Pediatric sinus care:Pediatric sinus care:

The role of the Adenoid The role of the Adenoid and reflux in Pediatric and reflux in Pediatric

sinus diseasesinus disease

David Parsons, MD, FAAP, FACSDavid Parsons, MD, FAAP, FACS

Clinical ProfessorClinical Professor

Universities of North & South CarolinaUniversities of North & South Carolina

Charlotte, North Carolina USACharlotte, North Carolina USA

Copywrite 2010Copywrite 2010

Tom HavasTom Havasdavid Kennedydavid Kennedy

For adults:For adults:

Diagnosis of sinusitis increasing EXPONENTIALLYDiagnosis of sinusitis increasing EXPONENTIALLYNumber of FESSurgeries increasing EXPONENTIALLYNumber of FESSurgeries increasing EXPONENTIALLY

Cost of each surgery increasing EXPONENTIALLYCost of each surgery increasing EXPONENTIALLYBenefit to patients in lost work time is worseBenefit to patients in lost work time is worse

the point is…the point is…

The more we do, the worse the The more we do, the worse the outcome for the patients!outcome for the patients!

We recognized this in children We recognized this in children 20+ years ago.20+ years ago.

Those of us with large Pediatric sinus Those of us with large Pediatric sinus practices began teaching, “The less you practices began teaching, “The less you do the better the outcome.”do the better the outcome.”

We teach aggressive medical management, We teach aggressive medical management, very conservative indications for sinus very conservative indications for sinus surgery, and when FESS is required, do surgery, and when FESS is required, do the least amount possible.the least amount possible.

Since starting this Since starting this approach 20+ years ago, approach 20+ years ago,

our outcomes are our outcomes are excellent!excellent!

And the same ideas should be used And the same ideas should be used with ADULTS!with ADULTS!

Because….Because….

Fact 1:Fact 1:

““Repeated courses of broad Repeated courses of broad

spectrum antibiotics as the spectrum antibiotics as the singlesingle

method of treatment for chronic sinusitis is method of treatment for chronic sinusitis is inappropriateinappropriate.”.”

--Parsons, OtoClinics of North America, Feb --Parsons, OtoClinics of North America, Feb 19961996

Must address ALL!Must address ALL!

Fact 2:Fact 2:

Chronic sinusitis is multifactorialChronic sinusitis is multifactorial

Daycare (recurrent/chronic URI’s)Daycare (recurrent/chronic URI’s)

AllergiesAllergies

Tobacco smoke exposureTobacco smoke exposure

Big adenoidBig adenoid

RefluxReflux

Bacterial sinus invasionBacterial sinus invasion

EtcEtc

In the 1980’s, we discovered In the 1980’s, we discovered these simple facts when we these simple facts when we started doing FESS in children.started doing FESS in children.

The surgeries often failed The surgeries often failed because the only indication for because the only indication for surgery was “failure to get well” surgery was “failure to get well” after many courses of antibiotics.after many courses of antibiotics.

We were failing to recognize and We were failing to recognize and address the other causes of address the other causes of sinus symptoms that were NOT sinus symptoms that were NOT infectious!infectious!

AllergiesAllergiesRefluxRefluxBig AdenoidBig AdenoidEnvironmental irritants – smokingEnvironmental irritants – smokingAnd… the impact of daycare And… the impact of daycare

AllergiesAllergiesRefluxRefluxBig AdenoidBig AdenoidEnvironmental irritants – Environmental irritants – smokingsmokingAnd… the impact of And… the impact of daycaredaycare

Rarely, is just one of these the cause Rarely, is just one of these the cause of the sinus symptoms… of the sinus symptoms…

It is usually several of these!It is usually several of these!

AllergiesAllergiesRefluxRefluxBig AdenoidBig AdenoidEnvironmental irritants – Environmental irritants – smokingsmokingAnd… the impact of And… the impact of daycaredaycare

NONE of these are made better by NONE of these are made better by antibiotics and some are made antibiotics and some are made

worse!worse!

90%90%

Diane Heatley’s study Diane Heatley’s study (Wisconsin) helped us better (Wisconsin) helped us better understand that the adenoid understand that the adenoid had to be removed as the first had to be removed as the first surgical step.surgical step.

I added the outfracture of the I added the outfracture of the inferior turbinates to the inferior turbinates to the adenoidectomy with excellent adenoidectomy with excellent outcomes for curing “sinusitis” outcomes for curing “sinusitis” in children.in children.

We taught, never do FESS until We taught, never do FESS until the adenoid is gone and the the adenoid is gone and the outfracture complete, then, outfracture complete, then, follow the child for an follow the child for an appropriate time.appropriate time.

It is so successful, we now do It is so successful, we now do about one FESS/yr in a child for about one FESS/yr in a child for chronic sinusitis!chronic sinusitis!

Never do FESS and adenoid together. Never do FESS and adenoid together. 90% of children get well with 90% of children get well with adenoid removal adenoid removal onlyonly..

But with adenoidectomy and But with adenoidectomy and outfracture and aggressive medical outfracture and aggressive medical care, 99% get well enough to avoid care, 99% get well enough to avoid sinus surgery.sinus surgery.

Still, we had many failures.Still, we had many failures.

Further searching revealed that Further searching revealed that most of these children had reflux. most of these children had reflux. H2 Blocker therapy was initiated H2 Blocker therapy was initiated and most of these patients got and most of these patients got well. well. (1995)(1995)

A subsequent study that we A subsequent study that we published revealed that if we published revealed that if we treated reflux treated reflux before before surgery, surgery, most children with chronic most children with chronic sinusitis didn’t need sinusitis didn’t need FESSurgery.FESSurgery.

What are the symptoms of What are the symptoms of reflux in a child?reflux in a child?

Most are silent, but if they do…Most are silent, but if they do… Throat clearingThroat clearing Cough Cough (dry, non-productive)(dry, non-productive) BelchingBelching Spitting / re-swallowing / vomiting / Spitting / re-swallowing / vomiting /

regurgitationregurgitation Frequent upset stomachFrequent upset stomach Heartburn Heartburn (rare)(rare)

Adenoid Hypertrophy SX:Adenoid Hypertrophy SX:

Nasal obst Nasal obst (mouthbreathing) (mouthbreathing)

Nasal discharge Nasal discharge (ant rhin or PND)(ant rhin or PND)

Hx of snoringHx of snoring

May additionally have May additionally have

CoughCoughBad breathBad breathHeadachesHeadaches

What are the sx of sinusitis?What are the sx of sinusitis?In children: In children: •Nasal obstructionNasal obstruction (mouthbreathing) (mouthbreathing)

•Nasal dischargeNasal discharge (anterior rhinorrhea or PND) (anterior rhinorrhea or PND) •CoughCough (dry, horizontal) (dry, horizontal)

•HalitosisHalitosis•Headache Headache These are the same as a big adenoid! These are the same as a big adenoid! Studies show they look, act, and Studies show they look, act, and

present the samepresent the same!!

What if the adenoid is small on What if the adenoid is small on Xray? Xray?

Gates middle ear study showed Gates middle ear study showed adenoid size and adenoid size and frequency/severity of OME was frequency/severity of OME was clinically insignificant. clinically insignificant.

We say OM/sinus are the same. We say OM/sinus are the same. Size is not a factor.Size is not a factor.

What are causes of What are causes of a big adenoid?a big adenoid?

•AllergiesAllergies•Recurrent URI’s Recurrent URI’s (Daycare)(Daycare)

•RefluxReflux•Environmental Irritants Environmental Irritants (Smoking)(Smoking)

(same as sinusitis)(same as sinusitis)

Chronic sinusitis is Chronic sinusitis is multifactorial! multifactorial!

We must address reflux, allergies, daycare, We must address reflux, allergies, daycare, smoking caregivers, adenoid, etc., before surgery smoking caregivers, adenoid, etc., before surgery is ever considered or surgery will have less than is ever considered or surgery will have less than

desirable results… desirable results… Failure!Failure!

Clearly need to remember the 2Clearly need to remember the 2ndnd Fact: Fact:

I average about 1 FESS per I average about 1 FESS per year in children with CS for year in children with CS for

the last 19 years.the last 19 years.

I tend to be medically aggressive, I tend to be medically aggressive, and surgically aggressive with and surgically aggressive with adenoidectomies/outfractures, but adenoidectomies/outfractures, but very conservativevery conservative with FESSurgery. with FESSurgery.

Can a large adenoid cause Can a large adenoid cause reflux? … reflux? … sure!sure!

The GI literature lists chronic The GI literature lists chronic airway obstruction as one of airway obstruction as one of important causes of reflux. This important causes of reflux. This is one of my reasons for is one of my reasons for aggressively treating the aggressively treating the enlarged adenoid. enlarged adenoid. (Option - oral steroids.)(Option - oral steroids.)

If reflux and the adenoid are If reflux and the adenoid are effectively addressed, other effectively addressed, other studies suggest less than 5-studies suggest less than 5-10% of kids with CS sx will 10% of kids with CS sx will need surgery. Throw in need surgery. Throw in allergies, and parents stopping allergies, and parents stopping smoking, and the incidence will smoking, and the incidence will decrease even further.decrease even further.

In my hands, less than 1% In my hands, less than 1% of children referred for of children referred for

sinus problems ever need to sinus problems ever need to undergo FESSurgery.undergo FESSurgery.

Medical therapy, coupled with an Medical therapy, coupled with an adenoidectomy/outfracture, is adenoidectomy/outfracture, is

extremely effective in children with extremely effective in children with sinus symptoms.sinus symptoms.

But, if FESS is necessary, how But, if FESS is necessary, how should we do it? Please attend my should we do it? Please attend my lecture on Minimally Invasive SS… lecture on Minimally Invasive SS…

or…or…

TreatmentTreatment Conservative

NO CAFFEINE! (sodas, CHOCOLATE, coffee, tea) No food, milk or juice 2 hours before bedtime No mints No fatty/spicy foods No citrus/acid beverages No alcohol, tobacco Elevation of the head of bed 4-6 inches Body position sleeping (left side or stomach down)

Proton Pump Inhibitor, 3 mg/kg/day divided BID. Never give with dairy products 30-45 minutes between

Thank you!Thank you!