Pediatric Paranasal Sinuses- Development, Growth, Pathology & Functional Endoscopic Sinus Surgery

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

Inflammatory Modifications in Paranasal Sinuses and Ostiomeatal Complex Anatomical Variations in Jet Aircraft Pilots: A Computed Tomography Study

Introduction  Jet aircraft pilots are exposed to huge pressure variation during flight, which affect physiological functions as systems, such as the respiratory system. Objectives  The objective of the present investigation was to evaluate inflammatory changes of paranasal sinuses of jet aircraft pilots before and after a jet aircraft training program, using multislice computed tomography (CT), in comparison with a group of nonairborne individuals with the same age, sex, and physical health conditions. A second objective of the present study was to assess the association between the ostiomeatal complex obstruction and its anatomical variations. Methods  The study group consisted of 15 jet aircraft pilots participating in the training program. The control group consisted of 41 nonairborne young adults. The 15 fighter pilots were evaluated before initiating the training program and after their final approval for the presence of inflammatory paranasal sinus disease. The ostiomeatal complex anatomical variations and obstructions were analyzed in pilots after the training program. Results  Jet aircraft pilots presented higher incidence of mucosal thickening in maxillary sinus and anterior ethmoid cells than controls. Prominent ethmoidal bulla showed significant association with obstruction of the osteomeatal complex. Conclusions  Jet aircraft pilots present increased inflammatory disease when compared with nonairborne individuals. The presence of a prominent ethmoidal bulla is associated with ostiomeatal complex obstruction.

[Pediatric chronic rhinosinusitis]

Pediatric chronic rhinosinusitis (PCRS) differs from adult chronic rhinosinusitis (CRS) in several aspects. The confrontation with the environment takes place in the growing sinus system, and the immune system is also developing. The inflammatory mechanisms differ to some extent from those of adult CRS patients. The adenoid vegetations play an important role, particularly during the first 6 years of life. Other pathogenetic aspects are important (e.g., asthma, gastroesophageal reflux disease, immunodeficiency). Genetically determined systemic diseases such as cystic fibrosis cause specific challenges in diagnostics and treatment already in childhood. Consistent conservative therapy is often successful, but surgical procedures that have been proven to be effective and associated with few complications are also increasingly used.

Anatomy of Maxillary Sinus: Focus on Vascularization and Underwood Septa via 3D Imaging

The study of the maxillary sinus anatomy should consider the presence of two features of clinical importance. The arterial supply course and the presence of the so-called Underwood septa are two important factors to consider when planning surgical treatment to reduce the risk of surgical complications such as excessive bleeding and Schneiderian membrane perforations. This study aimed to investigate the above-mentioned anatomical structures to improve the management of eventual vascular and surgical complications in this area. This study included a total of 200 cone-beam computed topographies (CBCTs) divided into two groups of 100 CBCTs to evaluate the arterial supply (AAa) course through the lateral sinus wall and Underwood's septa, respectively. The main parameters considered on 3D imaging were the presence of the AAa in the antral wall, the length of the arterial pathway, the height of the maxillary bone crest, the branch sizes of the artery in the first group, and the position of the septa, the length of the septa, and their gender associations in the second group. The CBCT analysis showed the presence of the arterial supply through the bone wall in 100% of the examined patients, with an average size of 1.07 mm. With regard to the septa, 19% of patients presented variations, and no gender difference was found to be statistically significant. The findings add to the current understanding of the clinical structure of the maxillary sinus, equipping medical professionals with vital details for surgical preparation and prevention of possible complications.

Pediatric Craniomaxillofacial Fractures: A Review

Pediatric facial fractures constitute a small portion of all facial fractures. The frequency of pediatric facial fractures by location, and mechanism of injury, changes over time associated with craniofacial growth and activity. Pediatric patients have protective anatomic features, such as increased soft tissue, excess adipose tissue, and more flexible bone. Conservative management is often sufficient. Surgical intervention can often be conservative. Follow-up monitoring is valuable for concerns of growth disruption from either the trauma itself or surgical interventions. Older teenage patients may often be treated similar to adults. Postoperative management varies by fracture type without a defined long-term follow-up course.

The development of paranasal sinuses in patients with cystic fibrosis: sinuses volume analysis

BACKGROUND

Cystic fibrosis (CF) is a severe systemic disease that affects many aspects of patients' lives. It is known that the progression of the disease adversely affects lower and upper airways including the paranasal sinuses. However, its impact on sinus development in the pediatric population is not fully examined. The purpose of this study was to evaluate the development of the paranasal sinuses in a pediatric population with CF and compare it to a control group consisting of healthy children.

METHODS

The results of computed tomography (CT) scans of children with the disease and the control group were evaluated. The study included 114 CT images of children in the study group and 126 images of healthy children aged 0-18 years. The volumes of maxillary, frontal, and sphenoid sinuses were analyzed. The obtained results were compared with those of the control group and analyzed statistically.

RESULTS

The volume and the development of the paranasal sinuses in both groups increased with age, but statistically significant differences were found between the study and the control group.

CONCLUSIONS

The obtained results provide valuable knowledge regarding the impact of the CF on sinuses development. Also, they may be important in understanding the progression of the disease and its influence on the quality and length of life of patients. The results may contribute to enhanced diagnostics and have implications for improving therapy for patients with chronic sinusitis associated with CF.

Pediatric Head and Neck Trauma

The pediatric patient population has unique anatomic characteristics that bring challenges and increased risk to management. The purpose of this article is to guide the head and neck trauma surgeon in decision making for the treatment of pediatric head and neck trauma with an emphasis on facial fracture management.

Epidemiology and Etiology of Facial Injuries in Children

Pediatric Trauma results in over 8 million emergency department visits and 11,000 deaths annually. Unintentional injuries continue to be the leader in morbidity and mortality in pediatric and adolescent populations in the United States. More than 10% of all visits to pediatric emergency rooms (ER) present with craniofacial injuries. The most common etiologies for facial injuries in children and adolescence are motor vehicle accidents, assault, accidental injuries, sports injuries, nonaccidental injuries (eg, child abuse) and penetrating injuries. In the United States, head trauma secondary to abuse is the leading cause of mortality among non-accidental trauma in this population.

Molecular defects in primary ciliary dyskinesia are associated with agenesis of the frontal and sphenoid paranasal sinuses and chronic rhinosinusitis

Background: Primary ciliary dyskinesia (PCD; MIM 242650) is a rare genetic disorder characterized by malfunction of the motile cilia resulting in reduced mucociliary clearance of the airways. Together with recurring infections of the lower respiratory tract, chronic rhinosinusitis (CRS) is a hallmark symptom of PCD. Data on genotype-phenotype correlations in the upper airways are scarce. Materials and methods: We investigated the prevalence, radiologic severity, and impact on health-related quality of life (HrQoL) of CRS in 58 individuals with genetically confirmed PCD. Subgroup analysis was performed according to the predicted ultrastructural phenotype based on genetic findings. Results: Among 58 individuals harboring pathogenic variants in 22 distinct genes associated with PCD, all were diagnosed with CRS, and 47% underwent sinus surgery. A total of 36 individuals answered a German-adapted version of the 20-item Sinonasal Outcome Test (SNOT-20-GAV) with a mean score of 35.8 ± 17, indicating a remarkably reduced HrQoL. Paranasal sinus imaging of 36 individuals showed moderate-to-severe opacification with an elevated Lund-Mackay Score (LMS) of 10.2 ± 4.4. Bilateral agenesis of frontal sinus (19%) and sphenoid sinus (9.5%) was a frequent finding in individuals aged 16 years or older. Subgroup analysis for predicted ultrastructural phenotypes did not identify differences in HrQoL, extent of sinus opacification, or frequency of aplastic paranasal sinuses. Conclusion: PCD is strongly associated with CRS. The high burden of disease is indicated by decreased HrQoL. Therefore, the upper airways of PCD individuals should be evaluated and managed by ear-nose-throat (ENT) specialists. Genetically determined PCD groups with predicted abnormal versus (near) normal ultrastructure did not differ in disease severity. Further studies are needed to gain evidence-based knowledge of the phenotype and management of upper airway manifestations in PCD. In addition, individuals with agenesis of the frontal and sphenoid paranasal sinuses and chronic respiratory symptoms should be considered for a diagnostic evaluation of PCD.

Evaluation of Maxillary Sinus Volume of Class III Individuals with Different Jaw Positions by Cone-Beam Computed Tomography

Objective

To compare maxillary sinus volumes and surface areas among individuals with Class III skeletal patterns, with different sagittal positions of maxilla and Class I patients with normal jaw positions using cone-beam computed tomography (CBCT).

Methods

CBCT images of 168 patients were analyzed retrospectively. The calculated surface areas and sinus volumes of 58 patients with Class I, normal mandibular and maxillary position (0SNA>80, 82>SNB>78) were compared with 61 patients with Class III retrognathic maxillary and normal mandibular positions (MRs) (ANB<0, SNA<80, 82>SNB>78) and 49 patients with Class III normal maxillary and prognathic mandibular positions (MP) (ANB<0, 84>SNA>80, SNB>82). Also, volume differences between genders and sides were investigated. One-way ANOVA and t-test were used to compare age, gender, skeletal patterns, and maxillary sinus measurements.

Results

CBCT images of 94 females and 74 males were examined. There was no statistically significant difference in the right and left maxillary sinus volume and surface area measurements among Class I, Class III MR, and Class III MP groups (p>0.05). When the maxillary sinus volume and surface area were evaluated according to gender, the right maxillary sinus surface area and volume of males were found to be statistically significantly higher than those of females (p=0.012 and p=0.024). Similarly, the left maxillary sinus surface areas and volumes of males were also found to be significantly higher than those of females (p=0.000 and p=0.002).

Conclusion

Different sagittal positions of the maxilla do not appear to affect maxillary sinus volume, and males tend to have greater maxillary sinus volume than females. CBCT images can be used to calculate intrabony air spaces.

Advancements in acoustic drug delivery for paranasal sinuses: A comprehensive review

Chronic rhinosinusitis (CRS) impacts patients' quality of life and healthcare costs. Traditional methods of drug delivery, such as nasal sprays and irrigation, have limited effectiveness. Acoustic Drug Delivery (ADD) using a nebulizer offers targeted delivery of drug to the sinuses, which may improve the treatment of CRS. This review examines the influence of aerosol particle characteristics, aero-acoustic parameters, inlet flow conditions, and acoustic waves on sinus drug delivery. Key findings reveal that smaller particles improve the ADD efficiency, whereas larger sizes or increased density impair it. The oscillation amplitude of the air plug in the ostium is crucial for the ADD efficiency. Introducing acoustic waves at the NC-sinus system's resonance frequency improves aerosol deposition within sinuses. Future research should address advanced models, optimizing particle characteristics, investigating novel acoustic waveforms, incorporating patient-specific anatomy, and evaluating long-term safety and efficacy. Tackling these challenges, ADD could offer more effective and targeted treatments for sinus-related conditions such as CRS.

Radiographic feature changes in an antral pseudocyst that existed prior to sinus floor augmentation and dental implant placement, 15 years after initial detection - a case report

INTRODUCTION AND IMPORTANCE

Maxillary sinus floor augmentation is acceptable and safe for bone augmentation prior to insertion of dental implants in atrophied maxillary bones. Anatomical variations and lesions of the maxillary sinus, including antral pseudocysts, are common radiological findings that can affect the outcomes of maxillary sinus augmentation. We show the changes in the radiological features of an antral pseudocyst that existed before maxillary sinus augmentation and 15 years after the insertion of dental implants.

CASE PRESENTATION

The patient was a 69-year-old male with an unremarkable medical history. The initial orthopantomogram revealed a very large antral pseudocyst in the left maxillary sinus. After upper left second molar extraction and maxillary sinus augmentation, two dental implants were inserted in regions 26 and 27. The pseudocyst had changed radiologically 15 years later, but a biopsy showed no characteristic changes, and the dental implants showed no functional failures.

CLINICAL DISCUSSION

We present a case of an antral pseudocyst that was not removed before or during sinus floor augmentation. A debate is ongoing regarding whether antral pseudocysts affect maxillary sinus augmentation, and various strategies have been applied to prevent intraoperative and postoperative complications, including removal of pseudocysts 3-12 months before maxillary sinus augmentation, removal during maxillary sinus augmentation, and leaving them alone when the floor is raised.

CONCLUSION

The present case showed a preexisting antral pseudocyst at maxillary sinus floor augmentation and insertion of the implants, which changed radiologically 15 years later, but did not affect the function of the dental implants.

Effect of Nasal Submucosal Injection of Low-concentration Epinephrine on Visual Field Visualization in Endoscopic Sinus Surgery: A Systematic Review and Meta-analysis

Objective: To determine whether nasal submucosal injection of low-concentration epinephrine improved the surgical field visualization and physician satisfaction compared to placebo or without intervention. Methods: A literature search of PubMed, Scopus, Web of Science, Cochrane library, China National Knowledge Infrastructure, and Wanfang Database was conducted from inception to January 10, 2023. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analyses were performed using Review Manager (RevMan version 5.3; the Cochrane Collaboration). Quality was assessed by 2 reviewers using the Cochrane Risk of Bias Tool. And we used funnel plots to visually assess the risk of publication bias. Results: We included a total of 11 studies with 492 patients, all of which were randomized controlled trials. Among the studies, 4 had a low risk of bias, 4 had a moderate risk of bias, and 3 had a high risk of bias. Five studies reported visual bleeding grade in the surgical field (P = 0.07) and total blood loss (P = 0.16), 8 studies reported preoperative baseline heart rate (P = 0.58) and baseline mean arterial pressure (MAP) (P = 0.78), and 9 studies reported intraoperative heart rate (P = 0.27) and MAP (P = 0.56), which showed no significant differences in these parameters between the 2 groups. None of these outcomes were statistically significant between the epinephrine group and the control group. Conclusion: There is insufficient evidence to support the nasal submucosal application of low-concentration epinephrine to improve surgical field dryness and reduce total surgical bleeding.

Assessment of Skeletal Maturity in a Sample of the Saudi Population Using Cervical Vertebrae and Frontal Sinus Index: A Cephalometric Study Using Artificial Intelligence

Aim This study aims to investigate the relationship between the frontal sinus index and different stages of cervical vertebral maturation and to determine whether these measurements can be used as accurate markers for evaluating skeletal maturity. Materials and methods The sample size was 120 subjects, with ages that ranged from 8 to 25 years. Standardized pretreatment digital lateral cephalograms were analyzed. Six groups representing different phases of cervical vertebral maturation were created from the entire sample. Each group had 20 subjects and was split into male and female groups. On the same radiograph, the cervical stages were assessed and the frontal sinus index was calculated. Correlations between the frontal sinus index and cervical vertebral maturation were assessed using statistical analysis. Results Sinus index values, which assess the ratio of frontal sinus dimensions to cervical stages, were found to be comparable between the two adjacent cervical stages. However, the patterns of sinus index values differed between males and females, suggesting potential variations in sinus development between the sexes. Conclusion Frontal sinus height and width were significantly correlated with cervical vertebral maturation stages in both sexes. The frontal sinus index, on the other hand, was not significant.

Predictors of Surgical Intervention for Pediatric Acute Rhinosinusitis with Periorbital Infection

Background: Medical versus surgical management of pediatric periorbital infection secondary to acute bacterial rhinosinusitis (ABRS) can be a dilemma for clinicians. This study aimed to evaluate the prognostic factors related to the need for surgical drainage and to help direct management decisions. Methods: Children admitted for periorbital infection secondary to ABRS between 2001 and 2019 were retrospectively reviewed. Demographics, clinical presentations, laboratory data, comorbidities, and computed tomography results were collected from medical records. Results: A total of 141 pediatric patients were enrolled. Forty-two patients (29.8%) required surgical intervention. Multivariate logistic regression analysis identified that delayed initiation of intravenous antibiotics from the onset of periorbital swelling (odds ratio [OR] = 1.94; p < 0.001) and proptosis at initial presentation (OR = 6.63; p = 0.008) were significantly associated with the need for surgical intervention. A C-reactive protein value of > 55.73 mg/L and initiation of intravenous antibiotic treatment > 2 days from the onset of periorbital swelling showed the best predictive power for surgery. Conclusions: Pediatric patients with delayed initiation of intravenous antibiotic treatment and initial presentation of proptosis had worse outcomes and required surgical intervention.