© Borgis - New Medicine 2/2002, s. 53-54
Mieczysław Chmielik, Eliza Brożek
Nasal and sinus diseases in children – surgical treatment
Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw, Poland
Head: prof. Mieczysław Chmielik M.D.
Plastic surgery of the lateral nasal wall in children has been performed in Warsaw Paediatric ENT Clinic since 1995. There have been 121 operations. They consisted of conservative reconstruction of congenital or acquired defects in this area.
In most cases a decrease in the number of upper airways infections and permanent improvement of nasal patency was attained. None of the cases has shown any inhibitory influence from these procedures on craniofacial development. The principles of accomplishing conservative plastic surgery of the nasal mucous membrane are defined.
Upper respiratory tract diseases at a developmental age constitute a very important social issue. Most children at pre-school or early school age undergo chronical upper airways infections, especially in seasons other than summer. These infections result in nasal breathing impairment and a poorer oxygen supply to the system. Additionally, the toxic products of bacterial metabolism also destroy human immunological mechanisms. Intensive intellectual and physical development is a characteristic at the age of the evaluated children. Therefore, all factors which negatively influence the child´s system may result in irreversible physical and intellectual defects. The main reason for a predisposition to a frequent incidence of infections are anatomic defects of the upper respiratory tract. These defects are: nasal septum deviations, adenoid tissue hypertrophy, and congenital deformities of natural paranasal sinus ostia. The diagnostic opportunities of computer imaging, recently developing in a stepwise manner, can give us another view of the shape of the above-mentioned sinus ostia. Also, defining the degree of change and the site requiring surgical correction become possible. Contemporary opportunities for sinus surgery, and knowing the development process (6) has enabled widen the indications for surgery at the developmental age. This is particularly important as long as persistent ostial narrowing may produce permanent changes in the sinus mucosa, and even then surgery to improve sinus ventilation is not able to reverse these changes. Consequently, such procedures should be performed early enough to anticipate any of the chronic changes mentioned above.
Experimental sinus surgery performed upon animals has suggested the possibility of an inhibitory influence on facial skeleton growth following extensive damage in this area (4). Thus, paranasal sinus surgery performed at the developmental age must differ from that performed on adults. The procedures can be executed only by a fully-trained surgeon equipped with instruments adjusted to the size of the patient. The surgery can encompass only the area of the congenital defect. The complete operating procedure according to Stammberger or Wigand (7, 10) should not be carried out, unless there are important reasons (e.g. oncological).
SURGICAL TECHNIQUE DESCRIPTION
The first stage is a complete endoscopic evaluation of the nasal cavities. In case there is a narrowing in the ethmoidal infundibulum area, it is necessary to remove the uncinate process. If Haller cells are present, their medial walls should be removed. The pneumatised middle nasal concha is fixed by removal of its lateral wall. In the event of cysts or polyps inside the sinuses, it is convenient to remove them too, remembering that the presence of a cyst itself is not an indication for surgery. Endoscopic control of the frontal duct requires particular caution due to the characteristic cilia movements in this region. The frontal sinus of a child, in a case of a pathological condition, should be opened from an exterior approach, carefully enough not to result in scarification of the above-mentioned region of the naso-facial ostium duct.
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