This leads to retained secretions in the sinuses and the potential for subsequent bacterial infection. This predisposes them to have significant inflammation in the sinus lining triggered by certain environmental factors. The external triggers differ for each individual, but may include environmental allergies pollens, trees, dust, molds, etc.
Once a susceptible patient is exposed to an external trigger, a cycle of inflammation begins. Often the resultant swelling and congestion leads to a secondary bacterial infection that further exacerbates the inflammation. Severe, prolonged inflammation can result in nasal polyp formation see picture on right. Other causes of sinus obstruction can include trauma or previous surgery. Scarring from prior sinus surgery may actually lead to blockage of the sinuses. When this happens, a detailed evaluation is needed by a surgeon with extensive experience in revision sinus surgery, as repeated surgery may be needed.
These are highly complex cases and usually require the care of a sinus specialist. The diagnosis of sinusitis is based primarily on clinical symptoms and physical exam. Many of the symptoms of sinusitis may be seen in other conditions, making it essential that an accurate diagnosis is made. Recent guidelines have defined sinusitis as the presence of two or more symptoms. Fever or pain alone without other symptoms does not typically suggest sinusitis.
The diagnosis and treatment of each patient must be individualized depending upon the specifics of their case. A CT scan CAT scan or X-ray are not usually obtained in order to make the diagnosis of sinusitis, unless there is concern for a potential complication. This painless procedure greatly enhances our ability to evaluate and treat patients with sinus problems. In addition to looking at the condition of the nasal lining, we can obtain very specific bacterial culture swabs if needed. Sinusitis is a very common disease that is treated by a variety of physicians. Patients with significant asthma may see a pulmonologist or allergist.
Others are often referred to ear, nose, and throat ENT doctors also known as otolaryngologists. ENT physicians are able to provide both comprehensive medical and surgical treatments for sinusitis. ENT surgeons who subspecialize have completed fellowships of at least one year and focus exclusively upon one area. Sinus specialists are called rhinologists and MUSC has two fellowship-trained rhinologists. While small sinuses in the maxillary cheek and ethmoid between the eyes regions are present at birth, the sinuses in children are not fully developed until their teenage years or early 20s.
Unfortunately, children can still suffer from sinusitis, and it may be more difficult to diagnose in children. Due to their immature immune systems, children usually get viral infections each year. While some of the symptoms are similar to adults with sinusitis, children may suffer more often from cough, irritability, and swelling around the eyes. Treatment of chronic sinusitis in children is similar to that of adults, beginning with reducing exposure to known environmental allergies and irritants tobacco smoke, daycare, acid reflux and progressing to the use of medications.
Fortunately, children respond to medical therapy even better than adults with chronic sinusitis.
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In those rare cases where surgery is needed, an adenoidectomy is often successful as an initial approach, especially in children younger than 6 years old. This removes enlarged tissue in the back of the nose that can cause many of the symptoms of chronic sinusitis. FESS is reserved for the most refractory cases. Polyps are non-cancerous, grape-like growths that can occur in the nose or sinuses.
Pediatric Sinusitis | Otorhinolaryngology – Head & Neck Surgery | McGovern Medical School
They are unrelated to polyps that may occur elsewhere in the body colon or bladder. They often occur in patients with asthma or allergies. Patients with polyps can suffer from nasal obstruction, decrease in taste or smell and other symptoms of chronic sinusitis. The best medication for treating polyps is oral or topical steroids. These medications can reduce or stabilize the size of the polyps. Unfortunately, once the oral steroids are stopped, the polyps often recur. Surgery FESS can be used to remove polyps, but when used alone, it also may be a temporary solution.
The best results are generally seen with surgery to remove the bulk of the obstructing polyps and then daily steroid irrigations. Our center has a number of clinical trials investigating novel methods of delivering steroid to the sinus cavity link. Intermittent bursts of oral steroids after surgery may also be used to minimize the chances for recurrence. Patients with polyps and asthma will usually have better control of their asthma once their polyps and chronic sinusitis are adequately managed.
AFRS is common in the south. Patients are generally younger and may have more severe erosion of the bone around their eyes or up towards their brain. This type of nasal polyposis actually responds quite well to complete surgery and steroid irrigations. Unfortunately immunotherapy alone or anti-fungal medications have been of limited benefit.
These patients improve most often with surgery, postoperative steroid irrigations and consideration of aspirin desensitization.
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Aspirin desensitization is typically done only at select centers. Patients can still have significant sinus inflammation and mucosal thickening without developing obvious nasal polyps.
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These patients often have diffuse inflammation on both sides of their nose, but this type of sinusitis is not associated with asthma and allergies as often as sinusitis with nasal polyps. Treatment does not rely as heavily upon steroids and instead may focus more upon antibiotics. Other causes for sinusitis without nasal polyps should be looked for, such as dental infections that spread to the sinuses or isolated fungus balls. Another form of chronic sinusitis without nasal polyps is mucoceles.
This occurs when the opening to a sinus is blocked. Mucus production continues behind this blockage and the sinus expands, similar to a water balloon. The prognosis for most of these isolated forms of sinusitis is quite good and the surgical cure rate is high. Most patients with cystic fibrosis CF have involvement of both the upper and lower airway. Sometimes this procedure is performed in conjunction with other procedures to improve nasal breathing ie: inferior turbinate reduction, nasal endoscopy, nasal cautery or septoplasty.
Children will have typically been treated with antibiotics, nasal steroid sprays, topical nasal saline irrigations and allergy therapy, as indicated, prior to being recommended for sinus surgery. Small bridges of thin bone or mucus membrane may be blocking the natural drainage pathways of the sinus cavities, leading to blockage and subsequent infection. The goal of sinus surgery is to establish natural, normal drainage patterns, and to allow access to the sinus cavities for topical medications and saline irrigation.
The procedure usually takes about hours, but can take much longer depending on the severity and any other additional combined procedures planned. The surgeon provides an idea of how much time is expected, but this may change during the procedure. Before and after surgery: a pediatric nurse prepares the child for surgery, assists the pediatric ENT surgeon during surgery, and cares for the child after the procedure.
Anesthesiology: The child is placed under general anesthesia by a pediatric anesthesiologist. It is important that the parent meet with the anesthesiologist prior to the procedure. Surgery: A pediatric ENT surgeon may use specialized telescopes to systematically evaluate the nasal airway in conjunction with specialized nasal instruments.
If additional procedures are needed, additional special instruments may be used to perform these procedures. The surgeon discusses the postoperative plan with the parent after the procedure. The usual duration of therapy is weeks. Antibiotics can be delivered systemically, via mouth or vein, or locally by inhalation or direct installation into the maxillary sinuses.
Systemic antibiotics are the standard of care, and usually treat sinus and pulmonary exacerbations simultaneously. Nebulization of antibiotics directly into the sinuses has been studied in a non-CF population. In an 8-week study of non-CF sinusitis, nebulized aminoglycosides were shown to decrease bacterial colonization and inflammation of the nasal cavity. It is generally accepted that there is some penetration of the sinuses with TOBI for patients who use the drug regularly. Commercial companies now sell nebulizers adapted for inhalation through the nose and dispense an array of antibiotics for nasal inhalation.
Anecdotally, many CF patients have benefited from this form of treatment. Flushing of the maxillary sinuses through catheters placed directly into the sinus is possible in patients who have undergone surgical antrostomies. A retrospective study of 32 CF patients with chronic sinusitis showed that those who had monthly flushes with tobramycin had fewer surgeries over a 2-year period of time.
Pediatric Sinusitis and Sinus Surgery
What still remains unclear is how this treatment compares to other forms of 'airway clearance' for the upper respiratory tract and what the influence of monthly checks on the sinuses is. Anecdotally, some patients get relief of their sinus symptoms by flushing their nares with saline. Symptomatic improvement is achieved by clearing mucus and hydrating thick secretions. It may also decrease blood flow resulting in decongestion.
Of course, infectious organisms are also removed with the nasal secretions. Many patients are asked to do this regularly after endoscopic surgery. Commercially available products include saline-filled squeeze atomizers, some which contain the moisturizing agent glycerol. More economically, patients can flush with a buffered saline solution they make themselves. The nares are washed with the saline using a bulb or catheter-tipped syringe.
Nasal steroids are a mainstay of therapy for non-CF sufferers of sinusitis. They are used with variable success in patients with CF related sinusitis.
There are reports that regular use of nasal steroids diminish the size and number of nasal polyps, and that use after polypectomy decreases the rate at which polyps reform. No convincing data exists to support the use or disuse of antihistamines and decongestants in CF. Some patients have been counseled to stay away from them for fear of further drying out secretions. Other CF patients, especially those with a clear history of allergies, use antihistamines regularly with relief of symptoms of stuffiness and runny nose and no worsening of their lung congestion.
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Decongestants, such as pseudoephedrine Sudafed , can be helpful for relieving symptoms of sinus headache or fullness.