CHRONIC BIAXIN

ALLERGY THE NOSE IS THE TARGET ORGAN FOR AEROALLERGENS, IRRITANTS, AND DEBRIS. TOPICAL THERAPIES AND NASAL RINSES ARE PARAMOUNT.

ALLERGY ALLERGY TESTING AND TREATMENT IS NEVER A BAD IDEA PRIOR TO SURGERY IDT IS THE MOST SENSITIVE AND SPECIFIC METHOD OF ALLERGY TESTING

SURGERY THE CHRONIC INFLAMMATION FROM ALLERGIES AND INFECTIONS CAN LEAD TO ANATOMIC CHANGES SINONASAL INFECTION IS A RELATIVE TERM MOST MUCOSAL PROBLEMS ARE REVERSIBLE SINUS SURGERY IS PLAN C

SINUS SURGERY WE DO IT BETTER--- UTILILIZE LASERS, ENDOSCOPES, TV MONITORS, MICRODEBIDERS, COMPUTER GUIDANCE SYSTEMS- ---STILL A DRAINAGE PROCEDURE

FUNCTIONAL

IMAGE GUIDED

LASER AND POWERED

MINIMALLY INVASIVE