Pediatric turbinate radiofrequency ablation improves quality of life and rhinomanometric values. A prospective study

OBJECTIVE

turbinate surgery in pediatric patients is gradually increasing in popularity amongst pediatric otolaryngologists. However, despite this, there is scarce information regarding this surgical procedure in children. The present research is designed with the aim of assessing changes in nasal resistance, nasal airflow and quality of life in pediatric patients undergoing turbinate radiofrequency ablation.

METHODS

A prospective uncontrolled intervention clinical trial design was followed. Children between 4 and 15 years old undergoing turbinate radiodiofrequency ablation (TRA) were consecutively selected. Children were examined preoperatively and 1, 3, 6 and 12 months after turbinate surgery. Anterior active rhinomanometry with and without nasal decongestant and examination of the turbinates and adenoid size were carried out in each follow-up visit. The SN5 quality of live survey was answered by parents.

RESULTS

81 children were included, 28 with associated adenoidectomy. A significant improvement in quality of life was demonstrated since the first month after TRA. Regarding nasal resistance, there was an improvement 1 month after surgery, but it only reached statistical significance for the whole sample (p < 0.001)) and for the cohort of isolated turbinate surgery (p < 0.001) at 3 months, while the values for the cohort of children who underwent adenoidectomy reached significance at 6 months after surgery (p = 0.04). The difference in nasal resistance before and after decongestant was compared to the change in nasal resistance after surgery. It demonstrated a strong correlation with the change in nasal resistance at 1 month (R = 0.985; p < 0.001), 3 months (R = 0.995; p < 0.001), 6 months (R = 0.98; p < 0.001) and 12 months (R = 0.98; p < 0.001) after surgery.

CONCLUSIONS

turbinate surgery in pediatric patients seems to be a safe procedure which objectively and subjectively improves the symptoms of children suffering from nasal obstruction.

Pediatric chronic sinusitis: diagnosis and management

PURPOSE OF REVIEW

Review the diagnosis and management of pediatric chronic sinusitis given recent advances in both surgical and medical management.

RECENT FINDINGS

Balloon catheter dilation (BCD) of the sinuses has been used as an adjunct to adenoidectomy or in lieu of traditional endoscopic sinus surgery. BCD has been shown to be a safe technique in children although its efficacy compared to maxillary sinus irrigation or traditional sinus surgery cannot be determined based on current studies.

SUMMARY

New advances in BCD and biologics may serve as useful adjuncts in surgical and medical therapy respectively with additional research needed to better delineate the optimal indications for each in the treatment continuum.

The management of paediatric rhinosinusitis

Paediatric rhinosinusitis (PDRS) is commonly used as a synonym for rhinitis within healthcare. Although they may share common symptoms, the pathophysiology does differ; PDRS is the inflammation of the nasal mucosa in addition to the sinuses whereas rhinitis is the inflammation of just nasal mucosa. This review provides a comprehensive overview of the epidemiology, pathophysiology, symptoms, diagnosis and management of PDRS. There is a greater emphasis on the diagnosis and management of PDRS within this review due to a lack of clear guidelines, which can lead to the common misconception that PDRS can be treated indifferently to rhinitis and other upper respiratory conditions. PDRS has detrimental effects on children's current health, long-term health into adulthood and education. Therefore, having a comprehensive guide of PDRS would provide a greater understanding of the condition as well as improved diagnosis and management. This article primarily focuses on the position of Europe and the United Kingdom; however, the recommendations can be applied to other countries as the causes and treatments would not differ significantly.

Cross-cultural adaptation of the sinus and nasal quality of life survey (SN-5) to Spanish

OBJECTIVE

There is a high prevalence for rhinitis with an increasing trend. However, there is a lack of specific quality of life pediatric questionnaires for sinonasal symptoms. The Sinus and Nasal Quality of Life Survey (SN-5) is the only validated instrument specifically designed with this objective. In this work we have translated and validated the Spanish version of the SN5 questionnaire.

METHODS

The SN5 was translated according to the World Health Organization recommendation for the translation and adaptation of instruments. The final version of the Sp-SN5 was administered twice (day 0 and day 7) to 137 participants with and without sinonasal symptoms. Reliability was measured with Cronbach α, temporal stability was measured with intraclass correlation coefficient. External validity was assessed with a ROC curve comparing a cohort of cases (children going to turbinate radiofrequency ablation) and controls (asymptomatic children).

RESULTS

A Spearman correlation between the total result of the Sp-SN-5 questionnaire and the QOL score showed a strong negative correlation in the general sample and all the age subgroups. Internal consistency measured with Cronbach α was 0.87 for 5 items and was still over 0.83 after removing each item of the test. The intraclass correlation coefficient (ICC) for test-retest measurements was 0.94. The receiver operating characteristic (ROC) curve for all the included participants showed a very high area under the curve (0.998).

CONCLUSIONS

The Sp-SN-5 questionnaire was successfully translated and cross-culturally adapted into Spanish, and the translated version exhibited adequate properties. The survey was effective in assessing the quality of life of pediatric patients with sinonasal complaints and can be used for this purpose both in a clinical setting and in future research.

Efficacy and safety of paranasal sinus balloon catheter dilation in pediatric chronic rhinosinusitis: a systematic review

Objective

Chronic rhinosinusitis (CRS) negatively affects quality of life (QoL), and balloon catheter sinuplasty (BCS) has shown good outcomes in adult patients. However, there has not been much research on the effects of BCS on pediatric patients. The objective of this review is to systematically assess the literature for studies demonstrating the effectiveness and safety of BCS in pediatric CRS patients.

Data sources

PubMed, Embase and Cochrane Library.

Study selection

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations (PRISMA) to conduct our study. Observational- and interventional-based studies reporting efficacy and/or side effects of BCS among pediatric populations were included. Efficacy was evaluated by clinically reliable measures including Sino-Nasal 5 (SN-5) QoL scale. Antibiotic usage and revision surgery were also evaluated.

Data extraction

Articles were screened, and data were obtained. Study design, sample size and demographics, treated sinuses, criteria of inclusion, adjunct procedure(s), follow-up time, and outcomes measured were reported.

Main findings

Out of 112 articles identified, 10 articles were included: two interventional controlled trials and eight observational studies. All studies evaluating QoL by SN-5 showed a remarkable reduction in SN-5 score postoperatively. Improvement in the computed tomography (CT) and endoscopic findings for up to 1 year after operation was reported. Furthermore, the majority of patinets treated with BCS did not recieve any course of sinusitis-indicated antibiotics during long-term follow-up, and they had low surgical revision rates. Minor side effects were reported, most commonly synechia.

Conclusion

Available evidence suggests that BCS is safe and effective for the treatment of CRS in pediatric patients. Future randomized controlled studies with large sample size are warranted. Such studies can further determine the efficacy of BCS in managing children with CRS.

Balloon Catheter Dilation in Pediatric Chronic Rhinosinusitis: A Meta-analysis

BACKGROUND

Paranasal sinus balloon catheter dilation (BCD) represents a tool that has been shown to be safe in the management of pediatric chronic rhinosinusitis (pCRS); however, its efficacy compared to standard treatment regimens has not been well established.

OBJECTIVE

The purpose of this meta-analysis was to evaluate the clinical utility of BCD in pCRS.

METHODS

Articles reporting BCD for pCRS in patients under 18 years of age were identified via the following search terms: sinusitis OR rhinosinusitis AND balloon dilatation OR balloon dilation OR balloon sinuplasty OR sinuplasty AND adolescent OR children OR infant OR pediatric OR toddler. The primary outcome analyzed includes quality of life improvement as measured via Sinus and Nasal Quality of Life Survey (SN-5) or Sino-nasal Outcome Test (SNOT-22) scores.

RESULTS

Eighty studies were abstracted; 10 studies were included for final qualitative analysis after dual investigator screening. Three studies described BCD with surgical controls, including adenoidectomy, saline irrigation, or maxillary antrostomy. Noninferiority was not demonstrated (ie, BCD is inferior) in 2 of 3 studies. Pooled analysis utilizing a random effects model revealed a decreased effect size yet no statistically significant difference between BCD and standard operative techniques as measured by quality of life measures (g = -0.04, I² = 41%).

CONCLUSION

This work highlights a lack of published evidence regarding the role of BCD in pCRS. Two of the 3 included studies demonstrated the inferiority of BCD when compared to other standard surgical interventions, whereas meta-analysis was unable to detect any statistically significant difference between standard treatment regimens. Future scientific investigations are necessary to assess the comparative effectiveness of BCD in pCRS.

SYSTEMATIC REVIEW OF THE LITERATURE ON SURGICAL TREATMENT OF CHRONIC RHINOSINUSITIS IN CHILDREN: WHAT IS THE BEST APPROACH?

Objective:

To carry out a systematic literature review on the surgical treatment of chronic rhinosinusitis in the pediatric population.

Data sources:

A bibliographic review methodology was used, based on data from National Library of Medicine (Medline), PubMed, Latin American and Caribbean Health Sciences Literature (LILACS) and Scientific Electronic Library Online (SciELO), of the indexed works from 2006 to 2016, including the pediatric population from zero to 13 years of age. The search keywords according to Medical Subject Heading (MESH) and Health Sciences Descriptors (DeCS) were: child, surgery, sinusitis and chronic disease. A total of 318 articles were collected, five of which met the inclusion criteria and were used as a basis for this review. All articles were prospective cohort studies, level of evidence 2B, according to the criterion used by evidence-based medicine.

Data synthesis:

The literature agreed that the next step for the cases refractory to drug treatment in chronic rhinosinusitis in childhood would be surgery. Adenoidectomy would be the initial method, for the safety of the procedure and improvement in about 50% of the cases, although more significant results were found in patients who associated this procedure with facial sinus surgery.

Conclusions:

Surgical treatment should be indicated for chronic rhinosinusitis in childhood after treatment failure. The results pointed out that adenoidectomy, when associated with some type of approach to the facial sinus, present better results.

Review and Analysis of Research Trends in Surgical Treatment of Pediatric Chronic Sinusitis

Background

Chronic sinusitis is a common otolaryngologic complaint with a significant impact on patients’ quality of life. There is current debate and differences in quality of evidence regarding the best surgical management approach to pediatric chronic sinusitis.

Objective

To investigate changes in publishing trends over time in surgical management of pediatric chronic sinusitis.

Methods

A systematic literature review was conducted in January 2019 using Embase, PubMed, and Web of Science, of all articles that included surgical treatments for pediatric chronic sinusitis. Publications were grouped into 3 time periods: pre-1998, 1999–2008, and 2009–2018. In addition, a subgroup of publications pertaining to endoscopic sinus surgery, balloon sinuplasty, and adenoidectomy were grouped into 2-year periods since 1988 to compare the number of publications on each topic and to examine overall trends.

Results

A total of 327 abstracts were included in the data collection and analysis. There was an overall significant increase in total number of publications ( P < .0001), total number of authors ( P = .001), and comparison studies ( P = .003) from pre-1989 to 2018. Relative number of prospective studies, systemic review, and case studies/expert opinions have not significantly increased over time when comparing decades ( P > .05). Among the surgery types, functional endoscopic sinus surgery has the most amount of publications regardless of year despite a statistically significant increase in publications pertaining to balloon sinuplasty in the pediatric literature from 1999–2008 to 2009–2018 ( P = .001).

Conclusions

Studies on pediatric chronic sinusitis have increased significantly during each of the last 2 decades with an increase in the concomitant number of authors and comparison studies. Although most publications are still Level C or D evidence, there has been a nonsignificant increase in Level A evidence in the past decade. Endoscopic sinus surgery still remains the most studied procedure despite the recent increase in publications on balloon sinuplasty.

Innovations in Endonasal Sinus Surgery in Children

Although there have been many advances in new tools and procedures for endonasal sinus surgery in children, the management and care for pediatric chronic rhinosinusitis has remained relatively unchanged. However, there have been advances in skull base surgery and tumor removal and new knowledge about perioperative concerns in children. This article discusses the role and risks of endoscopic sinus surgery, the use of balloon sinuplasty in children, management of complicated rhinosinusitis, and advances in skull base tumors and choanal atresia repair.

Surgical Treatment of Paediatric Chronic Rhinosinusitis

Rhinosinusitis (RS) is a common disease in children, significantly affecting their quality of life. Chronic rhinosinusitis (CRS) is frequently linked to other respiratory diseases, including asthma. Children affected by CRS may be candidates for surgery in the case of failure of maximal medical therapy comprising three to six weeks of broad-spectrum systemic antibiotics with adjunctive therapies. Although endoscopic sinus surgery (ESS) is the surgical treatment of choice in adult patients with CRS, different surgical procedures are scheduled for refractory paediatric CRS and include adenoidectomy, paediatric ESS (PESS), and balloon catheter sinuplasty (BCS). The present paper discusses the indications and limitations of each treatment option in children with CRS. Given the amount of current evidence, it is reasonable to suggest that, in young and otherwise healthy children with refractory CRS, an adenoidectomy (eventually combined with BCS) should be offered as the first-line surgical treatment. Nevertheless, this approach may be considered ineffective in some patients who should be candidates for traditional ESS. In older children, those with asthma, or in the case of peculiar conditions, traditional ESS should be considered as the primary treatment.

Long-Term Effectiveness of Balloon Catheter Sinuplasty in Pediatric Chronic Maxillary Sinusitis

The objective of our study was to assess the long-term effectiveness of balloon catheter sinuplasty in the treatment of pediatric chronic maxillary sinusitis following failed first-line medical and surgical management with adenoidectomy. Pediatric patients younger than 12 years were reviewed for having failed previous adenoidectomy and undergone a balloon catheter sinuplasty between August 2006 and March 2011 for chronic rhinosinusitis. Demographic data and clinical characteristics were recorded in patients who met inclusion criteria. Outcomes were assessed by need for functional endoscopic sinus surgery and persistence of chronic infection within at least 5 years of follow-up. Failure was defined by any child who was rediagnosed with chronic sinus disease after balloon catheter sinuplasty or who required endoscopic sinus surgery within 5 years. Sixty-two children were reviewed, with 38 patients meeting inclusion criteria (prior adenoidectomy, a preoperative Lund-Mackay score of ≥5, and balloon catheter sinuplasty). The mean age (standard deviation) was 6.76 (2.27) years with an age range of 2 to 11 years. Eight children (21.1%, P < .01) continued to have chronic sinus complaints following balloon procedure, with 5 (13.1%) individuals requiring eventual endoscopic surgery within 5 years. Age, asthma, allergy, and gender did not have any statistically significant impact on outcome. Balloon catheter sinuplasty is an effective long-term alternative for the treatment of chronic rhinosinusitis in pediatric patients, hoping to avoid further infections and eventual endoscopic surgery.

Update on pediatric sinus surgery: indications and outcomes

PURPOSE OF REVIEW

To review the recent literature of pediatric endoscopic sinus surgery (ESS).

RECENT FINDINGS

Sinus balloon catheter dilation is an important addition to the surgical treatment tools for pediatric chronic rhinosinusitis (PCRS). ESS is a safe and effective therapeutic modality for uncomplicated PCRS. For PCRS complicated by comorbidities including cystic fibrosis and primary ciliary dyskinesia, ESS and adjuvant medical therapy confers significant sinus, pulmonary, and quality of life benefits to pediatric patients.

SUMMARY

ESS is a safe and effective treatment modality in the management of pediatric acute and chronic sinus disorders.

The Sinus and Nasal Quality of Life Survey (SN-5) in the Management of Pediatric Chronic Rhinosinusitis: A systematic review and meta-analysis

OBJECTIVES

Pediatric chronic rhinosinusitis (CRS) is a prevalent condition with quality of life (QoL) impacts that are seldom reported in the literature. We aimed to conduct a systematic review and meta-analysis on studies using the Sinus and Nasal Quality of Life Survey (SN-5), the only validated symptom questionnaire in pediatric CRS.

METHODS

A literature search was conducted to identify studies that used the SN-5 to measure QoL before and after medical or surgical interventions for pediatric CRS. Comparison of means and standard deviations was performed between pre- and post-intervention SN-5 scores.

RESULTS

A total of 10 studies, consisting of 13 separate treatment arms of either medical therapy, adenoidectomy, balloon catheter sinuplasty (BCS), or functional endoscopic sinus surgery (FESS) were identified. The vast majority (92.3%) of the treatment arms demonstrated minimal clinically important differences between baseline and post-intervention SN-5 scores. Rates of treatment success and minimal clinically important difference among all treatment arms ranged from 43.2% to 94.0%. Comparison of means showed an improvement in SN-5 score of 1.97 [95% CI, 1.18 to 2.76; p < 0.00001] for BCS, 1.83 [95% CI, 1.47 to 2.19; p < 0.00001] for FESS, and 1.15 [95% CI, 0.36 to 2.66; p = 0.13) for medical treatment.

CONCLUSION

There is a paucity of literature on QoL outcomes in pediatric CRS. More studies using the SN-5, particularly those controlling for baseline patient characteristics, are necessary to fully elucidate the impact of various interventions on QoL in pediatric CRS.

Outcomes and Complications of Balloon and Conventional Functional Endoscopic Sinus Surgery

Background

Since the Food and Drug Administration approval of balloon sinuplasty (BSP) in 2005, no nationally representative population-based studies have examined the outcomes and adverse events of BSP.

Objective

To assess the rates of complications and revision surgery in patients who received BSP, functional endoscopic sinus surgery (FESS), or a hybrid procedure.

Methods

Using one of the nation’s largest commercial insurance databases, we conducted a retrospective cohort study of pediatric and adult patients diagnosed with chronic rhinosinusitis between 2011 and 2014 who underwent BSP, conventional FESS, or a hybrid procedure. The primary outcomes were surgical complication and revision rates within 6 months of initial surgery.

Results

A total of 16,040 patients who underwent sinus surgery were included. Overall, 2,851 patients underwent BSP, 11,955 underwent conventional FESS, and 1 234 underwent a hybrid procedure. BSP surgery was more likely to have been performed in an office setting (86.53%) compared to FESS (0.74%). The complication rate was 5.26% for BSP and 7.35% for conventional FESS. Revision rates were 7.89% for BSP, 16.85% for FESS, and 15.15% for a hybrid procedure.

Conclusion

Despite the low overall risk, major complications occur with BSP including cerebrospinal fluid leak, pneumocephalus, orbital complications, and severe bleeding. Otolaryngologists should discuss these risks with their patients. Prospective studies are still needed to compare outcomes of BSP with those of FESS.

Sinus and Upper Airway Surgery in Children

PURPOSE OF REVIEW

Chronic sinus and upper airway disease in children is a common health problem encountered every day. Its pathophysiology is complicated which leads to different treatment options and approaches. We seek to review the current literature and evidence to surgical treatments.

RECENT FINDINGS

Medical treatment with antibiotics and topical nasal sprays continues to be the first-line treatment. Surgical interventions include adenoidectomy, balloon catheter sinuplasty (BCS), and endoscopic sinus surgery (ESS). Each modality has proven to be safe; however, its effectiveness is widely variable. More research with higher level of evidence is needed to help in choosing the right surgical treatment with optimal benefit.

Prospective, multicenter evaluation of balloon sinus dilation for treatment of pediatric chronic rhinosinusitis

Background

Although balloon sinus dilation is a treatment option for adults with chronic rhinosinusitis (CRS), there have been few studies performed in pediatric patients.

Methods

This study was designed as a prospective, multicenter, single‐arm investigation. Children (2 to 21 years old) with CRS who had failed medical management were treated with balloon sinus dilation and followed to 6 months postprocedure.

Results

Fifty children were treated at 4 centers; 33 participants were 2 to 12 years old (mean ± standard deviation age: 6.6 ± 2.2 years) and 17 participants were >12 to 21 years (mean age: 15.7 ± 2.5 years). A total of 157 sinus dilations were attempted (98 maxillary, 30 frontal, and 29 sphenoid sinuses) and all were successful with no complications. Significant improvement in the Sinus and Nasal Quality of Life Survey (SN‐5) was seen for all children between baseline and 6 months (4.6 ± 1.2 vs 1.7 ± 0.8; p < 0.0001) and 92% improved by a minimal clinically important difference (MCID) of 1.0 or more. Those children aged 2 to 12 years with standalone balloon dilation also showed significant SN‐5 improvements between baseline and follow‐up (4.5 ± 1.0 vs 1.9 ± 0.8; p < 0.0001). Multivariate regression analysis showed no differences or associations of SN‐5 improvement at 6 months with the presence of allergy, asthma, or concomitant procedures. For adolescents, overall 22‐item Sino‐Nasal Outcome Test (SNOT‐22) mean scores were also significantly improved at 6 months (42.2 ± 19.2 vs 10.4 ± 9.7; p < 0.0001).

Conclusion

Balloon sinus dilation is safe and appears effective for children with CRS aged 2 years and older.

Quantitative sinonasal symptom assessment in an unselected pediatric population with cystic fibrosis

INTRODUCTION

The aim of this study was to establish baseline sinonasal quality of life scores in an unselected pediatric population with cystic fibrosis (CF) and to test the correlation of those scores with various clinical outcome measurements.

METHODS

A total of 50 consecutive children, ages 2-12 years, seen routinely in a large CF clinic were evaluated by using the Sinus and Nasal Quality of Life Survey (SN-5) tool at the time of their visit. At this time, the parent or guardian of the child was also questioned about recent episodes of sinusitis, antibiotic prescriptions for sinusitis, recent hospitalizations, and days missed from school or recreational activities due to sinonasal symptoms. CF genotype, pulmonary function, recent sinus surgeries, and computed tomography scores were established by thorough chart review.

RESULTS

The average SN-5 score of this group was lower than published averages in children with baseline, preoperative, or postoperative chronic sinusitis, and demonstrated significant correlations with a visual analog scale, recent episodes of sinusitis, antibiotic prescriptions for sinusitis, and the number of days missed from school or recreational activities due to sinonasal symptoms, with a nonsignificant trend observed with previous sinus surgery. No correlations were seen with CF genotype, pulmonary function, or hospitalization days. Computed tomography results were overwhelmingly abnormal, and Lund-MacKay scores did not correlate with SN-5 scores or clinical outcome measurements.

CONCLUSIONS

The SN-5 tool provides a quick, safe, and reliable qualitative metric for monitoring sinonasal symptoms in young children with CF.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Clinical consensus statement: pediatric chronic rhinosinusitis

OBJECTIVE

To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS).

METHODS

A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus.

RESULTS

After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty.

CONCLUSION

Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Pediatric chronic rhinosinusitis: when should we operate?

PURPOSE OF REVIEW

The timing and role of surgery in the management of pediatric chronic rhinosinusitis (pCRS) remains unclear. This review attempts to summarize the existing literature regarding this topic.

RECENT FINDINGS

pCRS is a complex clinical syndrome that results from multiple potential causes. Multimodal medical therapy is the accepted primary treatment. Adenoidectomy continues to be the appropriate first-line surgical therapy, and the addition of antral lavage or balloon dilation to this procedure may improve outcomes. Functional endoscopic sinus surgery (FESS) in children is safe and effective in relieving symptoms in the majority of patients. Failure to respond to maximal medical therapy continues to be a commonly cited, although poorly defined, requisite for proceeding to surgery. Recent literature has been focused on the outcomes after FESS rather than specifically defining when this intervention should be considered. Nevertheless, the literature seems to continue to support FESS in children with persistent symptoms despite adenoidectomy and appropriate medical treatment for pCRS. As the symptoms of chronic rhinosinusitis (CRS) may result from multiple underlying causes, clinicians must understand that the role and timing of surgery may vary with particular patients' disease.

SUMMARY

Surgical management of CRS in children continues to be a frequent topic of study in the otolaryngology literature. As recent research tends to be focused on outcomes after surgery, further prospective studies comparing surgical versus nonsurgical treatment of CRS will likely be required to better define indications for proceeding to surgery at all.