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 procedure of choice for adult sinusitis, both nationally and internationally, and its use in children has only recently been reported, but we believe that endoscopic sinus surgery is an equally safe and effective method of treating young patients.
As individuals grow and develop, the sinuses change significantly. Therefore, before operating on a child, the operator should have an in-depth understanding of the normal sinus anatomy and the etiology and pathophysiology of chronic sinusitis in children in this age group.
I. Etiology and pathophysiology of sinusitis in children
Healthy sinus function requires: open sinus orifices, functional ciliary apparatus and normal sinus mucus secretion. Mucus is continuously produced in the sinuses, and a healthy ciliary apparatus transports mucus to the open natural sinus orifice, where it is drained into the nasal cavity and nasopharynx and swallowed or spit out. If one or more of these steps are obstructed, sinusitis can be caused by the mechanisms discussed below.
Etiology
1. Mostly due to failure to treat acute sinusitis in a timely or effective manner, or due 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 related to allergic reactions. Allergic reactions often cause mucosal edema of the nasal cavity and sinuses, 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 bronchiectasis, which are the main causes of chronic cough. Chronic sinusitis and chronic bronchitis and bronchiectasis 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. Other diseases include cystic fibrosis (CF) and primary ciliary dyskinesia syndrome.
Pathophysiology
1. Sinus orifice obstruction The sinus orifice nasal complex (Ostiomeatal 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 mucociliary 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 cause sinusitis in children by mechanically impeding the mucociliary clearance of the sinonasal complex, such as nasal polyps, deviated septum, paradoxically curved middle turbinate (hyperflexion outward) or vesicular middle turbinate (significant enlargement of the middle turbinate, which often occurs twice as often in patients with sinusitis as in those without sinusitis); large septal vesicles that narrow the semilunar fissure; and significant overturning of the hooks that narrow the sinus opening. Other factors are shown in Table.
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: the production of excessive mucus or mucus thickening can lead to impaired ciliary activity, 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 in the anterior sinusitis group is mostly from the anterior nostril, while the pus in the posterior sinusitis group often flows backwards into the nasopharynx. Children can’t blow their nose, 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 headache, while younger children usually do not describe it, and often show irritability, irritability and crying in younger children.
Chronic cough is related to pus reflux on the one hand, and chronic bronchitis or bronchial dilatation on the other.
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, the possibility of intracranial complications should be alerted.
5. Hearing loss Due to edema of the eustachian tube or hypertrophy of the proliferator causing its dysfunction and causing secretory otitis media.
Examination and diagnosis
The diagnosis can generally be made based on the history, symptoms and signs, but the opinions of the parents and teachers of the child 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
Parsons et al. reported that 80% of children undergoing functional nasal endoscopy were positive for skin tests in the inhalation group. Preoperative allergic reaction tests for food and inhalation groups should be performed in children who are considered for surgical treatment and appropriate treatment should be administered. Because of the high incidence of allergic disease in patients with sinusitis, allergic reactions should be investigated in those whose initial drug therapy is unsatisfactory, regardless of a history of allergic reactions.
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, and 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 permeability of the sinus cavity.
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) to rapidly destroy bacteria in the secretions; (3) to
To prevent progression to chronic sinusitis and complications. The treatment of choice for children of any age with sinusitis is medication. Surgery is considered only after medication has failed. If nasal polyps are found on examination, surgical treatment is necessary.
[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 treatment is the basis of all treatment measures for sinusitis, and the choice of antibiotics is based on their susceptibility to pathogenic bacteria. 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, and Wald et al. concluded that hydroxybenzyl penicillin is similar to cefaclor in the treatment of acute sinusitis. Therefore, ampicillin (100 mg/Kg/day), or hydroxybenzyl penicillin (40 mg/Kg/day) for a minimum of 14 days may be preferred for the treatment of acute sinusitis in children without complications and without penicillin allergy. 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, cefixime or cefixime may be applied. These drug treatments shall be used for 21 to 30 days unchanged to avoid leading to chronic sinusitis.
2, other drug treatment In the treatment of sinusitis in children, antihistamines, decongestants, steroids, sodium cromoglycate, systemic dilution of secretions drugs and wet inhalation 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 to 5 days only, and the drug inhibits ciliary activity.
Antihistamines can dry 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, in resistant cases, topical steroids.
[Endoscopic sinus surgery for children].
When medication for acute sinus infection is ineffective, surgical treatment should be performed to prevent migration into chronic or recurrent sinusitis. In the past, the methods adopted for children with sinusitis that failed to be treated 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 uncertain. 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 (Computed Tomography,
CT) scans are the most sensitive imaging method and are often the only means of correctly diagnosing sinus lesions. Although plain radiographs of the sinuses in children can show certain abnormalities, they do not show sinus lesions accurately 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 infections 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 sinus abnormalities when analyzing CT scans in children. 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.
1992,
Ummat et al. observed 196 children (1-16 years old) with CT scans of the nasal cavity and sinuses and found that the sinus-oral-nasal tract complex had developed in children and could be visualized by CT scan. It was characterized by a constant sieve funnel width of 0.2 cm
This value suggests that this is the minimum width to ensure mucus outflow; the hook angle is relatively constant (142°~149°) and approaches the adult angle after 10 years of age (mean 140°); the middle turbinate is pneumatized about 4.2%, less than adults; the infraorbital air space is about 82% in children, more common than adults.
The authors analyzed the sinus CT scan results of 99 patients (174 sides) with chronic sinusitis in children and found that anatomical variation of the nasal cavity and sinuses was significantly associated with chronic sinusitis in children, and the side of the nasal cavity and sinus variation was more often associated with more severe sinusitis and could affect the development of the sinus-orifice nasal tract complex and maxillofacial bone. For children with chronic sinusitis that does not resolve after timely and reasonable pharmacological treatment, CT scans suggesting the presence of anatomic variants and correlating with sinusitis should be considered an indication for nasal endoscopic sinus surgery.
It should be noted that CT scans are not a perfect diagnostic method. in an analysis of 300 CT scans of children undergoing nasal endoscopic surgery, Lazar found that the extent of lesions seen intraoperatively was heavier than the preoperative CT scan in nearly 20% of cases; 7% of children with normal preoperative CT scans were found to have more severe sinus lesions intraoperatively.
2. Endoscopic sinus surgery approach for children
Doctors accustomed 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 all times while performing the surgery.
(5) Postoperative management and follow-up: Postoperative management and follow-up are as important as intraoperative removal of lesions for the success of nasal endoscopic surgery. Intranasal hormone sprays, decongestants, nasal saline rinses, and broad-spectrum antibiotics are applied to the child for 6 weeks postoperatively, and the 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 to 3 weeks after surgery and should, in principle, be performed under general anesthesia (see the chapter on anesthesia for anesthesia methods). Removal of clots, dried crusts, granulation tissue or adhesions and examination of the maxillary sinus are performed under the microscope. 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.
(6) Outcome and efficacy of endoscopic sinus surgery in children:The efficacy of endoscopic sinus surgery in children has been well established. The literature reports an effective rate of 75% to 90%. After long-term follow-up observations, it was found that many children with chronic sinusitis can be cured with reasonable and appropriate medication. Other authors have reported that the development of the palatine bone and craniofacial surface of children can be affected to varying degrees after undergoing sinus surgery; therefore, conservative treatment of chronic sinusitis in children is now mostly advocated. Endoscopic sinus surgery is used only after systematic medication has failed (requiring confirmation by both physician and parents).