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PEDIATRIC RHINOSINUSITIS

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.

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PEDIATRIC RHINOSINUSITIS

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

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

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

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

  5. 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

  6. FORM (ANATOMY) FUNCTION (PHYSIOLOGY) FORM AND FUNCTION

  7. ANATOMY (FORM) • DEVELOPING SINUSES

  8. 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 PHYSIOLOGY (FUNCTION)

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

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

  11. CAUSATIVE FACTORS: • URI’S---CHILDREN CAN GET 6-8-10 “COLDS” YEAR AND 5-10% CAN BE COMPLICATED BY ARS

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

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

  14. CAUSATIVE FACTORS • ALLERGIES: INHALANT AND INGESTANT---60-90% OF SURGICAL PTS HAVE SIGNIFICANT ALLERGIES ON SKIN TESTING

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

  16. CAUSATIVE FACTORS • AIRWAY POLLUTANTS: MOST PROMINENTLY SECOND HAND SMOKE

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

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

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

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

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

  22. RHINOSINUSITIS • HOW DO YOU DIAGNOSE IT? • HOW DO YOU TREAT IT?

  23. DIAGNOSIS • HISTORY • PHYSICAL • ENDOSCOPY • CT SCAN

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

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

  26. 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

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

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

  29. 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

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

  31. FUNCTIONAL

  32. IMAGE GUIDED

  33. LASER AND POWERED

  34. MINIMALLY INVASIVE

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