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© Borgis - New Medicine 2/2005, s. 20-23
Lechosław P. Chmielik, Anna Kaczmarczyk, Mieczysław Chmielik
Diagnostic and therapeutic difficulties in children with chronic rhinosinusitis
Clinic of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik MD, PhD
Chronic rhinosinusitis in children generates various clinical problems in laryngological practice. In our paper, we present two clinical cases and discuss diagnostic and therapeutic courses/proceedings for children with chronic rhinosinusitis.
Chronic rhinosinusitis is a combined condition, influenced by many factors. Symptoms of chronic or prolonged rhinosinusitis include mucopurulent secretion in nasal cavities, cough, particularly after falling asleep or shortly before awakening. Older children may complain of headaches or tenderness in sinus regions. Febrile or sub-febrile conditions may be observed. Chronic or prolonged rhinosinusitis is diagnosed in children when the abovementioned symptoms persist for at least 12 weeks. Retardation in physical development or disturbances of mental concentration may be associated to the symptoms. The most frequent causes for chronic rhinosinusitis in children are anomalies in the development of the lateral wall of the nose causing stenosis of the ostio-meatal complex and deformation of the nasal septum. The treatment of chronic conditions requires surgical elimination of the causes by endoscopic sinus surgery.
Analysis of the non-typical symptoms in children with chronic rhinosinusitis, based on 2 cases.
Case report – 1
A 7-year-old boy (W.N., no 10272/2005) was admitted to the Department of Pediatric Laryngology, transferred form other hospital because of a tumor found in the left nasal cavity. Medical history evidenced disturbances of nasal patency, purulent secretion in nasal cavities and snoring, observed for the last 6 months. According to the mother´s words, a pale-yellow discharge fluid appeared after effort. In June 2005, a pathological mass was evidenced in the left nasal. Computed topography revealed a mass which obstructed the left nasal cavity, with opacity present in the left maxillary sinus.
No communication of the tumour with the central nervous system was demonstrated. A cerebro - meningeal hernia was suspected, therefore the patient underwent exploratory surgery. Nasopharyngoscopy was performed in July 2005. A pale-grey polyp-shaped tumour with vascular netting on the surface, obstructing the left nasal cavity and nasopharynx was evidenced. The adenoid was also shown. The tumour was punctured and 2 ml of transparent, yellow fluid was obtained. The biochemical properties of the fluid were as follows: cytosis – 21/mL, glucose level – 85 mg%, chlorides – 107 mmol/l, polymorphonuclear cells – 28%, lymphocytes – 72%, and a small count of erythrocytes.
After surgery, a second computed topography was performed showing a reduction of the mass filling the left maxillary sinus, with continuity into the nasal cavity through a damaged section of the lateral nasal wall. The child was transferred to our Department for further therapy. At admission, the boy was in good general condition, without evident symptoms of acute infection of the upper respiratory tract. No abnormalities were evidenced on paediatric examinations, beside a haemangioma of the left shoulder and left upper limb. On laryngological examination: decreased patency of the nose, grey glossy mass in left nasal cavity. The previous CT images were presented to radiologists. Communication of the polyp with central nervous system was not visible, and cerebro-meningeal hernia was excluded. The boy was qualified for endoscopic sinus surgery. The procedure was performed in August 2005. During surgery, the mass from the left nasal cavity was removed. Amber fluid was aspirated from the sinus and remnants of the walls of the cysts and polypiform mucus, especially from the region of the natural ostium of the sinus, were found and removed. The uncinate process and the second part of the choanal polyp were removed. No complications were observed in the postoperative period (Fig. 1).
Fig. 1. Computed tomography shows a mass obstructing the left nasal cavity and opacity in the left maxillary sinus.
Cultures of material obtained from the maxillary sinus were positive for Staphylococcus aureus MRSA. A treatment with initially intravenous, later oral clindamycin (Dalacin C) was initiated. The histopathology examination showed: polypiform parts of ciliated mucous, oedema and moderate inflammatory infiltration of lymphocytes and plasmocytes into the stroma of the removed polyp. Mucous typical for sinuses with inflammatory infiltration was found in the tissues removed from the left maxillary sinus. The patient remains under follow-up observation.
Fig. 2. Intra-operative view – choanal polyp and adenoid seen in the nasopharynx.
Fig. 3. Choanal polyp protruded to the pharynx behind the soft palate.
Fig. 4. Computed tomography scans of paranasal sinuses with recurrent choanal polyp.
Case report – 2
A 14-year-old girl was admitted to the Department of the Paediatric Laryngology because of recurrent choanal polyp with total obstruction of the nasal cavities, headaches, apnoea and somnolence during the day. Medical history showed a first removal of a choanal polyp was performed in 2001. Later on, she underwent 4 surgical procedures because of renewed growth of the choanal polyp. In July 2002, April 2003, October 2003 endoscopic sinus surgery was performed with removal of the polyp, as well as in February.
Paediatric examination did not reveal any specific changes. Besides deficiency of coagulation factor XII, no other chronic conditions were found. Medical history of allergy was negative. On laryngological examination, a mucopurulent secretion in both nasal cavities and significant obstruction of the nose were observed. A mass of about 3 cm in diameter was noted in the pharynx, behind the soft palate, protruding 1 cm below the soft palate.
Computed topography showed a right maxillary sinus totally filled with tissue, the lateral wall of the nose on the right side with bony lesions (after surgery), hypertrophied mucous of the left maxillary sinus, and a mass (about 3.5 cm in diameter) in the nasopharynx, associated with right medium nasal turbinate. Furthermore, mucus hypertrophy in the left maxillary sinus, and a bilateral stenosis of the ostio-meatal complex was seen on CT scans.
The girl was qualified for endoscopic sinus surgery and polypectomy. The maxillary sinuses were opened and polypiform mucous membranes were removed. The choanal polyp was removed through the oral cavity. The histopathology examination showed a moderate inflammatory infiltration of lymphocytes and plasmocytes into the mucosa of the maxillary sinuses and inflammatory polyp of the nose. Patient remains under follow-up observation.
Nasal polyps are relatively rarely seen in children up to age of 2, and at this age they should suggest congenital lesions. A choanal polyp is the most frequent polyp found in children, also known as a Killian´s polyp. In most cases, choanal polyps form from the mucous membrane of the infundibulum of the maxillary sinus, extend through the natural or accessory ostia of the sinus to the nasal cavity and reach posterior choana and the nasopharynx. Choanal polyps may also develop in the sphenoid sinus, ethmoidal cellules, nasal septum, palate or frontal sinus. Differential diagnosis of unilateral polyps in children should include: cerebro-meningeal hernia, glioma, dermoid cyst, teratoma, haemangioma, lymphatic malformations, malignant tumours, lymphoma, sarcoma, inverted papilloma or juvenile angiofibroma. Before surgery, communication of the polyp with central nervous-system should be excluded. When confirmed, cooperation with a neurosurgeon is necessary.
The diagnostics of chronic sinusitis in children should include: medical history, physical examination and nasal endoscopy, radiographic studies (coronal computed topography scans show anatomical dissimilarities of the lateral wall of the nose or tumours), cytology studies of material obtained from the nasal mucosa (particularly to assess the eosinophil percentage), in older children rhinomanometry, allergy tests, investigation of immune congenital or acquired defects (children on steroids or immunosuppressive therapy administered for other systemic disorders may develop persistent sinusitis), microbiological studies (samples taken from the sinuses and below the medium nasal concha, new hypotheses that bio-films may play a role in chronic rhinosinusitis), histopathology examinations, tests used for diagnosing cystic fibrosis (i.e. seat test), investigation of primary or secondary ciliary dyskinesia (i.e. immotile cilia syndrome), and genetic studies.
1. Chronic rhinosinusitis in children requires broad paediatric and laryngological diagnostics.
2. Co-operation of various specialists (i.e. radiologists, microbiologists, allergy specialists and immunologists) is important in the diagnostic ant therapeutic management of chronic rhinosinusitis.
3. Proper radiological evaluation is necessary before surgical treatment.
4. Systemic disorders or external factors may influence the course of chronic of rhinosinusitis treatment in children and its results.
5. Children with chronic rhinosinusitis require poly-pragmatic treatment: conservative and surgical.
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