Sinusitis is one of the many diseases that can occur in children that we used to know very little about. The symptoms of sinusitis were ignored or unrecognized because children could not express them or because doctors believed that the sinuses were not yet developed and would not be the source of clinical morbidity. However, sinusitis does occur more frequently in children, although the incidence in this age group is not known. The inflammatory process of the sinus mucosa arises from many causes, ranging from simple, localized inflammation to severe systemic disease. However, the most common are the result of upper respiratory tract infections and/or allergic diseases.
How to properly treat sinusitis in children is as difficult as how to make a diagnosis. It is best treated medically, but after failure of reasonable and systematic medication, surgery should be performed. Endoscopic sinus surgery (ESS) is rapidly becoming the surgical method of choice for sinusitis in adults, both nationally and internationally, and its use in children has only recently been reported, but I believe that endoscopic sinus surgery is an equally safe and effective method of treating young patients.
The sinuses change significantly as the individual grows and develops. Therefore, before operating on a child, the operator should have an in-depth understanding of the normal sinus anatomy of that child and the etiology and pathophysiology of chronic sinusitis in children.
Healthy sinus function requires an open sinus orifice, functioning ciliary apparatus, and normal sinus mucus production. Mucus is continuously produced in the sinuses, and healthy ciliary apparatus transports mucus to the open natural sinus orifices, where it is drained to the nasal cavity and nasopharynx and swallowed or spat out. If one or more of these steps are obstructed, sinusitis can be caused by the mechanisms that will be discussed below.
I. Etiology
1. mostly due to failure to treat acute sinusitis in a timely or effective manner, or to repeated episodes of prolongation.
2., proliferative hypertrophy or infection: proliferative hypertrophy and infection cause nasal obstruction, affecting the normal function and activity of the mucosa and cilia of the nasal cavity and sinuses.
3., allergic reactions: 65% of children with sinusitis are associated with allergic reactions. Allergic reactions often cause mucosal edema of the nasal cavity and sinuses and sinus drainage dysfunction, leading to sinusitis.
4. lower respiratory tract infection and chronic inflammation: chronic sinusitis in children is often accompanied by chronic bronchitis and bronchial dilatation, which is the main cause of chronic cough. Chronic sinusitis and chronic bronchitis and bronchodilation are often causal and affect each other.
5. gastroesophageal reflux disease ( GERD) is an important cause of ear and sinus disease in children
6, genetic factors and systemic diseases: such as primary and secondary immunodeficiencies and immunoglobulin subgroup defects. The common one is immunoglobulin G (IgG) subgroup deficiency. Others are cystic fibrosis (CF) and primary ciliary dyskinesia syndrome.
Pathophysiology
1. Sinus orifice obstruction: The sinus orifice nasal complex (OMC) is the key to the pathophysiology of sinusitis because this middle nasal tract area includes the openings of the frontal sinus, maxillary sinus and septal sinus. The end result of pathologic alterations in the sinus orifice nasal tract complex caused by multiple factors is sinus orifice obstruction, which causes sinusitis by severely impeding the mucus cilia flow transport of sinus secretions.
The most common cause of acute sinusitis in children is sinus orifice obstruction due to an inflammatory response, usually due to acute upper respiratory tract infection or allergic disease, or both. The inflammatory response causes hypertrophy and swelling of the sinus mucosa, resulting in sinus orifice obstruction, inflammatory exudation, accumulation of secretions, and secondary bacterial infection. Gas exchange is also disrupted, causing hypoxia and promoting the growth of certain flora (e.g., anaerobic bacteria). In addition to sinus orifice obstruction, these symptoms can lead to abnormal mucus cilia clearance.
Other factors can also cause sinusitis in children by mechanically impeding the mucociliary clearance function of the sinonasal complex, such as nasal polyps, deviated nasal septum, paradoxically curved middle turbinate (outwardly over-curved) or vesicular middle turbinate (significantly enlarged middle turbinate, which often occurs twice as often in patients with sinusitis as in those without sinusitis); large sieve vesicles that narrow the semilunar fissure; and significant overturning of the hooks that narrow the sinus opening.
2, mucus cilia malfunction: mucus cilia system for sinus local defense mechanism. When the lysozyme, secretory IgA and other surface enzymes in the mucus are at normal level and activity, and the sinus mucosal cilia activity is normal, the secretion is transported to the distal end by cilia oscillation. However, any quantitative or qualitative changes in mucus and changes in cilia function, number, morphology or dynamic properties can lead to mucus cilia malfunction or sinus orifice obstruction, causing sinusitis.
(1) Mucus changes or abnormalities: excessive mucus production or mucus thickening can lead to cilia activity impairment, and mucus thickening can even be concentrated. Children with cystic fibrosis are characterized by mucus-like secretions, and the sinuses are susceptible to infection.
(2) Mucociliary dyskinesia: cytotoxic effects of viral infection can lead to temporary mucociliary dysfunction, as can cold air and certain drugs. Mucous cilia dysfunction can also be secondary to congenital abnormalities, such as immobile cilia syndrome.
Clinical manifestations
1, nasal congestion and purulent nasal discharge: the purulent nasal discharge of anterior sinusitis is mostly from the anterior nostril, while the pus of posterior sinusitis often flows backwards into the nasopharynx. Children can not blow their noses, and the pus flows backward into the throat or trachea causing irritating cough, which is more serious at night.
2. Facial or headache: older children can name the site of the headache, while younger children generally do not describe it and often show irritability, irritability and crying in younger children.
3.Chronic cough: on the one hand, it is related to pus reflux, on the other hand, it is related to chronic bronchitis or bronchial dilatation.
4. Behavioral changes: children are depressed, inactive, have poor memory, etc. A few children have nausea and vomiting. If high fever, convulsions or seizures and jet vomiting occur, one should be alert to the possibility of intracranial complications.
5. Hearing loss: due to edema of the eustachian tube or hypertrophy of the proliferator leading to its dysfunction, causing secretory otitis media.
Examination and diagnosis
The diagnosis can generally be made based on the medical history, symptoms and signs, but the opinions of the parents and teachers of the affected children should be taken seriously.
1.Nasal cavity examination
Older children can undergo nasal endoscopy, while younger children cannot cooperate and tolerate it, so anterior rhinoscopy can be performed after 0.5% ephedrine contraction of nasal mucosa. Pay attention to the localization of pus, whether there are nasal polyps in the nasal cavity, and whether the proliferators are hypertrophic.
2.Pathological examination
Preoperative allergic reaction test should be done for food group and inhalation group for children who are considered for surgical treatment and appropriate treatment. Because of the high incidence of allergic diseases in patients with sinusitis, a metaplasia investigation should be done for those who are not initially treated with medication, regardless of whether there is a history of metaplasia.
It is difficult to cooperate with skin testing in children. Intradermal testing is considered the most sensitive, but an in vitro blood study showed that Pharmacia CAP (immune CAP) is 5-8% more sensitive than intradermal testing.
3.Imaging
Imaging plays a very important role in the diagnosis. Sinus plain films in children can show some abnormalities, but the reference value is not much. X-ray plain films have been replaced by sinus CT scans. Coronal CT scan is the most sensitive imaging method, which can clearly show the sinus lesions and the anatomical structure of the nasal cavity and sinuses. Sinusitis can be diagnosed by mucosal hypertrophy of the sinus cavity, obstruction of the sinus orifice, or decreased sinus cavity permeability.
V. Treatment
Chronic sinusitis is an infectious disease, and there is increasing evidence that chronic sinusitis in children is a disease that can generally be treated with medication and does not necessitate surgery. The main objectives of sinusitis treatment.
1. to re-establish the normal physiology of the sinuses
2. rapid destruction of bacteria in the secretions.
3. to prevent the progression to chronic sinusitis and the occurrence of complications.
The treatment of choice for children with sinusitis of any age is medication. Surgery is considered only after medication has failed. If nasal polyps are found on examination, surgical treatment is mandatory.
VI. Medication
Pharmacological treatment of acute sinusitis in children usually includes antibiotics, decongestants, secretion-thinning drugs and moistened inhaled air; antihistamines, sodium cromoglycate and topical steroids are rarely applied in children. Such treatment can cure 80% of acute sinusitis in children.
1.Antibiotic treatment
Antibiotic therapy is the basis of all treatment measures for sinusitis, and the choice of antibiotic is based on its sensitivity to the causative organism. The common causative organisms of acute sinusitis are S. pneumoniae, Haemophilus influenzae, or C. catarrhalis, while chronic sinusitis may be dominated by anaerobic bacteria, which should be fully considered in the selection of antibiotics.
There are now a considerable number of antibiotics that can effectively treat sinusitis. For the treatment of acute sinusitis in children without complications and without penicillin allergy, ampicillin (100 mg/Kg/day) or hydroxybenzyl penicillin (40 mg/Kg/day) may be preferred for a minimum of 14 days. The drugs of choice for penicillin allergy are erythromycin (50 mg/Kg/day), sulfamethoxazole, and compounded sulfamethoxazole, although the latter may be ineffective against Streptococcus aureus.
Nearly 20% of pediatric cases are ineffective on first treatment, probably due to b-lactamase-positive (hydroxybenzyl penicillin-resistant) clusters. If the preferred drug therapy is ineffective, cefaclor or cefixime may be applied. These drug treatments shall be used for 21-30 days unchanged to avoid leading to chronic sinusitis.
2.Other medication
During the treatment of sinusitis in children, antihistamines, decongestants, steroids, sodium cromoglycate, systemic secretion-thinning drugs and humidified inhaled air must be applied in combination with antibiotics. Although these methods help to reduce edema and improve mucociliary clearance, their usefulness in the treatment of sinus disease is not known with certainty. Topical decongestants are used for 3-5 days only, and the drug inhibits ciliary activity.
Antihistamines can dry out secretions and make drainage difficult. Despite these effects, topical decongestants and antihistamines are beneficial in children with allergic factors.
Prevention and treatment of sinusitis in children with allergic factors must be carried out through environmental modification, pharmacotherapy, and immunotherapy. Pharmacological treatment includes sodium cromoglycate, antihistamines (with or without decongestants), and topical steroids in resistant cases.
VII. Endoscopic sinus surgery for children
When medication for acute sinus infection is ineffective, surgical treatment should be performed in order to prevent migration into chronic or recurrent sinusitis. In the past, the methods taken for children with sinusitis that did not work with medication were usually maxillary sinus irrigation, intranasal maxillary sinus opening, tonsillectomy and proliferator resection and limited septal orthopedics, the indications and results of which were not certain. However, the preferred surgical treatment for chronic and recurrent sinusitis in children is now endoscopic sinus surgery, the same as in adults, but the indications should be strictly controlled.
1. Preoperative nasal endoscopy: Before nasal endoscopy, the extent of the nasal sinus lesions must be clarified. Children can undergo detailed nasal endoscopy after successful anesthesia and develop a surgical plan in combination with imaging diagnosis.
2. Sinus CT scan: Sinus CT (CT) scan is the most sensitive imaging method and is often the only means to correctly diagnose sinus lesions. Although sinus plain films in children can show certain abnormalities, they are not accurate in showing sinus lesions compared to CT scans.
CT scans may even show microscopic mucosal edema that is often isolated in the nasal sinuses, and it is important to note the correlation of these abnormalities with the patient’s symptoms and recent upper respiratory tract infections. Children often have symptoms of upper respiratory tract infection, and the corresponding nasal inflammation can also lead to swelling of the sinus mucosa, which appears as “sinusitis” on CT scans, so it is important to note that almost half of all children have abnormal sinuses when analyzed on CT scans. This may explain the edema of the sinus mucosa in many children without symptoms of sinusitis or with the resolution of upper respiratory tract infections. If there are positive imaging findings, it is important to clarify whether subacute and chronic sinusitis and upper respiratory tract infections are present; therefore, positive CT scan findings are not in themselves an indication for surgery. There are two types of anatomic abnormalities seen on CT scans in children with recurrent acute and chronic sinusitis: bony and mucosal abnormalities. Bony structural abnormalities can lead to obstruction of sinus drainage channels.
It should be noted that CT scans are not a perfect diagnostic method.
3. Endoscopic sinus surgery in children
Doctors who are used to adult nasal endoscopic surgery should remember that children’s sinuses are smaller, their depth and lumen are smaller, and the adjacent structural relationships are different from those of adults when performing surgery on children. The operation must be performed gently and the tissue must be handled carefully in order to significantly reduce surgical trauma, postoperative edema, adhesions and granulation tissue formation, and to reduce complications, for better surgical results. Preoperative CT scan should be referred to at any time while performing the surgery.
4.Post-operative treatment and follow-up
Postoperative management and follow-up are as important as intraoperative lesion removal for the success of nasal endoscopic surgery. Postoperative children are placed on intranasal hormone sprays, decongestants, nasal saline rinses, and broad-spectrum antibiotics for 6 weeks, and hormone sprays and other medications may be discontinued during weeks 5 and 6.
The child should be reviewed weekly during the initial weeks of the nasal endoscopy procedure, with intervals gradually increasing with the recovery process. Nasal endoscopy is the basic management component of the postoperative follow-up 2-3 weeks after surgery and should, in principle, be performed under general anesthesia (see the chapter on anesthesia for anesthesia methods). Microscopic removal of clots, dried crusts, granulation tissue or adhesions and examination of the maxillary sinuses are performed. At the end of the examination and treatment, as at the end of the procedure, an antibiotic-steroid hormone ointment is applied to the operative cavity.
5. Surgical results and outcomes
The efficacy of endoscopic sinus surgery in children has been well established. With reasonable and appropriate medication, many children with chronic sinusitis can be cured. After undergoing sinus surgery, the development of the palatine bone and craniofacial surface of children will be affected to varying degrees; therefore, conservative treatment of chronic sinusitis in children is mostly advocated at present. Endoscopic sinus surgery is used only after systematic medication has failed (requiring confirmation by both physician and parents).