Chang P, Lee L, Huang C, Lai C, Lee T. Functional Endoscopic Sinus Surgery in Children Using a Limited Approach. Arch Otolaryngol Head Neck Surg. 2004;130(9):1033-1036. doi:10.1001/archotol.130.9.1033
To evaluate the efficacy of the limited approach of functional endoscopic sinus surgery (FESS) in pediatric patients with chronic rhinosinusitis (CRS) and to interpret the indications for second-look endoscopy.
A retrospective review of medical records of patients who received pediatric FESS between January 1995 and September 2002 and a comprehensive parental questionnaire were used to assess postoperative symptom improvement at a mean postoperative follow-up of 27.2 months after surgery.
A university-affiliated medical center.
We studied 101 patients who received treatment of pediatric CRS refractory to optimal medical treatment.
Main Outcome Measures
We analyzed preoperative and postoperative nasal obstruction, purulent rhinorrhea, postnasal drip, headache, hyposmia, and chronic cough.
Patients underwent a limited surgical approach of FESS, basically a drainage rather than an extirpation procedure, for the treatment of pediatric CRS refractory to optimal medical treatment. Additionally, 29 patients (28%) underwent second-look endoscopy.
The proportions of patients whose symptoms improved were as follows: nasal obstruction, 91%; purulent rhinorrhea, 90%; postnasal drip, 90%; headache, 97%; hyposmia, 89%; and chronic cough, 96%. Of the 101 patients, parents of 87 (86%) were satisfied with the surgery.
Our literature review did not reveal any other large series in the Asian population. The limited approach to FESS was effective in treating medically recalcitrant CRS in the children we studied. Second-look endoscopy was indicated for selected cases to ensure the extirpation of residual disease and the patency of ostiomeatal complex and sinus ostia.
Chronic rhinosinusitis (CRS) is defined as signs and symptoms of inflammation of the sinuses persisting more than 8 to 12 weeks.1 In most pediatric patients, acute and chronic rhinosinusitis resolves with adequate medical therapy. Surgery may be considered in patients with failed medical treatment. Traditional sinus surgery for pediatric rhinosinusitis, including the nasal antral window, Caldwell-Luc procedure, ethmoidectomy, and adenoidectomy, often has unsatisfactory outcomes and high morbidity.
Messerklinger developed the concept of the ostiomeatal complex and radically altered the understanding and management of CRS.2 The practical results of his theories about functional endoscopic sinus surgery (FESS) for adults were introduced by Kennedy during the 1980s, and the procedures were first applied to children by Gross et al.3 Because the physiological function of the paranasal sinus drainage pathways can be restored after FESS, it was recommended as a safe and effective procedure for the treatment of CRS in children.4 A modified technique for FESS, the limited surgical approach, was performed on our patients. Second-look endoscopy (SLE) was indicated in selected cases. More than 2000 patients have been treated with FESS in our institution, of whom 5.3% were younger than 18 years. Our literature review did not reveal any other large series of such cases in the Asian population. This study evaluated the effectiveness of this limited FESS procedure for CRS in pediatric patients and addressed the criteria for SLE.
We reviewed the medical charts of all patients younger than 18 years who underwent FESS between January 1995 and September 2002. There were 131 patients. Thirty patients with asthma, immunodeficiency, or antrochoanal polyps were excluded from this study, leaving 101 patients who met the selection criteria for the study. All of these patients were regularly monitored and had complete medical records.
Assessment of the disease included a full history and physical examination. Patients were considered to have CRS if they met the criteria of (1) 12 weeks of persistent symptoms and signs or (2) 6 times per year of recurrent episodes of acute rhinosinusitis, each lasting at least 10 days.5 Patients with symptoms and signs of rhinosinusitis were initially treated with broad spectrum antibiotics (erythromycin, trimethoprim-sulfamethoxazole, cefadroxil, or cephalexin), decongestants, antihistamines, and intensive local debridement. If poor response to the initial 2-week medical treatment was noted, antibiotics such as amoxicillin–clavulanate potassium, cefaclor, or cefixime were given instead. Computed tomography (CT) with a bone window of the sinuses was obtained to document the extent of their disease if the symptoms and signs persisted after more than 4 weeks of medical therapy. The CT scans of all our patients indicated Levine and May stage 3 or 4 disease.6
Our surgical technique, the limited approach, was modified from the Messerklinger technique for FESS. This operation was conservative and directed to the originating site of the disease. Sinonasal mucosa and soft tissue were handled very gently. Frontal recess was the superior-anterior boundary of surgical dissection. Opening of the maxillary sinuses was regularly performed. However, dilation of the ostia was not necessary unless ostial obliteration was found. If ostial dilation was indicated, dilation in the anterior direction after the excision of the uncinate process was the principal management. The superior, inferior, and posterior margins of the maxillary ostium were not manipulated. Partial removal of the ethmoid bulla (inferior medial portion) was performed. Instead of "wide excision," a small window on the basal lamella was created to facilitate the drainage of the posterior ethmoid sinus. Evacuation of the anterior ethmoid sinus was reserved for the extensive disease. Whether posterior ethmoidectomy was performed or not was related solely to the extent of the disease. If sinus lateralis existed, the enlargement of the basal lamellar window and posterior ethmoid sinusotomy were mandatory to minimize the possibility of residual disease.
Patients were monitored weekly for the first month, biweekly for the second month, and monthly thereafter, if necessary. Second-look endoscopy under general anesthesia was indicated in selected patients 3 to 6 weeks after surgery for examination and cleaning of the operative site. Patients were considered for SLE if they met the following criteria: (1) recurrence was strongly suspected during follow-up, (2) diffuse sinonasal polyposis was present before operation, or (3) extensive disease required revision. The SLE procedures comprised (1) general examination of the surgical wound; (2) release of synechiae, removal of debris, extirpation of polypoid tissue, and debridement of granulation tissue; (3) reventilation of the sinus; and (4) thorough irrigation of the sinus antrum if mucopus stasis existed.
A questionnaire designed to compare preoperative and postoperative signs and symptoms was administered at least 6 months after surgery. This comparison included nasal obstruction, purulent rhinorrhea, postnasal drip, headache, hyposmia (smell dysfunction), and chronic cough. The questionnaires were answered in conjunction with patients' parents, and were evaluated along with patients' medical records. Parents were asked to select a word from the following that best described the improvement of the symptoms and signs after surgery: worse, no change, better, or resolved. At the conclusion of the questionnaire, parents were asked whether they were satisfied with the outcomes of the FESS procedures.
The mean age of the 101 patients at the time of surgery was 14.5 years, ranging from 8 to 18 years. Nine patients (9%) were younger than 10 years and 92 patients (91%) were 10 years or older. The male-female ratio was 1.8 (65 males, 36 females). The average postoperative follow-up period at the time of the study was 27.2 months, ranging from 6 to 51 months. Preoperative and postoperative evaluations of symptoms and signs were calculated on a percentage basis, and the actual numbers of children affected are shown in Table 1.
All of the patients who underwent pediatric FESS also underwent preoperative sinus noncontrast CT (with bone window), and all of them had Levine and May stage 3 or 4 disease.
All patients exhibited diverse preoperative symptoms and signs. Chronic nasal obstruction and purulent rhinorrhea were found in almost all patients (96% and 94%, respectively), followed by postnasal drip (61%), headache (36%), smell dysfunction (35%), and chronic cough (25%).
Chronic nasal obstruction was the most common preoperative complaint (97 patients). After the operation, 91% (88 patients) reported that this symptom had resolved or was improved. In the 95 patients who had preoperative purulent rhinorrhea, 90% (86 patients) were free of this symptom or noticed a decrease in the amount and frequency of discharge. Postnasal drip was noted in 62 patients before surgery; 90% (56 patients) felt it was resolved or less severe postoperatively. No patients reported that these symptoms got worse after the operation.
The preoperative symptoms of headache, hyposmia, and chronic cough were less common in our patients. In the 36 patients who had headache preoperatively, 97% (35 patients) noted that their headache had disappeared or become less severe. Hyposmia was noted in 35 patients before surgery; 89% (31 patients) reported that this symptom resolved or improved after surgery. Chronic cough was noted in 25 patients, and after surgery it was resolved or improved in 96% (24 patients). None of these symptoms got worse postoperatively.
Among the parents of patients, 86% (87 patients) were satisfied with the postoperative improvement of their children's symptoms and signs.
Seventeen patients (17%) had localized synechiae, polypoid tissue, or copious discharge on anterior endoscopy during the follow-up period; recurrence of the disease was suspected in all 17 patients. Twelve patients (12%) had extensive disease or required revision. Second-look endoscopy was performed in these 29 patients (29%). Among them, 3 patients (3%) had extensive recurrent disease and a third-look endoscopy was performed 6 months after the operation. All 29 patients had no residual disease at a mean follow-up period of 23.6 months.
All patients in this study were monitored regularly. Most of the patients were symptomless and no evidence of recurrence could be found at the time of this writing. No major complications such as significant hemorrhage requiring blood transfusion, meningitis, or cerebrospinal fluid leaks were encountered during or after surgery.
Functional endoscopic sinus surgery is the most widely performed procedure for the treatment of chronic or recurrent rhinosinusitis in adults. In the recent decade, it was also considered an effective and safe procedure to treat refractory rhinosinusitis in children. But the concept of "the same procedure in a smaller patient" is not exactly correct. The main differences between adult and pediatric studies are related to surgical methods, postoperative care, and outcome assessment.
A limited surgical approach is mandatory for pediatric endoscopic sinus surgery. Although no notable hemifacial deformity has been reported among children who underwent endoscopic sinus surgery, sinus hypoplasia has been noted on CT examination.7 Mair et al8 conducted an animal study that showed even limited surgery in the anterior ethmoid region could affect sinus and facial growth in piglets. Surgery should be conservative and directed to the originating site of disease with maximal preservation of all living mucosa, periosteum, and bone. In our study, "drainage" procedures were more favorable than "extirpation" procedures even with anterior ethmoid sinus surgery or other ostiomeatal complex operations. As shown in Table 2, procedures for the limited approach were different, although similar, from those performed in traditional FESS. The limited approach can not only reestablish ventilation and drainage through the natural pathways but also optimize wound healing, prevent unnecessary removal of growing bone, and simplify postoperative care. Partial middle turbinectomy was proposed by Stammberger9 in an attempt to decrease synechiae formation with subsequent closure of the middle meatal antrostomy, frontal recess, or ethmoid fossa. However, the study showed that this alteration was counterproductive, with destruction of the natural anatomy and significant scarring between the middle turbinate and lateral nasal wall.2 Therefore, we did not perform partial middle turbinectomy in any of our patients. Rothman et al10 proposed a modified uncinectomy to preserve the mucosa on the uncinate process, and this approach reduced the incidence of recurrence disease. We used this procedure as a part of the limited approach to improve the surgical outcome of our patients. Middle meatal stenting remains a controversial issue. Various stent materials were used to prevent adhesions between the middle turbinate and the lateral nasal wall. Nonetheless, some materials used to stent the cavity may actually promote or redirect granulation tissue and, thereby, encourage adhesions. We did not use stents to prevent adhesions in our patients. According to our observations, precise and delicate handling of the tissue of middle turbinate and lateral nasal wall during the operation is far more important than the stenting procedure.
Because of the tiny and thin intranasal bony anatomy of children, surgical requirements for children are stricter than for adults. The optic nerve, extraocular muscles, cerebral tissues, and lacrimal drainage system are placed at a greater risk for injury. Availability of the 2.7-mm telescope with a high-intensity light source is often suggested. For our patients, we performed all FESS procedures without any difficulties and with a better feeling of depth using a 4.0-mm telescope. But owing to the precarious and fragile anatomy in children, meticulous handling of the instrumentation is mandatory.
Previously, tonsillectomy, adenoidectomy, antral lavage, and nasal antral windows were proposed to treat refractory sinusitis. These procedures are appropriate in some patients, but it is not possible to predict which procedures will be successful given our available knowledge.11 The failure of these procedures to control symptoms in some patients is most likely secondary to persistent disease in the ostiomeatal complex. The improvement following adenoidectomy most likely reflects a physiologic effect on the nasopharyngeal microflora, with a reduction in bacterial pathogens and an increase in commensal organisms after the surgery. The adenoids do not necessarily have to be hyperplastic to achieve a satisfactory response from surgery. Rosenfeld12 suggested a stepped treatment approach in that adenoidectomy should be considered before FESS even if the adenoids are unobstructive. In the study by Ramadan,13 the success rate was 77% in the endoscopic sinus surgery group and 47% in the adenoidectomy group. We concur that when FESS was used as the initial modality, the need for further surgery and another general anesthesia was reduced. We adopted FESS as our priority treatment modality.
In a study of 120 patients, Kennedy14 concluded that the only relevant prognostic factor was the extent of sinusitis. Nonetheless, in the study by Lazar et al,15 nasal endoscopic examination and close postoperative follow-up were other prognostic factors. Stammberger16 stated that follow-up treatment of adult patients after FESS, consisting of cleaning crusted blood and eschar, is essential. Because blood crusting, eschar, and granulation tissue may cause restenosis of the ostiomeatal complex after surgery, SLE has been a common procedure since the inception of pediatric FESS. The advantage of postoperative endoscopic examination under general anesthesia includes a detailed inspection of the surgical site and removal of crusting, blood clots, granulation tissue, or adhesions. It was usually performed 2 to 4 weeks after surgery to allow adequate healing of the surgical site without allowing maturation of scar tissue and subsequent synechia formation.
In recent years, several authors pointed out that there are no definite benefits of SLE but increased risk from the need for a second general anesthesia.17- 19 Mitchell et al17 reported no difference in clinical outcome in their study comparing 50 children who underwent SLE after FESS with 50 children who did not undergo SLE. Lazar et al15 reported that of 210 patients who underwent FESS, postoperative nasal endoscopic examination showed significant adhesions between the middle turbinate and the septum in only 20% of the studied group. Ten percent of patients had granulation tissue formation, 7% had persistent polyposis, and 11% had significant crusting. In 52% of patients, the endoscopic findings were essentially normal. In our study, we performed SLE under strict criteria. Under the following conditions, we thought that SLE was indicated: (1) cases in which recurrence was strongly suspected during wound debridement, (2) diffuse sinonasal polyposis was present before operation, and (3) revision cases with extensive disease. The follow-up period was longer and postoperative care became more troublesome when significant granulation tissue or recurrent disease was found during SLE.
Certain limitations of this study should be recognized. Assessment of FESS success was made from the parents' perspective of the improvement of the symptoms and signs of CRS and was obtained by questionnaire because most of the patients were too young to understand the concepts involved or to express themselves adequately. As with all questionnaires about symptoms, the responses were subjective and the parents may have been biased at the time by other factors. The comparisons of preoperative and postoperative symptoms were also subjective and allowed for errors because questionnaires were administered 6 months after surgery. In our study, there was no justification for subjecting all the children to another general anesthesia, sedation, or another CT scan to assess the condition of sinuses. Therefore, the physician's follow-up observation in the office and the parents' evaluation of the degree of improvement were used as the primary indicators of the effectiveness of pediatric FESS. To date, it has been difficult to establish a purely objective measure of outcome. Standardized methods should, therefore, be established to analyze the outcomes of the surgery.
According to our investigations, chronic nasal obstruction and purulent rhinorrhea were the most common preoperative symptoms of pediatric CRS. Our results showed that 89% (32/36) of our patients with headache and 84% (21/25) with chronic cough were completely recovered after the surgical treatment. The promising results in this study signify the benefits of our limited surgical approach for the treatment of pediatric CRS.
The limited approach of FESS, a technique specially designed for pediatric patients, is an effective treatment modality for severe medically refractory CRS in children. With meticulous handling of the tissue using the limited surgical approach, more than 80% of the patients were satisfied with the outcome of the operation, and the significant improvement of the symptoms and signs was encouraging. Careful preoperative evaluations, strict adherence to the surgical criteria, aggressive wound care, and timely and appropriate SLE are the keys to successful pediatric FESS.
Correspondence: Ta-Jen Lee, MD, Department of Otolaryngology, Chang Gung Memorial Hospital, 5 Fu-Shin St, Kweishan, Taoyuan 333, Taiwan (email@example.com).
Submitted for publication January 20, 2004; final revision received March 30, 2004; accepted March 31, 2004.