© Borgis - New Medicine 4/2007, s. 104-105
*Mieczysław Chmielik, Lechosław P. Chmielik
Surgery in chronic rhinosinusitis in children
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Prof. Mieczysław Chmielik, MD, PhD
Summary
Summary
Illnesses of the upper airways are the most common disorders in people in their developing years. Acute nasal catarrh can appear many times in the year, and if the defence mechanism is in good condition, the situation will last for a couple of days, after which the patient is cured.
However, the defence mechanism in children is not always reliable, for many reasons. In such cases, the child suffers infected illnesses of the upper airways, which can persist for many months, or recur many times in the year. Only those actions should be carried out which are important for the correct functioning of the binasal sinuses. These procedures are collectively known as Mini-FESS or PESS.
Illnesses of the upper airways are the most common disorders in people in their developing years. Acute nasal catarrh can appear many times in the year, and if the defence mechanism is in good condition, the situation will last for a couple of days, after which the patient is cured.
However, the defence mechanism in children is not always reliable, for many reasons. In such cases, the child suffers infections illnesses of the upper airways, which can persist for many months, or recur many times in the year.
Following the correct procedures with such a patient is extremely important, for some of these conditions may leave permanent changes. The patient must therefore have clinical diagnostics, and full visual medical checks, to establish the optimal method of cure.
A recommended scheme for the diagnostic and treatment procedure for such patients is shown in Table I.
Table 1. The scheme of the diagnostic and therapeutic management in rhinosinusitis
If the diagnostics show that the cause of relapse is connected with the flow of air, caused by birth defects, polyps, or swellings, the flow must be corrected by operative surgery. We must underline the importance of computer tomography in diagnosis, as well as in planning the operation. Without a CT scan in the coronal plane, endoscopic processes cannot be carried out in the binasal sinuses.
We know, on the basis of a large amount of literature, that FESS in children does not interfere with the later development of the operated structures. The functioning of membranes of the sinuses normalises. Considering the development potential of the patient at a young age, the operation must be performed with maximum economy. Only those actions should be carried out which are important for the correct functioning of the binasal sinuses. These procedures are collectively known as Mini-FESS or PESS.
The method of performing these procedures on children is derived from the procedures used for adults, but with greater precision, so there is a possibility of a-traumatic surgery, and if possible preserving the membrane of the nose where any manipulations have to be made.
The conservative method of conducting the process arises from the need to preserve the structures which can have an influence on the future development of the area. Before any treatment, it is necessary to carry out detailed paediatric, laryngological, and laboratory checks. In these, it is important to check for any complications – any accompanying illnesses or complications in the relapsing sinusitis. Amongst other factors, it is important to ascertain the exact time and route of blood clotting.
Samples taken from the nostrils have little clinical significance. If possible, samples should be taken from the middle nasal concha because these are the most reliable.
The FESS procedure in children and teenagers must be made under full anaesthesia, after specific mucosal decongestion of the appropriate membrane. For this, we use, for example, xylometazoline.
The next stage is a full endoscopic check of the nostrils, after which we can continue to the procedure for widening the outlets of the affected sinuses, or remove any secondary changes – for example, a nasal polyp, or obtaining material for a histopathological examination.
The procedure should be conducted under the rules given above, and only on the affected sinuses. After the procedure, it is recommended to separate any areas where there is a possibility of adhesion (between the nasal septum and turbinates, between the inferior and middle turbinates, or between the lateral nasal walls) which might knit together. A nasal tampon should be kept in place for about two days, and then removed.
Drains should be left in the operated sinuses, to allow daily rinsing of the structures operated, until the correct level of healing is achieved.
In the case of procedures without any complications, they can be carried out without an antibiotic shield, but the shield is important when the patient has specific or overall acute illness. It is necessary to limit the procedures with atypical patients in any period of exposure to allergens. These operations are mostly, but not always, connected with the ethmoidal infundibulum funnel, the maxillary sinuses, the ethmoidal anterior cells, and to a lesser extent the frontal and the sphenoid sinuses.
The method for the procedures has been described in previous publications. After the operation, it is advisable to carry out an endoscopic examination of the nostrils, after a period of seven days, one months, and three months. Special procedures are used for patients with nasal polyps, for whom it is advisable to use methods for curing the condition. The parents of the patient should be notified beforehand about the possibility of overall and specific operative complications.
Piśmiennictwo
1. Chmielik M, Brożek E: Nasal and sinus diseases in children - surgical treatment. New Medicine 2002/2; 55-57.2. Chmielik M, et al.: Mini-FESS in children. New Medicine 2004/3; 62-65.3. Lieser John D, Derkay Craig S: Pediatric sinusitis: when do we operate? Current Opinion in Otolaryngology& Head and Neck Surgery, 2005; 12: 60-66.4. Huang HM, et al.: Normalization of maxillary sinus mucosa after functional endoscopic sinus surgery in pediatric chronic sinusitis. Int J of Pediatr Otorhinolaryngol 2005; 69(9): 1219-1223.5. Bernal-Sprekelsen M, et al.: Pediatric endoscopic sinus surgery (PESS): Review of the indications. Rev. Laryngol. Otol. Rhinol., 2003; 124, 3: 145-150.6. Clement P, et al.: Management of rhinosinusitis in children. Int. J. Pediatr. Otorhinolaryngol., 1999; 49(supl): 95-100.7. Chmielik M: Nieżyty nosa u dzieci. [W]: Alergiczne i niealergiczne nieżyty nosa (red) B. Samoliński i M.Śliwińska-Kowalska. Mediton Łódź 2003; 86-90.8. Chmielik M, et al.: Funkcjonalna chirurgia endoskopowa zatok u dzieci. Otolaryngologia Polska; 1999, LIII, sup. 29:9-11.9. Chmielik M, et al.: Histological analysis of nasal polyps in children. Int. J. Ped. Otorhinolaryngol., 2001; (600): 131-133.
