The surgical management of chronic recurrent sinusitis (CRS) recalcitrant to medical therapy in the pediatric population has traditionally consisted of adenoidectomy and functional endoscopic sinus surgery (FESS), depending on age and imaging findings. Adenoidectomy relieves nasopharyngeal airway obstruction as well as potentially eradicates a bacterial reservoir. FESS, as in adults, promotes paranasal sinus ventilation and drainage. Pediatric FESS most commonly consists of uncinectomy, maxillary antrostomy and/or ethmoidectomy due to the relative underdevelopment of the sphenoid and especially the frontal sinuses in preadolescent children. FESS is generally considered to be safe, with major complications such as cerebrospinal fluid leak, meningitis or orbital violation occurring in <1% of cases. Initial concerns that FESS in the pediatric population may lead to retardation of facial growth have proven to be unsubstantiated.
Explore this issue:August 2013
Balloon catheter sinuplasty (BCS) was first introduced as a therapeutic modality of CRS in adults in 2006. In BCS a guidewire, passed into the target maxillary, sphenoid, or frontal sinus under endoscopic visualization with either fluoroscopic or fiberoptic light confirmation, is used to position a deflated oblong balloon across the natural sinus ostium. This balloon is subsequently inflated to a maximum diameter of 5 to 7 mm, dilating the natural ostium. In contrast to FESS, BCS does not involve tissue removal and theoretically is mucosal sparing. Purported limitations of BCS include the inability to address alternative predisposing anatomical abnormalities (the uncinate process, for example, is not removed in maxillary procedures) or to treat concurrent ethmoid sinus disease. The efficacy of BCS in adults with frontal, sphenoid and maxillary sinus disease is reported to be on par with FESS, suggesting a potential role for BCS in the treatment armamentarium of pediatric rhinosinusitis as well.
BCS appears to be safe for use in the pediatric CRS population. The combination of BCS plus adenoidectomy does appear to reduce rhinosinusitis symptoms beyond that achieved with adenoidectomy alone, but does not appear to confer additional benefit over the more traditional combination of adenoidectomy and maxillary sinus lavage. There is no data to date truly comparing the efficacy of BCS with FESS in the pediatric population. In the common setting where FESS is necessary to address the ethmoid sinuses, the additional routine use of BCS for concurrent maxillary and sphenoid sinus disease is difficult to justify from a cost-benefit standpoint. The potential beneficial therapeutic role of BCS for isolated maxillary, sphenoid or rare frontal sinus disease in the pediatric population remains to be answered. Read the full article in The Laryngoscope.