eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Pediatric Sinusitis, Surgical Treatment

John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School

Updated: Oct 29, 2008

Introduction

The paranasal sinuses consist of 4 paired sinuses, including the maxillary sinuses, ethmoid sinuses, frontal sinuses, and sphenoid sinuses. Maxillary sinuses lie under the cheek; ethmoid sinuses lie between the eyes; frontal sinuses lie above the eyes in the center of the forehead; and sphenoid sinuses lie in the back of the nose and nasal cavity. Infected fluid in the sinuses is termed sinusitis. Chronic sinusitis is an infection that lasts 3 months, and recurrent sinusitis is a condition in which acute sinusitis continues to recur following medical treatment.

Initially, treat all sinusitis cases without suppurative complications with medical therapy. If maximum medical therapy is unsuccessful in a child with chronic or recurrent sinusitis, evaluation for underlying medical disorders (eg, immunodeficiency, allergic rhinitis, cystic fibrosis [CF], immotile cilia syndrome) is warranted. If chronic sinus infections continue following treatment for an associated condition, consider surgery. Surgery for chronic sinusitis in children, as in adults, has changed over the years.

History of the Procedure

Surgical management of chronic sinusitis has 2 distinct eras in the past 50 years, before and after discovery of the true physiologic way that the sinuses clear secretions. In Europe in 1978, Messerklinger authored a book describing research demonstrating that the physiological flow of secretions in the sinuses was to their respective ostia or openings.¹ Cilia on the mucosal lining of the sinuses push secretions on top of a mucociliary blanket toward the natural opening, attempting to clear them into the nasal cavity and down the pharynx, eventually to be swallowed into the stomach. Based on this research, functional endoscopic sinus surgery (FESS), now commonly known only as endoscopic sinus surgery (ESS), was developed.

Prior to introduction of the physiological flow of the sinuses, surgery was aimed at removing ethmoid air cells, opening up the sphenoid widely, opening up the maxillary sinus via a Caldwell Luc or inferior meatal window, and possibly removing the middle turbinate. This was performed with a headlight and big forceps. With the innovation of the Hopkins rod telescopes and xenon light sources in the late 1960s and early 1970s, visualization in the nasal cavity was much improved. Surgeons became more interested in the intricate anatomy of the sinuses and lateral nasal wall. New techniques were developed to make the surgery safer and more successful. A new area of study was established.

Endoscopic sinus surgery (ESS) has been practiced for more than 2 decades. It began in Europe with techniques described by Messerklinger and Wigand. The Messerklinger technique involves initially opening up the anterior area where the sinuses drain, the ostiomeatal complex (OMC), which appears to be the bottleneck for disease. If this area can be opened, the sinuses may be able to ventilate and drain, keeping them clear of disease.

A second area of drainage is into the sphenoethmoid recess where the posterior ethmoids and sphenoid drain. Surgery is aimed at clearing out the ethmoid cells and opening up the sphenoid ostia. In a 1981 report, Wigand described increased access to this area by removing the posterior portion of the middle turbinate, thereby allowing for increased exposure during surgery and decreased obstruction after surgery.²

Several surgeons began to popularize Messerklinger's technique; the most noticeable was his pupil, Heinz Stammberger. Stammberger promoted the Messerklinger technique in Europe and then in America with Kennedy in 1985 and 1986.^3,4,5,6,7 Several pediatric otolaryngologists, including Lusk, Lazar, and Gross began performing ESS in children in 1986. Since that time, numerous articles and books have discussed the general technique of ESS, as well as specific techniques for specific sinuses and their ostia. A wider range of instrumentation for endoscopic sinus surgery (ESS) has been introduced with various opinions and results.

Overall, sinus surgery for chronic sinusitis has been proven to be effective in appropriately selected patients when the main goal of any particular technique is to open and aerate the sinuses where they naturally drain. Endoscopic sinus surgical techniques have been used successfully for other diseases of the nasal cavity and sinuses, including nasal polyposis, nasal tumors, and suppurative complications of sinusitis.

Problem

Sinusitis is defined as an infection of one or more of the paranasal sinuses. It implies the stasis of secretions in the affected sinus, usually caused by a bacterial infection. Sinusitis occurs when the outflow tract of the sinus is blocked, fluid becomes trapped, and fluid becomes infected with bacteria.

Frequency

The frequency of sinusitis is difficult to estimate because, throughout the literature, definitions are conflicting. If the loosest definition is accepted (ie, infection and inflammation of the nasal cavity and paranasal sinuses caused by bacteria and viruses), 1 billion cases of acute sinusitis have been estimated to occur in the United States each year, affecting at least 30% of the population, with a health care expenditure of 2.2 billion dollars on prescription and nonprescription drugs. Most acute cases of rhinosinusitis are viral, whereas chronic sinusitis is more often bacterial, requiring long-term medical therapy, or eventually, surgery. According to the National Ambulatory Medical Care Survey, if an adult is sick enough with rhinosinusitis symptoms to seek care from a physician, a bacterial infection is present 50% of the time.

Children, however, more often have viral infections with sinonasal symptoms, with bacteria present 10-20% of the time. Sinusitis is often observed in children with allergic rhinitis, and 10-25% of children around the world are estimated to have allergic rhinitis, reviewing data from Germany, Italy, Japan, Norway, Poland, Sweden, and Britain. In 1994, Wright estimated that 42% of children in the United States had seasonal rhinitis. The number of children who then proceed to surgical drainage of the sinuses is not well defined.

Etiology

The cause of acute or chronic sinusitis is obstruction of the outflow tracts of the individual sinuses, usually because of mucosal edema. The main outflow tract of the sinuses, especially the anterior sinuses (which are most commonly affected), is through the OMC near the ethmoid cavity and middle turbinate. Mucosal edema may arise from chemical or environmental irritants (eg, secondhand smoke, allergic rhinitis, chronic infections in the nasal cavity).

Similarly, if the mucociliary blanket does not function, as in children with immotile cilia syndrome or CF, secretions cannot be cleared, causing obstruction of the outflow tract of the sinuses with stasis of secretions and chronic infection. The most common bacteria observed in chronic sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, alpha-hemolytic streptococci, Staphylococcus aureus, and rarely, anaerobes. Anaerobes are more often observed in adults with chronic sinusitis.

Pathophysiology

The nasal cavity and paranasal sinuses are lined with pseudostratified ciliated columnar epithelium. The cilia on the lining are encased in a mucociliary blanket that beat in specific directions to move mucous and particulate matter through the nasal cavities and sinuses. Cilia in the sinuses beat toward their ostia. If inflammation of the mucosa of the outflow tracts of the sinuses occurs, whether from infection, allergic reaction, or irritation, the mucosal surfaces can come into contact with one another. For any mucosal surface, contact results in obstruction of the sinus and localized disruption of the mucociliary clearance. This leads to relative negative pressure in the sinus, stasis of secretions, and sinusitis. Therapy, whether medical or surgical, is aimed at decreasing this mucosal contact and opening up the sinuses, allowing them to ventilate and drain.

Maximal medical therapy is aimed at decongesting the mucosa of the outflow tracts to open up the sinuses, as well as to directly treat the infecting bacteria with antibiotics. If ventilation cannot be accomplished medically, surgical intervention may be indicated. For the endoscopic technique, surgery is aimed at removing the bony obstruction at the sinus outflow tracts. Once widened, mucosal edema arising from allergic reactions, upper respiratory infections, or chemical irritants hopefully will not be severe enough to result in obstruction. The actual size of the ventilation opening needed to prevent sinusitis is unknown.

Presentation

Children with sinusitis present with persistent or recurrent purulent rhinorrhea or postnasal drainage resulting in cough, nasal congestion, maxillofacial pressure and pain, and occasionally, fever and/or headaches. The most common signs are purulent rhinorrhea and cough. Chronic conditions are usually present for 3 months. Recurrent sinus infections may clear between episodes, and clinical symptoms of the sinus infection and nasal airway obstruction may clear. Purulent rhinorrhea in children is confusing. Purulence (yellow or green color) is derived from dead granulocytes that may or may not have arisen while fighting a bacterial infection. Purulent rhinitis can be the result of a viral infection, sinusitis, or adenoiditis.

Additional important information can be obtained from the physical examination. In young children, the initial physical examination of the nasal cavity is performed with an otoscope. Often, the inferior turbinate can be visualized, and the middle turbinate and lateral nasal wall in the area of the OMC can be visualized as well. If the inferior turbinate is large and the mucosa is pale, suspect allergic rhinitis. If the mucosa is erythematous and purulence is observed in the middle meatus, suspect a bacterial infection. Fever and maxillary sinus tenderness increases the suspicion for a bacterial infection. If the nose anteriorly looks clear overall but nasal congestion is encountered along with purulent rhinitis, suspect adenoiditis. For purulent rhinitis that lasts longer than a week or 10 days, with prolonged fever (temperature >102°F) or with maxillofacial pressure and pain, treat with antibiotics.

Indications

Purulent rhinorrhea, nasal congestion, and cough in toddlers to preteens warrant consideration of viral upper respiratory infection, adenoiditis, and sinusitis. If a child has had these symptoms repeatedly, requiring multiple courses of antibiotics, direct initial evaluation at the possibility of allergic rhinitis causing sinusitis, an enlarged and chronically infected adenoid, and chronic paranasal sinusitis. If adenoid hypertrophy is diagnosed, especially in the absence of allergic rhinitis, adenoidectomy is the first indicated surgical procedure (see Adenoidectomy).

In older children with signs and symptoms of chronic sinusitis and small adenoids, initial surgical options are more confusing. Some evidence supports that adenoidectomy alone does not improve the disease and that endoscopic sinus surgery (ESS), combined with adenoidectomy, is an appropriate initial surgical approach. Regardless, endoscopic sinus surgery (ESS) for chronic or recurrent sinusitis is indicated only when maximum medical therapy is unsuccessful.

For children, maximal medical therapy is usually defined as treatment with several 3-week courses of antibiotics and adjuvant medicine to decongest and clear the nasal cavity and OMC. Antibiotics should be directed at the most common pathogens of sinusitis, including S pneumoniae, H influenzae, and M catarrhalis. Other important bacteria cultured from the sinuses at the time of endoscopic sinus surgery (ESS) include alpha-hemolytic streptococci, S aureus, and rarely, anaerobes. Anaerobes are more often observed in adults with chronic sinusitis.

Adjuvant medicine to decongest and clear the nasal cavity and OMC should include oral decongestants, oral and intranasal antihistamines, isotonic and hypertonic nasal saline sprays and irrigations, nasal steroid sprays, histamine stabilization sprays, and expectorants. Screen and treat underlying medical conditions, such as allergic rhinitis, cystic fibrosis (CF), immunodeficiency, and dysfunctional ciliary syndromes if present and treatable. Consider endoscopic sinus surgical therapy for chronic sinusitis only after a thorough evaluation has been performed and proper adequate medical treatment has been administered.

However, certain medical conditions may warrant immediate endoscopic surgical intervention. A suppurative complication of acute or chronic sinusitis (eg, brain abscess, meningitis, orbital abscess) requires correction of the complication and surgical eradication of disease in the affected sinus. Tumors or other lesions of the sinus may mimic sinusitis and warrant removal or biopsy for diagnosis.

Sphenoid sinus

Controversy exists over whether or not to enter the sphenoid when it displays chronic sinusitis without polyposis on CT scan. In a 1996 report, Smith declared that, for cases of chronic sinusitis, eradication of ethmoid disease results in spontaneous resolution of sphenoid disease, inciting caution for formally entering the sphenoid sinus.⁸ For polypoid disease or lesions in the sphenoid sinus, surgical approaches must be considered.

Frontal sinus

Indications for pediatric frontal sinus surgery are similar to indications for adult surgery and include chronic sinusitis, frontal sinus polyposis, acute sinusitis unresponsive to 24-48 hours of appropriate antibiotics, and suppurative complications of sinusitis. A particularly interesting and not uncommon entity observed in teenagers with no history of chronic sinusitis is intracranial complications from acute frontal sinusitis. Initial presentation of these teenagers may consist only of a few days of nasal drainage, with subsequent fever and neurologic changes. Often, sinusitis is unilateral, occurring in the anterior ethmoids, frontal sinus, and occasionally, maxillary sinus.

A combined neurosurgical and otolaryngic approach must be coordinated to remove disease. The mucosa of the nose and sinuses is inflamed and infected. This can lead to increased bleeding and decreased visualization. In this situation, an external approach to the frontal sinus via a Lynch incision is recommended to drain the purulent fluid.

Nasal polyposis

Consider endoscopic sinus surgery (ESS) for children with nasal polyposis refractory to nasal steroids, short-course oral steroids, or leukotriene inhibitors. Nasal polyposis may be observed in patients with cystic fibrosis (CF), allergic fungal sinusitis, chronic sinusitis, or other types of lesions or tumors of the nose (see Nasal Polyps). In patients with CF and nasal polyposis, a dilemma arises concerning indications for surgery. CT scans in patients with CF almost uniformly show disease. Hallmarks include bulging of the medial maxillary wall with frequent mucocele formation of the maxillary sinus.

Most authors believe that patients should have surgery when they are symptomatic. In a 1996 report, Nishioka advocated that patients with CF who feel that they are asymptomatic or minimally symptomatic are unaware of the potential improvement because they have adapted to a subpar clinical state secondary to their disease.⁹ Once their disease is exonerated, they realize that their nasal airflow is increased, their ability to smell exists, and their food tastes better. They also become aware of their appropriate baseline.

Repeat surgery is not uncommon in patients with CF. With the advance of the surgical microdebrider, revision surgery can be performed quickly, precisely, and safely. In a 1997 article, Mendelsohn reported that the microdebrider greatly decreased the recurrence rate.¹⁰ Patients with CF who have surgery for symptomatic relief uniformly state that they would do it again.

Relevant Anatomy

Before successful endoscopic sinus surgery (ESS) can be performed in children, knowledge of the anatomy, physiology, and development of the nasal cavity and paranasal sinuses must be understood. The basic relationships of the anterior ethmoids and middle meatus, including the uncinate process, ethmoid infundibulum, hiatus semilunaris, and bulla ethmoidalis, are present at birth. These are relatively constant landmarks throughout life. Most of the change involves growth and pneumatization of these sinuses and the lateral nasal wall. Most of the growth for the sphenoid and frontal sinuses occurs later, from 4-14 years of age.

Infants are born with maxillary and ethmoid sinuses. The number of ethmoid air cells, ranging from 3-15 cells per side, rarely changes over a child's life. However, the cells themselves increase in size and pneumatize rapidly in the first 3-4 years of life. At birth, the maxillary sinus represents a shallow sac in the lateral nasal wall, developing rapidly in the first 4 years of life. By age 4 years, the maxillary sinus has expanded laterally to the infraorbital canal and inferiorly to the attachment of the inferior turbinate.

At birth, the sphenoid sinus is a blind mucosal sac that does not reach the sphenoid bone or cartilage, and the frontal sinus is not present. By age 4 years, the frontal sinus begins to expand from the frontal recess, and the sphenoid sinus is the size of a pea but is easily identifiable. From age 4-8 years, the ethmoid growth slows. By age 7 years, the maxillary sinus floor extends to the middle of the inferior meatus. At this age, the floor of the nose is still lower than the floor of the maxillary sinus, and the permanent teeth have not all erupted. A Caldwell Luc procedure or inferior meatal window performed in preschool aged children could damage permanent tooth buds. The sphenoid and frontal sinuses continue to expand in this developmental period.

For the most part, the final stages of development and pneumatization of the paranasal sinuses occurs from age 8-14 years, roughly equaling adult size. The maxillary sinus now has expanded to the floor of the nose and beyond. Over the next 10 years, some minor increases in pneumatization may occur, and the sphenoid sinus may change slightly in configuration.

Because the relationships of the paranasal sinuses stay relatively constant, surgical techniques for sinus surgery stay relatively similar throughout a child's life, especially for the anterior ethmoid and maxillary sinuses. Technically, it can be performed in young children. The author has endoscopically drained a subperiosteal abscess in a 7-week-old infant, opening up the lamina papyracea relatively widely to allow drainage. Although the lateral nasal wall landmarks were similar in position to older children, the ethmoid bulla and lamina papyracea appeared slightly higher in its relationship to the middle turbinate.

Knowledge of the endoscopic anatomic relationships of the nasal cavity, lateral nasal wall, and paranasal sinuses is extremely important to perform successful surgery and prevent complications. When endoscopic sinus surgery techniques were developing, certain aspects of the anatomy of the lateral nasal wall were named differently. In order to clearly define paranasal sinus anatomy and unify terminology, an international conference on sinus disease for terminology, staging, and therapy was held in July 1993. Most all of the leaders in endoscopic sinus surgery were present. The endoscopic sinus surgeon must be familiar with this anatomy in all age groups.

Contraindications

The only absolute contraindication to surgery is the inability to undergo general anesthesia. A relative contraindication to surgery is an incomplete workup or inadequate maximum medial therapy.

Workup

Laboratory Studies

• The only laboratory evaluation to consider in children with signs and symptoms of chronic sinusitis are the following:
  • Radioallergosorbent testing (RAST) for food and inhalant allergens
  • Sweat test or serological testing for cystic fibrosis (CF)
  • Immunologic evaluation, including immunoglobulins
• A culture and sensitivity can be taken from purulent drainage near the OMC to ensure proper antibiotic choice.

Imaging Studies

• CT scanning: CT scanning in the axial and especially coronal plane is the criterion standard for evaluation of chronic sinusitis in children and adults to look for chronic mucosal disease, anatomic abnormalities, and chronic stasis of secretions.
  • Scanning intervals of 3 mm in the coronal plane are adequate to define the anatomy and disease.
  • For endoscopic sinus surgery (ESS) to correct skull base defects or to further identify abnormalities observed on coronal scans of 3-mm intervals, 1- to 2-mm overlapping intervals can be obtained.
  • A screening CT scan that contains a scout radiograph of the lateral skull and neck and 11 other cuts through various key anatomic areas can provide information on the amount of disease in the paranasal sinuses and nasal cavity at a cost similar to plain radiography of the sinuses.
  • Anatomic abnormalities observed on CT scan (eg, concha bullosa, agger nasi cell, Haller cell, deviated septum) have a similar incidence in patients with or without chronic sinusitis symptoms. These abnormalities, however, combined with chronic inflamed mucosa, could contribute to the perpetuation of chronic sinusitis. If these abnormalities are observed in conjunction with CT scan evidence of chronic sinusitis and impinge upon the natural outflow tract of the sinuses, they should be corrected or removed. Isolated anatomic abnormalities without chronic sinusitis may have no bearing on the disease process.
• Plain radiography
  • The role for plain radiography of the paranasal sinuses in children in preparation for endoscopic sinus surgery (ESS) is limited.
  • When evaluating plain radiographs and CT scans, a 75-80% disagreement can occur. In 2 independent studies, roughly 35% of the time plain radiographs of the sinuses showed sinusitis when CT scans were clear. Forty percent of the time, plain radiographs were negative when CT scans showed disease.
  • In younger children, incomplete pneumatization of a sinus can be confused with an opacified sinus, and overlapping structures make determining mucosal thickening in the sinuses, a common finding in chronic sinusitis requiring surgical therapy, difficult.
  • Plain radiography is occasionally helpful in diagnosing acute sinusitis but still falls short in diagnosing disease in the ethmoid cavity because it is a labyrinth of 5-15 small cells that can overlap, clouding true disease.
  • Air-fluid levels and opacification can be identified more accurately in the single chamber cavity of the frontal, maxillary, and sphenoid sinus. A lateral plain radiograph of the neck is helpful, however, to evaluate for adenoid hypertrophy, which can mimic sinusitis.
• MRI
  • MRI is helpful if further soft tissue delineation is needed to differentiate polyps, tumors, or allergic fungal sinusitis.
  • It also is helpful if intracranial extension is suspected on CT scanning or clinical examination.
• Clinical significance: Significance of the findings on any radiographic examination of the sinuses can only be determined in conjunction with the current treatment and clinical picture. A CT scan (if taken at the time of maximum symptoms) of an acute viral respiratory illness lasting 24 hours can look exactly like chronic opacification of all of the sinuses. Therefore, the optimum time to obtain a CT scan of the sinuses is following maximum medical therapy.

Other Tests

• Routine maxillary sinus aspirates to obtain diagnostic information are not performed in healthy children with chronic sinusitis because of the pain associated with the procedure.
• In a sedated child, when culture of the fluid is paramount, an aspirate can be considered.
• Normally, children should have maximum medical therapy based on normal causative agents for acute or chronic sinusitis. CT scan evaluation of the sinuses is then performed prior to or following adenoidectomy if adenoid hypertrophy exists or chronic adenoid infection is suspected.
• If gastroesophageal reflux (GER) is suspected, a barium swallow or pH probe should be considered, as GER can cause or contribute to chronic sinusitis in children.

Diagnostic Procedures

• Rigid or flexible rhinoscopy in a clinical setting for a child with sinusitis symptoms may be beneficial to define the presence of adenoidal hypertrophy, a lesion in the nasal cavity, or polyps in the nasal cavity or middle meatus (where the anterior sinuses drain).
• If the child has had a CT scan, it may define these conditions, making rigid or flexible rhinoscopy unnecessary. Occasionally, the middle meatus can be observed with anterior rhinoscopy, and the adenoids can be evaluated by plain radiography. These tests help with these diagnoses, avoiding a procedure that may cause anxiety or discomfort to patients. However, rigid or flexible rhinoscopy can be performed safely and comfortably when necessary when the diagnosis is unclear.

Treatment

Medical Therapy

Medical therapy is covered extensively in the eMedicine article Pediatric Sinusitis, Medical Treatment. Therefore, it is summarized here.

Medical therapy starts with antibiotics directed at the 3 most common pathogens of sinusitis cultured in acute sinusitis, including S pneumoniae, H influenzae, and M catarrhalis. For nonresistant strains of bacteria, most beta-lactam antibiotics, such as the penicillin and cephalosporin family or the macrolides, are good choices. Resistant strains of bacteria have been reported more frequently in the past several years, and conferences on an appropriate step-wise approach to treating bacterial upper respiratory infections have been published. If infections are refractory to multiple courses of initial trials of antibiotics, attempt treatment with intramuscular ceftriaxone daily for 3 days, oral double-dose amoxicillin with or without clavulanic acid, or oral clindamycin.

Prescribe oral doses of antibiotics for chronic sinusitis for 3-4 weeks at a time. Other important bacteria cultured from the sinuses at the time of ESS include alpha-hemolytic streptococci, S aureus, and rarely, anaerobes. Anaerobes are more often observed in adults with chronic sinusitis. Clindamycin is often an appropriate treatment for these other pathogens, especially anaerobes.

Always prescribe adjuvant medical therapy for a child with recurrent or chronic sinusitis. Adjuvant therapy includes oral decongestants, oral or nasal antihistamines, nasal steroid sprays, histamine stabilizer nasal sprays, oral expectorants, and hypertonic and isotonic nasal saline irrigation and sprays. Consider a 1- to 2-month trial of a proton pump inhibitor for presumed or discovered gastroesophageal reflux (GER). Consider endoscopic sinus surgery (ESS) if a child continues to have recurrent or chronic sinusitis despite maximum medical therapy.

Surgical Therapy

Surgical techniques are described for each area of the sinuses.

Preoperative Details

Take care to explain possible complications of the procedure and that maximum medical therapy has been exhausted, including evaluation for immunodeficiency syndrome, immotile ciliary syndromes, and gastroesophageal disease in selected patients. Pretreat any child with nasal polyposis with steroids to help shrink the polyps and decrease bleeding during intraoperative removal.

Intraoperative Details

Messerklinger technique

Messerklinger described the most popular technique used in endoscopic sinus surgery (ESS). It involves performing sinus surgery in the anterior-to-posterior direction. The initial concern is opening the outflow track for drainage of the anterior sinuses by first performing a uncinectomy. The portion of the uncinate process is incised in its midportion with the backbiter, forming a small window. The uncinate bone and free mucosal edges of the lateral and medial mucosa of the uncinate process can then be removed with the surgical microdebrider.

Alternatively, the uncinate process can be incised at its base with a sickle knife or caudal elevator. However, injury to the lamina papyracea of the medial orbital wall may occur when the incision is made because the uncinate process can be in close proximity to the lamina papyracea in children of all ages. The uncinate process is usually attached superiorly to the lamina papyracea. Alternatively, it can attach to the skull base centrally or medially. Incising the uncinate at its mid or inferior portion helps prevent injury through the lamina. When performing uncinectomy with either technique, but especially with the caudal or sickle knife, take care to remove the bone and lateral mucosa, not just the medial mucosa. Failure to perform a complete uncinectomy results in difficulty identifying the remaining anatomy of the lateral nasal wall. Occasionally, a curve ball probe, ie, Lusk seeker, or curved curette can be used to pull the residual uncinate anteriorly so it can be removed.

Once uncinectomy is complete, the maxillary ostia can be identified. Natural ostia always lie under the uncinate process inferiorly. In 50 pediatric patients, Parsons found the maxillary ostia 1-2 mm from the attachment of the uncinate process to the lateral nasal wall. The most common mistake in failing to identify the maxillary ostia is incomplete removal of the uncinate process inferiorly. If the maxillary antrostomy has not been identified, visualization with a 30° endoscope and palpation of the lateral nasal wall just over the inferior turbinate with a small ball probe can be performed.

Care is taken not to punch in to the maxillary sinus with a curved instrument, especially suction because the force may strip the mucosa from the posterior/superior wall of the sinus. This actually occludes the ostia of the maxillary sinus with persistence of disease. In addition, if false iatrogenic ostia are formed by opening into the sinus in the posterior fontanelle of the medial wall of the maxilla posterior to the ostia, symptoms and signs of maxillary sinusitis persist until the natural ostia are opened.

Once identified, the maxillary ostia can be widened or left alone. Some rhinologists believe that the ostia should only be widened on the posterior and inferior areas. This may avoid any cicatricial scar formation while opening the ostia up and allowing them to drain. In a 1996 report, Setliff advocates avoiding the maxillary ostia completely.^11,12 If the ostia are widened, it should be done in the most atraumatic fashion to prevent stripping of any mucosa. Usually, this involves using punch-biting forceps or true-cut forceps or using a surgical microdebrider.

Once the maxillary ostia are open, the bulla ethmoidalis is then entered. The status of the mucosa is visualized, and the disease is removed. Anterior ethmoids are removed completely, forming a common cavity. Each individual ethmoid air cell has an ostium. However, technically, these tiny ostia cannot be individually opened, so a common cavity is established by removing the cells completely, eradicating disease, and forming a large area where the frontal and maxillary sinus can drain. Once the anterior ethmoid air cells are removed, the grand lamella is identified.

The grand lamella is the division between the anterior and posterior ethmoid air cells and is entered when posterior ethmoid disease is present or when the sphenoid sinus needs to be approached. Care is taken to preserve the inferior portion of the grand lamella that attaches the middle turbinate to the lateral nasal wall. Stabilization of the middle turbinate away from the lateral nasal wall maintains patency of the outflow tract of the anterior sinuses. The ethmoid cavity, maxillary ostia, and grand lamella are identified in the postoperative picture.

Tissue in the nasal cavity and paranasal sinuses can be removed with the straight-ahead and angled-punch or Weil-Blakesley grasping forceps or the surgical microdebrider. Use small pediatric forceps for precise removal of tissue and prevention of trauma to the surrounding structures, mainly the middle turbinate. Abrasion of the lateral surface of the middle turbinate can result in an increased potential for scarring between the middle turbinate and lateral nasal wall. Scarring in this area could cause obstruction of the outflow tracts of the sinuses and return of disease and symptoms.

The surgical microdebrider has been advocated for is effectiveness and safety. Several attachment blades are available, which have different degrees of cutting potential. Sizes range from 3.0-5.5 mm, depending on the company that manufactures them, the particular surgical microdebrider being used, and the size of the handpiece.

If the surgical microdebrider is used, bony fragments are usually left in the ethmoid cavity after the mucosa and disease have been cut, suctioned, and removed. These bony fragments are then grasped and removed with pediatric Weil-Blakesley forceps. Microguarded burrs are also available and can be used to remove bone. These are not indicated for routine endoscopic sinus surgery (ESS). In 1996, Gross reported use of microguarded burrs in removing the anterior lip of the frontal sinus recess when the agger nasi is not well pneumatized.¹³ If the surgical microdebrider is used, 2 suctions should be available for the surgery, 1 attached to the microdebrider and 1 for routine suctions.

Different angles and diameters of suction are available and should be used for different areas of the sinuses. Straight suctions have centimeter markings on them to readily identify the depth of surgery from the anterior nasal spine. Suctions can be used for gentle palpation of different structures in the sinuses, including the sloping skull base, opening of the frontal sinus, face of the sphenoid sinus, and sphenoid ostia.

Sphenoid sinus

Approaches to the sphenoid sinus can be made through the posterior ethmoids or medial to the middle turbinate by locating the natural ostia of the sphenoid sinus. When locating the sphenoid sinus through the posterior ethmoid cavity, begin the search in the inferior and medial area. Often, the posterior portion of the middle turbinate is traversed to find the ostia. Because the superior turbinate lies lateral to or covers the sphenoid ostia, the superior turbinate must be pushed medial to uncover the sinus ostia or the inferior half must be removed. The ostia can then be widened inferiorly and medially to prevent cicatricial scar formation and to avoid damage to the lateral sphenoid wall that houses the internal carotid artery and optic nerve.

If the sphenoid cannot be identified through this approach, the turbinate can be lateralized, and the sphenoid ostia can be found medial to the middle and superior turbinate. This may destabilize the middle turbinate, so care must be taken. However, if the grand lamella of the middle turbinate is left intact, destabilization is less likely. Again, the superior turbinate may require partial resection. Once the sphenoid ostium is identified, it can be widened with punch forceps or the surgical microdebrider. Again, care is taken to stay inferior and medial. If access is limited to open the sphenoid sinus medially, a thin suction can be placed in the sinus. Attention can turn back laterally to the middle turbinate to look again for the sphenoid sinus. The same techniques must be used, but now, an artificial landmark is placed for absolute identification.

Straight suctions of various diameters with distance markings are also used to determine the depth of dissection. In adults, the anterior face of the sphenoid sinus is roughly 7 cm, and the posterior wall is roughly 9 cm from the anterior nasal spine. For children, the height of the patient correlates with the distance of the anterior and posterior sphenoid wall. Roughly, once the child reaches 3 feet tall, the distance from the anterior nasal spine to the anterior sphenoid wall is roughly 7 cm. Care must be taken when making these comparisons because the minor variability that exists in these measurements can cause disastrous results.

Using both axial and coronal preoperative CT scanning to determine the exact anatomy and anatomic variants of the sphenoid sinus is the best way to prevent complications. The centimeter scale on the CT scan can be used as well to determine the true dimensions and depth of the sinus. Chambers found 4% of optic nerves and 8% of internal carotid arteries dehiscent, covered only by mucosa. Kennedy reported the incidence of carotid artery dehiscence to be as high as 32%.

Frontal sinus

The frontal sinus in children does not develop fully until age 8-12 years. Because of this, usually an approach to the frontal sinuses is unnecessary if one is not present. Opening the anterior ethmoids, especially the bulla ethmoidalis, ventilates the frontal sinus or frontal sinus recess in most cases, allowing it to drain and clear, even if disease is present. Care must be taken to prevent violating the frontal sinus recess in situations where it is not specifically addressed. If the frontal sinus recess is violated, scarring and obstruction of the outflow tract can occur. Frontal sinusitis in children may be reversible; iatrogenic anatomic changes causing scar tissue may be more problematic, leading to multiple surgeries.

If the patient is a preteen or teenager with developed frontal sinuses, 2 approaches can be performed. One is to approach the frontal sinus after performing the uncinectomy and visualizing the bulla ethmoidalis. The bulla is followed superiorly to the posterior portion of the frontal sinus recess. The face of the bulla is in continuity with the posterior wall of the frontal sinus recess. Care must be taken to watch for the anterior ethmoid artery that is at this junction. It is usually protected by the face of the bulla. The alternative approach is to perform a complete ethmoidectomy and identify the sloping skull base. The skull base is followed from posterior to anterior until the frontal sinus recess and fovea ethmoidalis are identified.

Once identified, the preoperative CT scan is reviewed to evaluate the agger nasi in the anterior portion of the frontal sinus recess. The agger region is the main obstruction for the outflow tract of the frontal sinus. If a large agger nasi air cell is present, the frontal recess is able to open widely. Visualization of the frontal sinus requires a 30° and possibly a 70° telescope. Angled curettes and giraffe forceps, with arcs from 45-110°, are required to access this area. The instruments are generally intended for use below the telescope, reaching around its anterior end. The 45° instruments work well with the 30° telescope, and the 90° angled instruments work well with the 70° telescope. Curettes are used to pull the bony cell walls forward and down. Giraffe forceps can be used to delicately remove bony fragments, small polyps, and diseased mucosa. Care is taken to leave as much mucosa as possible to prevent stenosis.

Dissection at the anterior skull base should never occur medial to the middle turbinate because injury to the cribriform plate could occur. The lateral lamella of the cribriform plate is the thinnest area of the anterior skull base and is subject to injury. Several variations of the anterior skull base have been identified. These can be identified by preoperative CT scanning to prevent iatrogenic injury and cerebral spinal fluid leak.

Middle turbinate

Controversy exists concerning treatment of the middle turbinate. Management options range from never removing it to routinely removing all of it. Advocates of partial resection of the middle turbinate believe it affords them better access to the middle meatus, intraoperatively and posteriorly, with less scarring and without crusting or anosmia. Many authors have shown increased antrostomy patency rates, increased airflow, and decreased revision rates. In 1993, May offered general guidelines for partial turbinate removal.¹⁴ These include when the turbinate is thin and floppy, when it is replaced by polypoid tissue, when it obstructs the surgeon's view intraoperatively or postoperatively, and when an anatomic variant (eg, concha bullosa) exists.

In children, take a conservative approach. In 1996, Mair reported that the middle turbinate remnant becomes a problem in the pediatric nose.¹⁵ He has seen it lateralize and occlude the frontal sinus, causing recurrent symptoms. Lusk and Parsons also advocate leaving the middle turbinate in children. Certainly, the affected portion of a significantly altered middle turbinate caused by polypoid disease or expansion and pressure of the maxillary sinus should be removed. However, only resecting the anterior portion as described by Biedlingmaier is best. This leaves enough of a remnant for further identification of normal anatomic structures and relationships if revision surgery becomes necessary.

No real controversy exists concerning whether or not to open up a concha bullosa. It should be opened. Most surgeons advocate removing the lateral portion of the concha. This provides good access to the middle meatus during surgery and better ventilation and visualization after surgery.

In adults, techniques to stabilize the middle turbinate have been reported. These include creating a controlled synechiae between the septum and middle turbinate and performing a transturbinate stitch. The transturbinate stitch requires suturing the middle turbinates to the septum. This maneuver is difficult in the pediatric nasal cavity because of its small volume.

Surgical approaches to pediatric sinus disease undoubtedly have become more conservative, both in indications for surgery and amount of surgery performed. Certainly, only those sinus cavities showing disease on CT scanning should be considered for surgical drainage. Because the OMC, which includes the uncinate process and infundibular area around the ethmoid complex, is the bottleneck for outflow of the anterior sinuses, many pediatric sinus surgeons have advocated only performing a mini-FESS. This involves removing the uncinate process, finding or opening the maxillary ostia, and performing an ethmoid bullectomy or anterior ethmoidectomy. All report as good or better success rates with lower complications. In 1996, Talbot advocated removal only of OMC disease to clear the frontal sinus and frontal recess, and Smith reported that the sphenoid clears by opening the ethmoids.¹⁶

Also in 1996, Setliff advocated a minimally invasive or small-hole technique.^11,12 This technique involves removing only the mucosa and bone of the uncinate process for maxillary sinus disease, leaving the maxillary sinus ostia untouched. He does not create a large hole to drain the maxillary sinus. Minimally invasive surgery is based on a theory that narrow mucous membrane–lined clefts are the predisposing factor to clinical disease, not the small ostia of the maxillary, ethmoid bulla, or frontal sinuses. The sinuses may not need a large hole to drain. In fact, when normal CT scan findings are viewed, the actual size of the tortuous and narrow draining pathway for the anterior sinuses is surprising.

The minimally invasive technique was performed in adults and pediatric patients. First, an uncinectomy was performed with the pediatric backbiter and surgical microdebrider to open up the draining pathway of the sinuses, the infundibulum. A maxillary antrostomy was not performed, regardless of the appearance of the maxillary ostia, whether it was normal appearing, polypoid, or edematous.

According to Setliff's 1996 report, edema or obscuration of the maxillary sinus ostium, with or without polyps, pus, or cysts in the maxillary sinus, was present in most patients. He did not comment on his surgical technique for the ethmoid, sphenoid, or frontal sinus. Of 300 patients on whom he performed this procedure, only 1 required revision surgery to open the maxillary sinus. Overall, his surgical revision rate dropped from 15% to 7% since he adopted the minimally invasive technique. The whole uncinate must be removed so that the maxillary ostia can drain. However, Mendelsohn and Gross in 1997 advocated widening the ostia to 3-5 times its normal size, as well as creating an even larger mega-ostia for patients with ciliary abnormalities.¹⁰

Technique for nasal polyps in children

Nasal polyposis in adults and children can be a difficult disease to treat based on the alteration of normal landmarks, the tendency for abundant bleeding, and the predisposition for recurrence. Certainly in children, cystic fibrosis (CF) must be ruled out. Other diseases, such as allergic polyposis or allergic fungal sinusitis (AFS), can cause nasal polyposis in children. Successful techniques require removing the polypoid disease using the tenets of endoscopic sinus surgery (ESS). Polyps should be removed and the sinuses should be opened using the Messerklinger technique. Preoperative and postoperative steroids can help shrink the fibrovascular nature of the polyps, decreasing the amount of bleeding during surgery and helping to prevent recurrence.

However, the best advance in performing endoscopic sinus surgery (ESS) in children with nasal polyposis is the surgical microdebrider. Any bleeding encountered is suctioned away while the polyps are efficiently resected and removed. Several authors advocate the increased safety when the surgical microdebrider is used. Nothing, however, takes the place of complete knowledge of the normal anatomy and anatomic variants of the nasal cavity, lateral nasal wall, and paranasal sinus in children of various ages. Preoperative CT scanning again is stressed to determine the extent of disease and changes the polyps have created to the nasal cavity and paranasal sinuses.

Children with CF uniformly have nasal and sinus disease. The hallmark is thick inspissated exocrine gland mucus that causes obstruction. CF nasal mucus is 30-60 times more viscous than non-CF mucus and blocks the outflow tract of the sinuses. Therefore, the surgical technique used is the same in patients with CF and chronic sinusitis as that used in patients with chronic sinusitis only. However, a minimally invasive or small-hole technique may provide inadequate access to the sinuses because some of the thick mucus must be mechanically flushed routinely to aid in clearing the sinuses.

For patients with allergic fungal sinusitis (AFS) with polyposis, the disease process has usually expanded the sinuses, particularly the ostia. Allergic mucin and thick tenacious fungal elements are found in the sinuses. Usually, the anatomy of the lateral nasal wall is distorted, but invasion of surrounding boundaries (eg, periorbita, dura) is never found, despite expansion into the orbit or brain. An example of a 15-year-old boy with extensive disease is shown in the eMedicine article Allergic Fungal Sinusitis. This adolescent had extensive expansion of the sinuses, which is observed uniformly in allergic fungal sinusitis (AFS). He had expansion into the orbit and anterior cranial fossa. The frontal sinus recess had been expanded to 3 cm, so access to the lateral superior orbital fungal elements could be performed endoscopically. His polypoid disease was effectively removed with the microdebrider.

The thick tenacious allergic mucin and pasty fungal elements usually clog the microdebrider and require removal with a curette or suction. Often, much of the dissection is done for the surgeon, so removing the polyps and allergic mucin constitutes the bulk of the surgery. However, fungal elements can expand each ethmoid air cell, requiring the surgeon to continue the dissection to make sure that the cells are completely eradicated. Retained fungal elements can cause persistent edema and polyposis. Preoperative and postoperative steroids are used to control edema of the opened cavities while they are healing.

Lasers

The use of lasers for endoscopic sinus surgery (ESS) has been reported in adults but not children. These include the carbon dioxide (CO₂) laser, argon laser, potassium-titanyl-phosphate (KTP) laser, erbium yttrium-aluminum-garnet (YAG) laser, and holmium YAG laser. The holmium YAG laser has had the most applications. It is efficient in excising or contouring bone. It produces adequate hemostasis, affecting only capillary bleeding. Positive attributes of using the laser include better hemostasis and greater precision in sculpting bone.

Negative features include increased postoperative tissue edema, increased length of surgery, more elaborate surgical setup, increased cost, increased collateral thermal deposition causing more synechia and scarring, and decreased visualization through the endoscope from the splatter effect of the tissue upon contact with the laser pulse. The KTP/532 laser has been used successfully in turbinate reduction and vascular disorders such as hereditary hemorrhagic telangiectasia. Use of lasers in pediatric endoscopic sinus surgery (ESS) for chronic sinusitis can usually be avoided.

Computer-assisted sinus surgery

Over the last several years, computer-assisted sinus surgery has become more popular. Sinus surgeons usually reserve this technique for revision cases or for cases where anatomy has been distorted.

The computer uses stereotactic software that integrates data it receives from a sensor mechanical wand. Sensors, usually 5-8 in number, are placed on the patient's face and forehead in multiple places. Axial CT scanning with 3-mm slice thickness and 3-mm increments is performed from the top of the forehead to the upper incisors. CT scan data are entered into the computer and the sensing wand. The registration process then begins by touching a sensor and marking it on the CT scan images that were entered into the computer.

Alternatively, facial structures (eg, lateral canthus) can be used for registering the patient with the computer images. Once registration is complete, a 3-dimensional reconstruction is then displayed on a screen as sagittal, coronal, and axial images. Accuracy of the probe tip is approximately 2 mm with a range of 0-3.7 mm. During surgery, the wand can be placed intranasally to provide a corresponding image outlining the location of the wand on the screen in 3 planes. This technique has been helpful in adult revision cases and large sinonasal lesions where normal anatomy has been altered or obscured. Recent reports have shown its effectiveness in the pediatric population. Increased technology has made it easier to use as well, with multiple systems currently available.

Packing

Once surgery is complete, the decision is made on whether or not to pack. Lusk popularized stenting the pediatric ethmoid cavity with a roll of gel film. This involves a second-look procedure at 2 weeks postoperatively to evaluate the status of surgery and remove any debris and granulation that could form synechia. Other ethmoid stents have been used with success. The author currently has had the best success with a Merocel sponge wrapped in a finger cot or portion of a glove. This easily slips out on the first postoperative visit at 5-7 days. It is attached to a string that is taped to the side of the face with adhesive and Steri-Strips or paper tape.

The main goal of packing is to keep the middle turbinate from lateralizing and scarring to the lateral nasal wall, resulting in obstruction with recurrence or persistence of disease.

Occasionally, packing may not be required. In children where the disease has expanded the sinuses and middle meatus and has not destabilized the middle turbinate (eg, extensive polyposis), usually from allergic fungal sinusitis or mucoceles, packing may be avoided. Extensive polyposis in patients with CF usually destabilizes the middle turbinate, so packing or partial resection of the middle turbinate may be indicated.

Postoperative Details

Postoperative care is critical. In adults, this involves saline irrigations and weekly debridements in the office. Postoperative care must continue until the cavities are well healed, usually 4-6 weeks. Postoperative care in young children is difficult. For the most part, they do not like nasal saline irrigations, much less manipulation of the nasal cavity with endoscopes. Preteens and some teenagers occasionally allow adequate visualization or cleaning in the office setting, similar to adult postoperative care. Any trick to keep their nasal cavities moist for the month or so following surgery is beneficial. The author has them spray isotonic sodium chloride solution 3-4 times a day and use the Rhinotherm (a machine to force moist steam into the nasal cavities) weekly or twice weekly. If patients perform saline irrigations, saline spray is substituted.

For young children, the second-look procedure may or may not be needed, depending on the ability of the parent or child to use nasal irrigations or a water pic to clean debris from the sinuses. Proponents argue that granulation and debris can be cleaned from the sinus cavity and that adhesions that have formed can be lysed. Postoperative care in any sinus procedure is as important as the procedure itself. Synechia form, with recurrence of disease and symptoms, if crust and debris are not removed by the surgeon or by the patient with saline irrigations. Some have begun to question the second-look procedure, evaluating outcomes of endoscopic sinus surgery (ESS) surgery in children who have and have not had a second-look procedure. In 1998, Walner found that the rate of revision surgery was the same (at roughly 20%) whether the second-look procedure was or was not performed.¹⁷

Follow-up

All follow-up care is at the discretion of the treating physician. For the author's practice, once the initial 4-6 weeks of postoperative care is complete, follow-up depends on the disease present. For chronic sinusitis without allergic rhinitis or polyposis, follow-up may only be necessary if the child is symptomatic. If the child has allergic rhinitis with or without polyps, follow-up depends on how symptomatic the child is and if immunotherapy is required. Most children need to be tested for allergies preoperatively. If allergies are present, most children are on immunotherapy. If the allergist is comfortable with a nasal endoscopic examination, the allergist may be able to do intermittent follow-up because the child is seen once a week for shots. Most often, symptoms dictate when an evaluation is necessary.

For children with allergic fungal sinusitis (AFS), close follow-up is mandatory. The disease in these children, like adults, has a propensity to recur. For a child with allergic fungal sinusitis (AFS) who does not tolerate examinations in the clinic, a baseline CT scan 4-6 weeks postoperatively is advisable to establish that all disease has been eradicated. Immunotherapy may not be effective if residual disease is present. Preliminarily, patients with AFS apparently benefit from immunotherapy, with decreased need for oral steroids and decreased recurrence (see the eMedicine article Allergic Fungal Sinusitis).

Complications

Relatively few complications of pediatric endoscopic sinus surgery (ESS) have been reported in the literature (see Table 1, Table 2). Complications occur more often in adults (see Table 3, Table 4), possibly secondary to generally more aggressive surgery or a greater degree of disease requiring more extensive surgery. However, the risks that apply to pediatric sinus surgery are the same as those that apply to surgery in adults. The aim of this section is to discuss the potential complications of pediatric sinus surgery and their management and to focus on techniques that help prevent complications from occurring.

In general, complications of pediatric functional endoscopic sinus surgery (FESS) can be divided into major complications, which may be life threatening or require further surgical intervention or advanced treatment. The other complications are considered minor.

Major complications are uncommon, occurring in less than 1% of pediatric functional endoscopic sinus surgery (FESS) cases. The major complications of pediatric functional endoscopic sinus surgery (FESS) are similar to those of adult functional endoscopic sinus surgery (FESS) and include intraorbital, intracranial, and intranasal injury. Intraorbital injury encompasses blindness, extraocular muscle damage, and orbital hematoma. Intracranial complications include cerebrospinal fluid leak and brain damage. Major intranasal complications include nasal lacrimal duct injury and major hemorrhage.

• Intraorbital complications
• Blindness
• Blindness secondary to functional endoscopic sinus surgery (FESS) can occur from 2 etiologies. The first and most common cause is a rapidly expanding intraorbital hematoma, usually secondary to damage to the anterior ethmoid artery. The anterior ethmoid artery runs along the superior portion of the medial orbital wall between the superior oblique and medial rectus muscles. If the artery is damaged, it can retract into the orbit, leading to a rapidly expanding retrobulbar hematoma. Increased orbital pressure causes a compromise of the vascular supply to the optic nerve. If not corrected within 60-90 minutes, blindness can result. More commonly, orbital hematoma occurs secondary to damage to the orbital veins lining the lamina. Hematoma accumulation is much slower, and proptosis and pupillary changes are much less common.
• The second cause of blindness is damage to the optic nerve itself, which is very rare. Injuries usually occur from poor intraoperative visualization or inadequate knowledge of the optic nerve anatomy. The optic nerve is especially vulnerable to injury in several anatomic sites. The optic nerve courses in the superior lateral aspect of the sphenoid sinus. In some individuals, the bone overlying the nerve may be thin or even dehiscent. Careful attention to the preoperative CT scanning frequently reveals this finding. The most posterior and lateral posterior ethmoid cells (ie, Onodi cells) are separated from the optic nerve by a thin layer of bone only, and damage to the nerve can also occur here.
• Prevention of permanent vision loss begins prior to surgery with careful preoperative screening to identify patients with risk factors for orbital injury (eg, prior surgery, long-standing disease, history of bleeding problems). A thorough review of the preoperative CT scanning enables identification of anatomic variations that may predispose to injury.
• Intraoperatively, keeping the patient's eyes uncovered at all times is very important. An assistant may be assigned to monitor the eye for any early signs of injury. Because pediatric functional endoscopic sinus surgery (FESS) must be performed under general anesthesia, the surgeon is unable to use the patient's perception of pain as an early indicator of orbital penetration, usually through the lamina papyracea on the medial orbital wall, which is the lateral wall of the ethmoid cavity. Have an assistant palpate the eye as the surgeon is observing the lamina papyracea endoscopically for its location as it moves back and forth for evidence of orbital fat or damage. If a question remains as to whether a specimen represents polyp or orbital fat, the material can be placed in saline. Orbital fat floats, whereas diseased mucosa or polyp does not float.
• When injury to the orbit becomes apparent, either with proptosis or pupillary change, urgent attention is required. Eye massage should be started immediately to decrease intraorbital pressures and redistribute the hematoma. Mannitol, an osmotic diuretic, should be started to decrease orbital pressures. The ophthalmology service should be consulted immediately for evaluation. If the above measures do not adequately reduce orbital pressures, surgical decompression is warranted. Initially, this consists of lateral cantholysis that usually suffices to immediately reduce dangerous intraorbital pressures. Occasionally, medial orbital decompression is necessary, either endoscopically or via an external ethmoidectomy (see Procedure for managing orbital hematoma).
• Penetration of the lamina papyracea
• Injury to the lamina papyracea is not a complication of endoscopic sinus surgery (ESS). In fact, to gain access to the orbital vault, to drain an orbital or subperiosteal abscess, or to decompress the eye, the lamina must be removed or penetrated. However, inadvertent penetration may cause complications to the eye, such as blindness or injury to the orbital contents (eg, extraocular muscle if not recognized). Injury can be avoided by carefully noting the position of the uncinate process during uncinectomy. In children, the attachment of the uncinate process may be very close to the medial wall of the orbit, so during uncinectomy with the sickle knife, the orbit may be entered. The lamina could potentially be damaged when evaluating the lateral nasal wall for the maxillary ostium with a curved instrument (eg, suction, ball-tip probe). Identification of the maxillary ostium should begin at the level of the superior portion of the inferior turbinate. Drifting superiorly risks injury to the lamina.
• Inadvertent penetration of the lamina papyracea occurs more commonly on the patient's right side when the surgeon is right-handed. This occurs because of differences in the visualized anatomy through the endoscope. The right ethmoids appear to be more straight back than they are in reality, leading to orbital injury. This can be avoided by staying medial against the middle turbinate.
• Damage to the extraocular muscles
• Extraocular muscle damage is very uncommon but is usually permanent. The 2 muscles most likely to be injured during functional endoscopic sinus surgery (FESS) are the superior oblique and medial rectus because of their proximity to the sinuses. If injury is suspected, immediate consultation with an ophthalmologist is in order.
• The superior oblique muscle is less commonly injured than the medial rectus because of its location high in the orbit, lateral to the ethmoid cavity. The prognosis for recovery following superior oblique muscle injury is better than for medial rectus injury, and an observation time of 6 months is often recommended prior to surgical treatment to allow for adaptation.
• Medial rectus injury carries a poor prognosis. This may be secondary to the increased incidence of direct muscle injury in addition to scar tissue formation from lamina papyracea penetration. Most affected patients require multiple surgical treatments. Prognosis may be improved with immediate high-dose steroids and surgical treatment within 3 weeks of injury.
• Intracranial complications
• Cerebrospinal fluid fistula
• Cerebrospinal fluid (CSF) leakage can occur at any number of sites. Certain anatomic subsites are more conducive to injury during functional endoscopic sinus surgery (FESS). Most commonly, CSF leaks occur at the cribriform plate, fovea ethmoidalis, posterior ethmoid roof, roof of the sphenoid sinus, and the skull base above the anterior wall of the sphenoid sinus. The lateral cribriform plate, where the anterior ethmoidal artery enters the olfactory fossa, is the weakest site in the anterior skull base. To avoid injury to this area, dissection should stay lateral to the vertical portion of the middle turbinate. Traction on the middle turbinate can also cause fracture of the cribriform plate and resultant CSF fistula. The surgeon must remember that anteriorly, the cribriform plate is lower than the fovea ethmoidalis. In the sphenoid, the surgeon must be cautious when removing disease from the superior wall or roof because most CSF leaks in the sphenoid occur in these regions.
• CSF leaks can usually be identified at the time of injury by observation of the washout sign. The CSF washes away the surrounding blood, making the fistula evident. Treatment should be initiated immediately. The site can be patched endoscopically with muscle, fat, septal, or other mucosal grafts or fascial grafts.
• Delayed CSF fistulae may manifest with meningitis, which often seals the leakage site secondary to dural inflammation. The site of dural dehiscence can often be identified with high-resolution CT scanning or with MRI cisternography. Occasionally, administration of intrathecal fluorescein is necessary to identify the site. Repair may be undertaken endoscopically or via craniotomy with the assistance of a neurosurgeon. Placement of a lumbar drain facilitates the speed of closure and enhances surgical treatment by shunting pressure from the site of the leak.
• Brain injury: Injury to the anterior communicating artery and its feeding vessels, intracerebral hematoma, encephalocele, and perforation of the ventricular system with massive pneumocephalus have been reported, although uncommonly, following sinus surgery. The proximity of the anterior communicating artery to the cribriform plate makes it vulnerable to injury if the cribriform plate is penetrated. These injuries are easily avoided if adequate visualization is available and the surgeon has appropriate knowledge of the anatomy of the sinus cavities. If visualization becomes inadequate secondary to hemorrhage, the procedure should be terminated immediately rather than compromise the patients' health.
• Intranasal complications
• Major hemorrhage
• Severe hemorrhage is rare and usually occurs in patients with underlying bleeding disorders, a history of multiple sinus surgeries, or extensive polyposis. Bleeding may occur from damage to any of several arteries.
• As discussed earlier, the anterior ethmoid artery may be injured during removal of disease in the anterosuperior region of the anterior ethmoid air cells or during work in the frontal recess. Often, the lacerated artery can be identified and cauterized at the time of injury. However, the artery may retract into the orbit, leading to hematoma. The posterior ethmoidal artery is most commonly injured during removal of disease in the posterior ethmoidal air cells or sphenoid sinus. Cautery is difficult in this region, and intranasal packing is usually required to stop hemorrhage.
• The sphenopalatine artery may also be injured during removal of disease in the posterior ethmoidal air cells or the sphenoid sinus. It may also be injured when enlarging the middle meatus antrostomy posteriorly or when removing a portion of the middle turbinate. Electrocautery or nasal packing usually is sufficient in halting the hemorrhage.
• Damage to the internal carotid artery is unusual but immediately life threatening. Injury usually occurs when the carotid artery protrudes medially into the sphenoid sinus. In addition, as many as 20-25% of patients may have only a thin bony wall separating the vessel from the sphenoid sinus. In the case of injury, Sofferman suggests a management plan that includes immediate nasal packing, compression of the affected carotid in the neck, immediate neurosurgical consultation, intraoperative arteriography, and ligation of the artery pending results of a balloon occlusion study to assess cerebral perfusion.
• Nasolacrimal duct injury
• Injury to the nasolacrimal duct and sac occurs frequently, although in most cases, the damage is not manifested clinically. Bolger et al found a 15% incidence of occult nasolacrimal duct injury in a study of 24 adult patients. None, however, had epiphora at 11 months of follow-up. The natural ostium of the maxillary sinus and the ethmoid sinuses in children lie in very close approximation to the nasolacrimal system, even closer than in adults. Injury usually occurs when attempting to enlarge the ostium anteriorly. The bone overlying the nasolacrimal duct is thicker, alerting the surgeon to the proximity of the duct. The nasolacrimal sac may also be injured, especially in the region of the superior aspect of the uncinate process, which is only several millimeters from the sac itself.
• Patients with postoperative epiphora should be observed initially because most cases resolve without additional treatment. However, the ophthalmology service should be consulted in all cases, and if the symptoms continue after several months, a dacryocystorhinostomy may be necessary to correct the stenosis. This may be performed intranasally or externally.

Minor complications of pediatric sinus surgery occur much more frequently than do major complications but have minimal, if any, long-term effects. Often, multiple minor complications occur in the same patient. Minor complications include synechiae formation, ecchymosis, sinus ostia stenosis, minor bleeding, and subcutaneous emphysema.

• Synechiae: Synechiae are the most common complications of pediatric functional endoscopic sinus surgery (FESS), with reported rates of 6-30%. Synechiae most often form between the middle turbinate and the lateral nasal wall or between the middle turbinate and the septum. Any disruption of 2 opposing mucosal surfaces can lead to scar band formation. Careful attention to surgical technique, especially when manipulating the middle turbinate, can decrease the incidence of synechiae formation. The placement of a spacer between the lateral nasal wall and the middle turbinate can decrease scar formation. Telfa, Merocel, Gelfilm, and silastic have been used with success. Use of intranasal steroids at the completion of the procedure has been recommended in the past to decrease synechiae formation, but recent work has shown little benefit. Most synechiae can be lysed under general anesthesia during a planned second-look procedure. Occasionally, revision surgery is necessary.
• Sinus ostium stenosis
• Incidence of middle meatal antrostomy stenosis is not known. In 1993, Stankiewicz reported nearly a 50% incidence of antrostomy closure visualized at routine second-look endoscopy 2 weeks to 2 months following functional endoscopic sinus surgery (FESS).¹⁸ Lazar, however, in a 1992 study of 260 children with an average of 20 months of follow-up, found only a 2% incidence of stenosis.¹⁹ Stenosis may occur secondary to extensive scarring in the middle meatus, recurrent polyposis, or insufficient widening of the antrostomy during the initial surgery. Unfortunately, stenosis of the middle meatal antrostomy is one of the most common reasons for revision surgery. Stenosis may be minimized by only opening the meatus inferiorly and posteriorly, thereby avoiding circumferential damage to the mucosa, which increases stenosis rates.
• In a 1996 article, Setliff reportedly decreased his rate of maxillary ostial stenosis in adults and children with the minimally invasive technique.¹² This technique involves removing the mucosa and bone of the uncinate process without touching the maxillary ostium, regardless of its appearance. In a review of 300 patients treated with this technique, only one has required revision surgery for a closed ostium, and his revision rate has decreased from 15% to 7% with short-term follow-up.
• Ecchymosis: Orbital ecchymosis can occur with violation of the lamina papyracea and minor hemorrhage. This condition resolves within 7-14 days, gradually progressing from a black and blue color to a yellow hue prior to return to normal skin color.
• Subcutaneous emphysema: Penetration of the lamina papyracea can lead to subcutaneous emphysema. Often, this is not noted until the patient awakens and begins to struggle or until aggressive bag-mask ventilation is begun. The air may dissect through various fascial planes involving the orbit, neck, face, or mediastinum. Treatment mainly is supportive because resolution is spontaneous. The patient should be told to avoid sneezing because this may increase the amount and duration of the emphysema. The patient should be placed on antibiotics, and all nasal packing should be removed.
• Minor hemorrhage
• Minor bleeding is a very common finding in functional endoscopic sinus surgery (FESS) and usually originates from a mucosal surface. Adequate preoperative vasoconstriction with local decongestants and lidocaine with epinephrine is key to preventing bleeding complications. Intraoperative bleeding is controlled with intranasal cautery or with 10 minutes of Afrin or cocaine-soaked cottonoid packing. Occasionally, nasal packing coated with Bactroban is necessary. Systemic antibiotics should be used as well if packing is necessary because several cases of toxic shock syndrome have been linked to the use of nasal packing.
• Patients with active infection, extensive polyposis, and possible bleeding diathesis are at increased risk for bleeding complications and should be identified preoperatively. Surgery should be delayed in patients with active infection for adequate treatment with antibiotics and nasal steroid sprays. Patients with extensive polyposis should undergo a course of oral steroids for 5-7 days preoperatively to decrease intraoperative bleeding. Patients with a history suggestive of bleeding abnormalities should undergo a prothrombin time (PT), activated partial thromboplastin time (aPTT), bleeding time, and platelet count. Any abnormalities warrant evaluation by a hematologist prior to surgery.
• Effects on facial growth
• Effects of early endoscopic sinus surgery (ESS) on facial growth are not completely known. In a 1996 piglet study, Mair et al found that facial growth was impaired following unilateral functional endoscopic sinus surgery (FESS).¹⁵ Although differences were evident on CT scanning, no clinical differences were noted. Stankiewicz reported 1 patient with a change in growth in the ethmoid and maxillary sinuses following subperiosteal abscess drainage 4 years previously. Of note, the patient had no clinically detectable differences in the 2 sides of the face.
• Examination of uncinate and ethmoid bone in humans reveals that mature lamellar bone is present by age 9 years. This implies that functional endoscopic sinus surgery (FESS) may have more effects on facial growth in patients younger than 9 years.
• Certainly, more information is needed about facial development after functional endoscopic sinus surgery (FESS). About 3.5% of individuals have unilateral maxillary sinus hypoplasia on CT scanning but have no detectable differences clinically. The differences in sinus growth noted on CT scanning following unilateral functional endoscopic sinus surgery (FESS) may not be clinically important.

Complications occur with any surgical procedure. Experience has a role in complication rates. However, most complications can easily be prevented by meticulous attention to preoperative planning. Knowledge of pediatric sinus anatomy is key to preventing poor outcomes. Become familiar with the anatomic variations that predispose to problems, such as a dehiscent optic nerve or carotid artery in the sphenoid sinus or an extremely high or low fovea ethmoidalis. Strict attention to preoperative coronal CT scans is a must. Many potential problems can be avoided by addressing the situation prior to surgery.

By adhering to the principles of careful preoperative planning, sound knowledge of pediatric sinus anatomy, meticulous surgical technique, and strict postoperative care, most complications can be avoided.

*NR = Results not reported

*NR = Results not reported

*NR=Results not reported

*NR = Results not reported

1. Awaken patient from general anesthesia.
2. Initiate immediate ophthalmology consultation.
3. Begin orbital massage (helps to redistribute hematoma and decrease pressures).
4. Start osmotic diuretic, such as Mannitol (1g/kg).
5. If no improvement in orbital pressures occurs, perform lateral canthotomy or medial orbital decompression via a Lynch excision.

Outcome and Prognosis

Pediatric functional endoscopic sinus surgery (FESS) has been shown to provide effective treatment for children with chronic sinus disease refractory to maximum medical therapy with success rates from 80-93%.

In patients with polyposis, especially associated with CF, recurrence instead of cure is the norm. In patients with CF and polyposis, resolution of preoperative symptoms occurs in 40-70% of cases. Recurrence rates are over 50%.

For patients with allergic fungal sinusitis (AFS), decreased recurrence rates, which are quoted to be 10-100%, have been observed with immunotherapy.

Future and Controversies

The main controversy is over whether or not any child should have sinus surgery because most rhinologists believe that the problem is basically a medical condition. Children have maturation of their immune system from birth to age 6-8 years. Over this time, if they are exposed to pathogens repeatedly, they are likely to have recurrent or chronic infections of the upper respiratory tract. Certainly, avoidance of social situations where multiple young children reside in the same physical space (eg, day care, preschool, nurseries) may decrease the likelihood of infections. Drastic measures of avoidance must be weighed against financial needs of the family and social needs of the child in this situation, and staunch proponents of both sides of the debate are easily found. New medical breakthroughs, including new antimicrobials, vaccines, and anti-inflammatory drugs rooted in basic science, may eliminate the need for surgery altogether.

If surgery is indicated for chronic sinusitis refractory to medical therapy in the absence of polyposis or an underlying medical condition, some controversy exists as to how aggressive the approach should be. Several authors advocate minimal surgery to open the outflow tracts to the sinuses, occasionally improving the status of adjacent sinuses without specifically manipulating them (see Minimally invasive technique in the Treatment section). In pediatric sinus surgery, sometimes less is more.

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Keywords

sinusitis, pediatric sinusitis, sinuses, sinus, paranasal sinuses, functional endoscopic sinus surgery, FESS, endoscopic sinus surgery, ESS, maxillary sinuses, ethmoid sinuses, frontal sinuses, sphenoid sinuses, chronic sinusitis, recurrent sinusitis

Contributor Information and Disclosures

Author

John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ted L Tewfik, MD, FRCS(C), Professor, Department of Otolaryngology, Director of Continuing Medical Education of Otolaryngology, McGill University Medical School; Director, Director of Professional Affairs of Otolaryngology, Department of Otolaryngology, Montreal Children's Hospital; Senior Staff, Montreal General Hospital and Royal Victoria Hospital
Ted L Tewfik, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society of Pediatric Otolaryngology, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jennifer Jordan, MD, to the development and writing of this article.

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