1. Pediatric sinus care: The role of the Adenoid and reflux in Pediatric sinus disease David Parsons, MD, FAAP, FACS Clinical Professor Universities of North & South Carolina Charlotte, North Carolina USA Copywrite 2010

2. Tom Havas david Kennedy For adults: Diagnosis of sinusitis increasing EXPONENTIALLY Number of FESSurgeries increasing EXPONENTIALLY Cost of each surgery increasing EXPONENTIALLY Benefit to patients in lost work time is worse

3. the point is… The more we do, the worse the outcome for the patients!

4. We recognized this in children 20+ years ago.  Those of us with large Pediatric sinus practices began teaching, “The less you do the better the outcome.”  We teach aggressive medical management, very conservative indications for sinus surgery, and when FESS is required, do the least amount possible.

5. Since starting this approach 20+ years ago, our outcomes are excellent! And the same ideas should be used with ADULTS!

6. Because…. Fact 1: “Repeated courses of broad spectrum antibiotics as the single method of treatment for chronic sinusitis is inappropriate.” --Parsons, OtoClinics of North America, Feb 1996

7. Must address ALL! Fact 2: Chronic sinusitis is multifactorial Daycare (recurrent/chronic URI’s) Allergies Tobacco smoke exposure Big adenoid Reflux Bacterial sinus invasion Etc

8. In the 1980’s, we discovered these simple facts when we started doing FESS in children. The surgeries often failed because the only indication for surgery was “failure to get well” after many courses of antibiotics.

9. We were failing to recognize and address the other causes of sinus symptoms that were NOT infectious! AllergiesReflux Big Adenoid Environmental irritants – smoking And… the impact of daycare

10. Allergies Reflux Big Adenoid Environmental irritants – smoking And… the impact of daycare Rarely, is just one of these the cause of the sinus symptoms… It is usually several of these!

11. Allergies Reflux Big Adenoid Environmental irritants – smoking And… the impact of daycare NONE of these are made better by antibiotics and some are made worse!

12. 90% Diane Heatley’s study (Wisconsin) helped us better understand that the adenoid had to be removed as the first surgical step.

13. I added the outfracture of the inferior turbinates to the adenoidectomy with excellent outcomes for curing “sinusitis” in children.

14. We taught, never do FESS until the adenoid is gone and the outfracture complete, then, follow the child for an appropriate time. It is so successful, we now do about one FESS/yr in a child for chronic sinusitis!

15. Never do FESS and adenoid together. 90% of children get well with adenoid removal only. But with adenoidectomy and outfracture and aggressive medical care, 99% get well enough to avoid sinus surgery.

16. Still, we had many failures. Further searching revealed that most of these children had reflux. H2 Blocker therapy was initiated and most of these patients got well. (1995)

17. A subsequent study that we published revealed that if we treated reflux before surgery, most children with chronic sinusitis didn’t need FESSurgery.

18. What are the symptoms of reflux in a child?  Most are silent, but if they do…  Throat clearing  Cough (dry, non-productive)  Belching  Spitting / re-swallowing / vomiting / regurgitation  Frequent upset stomach  Heartburn (rare)

19. Adenoid Hypertrophy SX: Nasal obst (mouthbreathing) Nasal discharge (ant rhin or PND) Hx of snoring May additionally have Cough Bad breath Headaches

20. What are the sx of sinusitis? In children: Nasal obstruction (mouthbreathing) Nasal obstruction (mouthbreathing) Nasal discharge (anterior rhinorrhea or PND) Nasal discharge (anterior rhinorrhea or PND) Cough (dry, horizontal) Cough (dry, horizontal) Halitosis Halitosis Headache Headache These are the same as a big adenoid! Studies show they look, act, and present the same !

21. What if the adenoid is small on Xray? Gates middle ear study showed adenoid size and frequency/severity of OME was clinically insignificant. We say OM/sinus are the same. Size is not a factor.

22. What are causes of a big adenoid? Allergies Allergies Recurrent URI’s (Daycare) Recurrent URI’s (Daycare) Reflux Reflux Environmental Irritants (Smoking) Environmental Irritants (Smoking) (same as sinusitis)

23. Chronic sinusitis is multifactorial! We must address reflux, allergies, daycare, smoking caregivers, adenoid, etc., before surgery is ever considered or surgery will have less than desirable results… Failure! Clearly need to remember the 2 nd Fact:

24. I average about 1 FESS per year in children with CS for the last 19 years. I tend to be medically aggressive, and surgically aggressive with adenoidectomies/outfractures, but very conservative with FESSurgery.

25. Can a large adenoid cause reflux? … sure! The GI literature lists chronic airway obstruction as one of important causes of reflux. This is one of my reasons for aggressively treating the enlarged adenoid. (Option - oral steroids.)

26. If reflux and the adenoid are effectively addressed, other studies suggest less than 5- 10% of kids with CS sx will need surgery. Throw in allergies, and parents stopping smoking, and the incidence will decrease even further.

27. In my hands, less than 1% of children referred for sinus problems ever need to undergo FESSurgery. Medical therapy, coupled with an adenoidectomy/outfracture, is extremely effective in children with sinus symptoms.

28. But, if FESS is necessary, how should we do it? Please attend my lecture on Minimally Invasive SS… or…

29. Treatment  Conservative  NO CAFFEINE! (sodas, CHOCOLATE, coffee, tea)  No food, milk or juice 2 hours before bedtime  No mints  No fatty/spicy foods  No citrus/acid beverages  No alcohol, tobacco  Elevation of the head of bed 4-6 inches  Body position sleeping (left side or stomach down)  Proton Pump Inhibitor, 3 mg/kg/day divided BID.  Never give with dairy products  30-45 minutes between

30. Thank you!