Long-term Follow-up of Pediatric Chronic Rhinosinusitis After Surgical Treatment

Introduction

Chronic rhinosinusitis (CRS) and chronic adenoiditis (CA) prevalence in the pediatric population has been reported between 2% and 4%.^1,2 They are defined as 2 or more symptoms, one of which should be either nasal obstruction/blockage/congestion or nasal discharge ± facial pain/pressure or cough for >12 weeks with either endoscopic signs or computed tomography (CT) changes consistent with disease.^1,2 The mainstay of treatment is medical therapy which consists of oral antibiotics, intranasal steroids, and nasal saline irrigations.^1,2 Surgery, including adenoidectomy, sinus lavage, balloon dilation sinuplasty (BDS), or functional endoscopic sinus surgery (FESS) may be required when medical therapy fails. The short-term outcome of surgical treatment of pediatric CRS has been demonstrated in several studies. Adenoidectomy has proven to be successful in 50-60% of the patients and is recommended as first line surgical treatment.^3,4 Two prior systematic reviews in 2013 showed that FESS had success rates of over 82% for improvement of pediatric CRS symptoms and quality of life with a low incidence of major complications.^5,6 Lusk et al studied long-term outcome of surgical intervention in pediatric CRS. ⁷ They found that FESS provided relief of nasal symptoms 10 years later as compared to medical management. ⁷ The goal of this study was to explore the long-term outcomes of pediatric CRS after surgical treatment.

Methods

A cross-sectional survey was conducted by phone or email through REDCap on pediatric patients who underwent surgery for uncomplicated CRS without nasal polyps (CRSsNP) or CA as children at West Virginia University between 1995 and 2015. CRSsNP and CA were diagnosed based on presence of chronic sinonasal symptoms that included purulent rhinorrhea, nasal obstruction, facial pain/pressure, and cough who underwent CT imaging. Chronic was defined as at least 12 weeks of symptoms which is consistent with the current guidelines used.^1,2 Patients with nasal polyps, acute complications of rhinosinusitis, cystic fibrosis, primary ciliary dyskinesia, or primary immunodeficiency disorders were excluded. All children who underwent surgery had failed medical treatment which consisted of 3 to 4 weeks of oral antibiotics, nasal saline sprays, and intranasal steroid sprays. West Virginia University Institutional Review Board approval was obtained before retrospective data acquisition and survey conduction. The survey included the sinonasal outcome test-22 (SNOT-22) questionnaire, additional surgical treatment, and their current status of allergic rhinitis (AR), asthma, obstructive sleep apnea, and smoking. A chart review was performed to review any additional surgical interventions performed and to review CT scan sinuses or facial bones that were available during the follow-up period. Stata 16 was used for all statistical analyses (StataCorp LP, College Station, Texas, USA). Univariate analysis with a P-value set at P = .05 was used to analyze the data. We used the 2-sample t-test for continuous variables and chi-square test for categorical variables.

Results

Three hundred thirty-two patients were contacted by phone or email. Seventy-three patients filled the survey (22.5% response rate) (Table 1). Current age was 26 years (±+/−4.7, 15.3-37.8 years). Age at initial treatment was 6.8 years (+/−3.1, 1.7-14.7 years). Fifty-two patients (71.2%) had FESS and adenoidectomy, and 21 patients (28.8%) had adenoidectomy only. Follow-up since surgical treatment was 19.3 years (+/−4.1, 12-28.5). SNOT-22 score was 34.5 (+/−22.2, 0-83). None of the patients had any additional FESS for the duration of the follow-up, and only 3 patients had septoplasty and inferior turbinoplasty as adults. Twenty-four patients had CT scan sinuses/face available for review. Scans were obtained at an average of 14 years after surgical intervention (+/−5.2, 6.5-25.5). CT LM score was 0.9 (+/−1.9, 0-6), compared to 9.3 at time of their surgery (+/−5.9, 6.7-11.8) (P < .0001) (Figure 1). Currently 45.8% and 36.9% of patients have asthma and AR, compared to 35.6% and 40.6% respectively as kids (P = .897 and P = .167). 16% of patients who responded to the survey are active smokers, and 11.1% are former smokers.

OPEN IN VIEWER

Table 1.

Summary of the Findings in the Study Population.

Variables
Current Age (years, SD)	26 (4.7)
Age at diagnosis	6.8 (3.1)
Female	56.2%
Current asthma	45.8%
Childhood asthma	36.9%
Current allergic rhinitis	35.6%
Childhood allergic rhinitis	40.6%
Current smoking	16.4%
Former smoking	11.1%
SNOT-22 (SD, range)	34.5 (22.2, 0-83)
SNOT-22 Subdomains (SD, range)
Rhinologic	11.6 (7.7, 0-36)
Ear/Facial	4.8 (4.3, 0-18)
Sleep	16.3 (12.2, 0-39)
Psychological	1.8 (2.4, 0-9)
Surgery
FESS +/− adenoidectomy	71.2%
Adenoidectomy	28.8%
CT LM score at time of surgery	8.5
CT LM score at follow up (N = 24)	0.9
Follow-up (years, SD, range)	19.3 (4.1, 12-28.5)

Abbreviations: LM, Lund-Mackay; SD, standard deviation; FESS, functional endoscopic sinus surgery.

OPEN IN VIEWER

Figure 1.

Box plot showing the CT Lund-Mackay scores at the time of surgery and at follow-up.

We then compared patients with had FESS/A versus adenoidectomy alone (Table 2). Patients who had adenoidectomy alone were younger at age of surgery (5.2 vs 7.3 years, P = .007), and had lower CT LM score (4.9 vs 9.8, P = .0004). There was no difference in their current clinical characteristics and survey outcome.

OPEN IN VIEWER

Table 2.

Comparison Between Patients Who Had Adenoidectomy Alone Versus Functional Endoscopic Sinus Surgery (FESS) and Adenoidectomy (A).

	Adenoidectomy (N = 21)	FESS/A (N = 52)	P value
Current Age (years, SD)	24.3 (4.4)	26.7 (4.7)	0.05
Age at diagnosis	5.2 (3)	7.3 (3)	0.007
Female	57.1%	55.8%	0.915
Current Asthma	42.9%	47.1%	0.745
Childhood Asthma	30%	40%	0.441
Current Allergic rhinitis	33.3%	36.5%	0.796
Childhood Allergic rhinitis	41.2%	40.5%	0.96
Current smoking	4.8%	21.2%	0.09
Former smoking	14.3%	9.8%	0.582
SNOT-22 (SD)	40.5 (19.9)	32.1 (22.7)	0.146
SNOT-22 Subdomains (SD)
Rhinologic	12 (5.6)	11.5 (8.5)	0.809
Ear/Facial	5.9 (3.4)	4.4 (4.5)	0.19
Sleep	20 (11.9)	14.7 (12.1)	0.096
Psychological	2.7 (3.2)	1.5 (2)	0.061
Follow-up (years, SD)	19.1 (3.5)	19.3 (4.4)	0.808
CT LM score at time of surgery	4.9 (4.9)	9.8 (4.6)	0.0004
CT LM score at follow up	0.2 (0.4) N = 5	1.1 (2.1) N = 19	0.383

Abbreviations: LM, Lund-Mackay; SD, standard deviation.

Discussion

Although the success rate of FESS for pediatric CRS is reported to be 82% to 100%, little is known about the long-term follow-up of those patients.^5,6 Studies on the long-term follow-up after pediatric CRS are limited. Lusk et al retrospectively compared children who underwent FESS for CRS to a group of kids who were managed medically, 10 years after either treatment. ⁷ That study showed improved nasal symptoms for children who underwent surgery. Our study offers a longer follow-up window, at an average of 19 years, for those children who underwent FESS for CRS.

It is not clear if children who suffer from CRS continue to suffer from their sinus disease as adults. This is the first study that attempts to characterize the progression of pediatric CRS into adulthood. The fact that none of these patients required additional FESS and the statistically significant reduced CT LM scores suggest that pediatric CRS does not typically persist into adulthood. However, it does appear that children with asthma or allergic rhinitis who have undergone CRS surgery continue to have rhinologic problems into adulthood, as evidenced by the relatively elevated SNOT-22 and rhinologic subdomain scores. This is consistent with recent studies that tried to predict the trajectories of allergic rhinitis and asthma from childhood into adulthood.^8,9

Our study was limited in that we did not have a comparison group of pediatric CRS patients treated exclusively with medical management. Another limitation is that this is a cross-sectional study that addresses patients’ quality of life symptoms at the time of the survey. It does not provide longitudinal details about their disease progress.

Conclusion

Children who had surgery for CRS do not seem to have CRS as adults. However, patients continue to have active allergic rhinitis that may affect their sinonasal quality of life.