September 2019 HSC Section 1 Congenital and Pediatric Problems

Am J Otolaryngol 39 (2018) 418–422

L.K. House et al.

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failure of medical management [ 10 , 15 , 16 ]. Initial treatment with an- tibiotics, nasal steroids, saline rinses, antire fl ux or other adjuvant medications is recommended, as well as consideration of allergy eva- luation. The use of intravenous (IV) antibiotics has also been advocated, with high rates of success, in the order of 90% success in resolution of symptoms [ 5 , 19 ]. However, this requires the placement of a peripheral inserted central catheter (PICC), the expense of home health and IV antibiotics, absence from school, as well as a caregiver in the home for anywhere from 2 to 9 weeks. While “ maximal medical management ” has no true de fi nition in regards to pediatric CRS, it is generally held that one must fail more conservative treatment measures before proceeding with surgical in- tervention. Adenoidectomy has long been the mainstay of surgical treatment. Most sources quote adenoidectomy alone to be approxi- mately 50% e ff ective in long term resolution of CRS symptoms, al- though a recent meta-analysis suggests it may be as high as 69% [ 11 ]. The procedure is relatively straightforward and safe, and it does not require preoperative CT imaging. The literature does suggest that upfront BCD has superior

e ff ectiveness than adenoidectomy alone without signi fi cantly in- creasing operative risk [ 10 ]. This study, though, suggests that this is not the most cost-e ff ective method for treating pediatric sinusitis and could possibly cause a signi fi cant increase in health-care costs overall. However, taking this step-wise approach involves proceeding with a surgery — adenoidectomy alone — that will not resolve symptoms in nearly half of pediatric patients with CRS. The outcomes for FESS and BCD in children are superior to adenoidectomy, ranging from 80 to 100 [ 1 , 9 , 18 , 20 ]. FESS is more complicated and lengthy, more expensive, and most authors ascertain that preoperative CT imaging is necessary. While generally considered safe, major complications do rarely occur. BCD, though, is felt to be less risky in the short-term, as well as less likely to interfere with the growth of the midface. It is di ffi cult to make decisions based upon cost, especially when a relatively safe and simple option such as BCD exists. Perhaps in the future, cost-e ff ectiveness data will be integrated into the clinic en- vironment. Clinicians can give patients several options and include cost as part of the discussion. This study only addresses cost to the health- care system and not to the patient, but this research could be done as

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