pedi-sinus-surg-slides-070424

pedi-sinus-surg-slides-070424 - PediatricEndoscopic...

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    Pediatric Endoscopic  Sinus Surgery Murtaza Kharodawala, MD Seckin Ulualp, MD University of Texas Medical Branch at Galveston Grand Rounds Presentation April 25, 2007
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Background Importance Children average 6-8 URIs per year 5%-13% of URIs are complicated by secondary bacterial infection of paranasal sinuses History Pediatric FESS reported to have success over 80% in late 1980s and early 1990s Initial surgical indications were broad but published studies were often retrospective Paradigm shifted when prospective studies showed that medical options were effective in treatment of pediatric sinus diseases and possible effect that surgery had on facial skeletal development In late 1990s to the present, evidence-based approaches to pediatric sinus disease include FESS as an option
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Indications for Pediatric FESS Clement, 1998 Management of rhinosinusitis in children: consensus meeting
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Indications for Pediatric FESS Complicated ABS with orbital or CNS involvement Sinonasal polyposis refractory to steroids Allergic fungal sinusitis Anterior skull base tumors: JNA Failure of medical management of CRS Multifactorial cause Recurrent URI Daycare Allergic rhinitis, Atopy, Asthma Adenoid hypertrophy Structural abnormalities GERD Immune deficiency Ciliary dyskinesia Smoking
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Allergic Rhinitis AR is reported to be present in up to 40% at some point in childhood AR is associated with up to 80% of cases of CRS Family history of allergy Serologic or skin testing should be considered in all children with sinusitis
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Structural Abnormalities Severely deviated septum Large agger nasi air cells Hypoplastic maxillary sinuses Bony remodeling or erosion Choanal abnormality CT of sinuses
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GERD GERD was documented in 19 of 30 pediatric patients with chronic sinusitis tested by pH probe 79% of these patients showed improvement after medical and behavioral therapy for reflux 25 of 28 children who were candidates for FESS due to sinusitis were able to avoid surgery with a regimen of PPI and behavior modification Empiric therapy with PPI with or without a prokinetic agent and behavioral modification is an acceptable approach
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Immune Deficiency, Cystic Fibrosis, and  Ciliary Dyskinesia Recurrent and chronic infections that respond poorly to medical therapy Quantitative and qualitative immunologic testing Antibody titers T-cell function Recurrent upper and lower respiratory tract infections should lead to further testing Sweat choride: CF Ciliary biopsy: dyskinesia
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Allergic Fungal Sinusitis AFS is caused by hypersensitivity response to fungi in the paranasal sinuses Aspergilles Alternaria Bipolaris Culvularia Drechslera Kuhn and Swain, 2003 Major criteria Type I IgE-mediated hypersensitivity Nasal polyps Characteristic CT findings Allergic mucin Positive fungal smear
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