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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.
http://dx.doi.org/10.1016/j.ijporl.2016.09.005
0165-5876/© 2016 Elsevier Ireland Ltd. All rights reserved.
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G. Sethi, A. Chakravarti / International Journal of Pediatric Otorhinolaryngology 90 (2016) 160e164 161
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.
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
Table 2
Lund Mackay CT scoring.
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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G. Sethi, A. Chakravarti / International Journal of Pediatric Otorhinolaryngology 90 (2016) 160e164 163
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164 G. Sethi, A. Chakravarti / International Journal of Pediatric Otorhinolaryngology 90 (2016) 160e164
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Conflict of interest
archotol.130.9.1029.
[20] H.-M. Huang, H.-P. Lee, C.-M. Liu, K.-N. Lin, Normalization of maxillary sinus
We have no conflict of interest or financial support with this mucosa after functional endoscopic sinus surgery in pediatric chronic sinus-
article. itis, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 1219e1223, http://dx.doi.org/
10.1016/j.ijporl.2005.03.031.
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