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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 510-514

Comparative study between different surgical treatment modalities of refractory chronic rhinosinusitis in children


1 Otorhinolaryngology Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Otorhinolaryngology Department, Ashmoon Hospital, Ashmoon, Egypt

Date of Submission03-Aug-2015
Date of Acceptance21-Feb-2016
Date of Web Publication23-Jan-2017

Correspondence Address:
Reda Omar
Otorhinolaryngology Department, Ashmoon Hospital, Ashmoon, 32811
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.198689

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  Abstract 

Objectives
The aim of the present study is to compare randomly the effect (symptoms and CT improvement according to results of the postoperative mean differences of total CT Lund Mackay score) of adenoidectomy, adenoidectomy with middle meatus (MM) wash, and adenoidectomy with endoscopic sinus surgery (ESS) in the treatment of chronic rhinosinusitis in children.
Background
Rhinosinusitis is a common disease observed in pediatric patients. Different modalities of treatment can be used in the management of chronic rhinosinusitis, but the best plan to treat the disease is not known.
Materials and methods
Fifty-five patients were enrolled randomly in three treatment groups: group I (adenoidectomy), group II (adenoidectomy with MM wash), and group III (ESS and adenoidectomy). Patients were assessed preoperatively and 6 months postoperatively regarding visual analogue scale for sinonasal symptoms and CT Lund-Mackay score.
Results
There were no significant differences between the groups preoperatively (P > 0.05). All groups had postoperative improvement regarding visual analogue scale for sinonasal symptoms and CT Lund-Mackay score (P < 0.001). The mean differences between the preoperative and postoperative total visual analogue scale for sinonasal symptoms and CT Lund-Mackay scores were higher in group III than in group II (P = 0.04 and 0.05) and group I (P < 0.001 and P < 0.001), respectively. In addition, group II had better symptoms and CT scores than group I (P = 0.03 and 0.01).
Conclusion
ESS and adenoidectomy had better symptoms and CT results improvements than adenoidectomy with or without MM wash.

Keywords: adenoidectomy, adenoidectomy and maxillary wash, chronic rhinosinusitis, endoscopic sinus surgery, visual analogue nasal symptoms scale


How to cite this article:
Ragab A, Tharwat A, El-Naga HA, Omar R. Comparative study between different surgical treatment modalities of refractory chronic rhinosinusitis in children. Menoufia Med J 2016;29:510-4

How to cite this URL:
Ragab A, Tharwat A, El-Naga HA, Omar R. Comparative study between different surgical treatment modalities of refractory chronic rhinosinusitis in children. Menoufia Med J [serial online] 2016 [cited 2020 Mar 29];29:510-4. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/510/198689


  Introduction Top


Chronic rhinosinusitis (CRS) in children is defined as more than 3 months of two or more symptoms of purulent rhinorrhea, nasal obstruction, facial pressure/pain, or cough, and either endoscopic signs of mucosal edema, purulent drainage, or nasal polyposis, and/or CT scan changes showing mucosal changes within the ostiomeatal complex and/or sinuses in a pediatric patient aged 18 years or younger [1] .

Different modalities of treatment can be used in the treatment of children with CRS. Medical treatments in the form of antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions are always the first station in the management. When it failed, the disease can be considered as a refractory form of the disease. Many options are available for treatment, but it is not known as to which modality can act better than the other. The effect of adenoidectomy is controversial because randomized studies have failed to prove that adenoidectomy alone is sufficient in curing CRS [2].

Other studies identified that children with more severe sinus diseases as evidenced by CT had a higher success rate if a maxillary sinus wash was performed with adenoidectomy [3]. Children with asthma, exposure to tobacco smoke, or children over the age of 12 years benefited least from adenoidectomy alone, and endoscopic sinus surgery (ESS) is another option for such a patient [4] . As there is no evidence as to which modality can entail more benefit to the patient, the following randomized study was conducted. The aim of the present study was to compare randomly the effect (symptoms and CT improvement differences) of adenoidectomy, adenoidectomy with middle meatus (MM) wash, and adenoidectomy with ESS in the treatment of CRS in children.


  Materials and methods Top


Fifty-five patients with CRS refractory to medical treatment (antibiotics, topical nasal corticosteroids, and nasal lavage with normal saline for 3 months) were subjected randomly to adenoidectomy, adenoidectomy with MM wash, and ESS at the Department of Otolaryngology - Head and Neck Surgery, Menoufia University and Ashmoon Hospital spanning the period from September 2012 to February 2015. Randomization was performed by random calculation; computer-generated numbers were obtained from the Graph Pad software. Children aged 1 to 18 years (IBM SPSS Software. Chicago, USA), symptoms present more than 3 months and refractory to medical management as defined by more than 3 months of two or more symptoms of purulent rhinorrhea, nasal obstruction, facial pressure/pain, or cough, and either endoscopic signs of mucosal edema, purulent drainage, or nasal polyposis, and/or CT scan changes showing mucosal changes within the ostiomeatal complex and/or sinuses in a pediatric patient aged 18 years or younger were included. Patients with a history of previous sinus surgery, primary ciliary dyskinesia, cystic fibrosis, immunodeficiency syndrome, immunoglobulin deficiency, and immotile cilia syndrome were excluded. The patients were assessed preoperatively by visual analogue nasal symptoms scale, CT Lund-Mackay score, and at 6 months postoperatively [5] . The symptoms were taken from patients and parents. The patients were divided into three groups. Group I underwent adenoidectomy using the adenoidectomy curette. Group II underwent adenoidectomy and maxillary wash through MM wash. The MM was irrigated with saline solution by an irrigation suction cannula introduced through the nose to the MM. The solution circulates inside the MM and sinus cavity and comes out together with accumulated discharge and is suctioned. Group III underwent adenoidectomy and ESS through uncinectomy, maxillary antrostomy, and ethmoidectomy (anterior and posterior) according to the involved sinuses. The study was approved by the ethics committee of the hospital, and the patients gave informed consent. Postoperatively, the patients were continued on antibiotics (amoxicillin-clavulanic acid) for 10 days. They were instructed to undergo regular saline irrigation of the nasal cavities.

Statistical procedures

The data collected were tabulated and analyzed by SPSS (Statistical Package for the Social Science software) statistical package version 20. Quantitative data were expressed as mean and SD (X ± SD) and analyzed by applying analysis of variance test for comparison between three groups of normally distributed variables and three groups of not normally distributed variables by applying Kruskal-Wallis test. Qualitative data were expressed as number and percentage [n (%)] and analyzed by applying χ2 -test. For comparison between non-normally distributed quantitative data, Wilcoxon signed ranks test was applied.

A P-value of 0.05 was used to determine significance as follows:

  • P value greater than 0.05 is considered to be statistically insignificant
  • P value of 0.05 or less is considered to be statistically significant
  • P value of 0.001 or less is considered to be highly statistically significant.



  Results Top


Fifty-five patients in the present study were randomly enrolled into three treatment groups. Their mean age was 10.35 years with SD ± 4.29 years in group I, 11.55 years with SD ± 3.35 in group II, and 9.33 years with SD ± 4.40 in group III. There were no significant differences between the groups regarding age, sex, total visual analogue nasal symptoms scale, and CT Lund-Mackay score preoperatively (P > 0.05). All the groups had postoperative improvement regarding visual analogue scale and CT Lund-Mackay score (P < 0.001) ([Table 1]). With regard to the postoperative mean total symptoms of visual analogue scale and CT Lund-Mackay score, the result in group III was better than that in group II (P = 0.09 and P < 0.001) and group I (P < 0.001 and P < 0.001), and the result in group II was better than group I (P = 0.05 and 0.03), respectively ([Table 2]). With regard to the postoperative mean differences of total symptoms of visual analogue scale and CT Lund-Mackay score, the result in group III was better than that in group II (P = 0.04 and 0.05) and group I (P < 0.001), and the result in group II was better than group I (P = 0.03 and 0.01), respectively ([Table 3]).
Table 1 Preoperative demographic assessment of the studied groups


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Table 2 Comparison between the studied groups regarding postoperative total symptoms visual analogue score and CT Lund-Mackay


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Table 3 Comparison between the studied groups regarding the postoperative mean differences of symptoms total score of visual analogue scale and CT Lund-Mackay score


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  Discussion Top


There seems to be a consensus favoring surgical intervention in children with refractory CRS who fail medical management. However, there is still disagreement about the type of surgical intervention that is appropriate. Adenoidectomy and functional endoscopic sinus surgery have both been recommended as surgical options. Some authors suggest that sinus washes through a middle meatal antrostomy should be considered at the time of adenoidectomy. However, which children will benefit from this intervention is not known [3] . In the current study, adenoidectomy can afford improvement to children with refractory CRS, but more efficacies can be gained when combined with ESS than MM maxillary washout. The improvement of children after adenoidectomy is expected, as the adenoids act as a barrier causing mechanical obstruction and a nidus for chronic sinus infection. This is consistent with the results reported by Ouyang et al. [6] , which showed that all index scores in the adenoidectomy group were lower than the control group (P < 0.01). In addition, Behnoud et al. [7] reported that 72.5% of patients showed a complete recovery following adenoidectomy as a treatment modality for CRS. In the present study, adenoidectomy can afford improvement to children with refractory CRS. This matches the results reported by Brietzke and Brigger [8] who performed a meta-analysis of eight studies investigating the efficacy of adenoidectomy alone in pediatric CRS patients (mean age = 5.8 years; range = 4.4-6.9 years) who failed medical management. They demonstrated that the condition of a majority of patients significantly improved of sinusitis symptoms after adenoidectomy (success rate = 69.3%, P = 0.001). However, Ramadan et al. [9] observed failure of adenoidectomy alone in treating pediatric CRS and requirement of an additional interference. Such children appear to require a salvage ESS at a mean of 24 months after the adenoidectomy. In the present study, more symptom improvement and CT improvement was gained when using MM maxillary sinus wash and adenoidectomy compared with adenoidectomy alone. Ramadan et al. [9] reported that balloon dilation, adenoidectomy, and maxillary wash were more effective compared with adenoidectomy alone. The patients' condition improved to a greater extent after adenoidectomy and maxillary wash compared with after adenoidectomy alone. The results of Criddle et al. [10] also support the same concept, with 78% long-term improvement after adenoidectomy and maxillary wash. In addition, Nathan et al. [11] reported that endoscopically guided MM cultures and antral biopsy with adenoidectomy decreases the time to symptom resolution to a greater extent than bilateral maxillary sinus aspiration and irrigation with adenoidectomy. This significant improvement with adenoidectomy and maxillary wash has been previously described by Ramadan and Cost [3] who showed that the success of adenoidectomy and maxillary wash compared with adenoidectomy was higher (93%) for children with a high CT score. In the present study, functional endoscopic sinus surgery and adenoidectomy can add more improvement than adenoidectomy with and without MM lavage. Some authors [9] support ESS mainly in children who are younger than 7 years of age and have asthma. Wang and Wei [12] reported more improvement after adenoidectomy and ESS than after ESS alone. In addition, Petros et al. [13] performed a systematic analysis and reported that pediatric ESS is an effective treatment for CRS, with positive outcome ranging between 71 and 100%. These improvements may be because of restoration of the functions of the ostiomeatal complex after ESS, which includes ventilation and drainage. Also other investigators reported that long-term improvement of postoperative findings of CT images in most patients at 4 years after ESS nearly in all the patients [14] . In the present study, ESS and adenoidectomy can add more improvement compared with adenoidectomy with and without MM lavage. In addition, Shyu and Chen [4] in their review concluded that the combination of ESS and adenoidectomy produces the best results ([Figure 1], [Figure 2] and [Figure 3]).
Figure 1: Total visual analogue nasal symptoms scale after intervention among the studied groups.

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Figure 2: Mean differences of total visual analogue nasal symptoms scale before and after intervention among the studied groups.

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Figure 3: Mean differences of total Lund-Mackay score before and after intervention among the studied groups.

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  Conclusion Top


ESS and adenoidectomy had better symptoms and CT results improvements than adenoidectomy with or without MM wash.

Acknowledgements

Authors' contributions : Concepts, design, and definition of intellectual content was carried out by Adel Tharwat, MD and Ahmed Ragab, MD, PhD. Manuscript preparation, editing, and manuscript review were performed by Ahmed Ragab, MD, PhD and Heba Abo El-Naga, MD. Clinical studies and data acquisition were performed by Reda Omar, MBBCh.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Brietzke SE, Jennifer JS, Sukgi C, Jivianne TL, Sanjay RP, Maria P, et al. Clinical Consensus Statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg 2014; 151 :542-553.  Back to cited text no. 1
    
2.
Cazzavillan A, Castelnuovo P, Berlucchi M, Baiardini I, Franzetti A, Nicolai P, et al. Management of chronic rhinosinusitis in children. PediatrAllergy Immunol 2012; 23 (Suppl 22) :32-44.   Back to cited text no. 2
    
3.
Ramadan HH, Cost JL Outcome of adenoidectomy versus adenoidectomy with maxillary sinus wash for chronic rhinosinusitis in children.Laryngoscope 2008; 118 :871-873.  Back to cited text no. 3
    
4.
Shyu BH, Chen YL. Rhinosinusitis management in pediatric patients: perspectives of an otolaryngologist. J Pediatr Resp Dis 2011; 7 :41-46.  Back to cited text no. 4
    
5.
Ragab A, A-L El-Rasheedy, Samaka RM, Hola NS, Hamdan A. Assessment of fi broproliferative healing after functional endoscopic sinus surgery. MMJ 2014; 27 :16-22.  Back to cited text no. 5
    
6.
Ouyang T, Tang S, Zhang J, Wang Y, Li C, Wang Y, Chen X. Clinical research of transoral endoscopic adenoidectomy on the treatment of the adenoid hypertrophy children with chronic sinusitis. J Clin Otorhinolaryngol Head Neck Surg 2013; 27 :764-767.  Back to cited text no. 6
    
7.
Behnoud F. Evaluation of children with chronic rhinosinusitis after adenotonsillectomy. Iran J Otorhinolaryngol 2012; 2 :69-73.  Back to cited text no. 7
    
8.
Brietzke SE, Brigger MT. Adenoidectomy outcomes in pediatric rhinosinusitis: a meta-analysis. Int J Pediatr Otorhinolaryngol 2008; 72 :1541-1545.  Back to cited text no. 8
    
9.
Ramadan HH, Bueller H, Hester ST, Terrell AM. Sinus balloon catheter dilation after adenoidectomy failure for children with chronic rhinosinusitis. Arch Otolaryngol Head Neck Surg 2012; 138 :635-637.  Back to cited text no. 9
    
10.
Criddle M, Stinson A, Savliwala M, Coticchia J. Pediatric chronic rhinosinusitis: a restropective review. Am J Otolaryngol Head Neck Med Surg 2008; 29 :372-378.  Back to cited text no. 10
    
11.
Nation D, Kruper GJ, Bui T, Coticchia J. Comparison of two minimally invasive techniques for treating chronic rhinosinusitis in the pediatric population. I J Pediatr Otorhinolaryngol 2011; 75 :1296-1300.  Back to cited text no. 11
    
12.
Wang Y, Wei L. Effect of adenoidectomy on pediatric chronic rhinosinusitis. J Clin Otorhinolaryngol Head Neck Surg 2008; 22 :493-494.  Back to cited text no. 12
    
13.
Petros V, Fetta M, Segas JV, Maragoudakis P, Nikolopoulos TP. Functional endoscopic sinus surgery improves sinus-related symptoms and quality of life in children with chronic rhinosinusitis a systematicanalysis and meta-analysis of published interventional studies. Clin Pediatr 2013; 52 :1091-1097.  Back to cited text no. 13
    
14.
Thottam PJ, Haupert M, Saraiya S, Dworkin J, Sirigiri R, Belenky WM. Functional endoscopic sinus surgery (FESS) alone versus balloon catheter sinuplasty (BCS) and ethmoidectomy: acomparative outcome analysis in pediatric chronic rhinosinusitis. Int J Pediatr Otorhinolaryngol 2012; 76 :1355-1360.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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