When Your Child Absolutely MUST Have Sinus Surgery
.When Surgery to Treat Sinusitis is Needed.
Part 1
When considering surgery for a child with chronic sinusitis …
Before even considering sinus surgery for a child, I insist that a strong, integrative holistic medical approach has been tried, and failed. All other options must have been exhausted. This includes doing daily sinus rinses. Really doing them. Really. Check this link for my 5-Step Program to Eliminate Biofilm and Chronic Rhino-Sinusitis.
It also means a thorough evaluation for why this child is having chronic sinusitis. After all, chronic infection is not normal, and it may reflect underlying pathology such as immune deficiency, or other severe disease. Only after we rule out ALL other, correct-able issues, so we move on to consider surgery.
A computed tomographic (CT) scan can reveal the condition of the sinuses, and whether there is obstructing adenoid growth in the nasopharynx or obstruction of the sinus openings. Check this link for How To Read Your Child’s Sinus CT Scan.
In my practice, even if the child’s adenoid tissue appears small on the CT scan, I will still consider an adenoidectomy to be the first surgery step for my patients with chronic sinusitis. Why? Removing the adenoid tissue can eliminate a potential reservoir of bacteria near the nose and sinuses. Check this link for more on the Anatomy of the Nose and Sinuses.
Also, if the child has been on multiple courses of antibiotics, there is increased risk of resistant bacteria being present in the sinuses. That is, the bacteria that are present are often resistant to most of our antibiotics. In order to treat those resistant bacterial infections, it can be very helpful to determine what bacteria are causing your child’s sinusitis.
How can we find out which bacteria are present?
If my patients go to surgery for an adenoidectomy, that is a good time to irrigate their maxillary (cheek) sinuses and send this for culture to identify the bacteria that are present (Faust, Rimell, 1996); the term for this procedure is “sinus centesis”. Knowing the types of bacteria that are present, and which antibiotics that are effective against them, can be useful for fighting chronic sinusitis.
Unfortunately, culture of sinus infections may not always reveal all of the bacteria that are present. The latest technique is to clone the DNA of bacteria that are present, and compare them to a database of known bacterial species. This method reveals that culture methods can miss a large number of bacteria. Check this link for thevery latest methods for identifying bacteria in the aero-digestive tract (Griffen & colleagues, 2011).
The time of an adenoidectomy is also the time to perform a “wash,” or irrigation, of the maxillary sinuses. Rinsing out the sinuses while under general anesthetic greatly increases the success over just doing adenoidectomy alone to treat chronic sinusitis (Ramdan & Cost, 2008).
Finally, there is never a downside to performing daily nasal saline rinses. I use the Nasopure nasal rinse system for myself and my family, and this is the system that I recommend to my patients.
Transparency: I have no financial or other arrangements with Nasopure.com, and by-the-way, they have THE best videos of how to do nasal rinses on their site! Check it out. Those videos were the only way that I could get my 5-year-old to try it.
Next Time: I will review my preferred method of minimally-invasive sinus surgery.
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Resources
Faust RA and Rimell FL: Chronic rhinosinusitis in children. Current Opinion in Otolaryngology, Head and Neck Surgery, vol. 4: 373-377, 1996.
Ramadan HH, Cost JL: Outcome of adenoidectomy versus adenoidectomy with maxillary sinus wash for chronic rhinosinusitis in children. Laryngoscope Vol. 118: 871-873; 2008.
Ramadan HH: Safety and Feasibility of Balloon Sinuplasty for Treatment of Chronic Rhinosinusitis in Children. Annals of Otology, Rhinology & Laryngology. Vol. 118(3): 161-165; 2009
Ann L. Griffen, Clifford J. Beall, Noah D. Firestone, Erin L. Gross, James M. DiFranco, Jori H. Hardman,Bastienne Vriesendorp, Russell A. Faust, Daniel A. Janies, Eugene J. Leys. CORE: A Phylogenetically-Curated 16S rDNA Database of the Core Oral Microbiome; PLoS ONE, 2011: http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0019051
Acclarent Balloon Sinuplasty: http://www.acclarent.com/solutions/overview/
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Image: Russell Faust, aka the boogordoctor
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10 Responses to “When Your Child Absolutely MUST Have Sinus Surgery”
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Welcome
Hello and thank you for stopping by "Ask the Boogor Doctor". This site is dedicated to helping you achieve optimal health for your children, following an integrative holistic approach to care of the Pediatric Airway: pediatric sinusitis, allergies, asthma, rhinitis, reflux, otitis, and all pediatric ENT.
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angela
08. Aug, 2011
My 8 YO son had FESS 3 years ago with minimal success, in my mind, as he continues to get (we think) sinus infections that do not seem to respond to AB’s. (NL immunology w/u, we’re repeating allergy testing and will probably try repeat PPI trial – I’m a pharmacist). We’re trying hard to avoid another CT of the sinuses as he’s had 6 in his lifetime.
For the FIRST time, we started saline rinses (nasopure- and you’re right ,it’s fairly easy). Can these be continued throughout a cold/infection or is it difficult? Right now, he’s doing great and I’m hoping they’ll improve his symptoms (mild, but constant- sniffling, stuffy, mild cough).
Next step is to add baby shampoo and honey…
Thanks!
ps. this is a TREMENDOUS website, wish it were around a few years ago! Great, quirky sense of humor,too! :)
Angela
Russell A. Faust, PhD, MD
08. Aug, 2011
Hi Angela,
Sorry to hear about your son’s troubles.
Yes – you can (and should) continue nasal saline rinses through a ‘cold’. In fact, I increase my once-per-day rinses to twice daily during my ‘colds,’ just to decrease my risk of developing sinusitis. However: note that more than 3 or 4 times daily can be irritating for the nasal and sinus lining.
My recommendation is to try including Manuka honey (search Manuka here on this site), and Xylitol. Both have beneficial effects against chronic rhinosinusitis and biofilm-forming bacteria. Try “Xlear” xylitol products (I personally use their “NetiXlear” saline / xylitol formula) in my Nasopure bottle.
Note that baby shampoo should only be used at very low concentration – a couple DROPS per bottle of nasal rinse. Anything more than that will BURN BURN BURN. Very uncomfortable (from personal experience).
Only one other comment: that is a lot of radiation for a child. I hope that your radiology group is familiar with the reduced radiation exposure protocols for children.
Thanks so much for visiting, for your kind comments, and for taking the time to contribute!
RF (boogs)
Angela
08. Aug, 2011
Thanks much!
(and, the CT’s were from pre-surgery, before all the newer rec’s came out concerning radiation and such- he had one post-surgery and none since then,)
When do you change to hypertonic rinses ? I know you only recommend them for a week or so.
Thanks again!
Angela
Russell A. Faust, PhD, MD
10. Aug, 2011
Hello again, Angela:
I usually recommend hypertonic saline rinses either during a bad cold, with severe congestion, or to help eliminate chronic sinusitis. For chronic sinusitis that has been going on for many months, hypertonic rinses are used along with all of the other tools in the repertoire – probiotics, Manuka honey and Xylitol in the rinses, and consideration of a surfactant or detergent – baby shampoo. That last option must be used with caution (it burns if the concentration is even a little too high).
Thanks again for joining our little community of boogorheads :))
RF (boogs)
Kim Rogers
30. Jan, 2012
I love this website. My almost 3 yr old has had sinus surgery and is now on his second course of LT augmentin. He’s been hospitalized with pneumonia for 8 days, had 11 ear infections prior to tubes and adenoidectomy at 18 mos, has asthma, and dev delays. He’s seen an ID/immunologist and his Ig responses were normal. He’s had a normal sweat test. We do nasal rinses and flonase BID along with allergy and asthma meds. Any other suggestions?
Russell A. Faust, PhD, MD
31. Jan, 2012
Hi Kim,
Your son sounds like my medical practice. Kids with those issues, but without clear reasons – normal immunity, often without significant allergies by testing – but with asthma, pneumonia, sinusitis, otitis, etc. They can be challenging for parents and physicians. The worst part, from my perspective? We specialists just don’t communicate with each other like we should, so parents with kids like this are often seeing 4 or 5 (or more) specialists, who don’t have a clue what the other docs are doing or why, and even when they do, they disagree on the remedy. My advice: take a look at the articles on Probiotics, and Xylitol. Both of these remedies have provided huge benefits in my clinical practice with children like your son. Ask your pediatrician about these, but don’t be surprised if they simply tell you that probiotics means eating yogurt, or say “xyli-what?” when you mention Xylitol.
Thank you for visiting, and thank you for your kind comments. I really appreciate that, and appreciate you sharing for our little community of “boogorheads”.
Please visit again and let us know how it is going!
RF
jen
27. Feb, 2012
What a great resource this is as I am learning about how sinus issues may be affecting my son’s asthma. He typically requires high amounts of inhaled steroids but lately we’re seeing him improve dramatically within 24 hours of being on antibiotics. Concerned about him having to be on antibiotics so often though. Hoping their is a solution to prevent all this. We’ve been doing probiotics for a few years (Garden of Life Raw for kids) and we started using the NasoPure (love it!) each day about a month ago but still just got another sinus infection (now doing it 3x day). I also started giving him fish oil when sick. Do you recommend the manuka honey just during a cold or all the time. We see a pediatric ENT for the first time on Friday. Can you give me advice as to what to ask at this appointment? Thanks so much for this wonderful site! Jennifer
Russell A. Faust, PhD, MD
28. Feb, 2012
Hi Jen,
Thanks for visiting, and for sharing. It’s hard to think of ways to improve what you are already doing. I personally add Manuka honey to my rinses only when I have a sinusitis (it’s pretty pricey), but I see no reason it cannot be used regularly – unless you have an allergy to honey. The only other thing to consider is reflux – GER. It has been found that many children with “asthma” and chronic sinusitis have GER as a contributing component, and – here is the great thing – the majority of those improve by simply treating their reflux! I am always surprises by the number of children with asthma that I improve by treating them for reflux. Otherwise, you should be in good hands with a pediatric ENT. And if you are looking for someone who practices more Integrative Holistic Medicine, check the doc-finder at http://www.abihm.org/search-doctors.
Thanks again, and thank you for your kind comments. Please visit again and let us all learn from your experience!
RF
angela
12. Mar, 2012
Hi again, Dr. Faust!
My now 9 YO son has been doing daily sinus rinses with great results this current school year- meaning colds have actually gone away within a normal time frame! He does currently have a “very bad” cold and tells me that the last sinus rinse was difficult to perform as he had to “force the water through”.
He’s an old pro at these by now, so I’m wondering, what are your recommendations in this case? Could the congestion really be so severe that it makes the rinses difficult ? Should he alter how he does the rinses if this occurs- “forcing” doesn’t sound like the right thing to do. Could water from the rinses get “trapped” and worsen anything? Thanks so much once again!
Russell A. Faust, PhD, MD
14. Mar, 2012
Hi Angela,
No, I agree that there should be no “forcing” of anything, but I do know from experience that severe congestion associated with a ‘cold’ can keep the rinses from flowing as easily as one expects. The key is to be consistent, keep doing the rinses. In my case, I also continue to use the same amount of saline packet, but reduce the amount of water that I add to the squeeze bottle. This makes the saline a little bit “hyper-osmolar.” The effect is to increase drawing fluid out of the swollen, congested nasal lining. I do this only when I have an active “cold” or sinusitis. Best success. Thanks again for your kind comments, and for sharing!
RF