September 2019 HSC Section 1 Congenital and Pediatric Problems

Annals of Otology, Rhinology & Laryngology 126(9)

(47/115) 1 monthly, 16% (18/115) 2 monthly, and 2% (2/115) 3 or more monthly. For initial surgical management of PCRS, 94% (108/115) include adenoidectomy. Adenoidectomy alone is performed by 70% (80/115), with sinus lavage and culture (18%, 21/115), balloon catheter dilation (BCD) (9%, 10/115), and ESS (8%, 9/115) being the most common concomitant pro- cedures. If initial surgical treatment fails, most respondents (88%, 95/108) perform ESS, while some perform sinus lavage (17%, 18/108) and BCD (13%, 14/108), and very few perform adenoidectomy (2%, 2/108). When performing ESS, the extent of surgery is determined based on the extent of disease. In a hypothetical case of performing ESS for mild maxillary and ethmoid disease, 99% (110/111) treat the maxillary sinus, 96% (107/111) the anterior ethmoid, 19% (21/111) the posterior ethmoid, 3% (3/111) the frontal, and 2% (2/111) the sphenoid. In a theoretical case of per- forming ESS for pansinusitis, 100% (111/111) treat the maxillary and anterior ethmoid, 89% (99/111) the posterior ethmoid, 63% (70/111) the sphenoid, and 43% (48/111) the frontal. Overall, BCD is not commonly utilized; 71% (81/114) rarely/never utilize BCD, 23% (27/114) sometimes do, 4% (5/114) usually do, and 1% (1/114) always/almost always do. Second-look procedures in the operating room are not common. Seventy-three percent (81/111) never/rarely employ a second look, 21% (23/111) sometimes do, 4% (5/111) usually do, and 2% (2/111) always/almost always do. Most respondents (60%, 68/113) do not avoid ESS when it is indicated. Twenty-five percent (28/113) avoid ESS due to high failure rates, 10% (11/113) for high revision rates, 4% (5/113) for facial growth concerns, 4% (5/113) for con- cerns of complications, and 3% (3/113) because it is techni- cally challenging. Comparison of ASPO and ARS Practice Patterns Results of this ASPO survey were compared to data from a survey of ARS 5 (salient differences are summarized in Table 2, full results are available in Supplementary Table in the online version of the journal). The geographic distribu- tion of respondents from ASPO and ARS surveys 5 did not differ ( P = .79). Medical therapy was similar between groups, although ARS members were more likely to use oral steroids. When medical therapy failed, adenoidectomy was the most common initial surgical treatment in both groups. ASPO members were more likely to perform adenoidectomy alone ( P = .001), while ARS members more commonly included concomitant procedures with adenoidectomy. If initial sur- gical treatment failed, both groups commonly performed ESS with similar frequency ( P = .557). When performing

ESS for both minimal disease and pansinusitis, both groups treated a similar distribution of sinuses, with the exception of ARS members being slightly less likely to treat the ante- rior ethmoid sinus in a case of mild inflammatory disease (88% vs 97%, P = .034). When queried about reasons for potentially avoiding ESS, both groups confirmed that they perform ESS when indicated ( P = .386). Timing of CT imaging differed between the 2 groups. ASPO members were more likely to perform adenoidec- tomy prior to CT scan ( P < .001). Overall, ASPO members were more likely to indicate that their use of CT imaging has declined over the past decade, whereas ARS members were more likely to report unchanged utilization ( P < .001). Discussion Pediatric chronic rhinosinusitis is a common disease that is managed by both rhinologists and pediatric otolaryngolo- gists. This study evaluated the current practice patterns by ASPO members and compared these management strate- gies to those of ARS members. Other diseases that are managed by different groups have shown differences in practice patterns, such as the use of intraoperative nerve monitoring between otolaryngolo- gists and general surgeons in thyroid and parathyroid sur- gery, 6 and this study sought to assess if differences exist between ARS and ASPO members in the management of PCRS. Data from this study demonstrate that the practice pat- terns of ASPO are largely aligned with published consensus statements on PCRS management (Table 3, modified from previously published work 5 ). 3,4 There are, however, notable differences in management of PCRS between ARS mem- bers and ASPO members. ARS members more commonly employ oral steroids for both initial and maximal surgical management. This may be due to the fact that oral steroids are commonly utilized for treating adult CRS 4 and ARS members more commonly see patients with this disease or concern over side effects of steroids in a pediatric population. Adenoidectomy has long been recommended as first- line surgical treatment for refractory PCRS disease. 3,4,7,8 Both groups follow this recommendation. The data from this study show that ARS members are more likely to include other procedures with adenoidectomy for initial surgical management. This may represent a difference in opinion in balancing the risks and benefits of a single gen- eral anesthetic, perceived improvements from surgical treatments, and the potential for complications between the 2 groups. ARS members are more likely to obtain CT imaging prior to performing adenoidectomy compared with ASPO

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