Computer-assisted functional endoscopic sinus surgery in children

There is a paucity of information in the literature concerning image-guided or computer-assisted endoscopic sinus surgery in children. Significant disagreement continues regarding the appropriate indications for endoscopic sinus surgery in children. The cost/benefit ratios have not been determined, but there is general agreement that medical management should be exhausted before surgical intervention. It is now known that many of the principles used in adults are not necessarily appropriate in children because of the significant differences in the pathophysiology of children and adults. These differences are caused in part by an immature immune system and maturing anatomic structures in children. Many studies include patients up to the age of 16 as children. It is unlikely that the anatomy of a child 12 to 13 years of age and older differs significantly from that of an adult. The anatomy of a 3-year-old to 10-year-old child is significantly smaller, however, and requires greater care during surgical intervention. There is no general consensus on the appropriateness of surgical intervention in children who have chronic sinusitis. In 1997 a consensus panel was able to agree on some appropriate indications for endoscopic sinus surgery (Box 1) [1]. Chronic sinusitis was listed as a possible indication after failed medical therapy, but the panel was not able to define failure to respond to adequate medical management in chronic sinusitis. Chronic sinusitis, however, is the most frequent indication for endoscopic sinus surgery. Most acute and chronic sinus infections in children are managed medically by treating concomitant diseases and the primary infection with antibiotics. A large body of literature is available on this subject but does not address the topic at hand. Surgical management of sinusitis has been traditionally conservative. Many surgeons recommend performing an adenoidectomy as the first method of surgically managing chronic sinusitis in children [2,3]. The success rate of with adenoidectomy alone is only about 50% [3]. If the symptoms continue, a child with CT-documented chronic sinusitis may undergo endoscopic sinus surgery, usually an anterior ethmoidectomy and maxillary antrostomy, as the primary procedure. Most children with chronic sinusitis do not have a developed frontal sinus, and the sphenoid is not usually involved with the chronic infection. There was concern that endoscopic sinus surgery in the pediatric patient could be associated with interruption of facial growth. This concern was based on to animal studies that demonstrated possible interruption of growth of the snout in piglets after endoscopic sinus surgery had been performed [4,5]. Bothwell et al [6] thoroughly reviewed children who had undergone endoscopic sinus surgery at a very young age. These childreb were examined 10 years after surgery and were compared with a similar control group with chronic sinusitis and with normal children. There was no evidence of interruption of facial growth in children who underwent endoscopic sinus surgery.