When Your Child Absolutely MUST Have Sinus Surgery

Minimally invasive sinus surgery

Minimally-invasive 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 the very 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

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Russell Faust boogordoctor Pediatric Sinusitis Unified Airway

Image: Russell Faust, aka the boogordoctor

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Comments

  1. 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 says:

      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)

      • 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 says:

          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)

  2. Kim Rogers says:

    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 says:

      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

      • This little guy sounds like our little man. He will turn 6 on Saturday. We actually are just home from his sinus CT scan (this morning). Our ENT wanted to check out his adenoids, but in addition, she was concerned about his sinuses being malformed or small. He has developmental delays, seizure disorder, reflux (with reactive airway component), severe orofacial dyspraxia/speech and language delays, sensory processing disorder, etc and is small for his age. Over the last several years, he’s had a lot of severe respiratory/sinus/pneumonia/strep type illnesses, and they have been trying to sort out if he has asthma or if the reactive airways are secondary to the reflux. He’s on his third set of tubes, which the tubes have helped immensely–and as soon as they fall out, the ear infections begin again. I was curious about the CT images, as we don’t see our ENT until tomorrow. They don’t look as much like the ones on your website. I am anxious to hear what she has to say. Thanks for the resources!

        • Russell A. Faust, PhD, MD says:

          Hi Vicki,
          I’m sorry to hear about your little guy’s troubles. You have your hands full. I suspect that you are in good hands with your ENT there (I know most of them in Minnesota, and they’re all great). Your boy sounds like my typical patients in my clinics. Please take a look at the articles on this site, including those on probiotics, and also on Xylitol, for clinical-trial-proven benefit for those children with recurrent ear and sinus infections. With this history, it is prudent to consider removing the adeoids, since they can be a reservoir for microorganisms, even if the adenoids are not big.
          Thank you for visiting, and for sharing.
          Best success, and please keep us informed.
          RF

  3. 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 says:

      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

  4. 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 says:

      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

  5. Russ Barker says:

    My 5 year old had adnoids removed after chronic symptoms ( they were very enlarged ).
    After courses of antibiotics, Dr recommended a scrapping of sinuses ( due to them being very narrow ).
    Is this a normally prescribed procedure and what are the next steps if this does not work?

    Thank you

    • Russell A. Faust, PhD, MD says:

      Hi Russ,
      “Scraping” sinuses is not a common medical / surgical procedure. I am guessing that your Dr. is not a Pediatric Otolaryngologist (ENT surgeon). Regardless, it may be time for another opinion. Whenever anyone tells you that surgery is indicated, you owe it to yourself to get another opinion. For my patients, when I recommend surgery, I urge them to seek another opinion.
      Thanks for visiting, and please keep me updated.
      RF

  6. leann barker says:

    Hi my husband posted above it wasn’t a scraping as it was endoscopic sinus surgery to remove infected tissue that antibiotics were not effecting. She has a narrow nasal passage as well. Has had chronic sinusitis. We tried multi antibiotics for varying time limits, allergy testing (all negative)and an adenoidectomy. And out ENT is well known in Florida .. We r hoping this will b the solution

  7. My 22 mo old has had chronic sinus infections for at least 1 yr. Our ped feels like this is originating from allergies then turns to sinusitis & occasionally bronchitis. She was tested for allergies earlier this year as well as IMG’s drawn. All was normal. She has been on abx off & on for the last 18 mo. She just completed 24 d of abx (10d omnicef, 14d suprax), takes zyrtec qd, just started singulair yesterday, takes albuterol nebs prn. She continually has a clear runny nose w/ intermittent wet rattly cough. Drainage eventually turns green & fever starts. She takes abx & gets better for 2-3 wks then the cycle repeats. At present- no temp in 2 d, completed abx 3d ago,continues to have clear runny nose, wet cough (this is better than last wk when cough was persistent to the point of gagging). Ent suggested several things- take out daycare for 2 mo or so, CT to check sinuses, sinus washing, remove adenoids. Allergist suggested repeating allergy test (southeast panel by blood draw) after age 2. I am exacerbated with this! Not sure what to do. Tired of pumping my child full of drugs. Any thoughts?

  8. Lindsay Stewart says:

    Hi Dr Faust
    I am in South Africa. My daughter (6) and son (4) are both treated by a paediatric pulmonologist and an ENT who speak with each other about treating my children.
    My son has GERD and also sees a paediatric gastroenterologist who works together with the pulmonologist too. They have put him on maximum dose of reflux med and at the end of 6 months will do another gastroscopy to help us decide whether he needs the Nissan Op. They said they don’t often suggest it for children but in his case it might be the answer. He has asthma and chronic sinuses+allergies and also on maximum dose of med. They also found that he had not developed any antibodies from some of his baby vaccinations so had to be revaccinated. He has had tonsils,adenoids removed and had grommets for 3 years. He is attending speech therapy.

    We sinus rinse both our children every day. We also give them probiotics and many other immune boosting foods. Their diet contains no gluten,dairy and very little sugar (honey instead). Neither of them have cystic fibrosis.

    My daughter (6) has been diagnosed with a slight lung immune deficiency. At age 3 she had her tonsils and adenoids removed and a sinus rinse,the ENT found she had the pneumonia bacteria in her sinuses. She also has reflux and asthma. Last year the doctor told me to take her out of school for 6 months and put her on an antibiotic used to strengthen the lungs. This week she got severe ear infection which is not responding to two antibiotics. She will have grommets put in on Monday as well as a sinus rinse. The ENT wants to test to see what bacteria is resisting the antibiotics.

    Interestingly enough this week too,the ENT did a CT scan of my sinuses (I’m 33 and have never been seen by an ENT) and he found they are a disaster and my nasal septum is buckled. I am on 3 weeks of serious treatment and after that he will need to decide if he needs to operate.

    Thank you for listening to my story. Its a relief to know there are others who understand!

    • Russell A. Faust, PhD, MD says:

      Lindsay,
      Thank you so much for sharing. Everyone learns when folks share, and just knowing there are other parents out there going through similar experiences is reassuring for many people.
      Please keep me updated on how all of you are doing.

  9. Hi Dr Faust,
    My son is almost 5 yrs old and in the last 8 months he has gotten orbitol cellulitis 3 times. The last 2 were one month apart. The first 2 times he had to have iv antibiotics. The 3rd time oral antibiotics coupled with prednisone was enough to do the trick. The first episode was caused by sinus infection. The second episode occured with a cold while we were out of the country so we assumed another sinus infection. The third episode occured a week after he had a cold but the ent checked him and said no sinus infection. He is stumped, saying perhaps its allergy related since his immunoglobulin e was elevated. Another ent was taking the less conservative approach and suggested possible sinus surgery stating how dangerous cellulitis is. I think my son us too young for sinus surgery any thoughts?

    Thank you in advance.

    • Russell A. Faust, PhD, MD says:

      Hi Tatiana,
      Thank you for sharing your son’s story.
      Unfortunately, I have had to perform “sinus surgery” on infants as young as 8 or 9 months old in order to save their eyesight; so yes, 5 years is young, but not too young if absolutely necessary. It is extremely rare for ANY child to experience even a single episode of orbital (or peri-orbital) cellulitis during a lifetime; 3 episodes is alarming. I would seek super-specialist counsel at a Children’s Hospital, preferably one that is associated with a teaching hospital.
      Please contact me by email if you would like references for the Florida area.
      Best success!

    • Hi Tatiana how is your son doing. My kid had episode of cellulitis twice and we are looking for answers too.

      • Russell A. Faust, PhD, MD says:

        Peri-orbital abscess:
        Peri-orbital cellulitis is a risky problem, but becomes an emergency if it develops into a peri-orbital abscess.

        The majority of times I have needed to go to the operating room as an emergency in the middle of the night (except for trauma), has been to save a child’s eyesight due to an expanding peri-orbital abscess.

        Lamina papyracea:
        The bones that surround the ethmoid sinuses are paper-thin, and normally have holes in them. In fact, the Latin name for this bone is “lamina papyracea, meaning “paper thin sheet.” Some children have unusually-thin lamina, with many openings between the ethmoid sinuses and the orbits (eye sockets). That simply increases the risk of a “cold” entering the orbit and extending into the soft skin and tissues around the eye. That infection around the eye – “peri-orbital cellulitis” – isn’t particularly threatening, although in this age of resistant bacteria is becoming more of a worry. But if that infection becomes walled-off and develops an abscess near the eye – “peri-orbital abscess” – that can become a surgical emergency.

  10. Yes my 5 years old daughter just had tube put in last Wednesday and adenoid surgery but now she draining bad in her nose and coughing now bad is that supposed to be normal after surgery like that she coughing now and can’t stop and I don’t know what to do

    • Russell A. Faust, PhD, MD says:

      Hi Kelly,
      Thank you for writing and sharing. I’m sorry that your daughter is going through this.
      In my experience, some children develop an infection – a “cellulitis” or “pharyngitis” following surgery to remove the adenoid tissue. The symptoms that you describe – nasal drainage and cough – are common if that happens.
      Your best course of action is simply to call the on-call physician for the ENT docs that performed her adenoidectomy surgery. They will know best how to handle that.
      And I hope she recovers soon!

  11. Getting ready to take my now 24 year old to our family physician tomorrow. He has had chronic sinusitis forever. I noticed that several years ago ( when he was still in high school) His forehead looked like it was swelled up and it has continued to look that way until this day. I brought it up at the time and it was dismissed as acne or something. It has always bothered me and tomorrow I will be seeking some answers. I just want to make sure that there is not something going on that we don’t see. His right eye sometimes looks droopy to me too. As a small child he had the biggest eyes. Not so now. He did have adenoidectomy (sp) when he was about 8 or 9, it did not help. Wondering about Pott’s Puffy tumor?

    • Russell A. Faust, PhD, MD says:

      Pott’s Puffy tumor is a reasonable thought. There aren’t many things that will make your forehead swell in association with sinusitis. Pott’s puffy tumor is a sign of inflammation of the underlying bone, resulting from infection in the frontal sinus. This is a serious condition, because if that inflammation causing the swelling extends through the bone in the other direction – toward the brain – bad things can result. Please get him to an expert for a thorough evaluation. You have access to some wonderful ENT docs there in the Minneapolis area. Dr. Frank Rimmel at the University is one of the docs who trained me, a great Pediatric Otolaryngologist! Best success,and please keep me updated.

      • Deb Prescott says:

        Well here is the update, our regular doctor really felt around on my son’s forehead and said it is just how it has grown and it is normal. I guess some people’s foreheads grow out in a bulge? So that is that I guess.

        • Russell A. Faust, PhD, MD says:

          That’s a relief, you don’t want to be dealing with Pott’s Puffy Tumor!
          Thanks for the follow up!

  12. My son is 6 months. My pedi reffered my son to a pedi orthodontists where he looked over my son for his tongue tie. He took one look at him and told me he has an infection in his nasal passage and reccomends the surgery so We scheduled surfery on the 28th for both his nose and tongue tie of this month. He didnt do a ct scan. Should I request a ct scan before surgery? Is he too young??

    • Russell A. Faust, PhD, MD says:

      Ren:
      I’m sorry that I can’t comment without examining your son. But I CAN give you this advice: whenever you have questions about a medical recommendation – especially when the recommendation means surgery – you should seek another opinion. And I don’t mean an online opinion, I mean face-to-face with a different physician. Best success.

  13. Hello Doctor, Our daughter was born with bilateral choanal atresia. She had the initial surgery to open both sides and our surgeon inserted a stint in a U shape to keep the openings open and to allow air to flow through her nose. The stint stayed in for 90-days and a second procedure was done as the first enlarging the openings and the insertion of a larger stint. We are being told this stint needs to stay in for another 90-days. My question is two fold. Have you ever heard of this method of multiple surgeries and can we expect a huge difference when the stint comes out and our daughter has full use of her nose? I’m asking because this is contrary to what I’m reading on the internet where the stints only stay in play for about 3 to 4 weeks and not months on end. We live in Spain and this also may be the reason, they may be a bit behind the times here. Thanks

    • Russell A. Faust, PhD, MD says:

      Hi John:

      You will find many variations for this surgical procedure. And whenever there is more than one way to do something it should tell you that none of them works particularly well. Bilateral Choanal Atresia repair is extremely difficult, especially because we (the surgeon) can’t predict the healing. Specifically, some children will heal quickly without re-stenosing the openings; some will create such “good” healing that they scar shut over and over, despite aggressive stenting or even topical treatment with medications to prevent scarring.

      I’m sorry that I don’ have the definitive answer for you. I am distressed simply reading your comment, only because this procedure is one of only two in my career as a pediatric-ent that continued to be frustrating, with less than perfect results – including placement of cochlear implants (“electronic ears”), endoscopic skull-base surgery, endoscopic robotic neck surgery in infants, and laryngotracheal reconstruction (larynx and trache), and traumatic facial reconstruction.

      In my career as a Pediatric-ENT, this area of surgery has continued to evolve, and despite this it continues to be an area of debate, controversy, and frustration. If you are very driven, you can search scholar.google.com for “choanal atresia repair” to see what the latest techniques are.

      Thanks so much for visiting, and for sharing. Please keep me updated on how things go for your little one, and best success!

  14. Estrolete says:

    Hi

    My Daughter had her adenoids and tonsils removed in November last year. She will be turning 4 in July but she has a problem with this sinuses.
    She coughs a lot and it gets worse at night time. I tried everything. Went to the doctor with her but it doesn’t help. She got a lot of mucus coming from her nose and I suspect that’s the reason for her bad cough. What should I do? Is surgery necessary because the hospital didn’t want to remove the sinuses till they were sure that’s also a problem. Should I go back to the ENT specialist or what?

    Estrolete

  15. Hi im from panama sorry my english not good. my son is 5 years 6
    months old. He suffee sinusite about 2 years ago. Adenoid out already on
    june 2016. Nothing help. 6 – 8 episodes sinusite a year. Always thick mucos yellow and green. Only way mucos come out is using sinupulse machine with warm saline water. Always antibiotic. He took alots of medicine. Corticoi spray. Allergy medicine. No improve. Visited 3 ENT in my country. 1 suggest FESS surgey. 2 suggest still with corticoid spray. I think i have to go to miami or singapore for opinion number four. I think my son need sinuplasty ballon.

    • Russell A. Faust, PhD, MD says:

      Rafael:
      I’m sorry for your frustration and your son’s struggles. Unfortunately, I don’t know Pediatric ENT docs that I can recommend – in Miami or Singapore. Best success to you and your son!

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