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Functional endoscopic sinus surgery—A retrospective analysis of 115 children and adolescents with chronic rhinosinusitis
International Journal of Pediatric Otorhinolaryngology 73 (2009) 741–745
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Functional endoscopic sinus surgery—A retrospective analysis of 115 children and adolescents with chronic rhinosinusitis Vanessa Siedek *, Klaus Stelter, Christian S. Betz, Alexander Berghaus, Andreas Leunig Ludwig Maximilians-University, Department of Otorhinolaryngology, Head and Neck Surgery, Marchioninistr. 15, 81377 Munich, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 November 2008 Received in revised form 20 January 2009 Accepted 26 January 2009 Available online 6 March 2009
Objective: Functional endoscopic sinus surgery (FESS) is not frequently performed in children. The aim of our retrospective analysis was to determine symptoms, surgical extent, complications and outcome of operated children. Methods: For a period from 1994 to 2004 the clinical records of the Department of Otorhinolaryngology, LMU Munich, Germany, were screened for pediatric FESS procedures. Subsequently, a retrospective chart review was performed in all cases. For assessment of outcome, symptom- and quality of life-related questionnaires were sent out to all patients. Results: 115 children had a FESS procedure due to CRS, 77 were boys and 38 girls. The response rate of the questionnaires was 64% (73 of 115); the mean follow up of these was 5.4 (1.8) years. 76% of the patients reported an improvement of their chief symptoms and 71% of their general quality of life. The overall quality of life had improved significantly (p < 0.01) on VAS. In CRS patients nasal obstruction was completely relieved in 62.3%, facial pain in 65.5% and postnasal drip in 72.5%. Improvement of primary nasal symptoms (PNS) of CRS in patients with CF, asthma or allergies as well as in youngsters who had started or continued to smoke 35 out of 73 (48%) was significantly less. Conclusions: Self-assessment after FESS showed in 76% improvement of chief symptoms in children with CRS. Besides known negative prognostic factors for long-term outcome as CF, asthma, nasal polyps, allergies and previous surgery, smoking was correlated with less favourable improvement. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Chronic rhinosinusitis (CRS) FESS in children Long-term results
1. Introduction 1.1. Chronic rhinosinusitis On average children suffer from about six to eight infections of the upper respiratory tract (URTI) per year, with 5–10% of those being complicated by rhinosinusitis (RS). There is a lack of reliable international epidemiological data due to a lack of uniformly accepted definition of CRS and greatly differing selection criteria [15]. URTI infections are especially common in day care environments. Both pediatricians and ENT doctors are therefore often confronted with these problems. It is often difficult to differentiate between a viral infection and an acute bacterial rhinosinusitis (ARS). After the age of 8 there is a clear-cut decrease in the prevalence of RS [26]. Chronic rhinosinusitis (CRS) in children is now defined by the European Position Paper on Rhinosinusitis [15] as follows: two or more of symptoms of rhinosinusitis (obstruction, discharge, facial pain, reduction of smell, CT), lasting more than 12 weeks, similar to adults.
* Corresponding author. Tel.: +49 89 7095 2991; fax: +49 89 70956869. E-mail address: [email protected] (V. Siedek). 0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.01.019
In pediatric CRS predisposing factors are particularly relevant: environment causes are passive smoke [2,11], active smoking [13], day care [9,25] or urban pollution [48]. Others are nasal obstruction [19], hyperplastic adenoids [17], gastroesophageal reflux [43] and genetic factors as CF and Karthagener’s syndrome. The role of allergic component is unclear, though the incidence of atopy goes up to 94% in children undergoing sphenoidectomies [16]. The role of anatomical variants (AV) in triggering CRS is controversally discussed. Some found a significant correlation [36] others not [27,49]. Frequencies of AV in CRS were reported to be: pneumatisized middle turbinate (35%), uncinate hyperplasy (19%), deviation of uncinate (45%), large ethmoidal bulla (30%), large agger nasi (0.7%), Haller cell (1%) [36]. Nasal polyps (NP) in children are rare, besides in CF. Genetic factors may play an important role, especially in children and patients with recurrent CRS. 52% of the children with NP have a positive family history [42]. A antrochoanal polyp is more frequently seen in children than in adults (Fig. 1). CRS and asthma are frequently associated in the same patient. Asthma is reported in 26% of adult CRS patients with NP compared to 6% in the controls [30]. Improvement of asthma symptoms has been obtained after surgery for CRS in children [25].
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Fig. 1. (a–d) 8-year-old child with an extensive antrochoanal polyp that has its origin in the left maxillary sinus and blocks the nasopharynx. (d) Postoperative endoscopic view.
The relationship between ARS and CRS and various complications is not clearly defined in the literature [15]. They were common and extremely dangerous in the pre-antibiotic era, but they still exist inspite of antibiotics. Complications of ARS or CRS in children may be orbital (6% [40], especially in ethmoiditis, often without pain), osseous, intracranial (3% [34]) or concerning the soft tissue. Being the most serious of all, an intracranial complication has still a mortality rate ranging from 0% [4] to 5% [33]. Diagnostic procedures in children concerning CRS are similar to those in adults: history of patient, clinical examination, nasal endoscopy and allergy testing. Characteristics for a CRS in children are long lasting, suppurating secretions from the nose, facial pain and cervical lymphadenopathy. If a family predisposition is known, biopsy of the nasal mucosa should exclude a primary ciliary dysfunction. By analysis of immunoglobulins, particularly IgE, immunodeficiency syndromes will be excluded as well as by an assay of antinuclear or cytoplasmic antibodies a Wegener granulomatosis. If in children with CRS appropriate medical treatment for 6 weeks has failed and indication for operation is discussed, a MRI scan may be done primarily, which has no risk for the child’s lens. Additionally cancer risk after head CT in the very young child must be considered [7]. If surgery becomes necessary, a CT scan should be performed additionally [35]. The aim of our investigation was to evaluate long-term outcome of FESS in children due to CRS. 2. Materials and methods We present the results of 115 children with CRS (aged 3–16 years) following surgical treatment (FESS) at the Department of Otorhinolaryngology, LMU University in Munich, Germany. This retrospective study covers a time period of 10 years (1995–2004). Approval of the Institutional Review Board for Data Privacy in
Medical Research was provided for the study. In a retrospective analysis the initial diagnosis, prior operations, the chief symptoms, the type of operation, allergies, medications (steroids), postoperative pain (VAS from 0 to 10, best to worst), CT or MRI scans, peri-/postoperative complications, laboratory results, patients general histories and relapses were documented. Patients with immunodeficiency disorders (congenital or acquired), primary ciliary dyskinesia, invasive fungal disease, systemic vasculititis or granulomatous disease were excluded. All children had a preoperative CT scan. The surgical procedure was performed according to the Messerklinger technique [41]. The extent of surgery was determined by the preoperative radiographic assessment [37] and intraoperative findings. A powered instrument (i.e. shaver) was used on demand. All patients received topical corticosteroids (Mometasone nasal spray, Essex Pharma, Munich, Germany), nasal irrigation with saline solution and nasal emulsions for 2 weeks postoperatively. 2.1. Long-term outcome assessment A questionnaire was sent out to all 115 patients. We used a specific health profile HRQL questionnaire with 25 items summarized in 6 symptom groups: sleep disorders, non-nasal, nasal, and emotional symptoms, headache and practical problems (symptom score 1–4). VAS was used to measure the patient’s general feeling related to their nasal disease [31]. Further questions concerned need for medication and another operation. Data were summarized in four score-subgroups of primary nasal symptoms (PNS) [3], which were correlated to preoperative status. 3. Results 115 children (77 boys and 38 girls) had undergone FESS due to CRS. Mean age of the patients was 12 years. Reasons for FESS were
V. Siedek et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 741–745 Table 1 Indication for FESS in children with CRS (n = 115); 21% had prior sinunasal operation. CRS without polyps CRS with polyps Maxillary cyst Antrochoanal polyp
51.3% 39.1% 5.2% 4.3%
Table 2 Preoperative Symptoms due to CRS, children operated with FESS. Preoperative symptoms
Percent
Nasal obstruction Facial pain Postnasal drip ‘‘toothache’’ Obstructive sleep apnea Otitis media Anosmia Orbital symptom
87.0 62.0 25 11.7 1 1 1 14.6
CRS without nasal polyps in 59 cases (51.3%), CRS with nasal polyps (6 with CF) in 45 cases (39.1%), a maxillary cyst in 6 cases (5.2%) or an antrochoanal polyp in 5 cases (4.3%) (Table 1). 36 (31%) of 115 had prior operations (13 (18%) AT, 21 (18%) FESS (one 2x, another 3x), 3 polypectomy, 2 septum correction,). 6 had asthma, 6 cystic fibrosis (CF). The second operation of 24 patients (21%) was due to synechia in 15 cases (13%), in 8 cases due to recurrent polyposis (7.0%) and 1 case due to a recurrent choanal polyp. The main preoperative symptoms in CRS were nasal obstruction (82%), facial pain (62%) and postnasal drip (25%). Sleep apnea, acute otitis media and anosmia were found in single cases (Table 2). Perioperative complications occurred in seven cases: major complications (2.6%) were 1 arterial intraoperative bleeding, 1 delayed hemorrhage, 1 CSF leak; minor complication (3.5%) were 4 intraoperative diffuse bleedings. The return rate of the questionnaires (self-assessment, not from parents) was 64% (73 out of 115 patients). The mean time after surgery for those 73 patients was 5.6 years (std. dev. 1.9). Nine patients (12.6%) had a second or more operations in the meantime: 3 CF-patients had seven, three or two revisions, 2 asthma patients had two and one revision, 4 others one revision. Of the 6 non-CFpatients 4 used to smoke about half a package per day or more. 89% of the patients decided, that they would undergo this operation again, if they were confronted with the same sort of symptoms they had preoperatively. Generally, nasal obstruction was completely relieved in 62.6%, facial pain in 65.8% and postnasal drip in 72.5% in those with CRS. There was no significant
Table 3 Evaluation of the follow-up questionnaire of 71 patients after FESS.
Better general condition? Better QOL? Had revision Approval of operation again if necessary?
All
Male
Female
75% 71% 12.6% 88%
77% 70% 13.8% 96%
71% 71% 11.0% 76%
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difference in the outcome between male and female patients. In the self-assessment, 77% felt an improvement of their symptoms and 74% declared to have a better quality of life (Table 3). The mean subjective quality of life improvement had significantly changed (p < 0.01) in the VAS (0–10, best to worst) from 7.27 (1.5) preoperatively to 3.12 (2.2) postoperatively. 33% referred to have allergies. 46% of the adolescents, most of them having been between 10 and 14 years at time of operation, now being over 20, were smoking at the time of the inquiry. The patient’s self-assessed data of the primary pre- and postoperative nasal symptoms of our questionnaire were transferred into the SNOT 20 GAV (German Adapted Version [3]). Four subgroups were distinguished according to score-points (Table 4). Those who smoke more than half a package a day had significantly (p 0.01) less improvement with more belonging to the PNS-subgroup 3 or 4 (PNS-subgroup 3: moderate to severe, PNS-subgroup 4: severe to extreme symptoms), Non-smokers belonged mostly to group I (74%) or II (21%) (PNS-subgroup I: no or little, PNS-subgroup II: little to moderate) (Table 4). 4. Discussion The general number of endonasal procedures has highly increased within the last decades, especially since FESS is performed. The ‘‘functional’’ in FESS stands for restoration of the function of the osteomeatal complex: ventilation and drainage. In 1996, an international consensus was reached concerning the indications for FESS in children [12]. FESS in CRS is mostly limited to a partial ethmoidectomy: removal of the uncinate process, with or without a maxillary antrostomy in the middle meatus, and removal of the ethmoid bulla. A more extended surgery including wide opening of the frontal recess or sphenoethmoidectomy depending on the extent of disease is not superior to a limited approach (infundibulotomy) [32]. This emphasizes a more individual and cautious surgical procedure. Laser assisted endonasal surgery, powered instruments or sharp forceps offer some advantages over conventional instruments but may be associated with some particular risks. Currently, there is no evidence that they improve sinus surgery outcomes [47]. We prefer the shaver in the cases with extensive nasal polyps. The results of FESS due to CRS in children have been shown in several studies [18,21,24,38]. Most of the reported outcomes are based on the levels of symptomatic relief and do not include objective measures such as nasal endoscopy or CT scans. Giger proved that endoscopic scores correlate significantly with subjective satisfaction ratings (p > 0.001) [18]. Jiang and Hsu [24] and Fakhri et al. [14] observed postoperative improvement in 84%, a meta-analysis performed by Hebert and Bent [21] including 832 children (8 clinics) revealed a positive outcome from 88 to 92% after average follow up of 3.7 years. In very young children (under 4.8 years), a higher rate of further surgical interventions due to osteomeatal scarring was noted by Chan et al. [10]. FESS is unlike to be successful in children below the age of three [45]. But Lusk et al. reported a 10-year retrospective study, which proved superiority (p > 0.001) of FESS in the age of 2–5 years over medical treatment in parenteral assessment of
Table 4 Answers concerning sinunasal symptoms in questionnaires graded in four SNOT groups. Group
SNOT points
Level of complaints
All children
Smokers
Non-smokers
I II III IV
12 >12 and 32 >32 and 52 >52
No or little Little to moderate Moderate to severe Severe to extreme
32 26 13 2
4 18 11 2
28 8 2 0
(43.8%) (35.6%) (17.8%) (2.7%)
(11.4%) (51.4%) (31.4%) (5.7%)
(73.8%) (21.0%) (5.2%) (0%)
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improvement [38]. Efficiency of FESS has been found to be reduced if a child is exposed to tobacco smoke [44]. Concerning the mentioned fear, that endonasal operations might influence facial growth, Bothwell et al. [6] found no statistically significant differences with or without FESS using quantitative anthropomorphic analysis after a 13.2 years follow up. In CF improvement after FESS is less good than in non-CF children, but still significant with 50% after 2 years [1]. FESS is associated with a lower incidence of tracheobronchitis and pneumonia in CF-patients with a transplanted lung [22]. Adenoidectomy instead of FESS especially in very young children has been discussed [52], but Ramadan [45] reported in a prospective study comparing FESS to adenoidectomy in the treatment of CRS in children an improvement of 77% in the FESS group compared to 47% in the adenoidectomy group. In our patients the most frequent perioperative minor complications were diffuse bleeding in 4 cases; major complications were one arterial bleeding, one cerebro spinal fluid (CSF) leak. We did not see an iatrogenic lesion of the medial or inferior rectus nor the obliquus muscle, followed by scarring and global ocular motility dysfunction [5]. Our data confirm that FESS is a safe and efficient procedure. Most surgeons prefer FESS to conventional endonasal surgery [20], though there is no study, which proves significant superiority. In postoperative therapy we used topic steroids. Ramadan prefers intravenous dexamethason therapy perioperatively to reduce swelling and scarring; in his study it was particularly useful in children with asthma, lower CT scan grades, no tobacco smoke exposure and those over 6 years [44]. Our experiences with FESS in CRS show after a long follow up from 5 to 15 years with 75% improvement results similar to Ramadan and others [46]. As most studies have a lower mean follow up of about 3 years, we conclude that the benefit of FESS is stable after that time. Quality of life seems correlated with the absence of further discomfort caused by CRS. Though male and female patients agree in their assessment concerning the benefit of FESS, the female patients are more restrict concerning a reoperation if necessary. Previous revision surgery, extensive polyps, bronchial asthma [42], ASA-intolerance and CF are predictors for revision surgery [39]. The high frequency of revision surgery in our patients (21%) may be due to long-term follow up if compared to data based on a mean 3 years follow up with a frequency of about 12% [51] and on the high percentage of children having predisposing factors. In our patients 9 of 73 had revisions again, 3 of them having CF and 2 asthma; of the 6 non-CF patients 4 had started to smoke. The rate of revision surgery during the follow up was 12.6%. The negative influence of tobacco in CRS is well known. Patients with allergic rhinitis who have ever smoked have a 43-fold risk to have nasal polyps [23]. Smoking proved to play a significant role in outcome after FESS in adults [8,13]. Several authors have reported the role of passive smoking in children in CRS after FESS [29]. Significantly prolonged mucociliary clearance [50] and local impaired immune response [28] may play a major role. Further negative prognostic factors have an influence on the outcome after FESS: the most important of those are CF, asthma, and a high graded CT-scan. Ramadan noticed reduced improvement from 90% to 70% [44]. Our research showed a strong impairment of results after FESS in adolescents who had started or continued active smoking after operation. 5. Conclusion Our results show that 76% of the children had a significant benefit of FESS concerning symptoms and 71% in self-estimated
quality of life. FESS proved in most published series superiority to conventional endonasal surgery in outcome and acceptance. Unfortunately, nearly half of the adolescents of our inquiry started or continued to smoke. Subdividing the group into smokers and non-smokers, results show, that especially the non-smokers revealed improved outcome. The outcome after FESS in children is influenced in a high extent by passive and active smoking. Indications for FESS in childhood are now well-established [15]:
nasal obstruction due to massive nasal polyps; a muco- and pyocele; antrochoanalpolyp; orbital complications; CRS when adequate therapy has failed.
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Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Functional endoscopic sinus surgery—A retrospective analysis of 115 children and adolescents with chronic rhinosinusitis Vanessa Siedek *, Klaus Stelter, Christian S. Betz, Alexander Berghaus, Andreas Leunig Ludwig Maximilians-University, Department of Otorhinolaryngology, Head and Neck Surgery, Marchioninistr. 15, 81377 Munich, Germany
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 November 2008 Received in revised form 20 January 2009 Accepted 26 January 2009 Available online 6 March 2009
Objective: Functional endoscopic sinus surgery (FESS) is not frequently performed in children. The aim of our retrospective analysis was to determine symptoms, surgical extent, complications and outcome of operated children. Methods: For a period from 1994 to 2004 the clinical records of the Department of Otorhinolaryngology, LMU Munich, Germany, were screened for pediatric FESS procedures. Subsequently, a retrospective chart review was performed in all cases. For assessment of outcome, symptom- and quality of life-related questionnaires were sent out to all patients. Results: 115 children had a FESS procedure due to CRS, 77 were boys and 38 girls. The response rate of the questionnaires was 64% (73 of 115); the mean follow up of these was 5.4 (1.8) years. 76% of the patients reported an improvement of their chief symptoms and 71% of their general quality of life. The overall quality of life had improved significantly (p < 0.01) on VAS. In CRS patients nasal obstruction was completely relieved in 62.3%, facial pain in 65.5% and postnasal drip in 72.5%. Improvement of primary nasal symptoms (PNS) of CRS in patients with CF, asthma or allergies as well as in youngsters who had started or continued to smoke 35 out of 73 (48%) was significantly less. Conclusions: Self-assessment after FESS showed in 76% improvement of chief symptoms in children with CRS. Besides known negative prognostic factors for long-term outcome as CF, asthma, nasal polyps, allergies and previous surgery, smoking was correlated with less favourable improvement. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Chronic rhinosinusitis (CRS) FESS in children Long-term results
1. Introduction 1.1. Chronic rhinosinusitis On average children suffer from about six to eight infections of the upper respiratory tract (URTI) per year, with 5–10% of those being complicated by rhinosinusitis (RS). There is a lack of reliable international epidemiological data due to a lack of uniformly accepted definition of CRS and greatly differing selection criteria [15]. URTI infections are especially common in day care environments. Both pediatricians and ENT doctors are therefore often confronted with these problems. It is often difficult to differentiate between a viral infection and an acute bacterial rhinosinusitis (ARS). After the age of 8 there is a clear-cut decrease in the prevalence of RS [26]. Chronic rhinosinusitis (CRS) in children is now defined by the European Position Paper on Rhinosinusitis [15] as follows: two or more of symptoms of rhinosinusitis (obstruction, discharge, facial pain, reduction of smell, CT), lasting more than 12 weeks, similar to adults.
* Corresponding author. Tel.: +49 89 7095 2991; fax: +49 89 70956869. E-mail address: [email protected] (V. Siedek). 0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.01.019
In pediatric CRS predisposing factors are particularly relevant: environment causes are passive smoke [2,11], active smoking [13], day care [9,25] or urban pollution [48]. Others are nasal obstruction [19], hyperplastic adenoids [17], gastroesophageal reflux [43] and genetic factors as CF and Karthagener’s syndrome. The role of allergic component is unclear, though the incidence of atopy goes up to 94% in children undergoing sphenoidectomies [16]. The role of anatomical variants (AV) in triggering CRS is controversally discussed. Some found a significant correlation [36] others not [27,49]. Frequencies of AV in CRS were reported to be: pneumatisized middle turbinate (35%), uncinate hyperplasy (19%), deviation of uncinate (45%), large ethmoidal bulla (30%), large agger nasi (0.7%), Haller cell (1%) [36]. Nasal polyps (NP) in children are rare, besides in CF. Genetic factors may play an important role, especially in children and patients with recurrent CRS. 52% of the children with NP have a positive family history [42]. A antrochoanal polyp is more frequently seen in children than in adults (Fig. 1). CRS and asthma are frequently associated in the same patient. Asthma is reported in 26% of adult CRS patients with NP compared to 6% in the controls [30]. Improvement of asthma symptoms has been obtained after surgery for CRS in children [25].
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Fig. 1. (a–d) 8-year-old child with an extensive antrochoanal polyp that has its origin in the left maxillary sinus and blocks the nasopharynx. (d) Postoperative endoscopic view.
The relationship between ARS and CRS and various complications is not clearly defined in the literature [15]. They were common and extremely dangerous in the pre-antibiotic era, but they still exist inspite of antibiotics. Complications of ARS or CRS in children may be orbital (6% [40], especially in ethmoiditis, often without pain), osseous, intracranial (3% [34]) or concerning the soft tissue. Being the most serious of all, an intracranial complication has still a mortality rate ranging from 0% [4] to 5% [33]. Diagnostic procedures in children concerning CRS are similar to those in adults: history of patient, clinical examination, nasal endoscopy and allergy testing. Characteristics for a CRS in children are long lasting, suppurating secretions from the nose, facial pain and cervical lymphadenopathy. If a family predisposition is known, biopsy of the nasal mucosa should exclude a primary ciliary dysfunction. By analysis of immunoglobulins, particularly IgE, immunodeficiency syndromes will be excluded as well as by an assay of antinuclear or cytoplasmic antibodies a Wegener granulomatosis. If in children with CRS appropriate medical treatment for 6 weeks has failed and indication for operation is discussed, a MRI scan may be done primarily, which has no risk for the child’s lens. Additionally cancer risk after head CT in the very young child must be considered [7]. If surgery becomes necessary, a CT scan should be performed additionally [35]. The aim of our investigation was to evaluate long-term outcome of FESS in children due to CRS. 2. Materials and methods We present the results of 115 children with CRS (aged 3–16 years) following surgical treatment (FESS) at the Department of Otorhinolaryngology, LMU University in Munich, Germany. This retrospective study covers a time period of 10 years (1995–2004). Approval of the Institutional Review Board for Data Privacy in
Medical Research was provided for the study. In a retrospective analysis the initial diagnosis, prior operations, the chief symptoms, the type of operation, allergies, medications (steroids), postoperative pain (VAS from 0 to 10, best to worst), CT or MRI scans, peri-/postoperative complications, laboratory results, patients general histories and relapses were documented. Patients with immunodeficiency disorders (congenital or acquired), primary ciliary dyskinesia, invasive fungal disease, systemic vasculititis or granulomatous disease were excluded. All children had a preoperative CT scan. The surgical procedure was performed according to the Messerklinger technique [41]. The extent of surgery was determined by the preoperative radiographic assessment [37] and intraoperative findings. A powered instrument (i.e. shaver) was used on demand. All patients received topical corticosteroids (Mometasone nasal spray, Essex Pharma, Munich, Germany), nasal irrigation with saline solution and nasal emulsions for 2 weeks postoperatively. 2.1. Long-term outcome assessment A questionnaire was sent out to all 115 patients. We used a specific health profile HRQL questionnaire with 25 items summarized in 6 symptom groups: sleep disorders, non-nasal, nasal, and emotional symptoms, headache and practical problems (symptom score 1–4). VAS was used to measure the patient’s general feeling related to their nasal disease [31]. Further questions concerned need for medication and another operation. Data were summarized in four score-subgroups of primary nasal symptoms (PNS) [3], which were correlated to preoperative status. 3. Results 115 children (77 boys and 38 girls) had undergone FESS due to CRS. Mean age of the patients was 12 years. Reasons for FESS were
V. Siedek et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 741–745 Table 1 Indication for FESS in children with CRS (n = 115); 21% had prior sinunasal operation. CRS without polyps CRS with polyps Maxillary cyst Antrochoanal polyp
51.3% 39.1% 5.2% 4.3%
Table 2 Preoperative Symptoms due to CRS, children operated with FESS. Preoperative symptoms
Percent
Nasal obstruction Facial pain Postnasal drip ‘‘toothache’’ Obstructive sleep apnea Otitis media Anosmia Orbital symptom
87.0 62.0 25 11.7 1 1 1 14.6
CRS without nasal polyps in 59 cases (51.3%), CRS with nasal polyps (6 with CF) in 45 cases (39.1%), a maxillary cyst in 6 cases (5.2%) or an antrochoanal polyp in 5 cases (4.3%) (Table 1). 36 (31%) of 115 had prior operations (13 (18%) AT, 21 (18%) FESS (one 2x, another 3x), 3 polypectomy, 2 septum correction,). 6 had asthma, 6 cystic fibrosis (CF). The second operation of 24 patients (21%) was due to synechia in 15 cases (13%), in 8 cases due to recurrent polyposis (7.0%) and 1 case due to a recurrent choanal polyp. The main preoperative symptoms in CRS were nasal obstruction (82%), facial pain (62%) and postnasal drip (25%). Sleep apnea, acute otitis media and anosmia were found in single cases (Table 2). Perioperative complications occurred in seven cases: major complications (2.6%) were 1 arterial intraoperative bleeding, 1 delayed hemorrhage, 1 CSF leak; minor complication (3.5%) were 4 intraoperative diffuse bleedings. The return rate of the questionnaires (self-assessment, not from parents) was 64% (73 out of 115 patients). The mean time after surgery for those 73 patients was 5.6 years (std. dev. 1.9). Nine patients (12.6%) had a second or more operations in the meantime: 3 CF-patients had seven, three or two revisions, 2 asthma patients had two and one revision, 4 others one revision. Of the 6 non-CFpatients 4 used to smoke about half a package per day or more. 89% of the patients decided, that they would undergo this operation again, if they were confronted with the same sort of symptoms they had preoperatively. Generally, nasal obstruction was completely relieved in 62.6%, facial pain in 65.8% and postnasal drip in 72.5% in those with CRS. There was no significant
Table 3 Evaluation of the follow-up questionnaire of 71 patients after FESS.
Better general condition? Better QOL? Had revision Approval of operation again if necessary?
All
Male
Female
75% 71% 12.6% 88%
77% 70% 13.8% 96%
71% 71% 11.0% 76%
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difference in the outcome between male and female patients. In the self-assessment, 77% felt an improvement of their symptoms and 74% declared to have a better quality of life (Table 3). The mean subjective quality of life improvement had significantly changed (p < 0.01) in the VAS (0–10, best to worst) from 7.27 (1.5) preoperatively to 3.12 (2.2) postoperatively. 33% referred to have allergies. 46% of the adolescents, most of them having been between 10 and 14 years at time of operation, now being over 20, were smoking at the time of the inquiry. The patient’s self-assessed data of the primary pre- and postoperative nasal symptoms of our questionnaire were transferred into the SNOT 20 GAV (German Adapted Version [3]). Four subgroups were distinguished according to score-points (Table 4). Those who smoke more than half a package a day had significantly (p 0.01) less improvement with more belonging to the PNS-subgroup 3 or 4 (PNS-subgroup 3: moderate to severe, PNS-subgroup 4: severe to extreme symptoms), Non-smokers belonged mostly to group I (74%) or II (21%) (PNS-subgroup I: no or little, PNS-subgroup II: little to moderate) (Table 4). 4. Discussion The general number of endonasal procedures has highly increased within the last decades, especially since FESS is performed. The ‘‘functional’’ in FESS stands for restoration of the function of the osteomeatal complex: ventilation and drainage. In 1996, an international consensus was reached concerning the indications for FESS in children [12]. FESS in CRS is mostly limited to a partial ethmoidectomy: removal of the uncinate process, with or without a maxillary antrostomy in the middle meatus, and removal of the ethmoid bulla. A more extended surgery including wide opening of the frontal recess or sphenoethmoidectomy depending on the extent of disease is not superior to a limited approach (infundibulotomy) [32]. This emphasizes a more individual and cautious surgical procedure. Laser assisted endonasal surgery, powered instruments or sharp forceps offer some advantages over conventional instruments but may be associated with some particular risks. Currently, there is no evidence that they improve sinus surgery outcomes [47]. We prefer the shaver in the cases with extensive nasal polyps. The results of FESS due to CRS in children have been shown in several studies [18,21,24,38]. Most of the reported outcomes are based on the levels of symptomatic relief and do not include objective measures such as nasal endoscopy or CT scans. Giger proved that endoscopic scores correlate significantly with subjective satisfaction ratings (p > 0.001) [18]. Jiang and Hsu [24] and Fakhri et al. [14] observed postoperative improvement in 84%, a meta-analysis performed by Hebert and Bent [21] including 832 children (8 clinics) revealed a positive outcome from 88 to 92% after average follow up of 3.7 years. In very young children (under 4.8 years), a higher rate of further surgical interventions due to osteomeatal scarring was noted by Chan et al. [10]. FESS is unlike to be successful in children below the age of three [45]. But Lusk et al. reported a 10-year retrospective study, which proved superiority (p > 0.001) of FESS in the age of 2–5 years over medical treatment in parenteral assessment of
Table 4 Answers concerning sinunasal symptoms in questionnaires graded in four SNOT groups. Group
SNOT points
Level of complaints
All children
Smokers
Non-smokers
I II III IV
12 >12 and 32 >32 and 52 >52
No or little Little to moderate Moderate to severe Severe to extreme
32 26 13 2
4 18 11 2
28 8 2 0
(43.8%) (35.6%) (17.8%) (2.7%)
(11.4%) (51.4%) (31.4%) (5.7%)
(73.8%) (21.0%) (5.2%) (0%)
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improvement [38]. Efficiency of FESS has been found to be reduced if a child is exposed to tobacco smoke [44]. Concerning the mentioned fear, that endonasal operations might influence facial growth, Bothwell et al. [6] found no statistically significant differences with or without FESS using quantitative anthropomorphic analysis after a 13.2 years follow up. In CF improvement after FESS is less good than in non-CF children, but still significant with 50% after 2 years [1]. FESS is associated with a lower incidence of tracheobronchitis and pneumonia in CF-patients with a transplanted lung [22]. Adenoidectomy instead of FESS especially in very young children has been discussed [52], but Ramadan [45] reported in a prospective study comparing FESS to adenoidectomy in the treatment of CRS in children an improvement of 77% in the FESS group compared to 47% in the adenoidectomy group. In our patients the most frequent perioperative minor complications were diffuse bleeding in 4 cases; major complications were one arterial bleeding, one cerebro spinal fluid (CSF) leak. We did not see an iatrogenic lesion of the medial or inferior rectus nor the obliquus muscle, followed by scarring and global ocular motility dysfunction [5]. Our data confirm that FESS is a safe and efficient procedure. Most surgeons prefer FESS to conventional endonasal surgery [20], though there is no study, which proves significant superiority. In postoperative therapy we used topic steroids. Ramadan prefers intravenous dexamethason therapy perioperatively to reduce swelling and scarring; in his study it was particularly useful in children with asthma, lower CT scan grades, no tobacco smoke exposure and those over 6 years [44]. Our experiences with FESS in CRS show after a long follow up from 5 to 15 years with 75% improvement results similar to Ramadan and others [46]. As most studies have a lower mean follow up of about 3 years, we conclude that the benefit of FESS is stable after that time. Quality of life seems correlated with the absence of further discomfort caused by CRS. Though male and female patients agree in their assessment concerning the benefit of FESS, the female patients are more restrict concerning a reoperation if necessary. Previous revision surgery, extensive polyps, bronchial asthma [42], ASA-intolerance and CF are predictors for revision surgery [39]. The high frequency of revision surgery in our patients (21%) may be due to long-term follow up if compared to data based on a mean 3 years follow up with a frequency of about 12% [51] and on the high percentage of children having predisposing factors. In our patients 9 of 73 had revisions again, 3 of them having CF and 2 asthma; of the 6 non-CF patients 4 had started to smoke. The rate of revision surgery during the follow up was 12.6%. The negative influence of tobacco in CRS is well known. Patients with allergic rhinitis who have ever smoked have a 43-fold risk to have nasal polyps [23]. Smoking proved to play a significant role in outcome after FESS in adults [8,13]. Several authors have reported the role of passive smoking in children in CRS after FESS [29]. Significantly prolonged mucociliary clearance [50] and local impaired immune response [28] may play a major role. Further negative prognostic factors have an influence on the outcome after FESS: the most important of those are CF, asthma, and a high graded CT-scan. Ramadan noticed reduced improvement from 90% to 70% [44]. Our research showed a strong impairment of results after FESS in adolescents who had started or continued active smoking after operation. 5. Conclusion Our results show that 76% of the children had a significant benefit of FESS concerning symptoms and 71% in self-estimated
quality of life. FESS proved in most published series superiority to conventional endonasal surgery in outcome and acceptance. Unfortunately, nearly half of the adolescents of our inquiry started or continued to smoke. Subdividing the group into smokers and non-smokers, results show, that especially the non-smokers revealed improved outcome. The outcome after FESS in children is influenced in a high extent by passive and active smoking. Indications for FESS in childhood are now well-established [15]:
nasal obstruction due to massive nasal polyps; a muco- and pyocele; antrochoanalpolyp; orbital complications; CRS when adequate therapy has failed.
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