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International Journal of Pediatric Otorhinolaryngology 90 (2016) 160e164

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International Journal of Pediatric Otorhinolaryngology


journal homepage: http://www.ijporlonline.com/

Quality of life after endoscopic sinus surgery in refractory pediatric


chronic rhinosinusitis
Gyanesh Sethi, Arunabha Chakravarti*
Department of ENT and Head & Neck Surgery, Lady Hardinge Medical College and Associated Hospitals, Shaheed Bhagat Singh Marg, New Delhi, 110001,
India

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The present study aims to evaluate the role of Endoscopic Sinus Surgery (ESS) in refractory
Received 19 June 2016 pediatric Chronic Rhinosinusitis (CRS) and to assess the change in quality of life after ESS.
Received in revised form Materials and Methods: This prospective interventional study included 35 children (aged between 6 and
4 August 2016
12 years) of refractory CRS, not responding to 4 weeks of maximal medical therapy attending the pe-
Accepted 6 September 2016
Available online 8 September 2016
diatric ENT clinic of a tertiary referral centre. Study period was from November 2013 to March 2016. This
patient pool underwent Non Contrast Computed Tomography scan (NCCT) paranasal sinuses and diag-
nostic nasal endoscopy and those fulfilling the requisite inclusion criteria underwent Endoscopic sinus
Keywords:
Endoscopic sinus surgery
surgery. Global assessment of Rhinosinusitis Symptom severity score and SN-5 quality of life score of the
Pediatric patients was assessed preoperatively and 1 year after the surgery.
Chronic rhinosinusitis Results: 91.4% children showed an improvement in the total symptom score with a statistically signifi-
Quality of life cant (p value < 0.001) reduction in the mean total score postoperatively. Similarly 91.4% of the children
showed an improvement in their quality of life with a statistically significant (p value < 0.001) difference
seen in the average SN-5 scores after ESS. No major complications were encountered in any of the cases.
Conclusion: ESS is a safe and effective surgical management for children with CRS refractory to maximal
medical therapy leading to an improvement in their quality of life.
© 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction The etiology of chronic rhinosinusitis is not completely under-


stood but is derived from the interactions among local host factors,
CRS is defined as symptomatic inflammatory condition of the systemic host factors and environmental factors. Diagnosing CRS in
mucosa of nose and paranasal sinuses for more than 12 weeks [1]. children can be more difficult than diagnosing CRS in adults as
Acute Pediatric sinusitis is expected to complicate approximately physician must determine whether the pediatric patient truly has
5e10% of upper respiratory tract infection [2]. Pediatric CRS is a CRS or merely has frequent upper respiratory tract infection, pe-
frequent problem in children with a prevalence of approximately diatric allergic rhinitis or asthma [5].
8%, which is more common than chronic diseases of tonsils or ad- The Quality of life and economic impact of pediatric sinusitis is
enoids affecting approximately 2% of the children [3]. immense. The impact includes days off from school, cost of anti-
According to the European position paper on Rhinosinusitis and biotics and other medication, number of physician visits, parental
Nasal polyposis (EPOS 2012), CRS in children is clinically defined by days off from work to care for sick child and potential behavioral
two or more symptoms, one of which should be either nasal problems from both chronically sick child and the siblings [6].
blockage/obstruction/congestion or nasal discharge (anterior or Children are usually referred to otorhinolaryngologist when the
posterior nasal drip), along with facial pain/pressure, cough, medical therapy fails, the surgical indications are not well defined
endoscopic evidence of sinus disease, or relevant changes on and moreover they are not uniform between otorhinolaryngolo-
computed tomography scan of the sinuses [4]. gists and pediatrician. The decision about surgical therapy is diffi-
cult. The goal of the surgery is to control symptoms, assure a better
quality of life and prevent complications [7].
* Corresponding author. When surgery is indicated adenoidectomy and Endoscopic Sinus
E-mail addresses: gyan2s@gmail.com (G. Sethi), drachakravarti@yahoo.co.in Surgery (ESS) or both are most commonly used surgical procedures
(A. Chakravarti).

http://dx.doi.org/10.1016/j.ijporl.2016.09.005
0165-5876/© 2016 Elsevier Ireland Ltd. All rights reserved.

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all over the world. The choice of surgery depends upon the severity Those fulfilling the requisite inclusion criteria underwent FESS
of symptoms, associated systemic disease and extent of disease on by Messerklinger technique under general anaesthesia and were
CT scan [7]. evaluated and followed up till 1 year after the surgery.
Currently ESS is emerging as the choice of surgery, Functional
Endoscopic sinus surgery (FESS) focusses on enlarging the natural 2.3. Quality of life assessment
ostia of maxillary and ethmoid sinuses, while preserving most or all
of the sinus mucosa. In properly selected children results are good SN-5 Sinus and Nasal Quality of life survey [11], a validated
with an expected improvement of 80e100% [6]. disease specific questionnaire, was used to assess the quality of life
There is paucity of literature on Pediatric CRS and the affect of preoperatively and 1 year after the surgery.
surgical management on quality of life. The present study aims to
evaluate the role of ESS in refractory pediatric CRS and to assess the 2.4. Statistical analysis
change in quality of life after ESS.
Data was recorded on a pre designed proforma. Data analysis
2. Materials and Methods was done by using SPSS (Statistical Package for the Social sciences)
software for Windows version 22.0 (SPSS Inc., Illinois, USA). The
2.1. Study design observations were described in terms of Mean, Percentage, stan-
dard deviation and 95% confidence limits for the continuous data.
This prospective interventional study was carried out from Quantitative data like symptom score and Quality of life score was
November 2013 to March 2016 in the Department of ENT and Head compared using Paired Student's T Test. A P value of <0.05 was
& Neck surgery of a tertiary referral centre with prior approval from considered as cut off point for level of significance.
institutional ethical committee.
3. Observation and results
2.2. Patient sample and approach to the patient
35 patients of both sexes aged 6e12 years were included in the
➢ A total of 35 children of both sexes aged 6e12 years refractory to study. The mean age of the recruited patients was 9.26 ± 2.05 years.
maximal medical therapy (at least 4 weeks of Amoxycillin There were 27 males (77.1%) and 8 females (22.9%) in the study
clavulanate potassium 40 mg/kg/day, steroid nasal spray group.
mometasone furoate 200 mg daily, levocetrizine and ambroxol On Examination 22 out of the 35 enrolled patients (62.86%) had
combination once a day and a proton pump inhibitor once a day varying degree of deviated nasal septum and all the patients had
before breakfast) with CT score of at least >5 (Lund Mackay CT mucopurulent nasal discharge.
scoring [8]) were included in the study. Symptom scoring was done according to the Global Assessment
➢ Children with previous ESS, adenoidal hypertrophy of more than of Rhinosinusitis Symptom Severity score and each symptom was
Grade 2 on nasal endoscopy [9], nasal polypi, Craniofacial ab- graded from 1 to 7 according to its severity.
normalities, diagnosed cases of Cystic fibrosis and other sys- Preoperatively, nasal obstruction was the most severe symptom
temic disorders like immunodeficiency, primary ciliary with a mean of 3.89 ± 1.18 followed by anterior nasal discharge
dyskinesia and chronic respiratory or cardiac disease were 3.43 ± 0.85. 32 out of 35 patients (91.4%) showed an improvement
excluded from the study. in the total symptom score postoperatively. Each symptom had
➢ Written Informed Consent was taken from the patients' care- shown a statistically significant improvement (Table 1, Fig. 1). Mean
givers. Detailed History and ENT examination was done of all the of total preoperative symptom score was 22.66 ± 7.10 while that of
patients and clinical grading of symptoms was done preopera- total postoperative score was 14.20 ± 2.77 and there was a statis-
tively and 1 year after the surgery by Global Assessment of tically significant improvement between the two (Table 1).
Rhinosinusitis Symptom Severity Score [10] in which patients' Preoperatively nasal discharge anterior was the most prevalent
caregivers encircled a number from 1 to 7 based on the severity symptom present in all the 35 patients followed by nasal obstruc-
of symptoms. Patient pool also underwent Diagnostic Nasal tion which was present in 33 out of 35 patients and post nasal drip
Endoscopy (DNE), NCCT PNS and Lund Mackay CT scoring was in 21 patients. The difference in the prevalence of each symptom
done. pre and postoperatively was statistically significant (Table 1).

Table 1
Global Assessment of Rhinosinusitis Symptom severity score.

Global Assessment of Rhinosinusitis Symptom severity score Severity Prevalence

Preop Follow-up P Value Preop Follow-up P Value

Mean ±SD Mean ±SD n % n %

Nasal obstruction 3.89 1.18 2.60 1.58 0.001 33 94.3% 12 34.3% 0.000
Nasal discharge anterior 3.43 0.85 1.80 0.90 0.000 35 100.0% 19 54.3% 0.000
Nasal discharge posterior 1.91 0.95 1.31 0.76 0.006 21 60.0% 7 20.0% 0.002
Facial pain/pressure 1.77 1.19 1.06 0.24 0.002 15 42.9% 2 5.7% 0.001
Headache 2.09 1.46 1.31 0.80 0.003 19 54.3% 5 14.3% 0.001
Fatigue 1.63 0.97 1.11 0.32 0.002 12 34.3% 4 11.4% 0.046
Decreased sense of smell 1.43 0.78 1.06 0.24 0.003 9 25.7% 2 5.7% 0.049
Ear pain/pressure 1.17 0.51 1.00 0.00 0.057 4 11.4% 0 0.0% 0.123
Cough 1.74 1.09 1.03 0.17 0.001 16 45.7% 1 2.9% 0.000
Halitosis 1.37 1.19 1.00 0.00 0.074 5 14.3% 0 0.0% 0.063
Dental pain 1.00 0.00 1.00 0.00 0 0.0% 0 0.0%
Fever 1.23 0.94 1.00 0.00 0.160 2 5.7% 0 0.0% 0.475
Total 22.66 7.10 14.20 2.77 0.000

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162 G. Sethi, A. Chakravarti / International Journal of Pediatric Otorhinolaryngology 90 (2016) 160e164

Fig. 2. Mean Lund Mackay scoring.

average SN-5 score was statistically significant (p value  0.001)


Fig. 1. Mean symptom score before and after surgery for individual symptoms. (Table 3, Fig. 5).
In our study no major complications were encountered in any of
the cases. 5 cases developed synechiae postoperatively and un-
All patients underwent NCCT PNS before surgery and was derwent adhesiolysis in subsequent hospital visits. Recurrence
graded according to the Lund Mackay CT scoring. The minimum occurred in 3 cases out of which 2 cases were re operated.
Lund Mackay score in our study was 6 while maximum was 22 out
of 24. The average Lund Mackay score was 10.66 ± 4.61. It was seen
that disease was most severe in maxillary sinuses (Left > Right) 4. Discussion
with a mean score of 2.23 ± 0.77 followed by Anterior ethmoid
(Left > Right) 1.71 ± 0.99 (Table 2, Fig. 2). Chronic rhinosinusitis (CRS) in children is a global health
In our study Maxillary sinus was the most commonly involved problem and has severe negative impact on quality of life. Pediatric
sinus (left > right), opacified in all the 35 cases followed by anterior CRS poses a diagnostic dilemma as it lies within a spectrum of
ethmoid (left > right) which was involved in 30 out of 35 cases. Left disorders with similar presenting symptoms like those of upper
osteomeatal complex (32 cases) was more commonly blocked than respiratory tract infection and allergic rhinitis [5].
right (28 cases) (Table 2). Medical therapy is widely accepted first line of treatment and
A statistically significant (p value < 0.001) positive correlation surgical treatment is considered when maximal medical therapy
was seen between Global Assessment of Rhinosinusitis Symptom fails. Functional endoscopic sinus surgery is one of the available
severity score and Lund Mackay CT score with Pearsons's correla- surgical options and it focuses on preserving the physiological
tion coefficient as 0.655. (P value less than 0.05 was considered drainage pathways of sinuses by enlarging the natural ostia.
statistically significant.) (Fig. 3). There is limited data evaluating the outcome of ESS for pediatric
A weak positive correlation (pearson's correlation coefficient CRS and many questions still remain unanswered about the impact
0.22) was seen between preoperative SN-5 score and Lund Mackay of pediatric CRS and ESS on quality of life [12].
CT score which was statistically insignificant (p value 0.898) (Fig. 4). Our study included children from 6 to 12 years of age with a
Quality of life of the patients was assessed pre and post opera- mean age of 9.26 years. Only those cases were included in the study
tively using SN-5 Sinus and Nasal quality of life questionnaire. Each who did not respond to maximal medical therapy. Hence a control
symptom group (domain) was given a score of 1e7 depending on group could not be taken. Ramadan HH [13] had concluded that
their frequency of presentation and their mean was taken. In our endoscopic sinus surgery in children younger than 3 years was not
study Nasal obstruction was the domain affecting the quality of life successful but it was beneficial in children older than 6 years and El
maximally (mean score 5.51 ± 1.09) followed by Sinus Infection Sharkawy AA et al. [14] in 2011 found out that results of Pediatric
(mean score 5.11 ± 1.32). 32 out of 35 patients (91.4%) showed an ESS were influenced by age group with more adhesions and re-
improvement in the average SN-5 score postoperatively. The currences seen in younger age group. This age specific prognosis of
average preoperative SN-5 score was 3.98 ± 0.79 and the difference ESS could be attributed to delicate anatomy of children making the
between pre and postoperative score of each domain and the procedure technically more demanding and an immature immune

Table 2
Lund Mackay CT scoring.

NCCT (Lund Mackay scoring) Severity Frequency

Right Left Combined Right Left Combined

Mean ±SD Mean ±SD Mean ±SD n % n % n %

Anterior ethmoid 0.80 0.58 0.91 0.66 1.71 0.99 25 71.4 26 74.3% 30 85.7%
Posterior ethmoid 0.60 0.69 0.69 0.72 1.29 1.27 17 48.6% 19 54.3% 23 65.7%
Maxillary 0.97 0.62 1.26 0.61 2.23 0.77 28 80.0% 32 91.4% 35 100.0%
Frontal 0.31 0.58 0.46 0.70 0.77 1.17 9 25.7% 12 34.3% 13 37.1%
Sphenoid 0.54 0.73 0.63 0.69 1.17 1.27 14 40.0% 18 51.4% 22 62.9%
OMC 1.60 0.81 1.88 0.47 3.49 0.89 28 80.0% 32 94.3% 35 100.0%
Total 10.66 4.61

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Fig. 3. Correlation between Symptom score and CT score.


Fig. 5. Mean preoperative and postoperative SN-5 quality of life symptom score.

observed in the mean total symptom score postoperatively (P


value < 0.001). A similar trend was noted by El Sharkawy et al. [14],
Chang et al. [15] and Ramadan HH [17] in their respective series in
which nasal obstruction and nasal discharge were the most com-
mon symptoms followed by headache and post nasal drip and there
was a statistically significant (p value < 0.05) improvement in all
the symptoms post FESS. Lusk et al. [3] however observed that
there was no statistically significant difference between the
severity of symptoms on 10 years follow up between the patients
who underwent FESS and those who were medically managed. But
when parents were asked to rate the change in symptoms over the
study period, a significantly higher (p < 0.001) improvement was
seen in the FESS group. Most of the studies have shown that
endoscopic sinus surgery has a positive outcome for the treatment
Fig. 4. Correlation between SN-5 Quality of life score and CT score. of medically refractory CRS in children.
CT scoring was done with Lund Mackay CT score and only pa-
tients with CT score above 5 were included in our studies. Bhatta-
Table 3
charya et al. [19] observed that the mean incidental Lund Mackay
Mean preoperative and postoperative SN-5 quality of life score.
score in children without CRS was 2.8 and a score of 5 or above had
SN 5 quality of life survey Preop Follow up P value an excellent positive predictive value for CRS. The average CT score
Mean ±SD Mean ±SD in our study was 10.66 and it was seen that maxillary sinuses were
Sinus infection 5.11 1.32 3.37 1.52 0.000
the most frequently and severely involved sinuses followed by
Nasal obstruction 5.51 1.09 2.60 1.58 0.000 anterior ethmoids. European position paper on rhinosinusitis and
Allergy symptoms 3.20 1.71 1.97 0.92 0.001 nasal polyps 2012 [4] supports our observation that in children
Emotional distress 3.57 1.63 1.89 1.30 0.000 with clinically diagnosed CRS, the most commonly involved sinus
Activity limitation 2.49 1.54 1.20 0.53 0.000
on CT is maxillary (99%) followed by ethmoid sinus (91%). However
Global faces scale 3.89 1.66 7.49 2.06 0.000
Average 3.98 0.79 2.20 0.85 0.000 in our study peroperative findings did not correlate with the CT
findings and we found that Anterior Ethmoids were the most
commonly and severely involved. This contradictory finding may
be due to edematous mucosa found in the maxillary sinus sec-
system in young children making them more prone to frequent ondary to OMC blockage which reverts back to normal 8 weeks
upper respiratory tract infections. Also adenoid hypertrophy may after middle meatus antrostomy [20].
play a bigger part in the pathogenesis of CRS in children aged below Present study showed a statistically significant (p value 0.002)
6 years. positive correlation was seen between Global Assessment of Rhi-
CRS was found to be more common in males with 27 males nosinusitis symptom severity score and Lund Mackay CT score with
(77.1%) and 8 females (21.9%). Similar observations were noted by a Pearson's coefficient of 0.655. This is in contrast to adults where
Chang et al. [15] who had 65 males and 36 females in their study. no correlation is seen between the symptom score and CT score
However this gender distribution in our study cannot be general- [21e23]. To the best of our knowledge there is no study correlating
ised due to small sample size. symptom score with CT score in pediatric patients.
Nasal obstrution (94.3%) and anterior nasal discharge (100%) However a weak positive correlation was seen (Pearson's coef-
were the two most severe and most prevalent symptoms, followed ficient 0.022) between SN-5 quality of life score and CT score which
by posterior nasal discharge (60.0%) and headache (54.3%). 91.4% of was statistically not significant (P value 0.898). This finding is in
the patients showed an improvement in the total symptom score contradiction to that of Terrel AM and Ramadan HH [24].
postoperatively. The symptomatic improvement after ESS in Chronic Rhinosinusitis has immense impact on the quality of life
various studies has been ranged from 75% to 100% [16e18]. A sta- with frequent hospital visits, high cost of medication and an impact
tistically significant improvement was seen in the severity as well on the behavioral and school performance. According to a study
as the prevalence of these symptoms 1 year post surgery (P conducted by Cunningham et al. [25] children with CRS were
value < 0.05). Similarly a statistically significant improvement was perceived by their parents to have significantly (p < 0.001) more

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164 G. Sethi, A. Chakravarti / International Journal of Pediatric Otorhinolaryngology 90 (2016) 160e164

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