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The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.

Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we discuss pediatric endoscopic sinus surgery with Dr. William Collins. He's the Chief of the Division of Pediatric Otolaryngology at the University of Florida College of Medicine. And he practices at UF Health Shands Hospital. Dr. Collins, it's a pleasure to have you with us. So we've seen really cool improvements in children's health thanks to research from cancer and life expectancy and chronic disease, as well as prevention. Can you tell us a little bit about some of the challenges that face children's health in terms of sinus issues today? What have you been seeing? What are the most common types?

William Collins, MD: Yes. Thank you, Melanie. First of all, I really appreciate the opportunity to chat with you today and to talk about this particular topic that consumes a lot of my clinical practice time. So, the disease burden, particularly the financial burden that pediatric sinusitis impacts on society is significant. It's been estimated the past that several billion dollars a year in doctor's visits, antibiotic costs, things like that, they can really add up for families. So, although it may seem like a sort of bothersome type of condition, it can certainly have a big impact on the quality of life for children and their families.

So, as time has gone along, you know, we have adapted some of the technology that was initially used in the adult population to the pediatric population in management of sinus disease, particularly inflammatory disease like sinusitis in children.

Melanie: Well, thank you for that. So, as we're talking about the clinical indications for pediatric endoscopic sinus surgery, I'd like you to tell us a little bit about endoscopic sinus surgery. What conditions might warrant this? And what types of cases are really typically adequately managed with medications or when is surgery indicated?

William Collins, MD: So first step in evaluation is always making sure you have the diagnosis right. And, you know, probably over the last couple of years, we as a society and certainly as a medical profession have paid a lot more attention to viruses of the respiratory tract than we ever did in the past. So there are a lot of overlapping conditions in children, and it's important to make that proper diagnosis so that you can tailor your treatment to them. Common symptoms such as nasal congestion in kids or runny nose could be indicative of underlying environmental or inhalant allergies. Depending on the nature of the drainage, could be an acute episode of sinusitis or, depending on the time course, could be evidence of a chronic sinusitis. So it's important for the practitioner to make that proper diagnosis because many of these common conditions can be managed medically.

In the children that we have sort of maximized the medical treatment or the term we often use is maximum medical therapy, those are the ones we start looking at surgical options for their sinus disease particularly with their inflammatory sinus disease or sinusitis. So these might be children that have done the full gauntlet of allergy treatment, nasal sprays, anti-histamines, things like Montelukast, Singulair and if they just aren't improving with their symptoms. Those are children that we start to think about surgical therapy as an option for them. And that's probably the most common patient population, is the inflammatory sinus patients.

But there are also expanding indications for endoscopic sinus surgery and kids. For instance, children that are born with congenital anomalies of the nose, such as choanal atresia or if they were to have congenital malformations of the nose, such as an encephalocele, we've now adapted some of that technology to children and can surgically treat those conditions in a much more minimally invasive approach, which results in quicker recovery, shorter hospital stays in these pediatric patients.

Melanie: So then Dr. Collins, what are some of the unique surgical technique differences in pediatric sinus surgery compared to adults? Can you give us a little bit of an overview of the technical aspects and predictors for successful surgery? Any technical considerations you'd like to share with other providers to help them achieve better outcomes with their pediatric patients?

William Collins, MD: Absolutely. So from a technical standpoint, I mean, one of the most obvious considerations is kids are smaller. In the pediatric fields, we like to say, you know, kids are not just little adults. But in this particular instance, their nasal cavities, their nasal passages, the anterior nasal cavity in particular is smaller in children. So we've had to adapt over time to use smaller and smaller instruments to access these surgical fields. You know, another consideration in children as opposed to adults is children are still growing. And there is some concern that there are facial growth centers within the nose that, if disrupted with surgery or trauma, can affect long-term facial growth in children.

So as a general rule, we try to be a little bit more conservative in tissue removal when we're operating in the sinonasal cavities in children compared to adults. You know, another consideration in some of the more advanced or technically complicated endoscopic sinus procedures in kids, for instance, those in which we are looking at maybe tumors of the nasal cavity or that anterior skull base area, the techniques that were originally developed for adults to do what we call endoscopic skull-based surgery have slowly been adapted to children as well. And children are not born with fully developed sinus cavities. They're usually born with the maxillary and ethmoid sinuses developed, but they still enlarge over time and the frontal and sphenoidal sinuses can develop later. So depending on the location of these different lesions, if there is not a well-developed sinus cavity, that can impede our access to those areas. So, a big part of it is just the child's growing and developing sinonasal anatomy that can make the technical access a little bit trickier in the smaller children compared to the adult population.

Melanie: To expand on that just a bit more, Dr. Collins, some of the limitations of performing this type of surgery in the pediatric population, is there any technology or technological advancements or radiologic imaging that you feel are very exciting that can augment your diagnostic and therapeutic capabilities and/or limiting some of them that you feel that there might be something that you wish were available now for these small passages you're working in?

William Collins, MD: Yeah, well, you know, one of the things that we use very frequently in children now is something called image-guided surgery. And this is a method where we can, based on a preoperative CT scan and/or MRI imaging that we can surgically track our instruments at the time of surgery to provide a little more confidence in exactly the anatomic locations that we're reaching. This is particularly useful in more complicated cases. For instance, children that may have, you know, really extensive nasal polyps, which we sometimes see in the cystic fibrosis population where the typical intranasal anatomy is significantly altered.

At an institution, you know, here like UF Health and Shands hospital, we often see the more complicated referrals, revision cases where the native anatomy has been disrupted. So some structures that we would normally use to guide our surgical dissection may not be present. So this type of technology allows us to, you know, as I mentioned, sort of track the tip of our instrument into the different areas within the sinus and nasal cavities to provide a little more extensive removal of tissue, removal of polyps, potentially removal of tumor which can be particularly important when you're talking about trying to get oncologic clearance of a neoplasm within the nose.

Melanie: This is a very interesting topic, Dr. Collins, and you're an excellent educator. Do you have any final thoughts for other providers on what you would like them to know about the importance of the multidisciplinary management for these kids? Any technology or exciting things on the horizon you'd like to mention, and when you feel it's important they refer to the specialists at UF health Shands Hospital?

William Collins, MD: Yeah. You know, we think of evaluation of these children as we do most patients in kind of a stepwise fashion. So again, I can't emphasize enough, it's important to get the diagnosis right. And for many, many of the common diagnoses, there are readily available treatments that will adequately manage the symptoms and the condition in these children, such as, you know, management of allergic rhinitis. But the patients that have been maximized on those therapies and there really isn't any additional medicine that can be offered, it's important for providers to know that there are options that we can use to treat these children.

You know, we were kind of talking mostly about endoscopic sinus surgery, but I wouldn't want to overlook the importance of adenoidectomy, good old fashion removal of the adenoid tissue from the nasopharynx is very effective in children that have chronic sinusitis and the mechanism by which that works is the bacteria hide out. Adenoid tissue serves as a bacterial reservoir. So that is, you know, an additional step before we get to endoscopic sinus surgery in kids. But it is important for people to understand that, as you go through the different steps, there are a lot of different options that we can offer for these patients. And if they're not getting better, and they're not getting better with the usual course of treatment, then you got to start digging a little deeper, you know, maybe that nasal congestion is due to a tumor or perhaps, you know, it's a polyp. And if a child has nasal polyps, you have to start thinking about other co-morbidities such as cystic fibrosis.

You know, again, I think there's a lot of treatment options out there, but it's important for people, you know, to recognize that when all the usual therapies fail to give you adequate improvement, there are still a lot of options available to these patients and their families.

Melanie: Thank you so much, Dr. Collins, for joining us today and sharing your incredible expertise for other providers. And you can visit ufhealth.org/ent or ufhealth.org/oaks. For information on our two locations and to schedule an appointment or to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters.

That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please always remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.