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 inflammationACUTE – LESS THAN 4 WEEKSRECURRENT ACUTECHRONIC-MORE THAN 12 WEEKS

FORM AND FUNCTION

FORM (ANATOMY) FUNCTION (PHYSIOLOGY)

ANATOMY (FORM)

DEVELOPING SINUSES

PHYSIOLOGY (FUNCTION)

NASAL PASSAGESBREATHING

WARMING

FILTERING

HUMIDIFYING

OLFACTION (SENSE OF SMELL)

RESISTANCE

SINUSESLIGHTEN 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 6-8-10 “COLDS” YEAR AND 5-10% CAN BE COMPLICATED BY ARS

CAUSATIVE FACTORS

BACTERIAL PATHOGENS:

BIOFILMS

SUPERANTIGENS (RELATIONSHIP WITH ATOPIC DERMATITIS)

HIGH MOLECULAR WEIGHT PYROGENIC PROTEINSELICIT 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---60-90% 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 SEPTUMMAXILLARY SINUS HYPOPLASIALATERAL WALL ANOMALIES (HALLER CELL, CONCHA BULLOSA, PARADOXICAL MIDDLE TURBINATE)

CAUSATIVE FACTORS

PRIMARY IMMUNO- DEFICIENCY (PID)TRANSIENT HYPOGAMMA GLOBULINEMIAIgG SUBCLASS DEFICIENCYOTHERS

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 INHIBITORSANTIBIOTICS (TOPICAL/SYSTEMIC)USUALLY START TREATMENT

EMPIRICALLY---TREAT AT LEAST 1 WEEK PAST THE RESOLUTION OF SYMPTOMS (OFTEN 20 DAYS)

SINUNEB—IRRIGATIONSCHRONIC---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 TERMMOST MUCOSAL PROBLEMS ARE REVERSIBLESINUS 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