Good afternoon everyone, Thanks so much for joining us. I'm tabatha, one of the physician liaisons and welcome to our first cmu lecture of the year, I'm just gonna go over a few housekeeping rules before we get started um as you all know, you're all muted and we are leaving the chat quiet and if you could please put all of your questions in the Q. And A. And then I will read them to dr Nadarajah at the very end and we'll answer all those questions. Um I'm just gonna go through. So as you know, we have our lecture series. So next actually tomorrow um our cap, our child and adolescent psychiatry portal is doing another webinar, it's at 12 o'clock from 12 to 1 30 they're doing it on um the basics of psychotherapy principle. So if that's something you want to join you can reach out to one of your physician liaisons or if you know how to reach the capt portal you can find the registration on there. And then next week we are doing a talk with dr sun on lumbar and sacral dimples and then we'll round out march with dr uh I'm gonna try to say his name correctly, fredericks Friedrichs Dorf use our pain and palliative medicine physician. Um And these are your liaisons myself, Maria Bremer amy johnson and Lauren Robertson, who is our newest member um If you have any questions, if you have any issues, if you have a problem with anything, please reach out to us. Um If you would like to meet any of our specialists like dr Nadarajah or any of our of our other speakers. We can do virtual meetings. We can and we are doing some in person meeting now to um and you can reach out to us and we can set those up for your practice. And all of your lectures are all going to be on our webinar. Our medic medic connection webinar page so you can find it right there. We are also recording this and this will actually be our first CMI lecture that will be available for credit if you watch it on our med connection page. So please give it at least a week or two and then we'll have it posted. If you have colleagues who missed out on this lecture or you wanted to share it with somebody else who can receive credit for it. They can watch it on our med connection page and we'll be doing that with our cmi lectures. Not are just regular webinar ones but are once a month cmi lectures from here on out. So I'm going to introduce our speaker dr granny Nadarajah, she's a surgeon who cares for Children with ear nose and throat problems. Especially kids with hearing loss, chronic ear infections. I'm gonna try to say this coalesced. Yes thomas, sinus disease airway abnormalities and snoring or sleep apnea. And she's also the medical director and section chief of our pediatric OhMS services at Children's Hospital Oakland and I'm going to stop sharing my screen so she can share hers. Hi everybody. Um Thank you Tabatha. I'm Garni Nadarajah. I am one of the pediatric ear, nose and throat here at Benioff Children's Hospital Oakland and I'm one of 10 pediatric ear nose and throat. Now here in in many off my practice is primarily in Oakland and walnut Creek. Um But we have physicians across the bay area including now Redwood Shore's marin and Brentwood as well. And so I'd like to thank you all for attending Today's session on pediatric rhino sinusitis or nasal congestion in rhino rhea. I heard this was a popular request. So I hope this answers many questions and I'm happy to field questions at the end of this. Um at the end of this talk. So how to manage the stuffy and snotty nose kid. Um I don't have anything to disclose. And nobody involved in planning this presentation has anything to disclose as well. So these are the objectives. Um This I believe was handed to everybody. Um I hope at the end of this talk you can you will be able to discuss the differential for pediatric nasal congestion and Ryan Andrea, understand the difference between between viral upper respiratory infections and bacterial viral sinusitis. Both acute and chronic. Um I hope you can list the co morbid conditions as well as the rare conditions associated with pediatric chronic sinusitis describe the maximal medical management for patients with nasal congestion and Ryan area. And then finally explained the difference in management um with with with regards to age as many of you know, there's a very different way we manage kids with these symptoms who are young versus those who are teenage teenagers. So this is the crux of my presentation. So if you want to fall asleep for the rest of the talk, I'm okay with that. As long as you know, you take this, take this, take home message. This is kind of my thought of how you look at the differential for Children with nasal congestion and rhinitis. I see it as two major categories. I think of the um disease processes that result in mucosal inflammation and um and then the disease processes that are due to an atomic obstruction. And so if you really are concerned about a child having an an atomic obstruction of the nasal cavity. The very simple treatment treatment algorithms, you should want to you want to refer to a pediatric otolaryngologist to help with the management as well as typically surgical treatment. I want to focus a lot of this talk on the second category Nicole's inflammation that results in nasal congestion rhinitis. And the reason I'm going to focus on that is because I think as primary care physicians, this is where, you know, we rely on all of you to help with the management of these kids before they come to come to see and um, otolaryngologist or other pediatric specialists. Um and so my general general rule of thumb is you want to try to treat this as much as you can in the primary care setting. And of course if the symptoms persist despite maximal treatment um then consideration for referral to a specialist would be the right um right process. Um So when you talk about mucosal inflammation um the three most common categories within that is acute upper respiratory infections, viral or bacterial um allergic rhinitis and chronic sinusitis. And I'm also going to highlight adenoid hypertrophy and nasal turbinate hypertrophy, which is technically an an atomic obstruction. But oftentimes adenoid hypertrophy and nasal turbinate hypertrophy is a result of some of the Nicole's inflammation. So I kind of highlight that as something that you may want to consider medically treating before considering a referral for surgical management. So As you all know, the most common cause of nasal congestion is a viral upper respiratory infection. Um and in a school aged kid or a kid going to daycare, it is very normal for a child to have 6-8 upper respiratory infections per year. That is very normal. And these symptoms typically last um these infections typically last 10 days but can last longer. 5-13% will progress to a post viral bacterial sinusitis. And the treatment for acute rhinosinusitis um consisted of the following um um treatment options I think nasal saline is probably the most effective of the treatment options here. Um And when I I kind of want to take a side step and say my favorite is the nasal saline Miss cans. There are different brands Armand Hammer Neil Med or even just the Walgreens brand. But I think this is the one, this is a sailor that's most tolerated my Children. Um decongestants, both systemic and topical are useful. Nasal steroid sprays are useful and antihistamines such as Claritin. Loratadine is useful as well when you're striving to consider that this acute viral infection is becoming more bacterial in nature. So if symptoms are lasting longer than 10 days um then you can consider antibiotics. Um The most the classic is amoxicillin or Augmentin. Um But there are other antibiotics that we consider cephalosporins, clinton missin. Um some infections resistant to penicillin. Um so you may want to consider a macro light or try meta prim culture directed therapy is not indicated for acute bacterial rhinosinusitis. And of course if symptoms are persistent despite medical um antimicrobial therapy after 72 hours, you want to consider changing the antibiotic. These are your classic bugs. Um They're the same bacteria that cause acute otitis media and that's to be expected since the nasal cavity um and the middle ear cavity cavity are connected strep Pneumo Merak, Saleh collaterals, haemophilus influenza are your boards answers. But as symptoms continue staph aureus pseudomonas and Arabs can also be contributing to a sinus infection. Many of you wonder when to image. I will say. Um you don't need to image for acute viral or bacterial sinusitis, you only want to consider imaging or sending to the emergency room if there's a concern for a complication. So if a child presents with headaches, seizures, any type of focal neurologic deficit, peri orbital oedema, any abnormal um extra ocular muscle function that suggests that the sinus infection is extending to the eye. Those are that's the time you want to consider sending them to the emergency room for an urgency T. Scan. So in this example for this child here you have um forehead swelling as well as I swelling and erythema which is suggestive Potts, puffy tumor or acute frontal osteomyelitis with an abscess. So this type of child. Yes this is you know this is not your you know outpatient medical management, this is a surgical emergency. So um what happens after though if you have if the symptoms persist despite medical management you start to get into the sub acute chronic sinusitis categories. So we define a child or an adult having sub acute sinusitis. If the symptoms are lasting 4 to 12 weeks and chronic sinusitis for those kids who have symptoms lasting more than 12 weeks um it's about a 4% prevalence. If you look at the literature which equals equals about 5.6 million visits per year or 2.1% of all ambulatory pediatric visits. Um When you compare this number to otitis media otitis media accounts for about 17 million visits. So one third the amount. Um and these numbers are pre pandemic. So I will tell you from anecdotal experiences that um during these last couple of years, both ear infections as well sinus infections have or rhinitis, just even your common cold have all decreased in prevalence just because kids are now and for a while we're not going to school, They were staying at home and they've been asking. So it'll be interesting to see as you know, the guidelines have changed in the very recent past where we will maybe we'll start to see some of these um sinus infections as well as in your ear infections return um to our outpatient practices. So the american Academy of Otolaryngology defines pediatric chronic sinusitis as 90 continuous days of two or more symptoms peril and refineria, nasal obstruction, facial pressure pain or cough and either endoscopic under cT scan find cT scan changes and I highlight nasal obstruction because that's a very that that is um a very common um symptom in chronic sinusitis And in the 2020 european position paper, they just recently updated it. They also define pediatric chronic sinusitis similarly, but they also emphasize cough and I will say that that is very common presentation for Children and adults. You don't see cough, chronic cough as a sign of um chronic sinusitis um they are more than nasal congestion and drainage but chronic cough, chronic wet cough and a kid. um You should be alerted to the fact that they may be having sinus problems. Um We talk about endoscopic or ct scan findings and the otolaryngology literature that's because as E. N. T. S. When we see them in clinic you do want to have objective findings. Oftentimes this is by us placing a scope in the child's nose. Um Or even just looking with our with by anti R. Endoscopy to see evidence of sinus and sinusitis congestion, refineria. Um Even polyps for example. And we'll talk about the the indication for C. T. Scan in a few a few more slides in a few minutes. So the medical treatment for chronic sinusitis. Um Once again nasal saline is kind of the workhorse. I think it's very effective especially for child tolerates having um some type of nasal spray in their nose and then nasal steroids becomes a bigger part of the treatment of these Children. Um decongestants and antihistamines while I know are being offered to Children um are actually not supported. Um There was a code review that came out that did not support this for chronic sinusitis. It's been shown to help maybe with the symptoms but but does not cut down the length of illness if you're worried if you're starting to um You want to start thinking about antimicrobials. You want to go to a 21 day course so a little bit longer day course and then oral steroids or something that can be considered as well especially you know as an E. M. T. When I see these kids I'm starting to think about a short course of predniSONE for these Children. You also want to treat co morbid conditions such as asthma allergies and reflex. And we'll talk about that shortly too. Um So you know felonies I think is probably the most common medication that's prescribed to these Children. Um And now it's over the counter the adult size dozing the 50 mics per spray. Um Of course it's generic. Ii still prescribe it because it seems like insurance still pays for it or prescribes it's too are provided to our Children though. You know you can also direct recommended over the counter spray um nasal next to another one that seems to not be as covered by insurance. From my based on my experience for the Flonase. And these nasal steroid sprays are technically FDA approved for above age too. So underage to it gets a little bit harder to offer these medications that I will I immediately do offer them to my you know my 20 month old or even a little bit younger. I do tell them that this is technically um not the FDA approved. Sometimes I suggest the half dose the vera mist or the senselessness the half dose for those younger kids. Um And I find that to be um you know I'm not having noticing any particular difference in these kids in terms of side effects to worry about you know the FDA um age restriction. Um But when you're trying to think about treating a child for chronic sinusitis, we want to start thinking about other causes for this. And so pediatric sinuses are not the same as adults. When you think of sinusitis. In adults you know are teenagers. For example you're thinking about the actual sinuses. But in Children um the sinuses are not fully developed. Um The maximum death my sinuses are present at birth but the maximum scientist does not become you know pretty relevant till you know later on in life. It doesn't become adults adult size reached um until about age nine even the eth Boyd sinuses while present at birth, they don't start to, you don't even see them on imaging until about age two. The frontal sinuses and the solenoid sinuses appear later on in life. Um The frontal sinus starts around age seven and fully developed by age 12 to 14. The solenoid sinus develops around starts to develop around age three but doesn't fully develop until about age 9 to 12. In addition, you know Children have adenoids and adenoids are lymphoid tissue that sits in the back of the nose just like um just like your um tonsils in the back of the throat and these adenoids can cause physical obstruction of the nasal sinus mucus. Hillary clearance. In addition they can be a reservoir for bacteria in the form of biofilm. So in Children we start to think about these kids who are having chronic nasal congestion. You want to start thinking about referring to an otolaryngologist about consideration that these Children may need. The adenoids addressed. And there's a lot of studies that you know that associate adenoid um inflammation and adenoid hypertrophy to chronic nasal congestion and that there are when you culture the adenoids, we take those adenoids out and you culture it You have and then you culture the middle mediating or the entrance to the Maxillary Sinus. There is about a 90% positive predictive value that whatever is growing in the adenoids is what's growing in the nose. So there's a meta analysis that came out now, you know more than 10 years ago, but I haven't seen one more recent updated version that looked at 10 studies that treated um chronic sinusitis in Children with an annual Idec to me and about 70% of those Children had improvement in their symptoms. And so there was in the 2014 american academy with otolaryngology consensus statement, Adenoid ectomy is considered the effective first line surgical procedure for young Children. And it's strongly recommended in Children under age six who are representing with nasal congestion and rhinitis for more than 12 weeks And suggest and and somewhat suggested in the kids under age 12 and and the reason why there's kind of an age difference there is that as we talked about earlier, the scientists start to become more relevant as the child gets older and the animals become less relevant. So um when you have these kids you want to send them to, you know an otolaryngologist for consideration and Idec to me. Um but then of like based on that meta analysis, 76 70% will get better. 30% will progress. And so why do we care about that? 30%. Well, we do know that these Children are being affected in their quality of life. They're missing school, they have daytime symptoms such as concentration issues, They have poor sleep quality, some even will complain of just overall fatigue and my and body pain. So there is a um we do want to Take note of these 30, um that do not resolve their symptoms with an android ectomy because they do have they have they have consequences quality of life consequences. So what next? Well, you know in this hole treatment algorithm, you want to treat the co morbid conditions from the very beginning. But you really if you're starting to really think about other like more aggressive sort of treatments, you really want to look at the co morbid conditions. So what are those co morbid conditions? Well, this is one of my favorite slides I took from a paper that came out of the allergy immunology group at Harvard and this is kind of the general pathogenesis for pediatric sinusitis, you have a few things that are kind of affecting this pediatric knows you have the acute viral or bacterial infection. There could be an atomic issues or mucus o'leary defects in a child and then the child in general has an immature immature immune system. All of this will result in osteo obstruction and local hypoxia and mucus biliary stasis and that will result in acute implement acute inflammatory state a demon exiting. If this process continues for long enough you get prolonged repeated osteo obstruction. You get you get the persistent or chronic sinusitis symptoms and then the check the and the antimicrobial. Sorry, the microbial spectrum changes to more anaerobic and you start to get the biofilm and now you also have to consider the adenoids and these younger kids that act as a repository of infections through biofilms. So you can treat them with antibiotics. But if there is a biofilm formed in the nasal, in the um adenoid in the nasal pharynx, no matter what you do, it's gonna continue to process the symptoms are going to process in this pathogen in this process. We do know that allergy or allergic rhinitis is contributing. Now it's difficult to show causation and the reason why you can't show a causation that allergies contribute that causes um sinusitis is that the prevalence of allergic rhinitis and Children and adults is pretty high. So it's very hard to show causation but we do suspect that there is an overlap that there is a correlation that and the suggested path the physiology of allergic rhinitis is that it's blocking the nasal sinus mucus clearance by causing baseline inflammation. So it's contributing to that chronic inflammation that that the bacterial or viral infections are kind of exacerbated. Um the prevalence of a toupee in the pediatric population who have chronic sinusitis is about 27-29%. And there are other sites and even bring it up to about 50%. That's why it's really hard for us to really say if you have allergic rhinitis you have a higher risk of having chronic sinusitis. But we do see that correlating so when you have a child is presenting with chronic nasal congestion you do want to really kind of probe the parents about whether they're having under baseline allergic rhinitis. Is there a family history of allergic rhinitis And you want to consider allergy testing that could be in the form of sending them to an allergist for skin testing versus you know doing um ordering rast testing um to look for a elevated I. G. E. Or elevate I. G. Two particular allergies that are in the community. Um And you want to consider treating those Children and so that treatment can be the Flonase the nasal steroid spray but can also include um the anti histamines both topical as well as um the systemic anti histamines um also um Antilock retreat Luca tryin receptor antagonists. Those can also be like Montel Luca is going to be considered at this time as well. Now if the chronic sinusitis persists for long enough you start to get into what we call a neutral pelvic inflammation to what's called an eosinophilic inflammation. If you start biopsy in Children who have chronic symptoms sinus symptoms for a really long time, you start to see tissue hemophilia and if you look at them they start to have pollen point changes of the nasal nasal mucosa. And so we do see an association of this really in this this late stage chronic disease um with th two inflammation or asthma. So if you're starting to see a child with reactive airway disease, you really want to treat that asthma. And that's where you know me as the pediatric E. And T. I'm not gonna be the one treating them. But we rely on you all to really maximize their um their um asthma treatment and they may need to see a pulmonologist for further for further evaluation and management. So um in addition to both to allergic rhinitis and asthma, we talked about reflux or gastroesophageal reflux disease is contributing to um sinusitis. Now this is a hard, almost it's even harder than allergic rhinitis to um to correlate because um it's unclear whether if it's truly to process is happening at the same time or does reflux make the Sunnyside. It's worse. Trying to prove that the theory behind it is that there's a direct inflammation by the gastric juices coming up into the nasal cavity, nasal flaring so classically see these babies, you know, of infants with nasal nasal congestion of uh in infancy. Um We blame the reflex on that. But even in older kids you can you can imagine that being a cause. Another theory is that there's neurogenesis mediated secretary reactions occurring as well. So my recommendation is you do not empirically treat these Children with anti reflux medicines such as your Pepcid or your P. P. I. But you can screen these Children and if they if a child does endure symptoms of heartburn, you may want to consider treating the heartburn because maybe that might also help the congestion as well. And then finally secondhand cigarette smoking, this is we do know that secondhand cigarette smoking causes chronic Nicole's inflammation of the nose and the ears. That's why we see Children who are exposed to cigarette cigarette smoke can have have a higher risk of ear infections, reactive airway disease, as well as also sinus issues nasal congestion too. So you treated the cold morbid conditions, you're still persistent. You treated them maximally with antibiotics, you take another add noise. You're still symptomatic. This is the time when imaging actually becomes relevant. Until then. I don't think it's really um I don't there's no indication for any imaging, we've the sinus x rays have fallen out of favor. Um And so when you're really considering imaging, you want to get a CT scan. And so in 2012, um the american Academy of Otolaryngology came out with a clinical consensus statement, which has not been changed since. And yes, the ao loves clinical consensus statements um on that. They did a statement on the appropriate use of CT scan for para nasal sinus disease. And they state that imaging is indicated for those Children with chronic sinusitis who have when medical management and or an appendectomy have failed. And it does also emphasize that it is not indicated in Children under age three. And that is because the sinus anatomy has not been developed. So we do not get science. We don't even consider cT scans and the really young population unless there's a sinus emergency. I would recommend that the CT scans we've done at a Children's hospital. And the reason is that we do know that radiation and Children has a increases the risk of hematology malignancies and brain malignancies. And so um while we were at a Children's hospital such as a penny off, for example, the radiologists are really cognizant of this and they are the goal is to offer the lowest dose radiation scan with the best imaging um to evaluate the sinuses. So, um but we do we do obtain them when the symptoms are persistent, but we are very careful to have that conversation with families as well as emphasizing the recommendation to have it in a Children's hospital for this reason. So you scans can, there can be various results of the scans. You can have a ct scan like here on the top left where basically the sinuses are completely clear. They probably don't have chronic sinusitis though the symptoms are present. Uh and then we go down a different path of how to manage these kids. You get a ct scan like this one in the center where you have sinus nasal mucosa inflammation. Or you can get a cT scan. Look here on the bottom right where you have complete pacification of the sinuses and all of these are pediatric patients. And so you get a full variety. But the scan does become helpful in how we manage these kids. When you do find symptoms, find when you do find objective findings of sinus nasal sinus inflammation. This is where we all as E N. T. S. We take a stop and think about these kids because scientist disease and Children is very rare. We don't you know, in the in the adult world that you know, there's many adults are getting sinus surgery. But in the pediatric world it's actually a rare procedure to do. So when we start to see a child with chronic sinus symptoms and actually objective findings, we want to think about rare conditions and so the classic board answers or the rare conditions that are associated with pediatric sinusitis is cystic fibrosis. Primary biliary dyskinesia immuno deficiencies and I also add the anca associated vasculitis is such as Wagner's, which is now I believe called, which I know is called granulomas, granuloma ketosis with polly and itis, but in my head is still Wagner's. Um and so when I see a child like this, I'm starting to ask some of my other medical colleagues, specifically my pulmonologist, my immunity immunologist um to start to get involved a little bit, especially if I'm starting to consider surgery to treat their symptoms. So cystic fibrosis, as you all know, use is also associated with chronic lung infections, pancreatic insufficiency. So my headlights go up a little bit if I hear the child's having some lower airway issues as well. Uh if identified, um these are management's by the pulmonologist and when I find very interesting in the last, you know, decade or so the CFTR modulators have really changed this disease to be less surgical and more medical and it's it's pretty impressive how what has changed what has happened in the last um few years with regards to manage the treatment of cystic fibrosis. Um Primary salary dyskinesia is a very rare disease that has to do with it's a syndrome and there's multiple genes and gene mutations that are associated with this syndrome, which results in cilia Reedus motility. Um once again these kids have other um issues and other parts of their bodies such as their ears. They can classically pretty present with chronic otitis media, they can have lower airway disease. Um They can have cited advertise or any because of the way uh fetus develops. It requires cilia motility for that so you can have um other findings. Um but there are some subtleties where they may present as chronic sinusitis. So I'm always once again thinking about this and I always have my pulmonary colleagues um get involved if I'm if I'm concerned oftentimes diagnosis is made genetically but can be also made by a salary biopsy of the nasal cavity or even the trachea treatment is um medical as well. There's no real consensus on how to treat it. But most pulmonologist would treat this similarly to the cystic fibrosis population, um immuno deficiencies have been identified in these in this population. Um My typical um what I typically order R. I. G. G. And sub classes I. G. A. And then pre and post vaccination titles to tetanus and pneumococcal um policy aka ride. And usually if I'm concerned about this, you know, they usually have other you know, recurrent infections And so I have an immunologist to get involved as well to help me with the management of these Children. Now once you have, you know, I don't know if you've done your due diligence and I looked for these rarer conditions and treated them accordingly and their kids are still symptomatic this is when functional endoscopic sinus surgery becomes the next step. And in these kids who have function who have these rare conditions. It's kind of a combination of the medical treatment as well as the surgical management. There's a lot of data um that has shown the efficacy of functionality, topic sinister. During the pediatric population. There are a couple of meta analysis that came out 10 years ago that showed the success rate ranging between 70 to 100% reduction in symptoms and improve quality of life. The complication rate is very low. Um This is with the use of cT navigation. So we use that CT scan. We obtained a while back um during surgery to help us navigate through the sinuses and this is um this is standard of care and this is because the sinuses and Children are smaller and a little bit more difficult to navigate. Um classically. Um These the sinus surgery just consists of opening up the maxillary sinus or the unemployed sinuses. And the younger population sometimes in the older kids. The teenage population, we start thinking about the funnels and city noise as well. Um There are many studies that show no long term effect on facial growth and so I counsel these kids historically. People used to not want to do sinus surgery in Children because we thought that maybe um there will be changes in the way the mid face grows and that's stemming from a lot of the cranial facial literature. Um But there's a lot of good um evaluation of this. Looking at um postoperative facial growth that shows us no change in these Children's um facial growth with after sinus surgery. And in fact you may argue that if you don't take care of these kids, these kids that are chronically mouth breathing, breathing, not able to breathe through their nose, there can be some um long term effects um that quoting what adenoid faces you see can be a effect of chronic nasal congestion is not being treated. Um So very recently there is a new technique that some of us have used called balloon sinew class D. And the thought that um the theory behind this is that you're dilating the natural sinus osmium causing less bony destruction is argued to be less less traumatic. So clasp your typical function. Endoscopic sinus surgery is removing diseased tissue removing bone removing diseased mucosa versus the balloon. It's like it's almost like you know an angioplasty for the sinuses. Um It's used in to two separate ways. Um Sometimes we add this procedure to our first line treatment of an appendectomy, especially in the older kid because we know the older kids have sinuses that may need to be addressed. Um And sometimes we use this as a second as a second stage surgery for these kids who have mild disease. So not the kids who have a ct scan that have completed pacification but with the mild the mild mucosal inflammation, you may want to consider, we sometimes consider this as a treatment option for those Children. And I showed these images here because many years ago before balloon angioplasty, there was something called the maxillary central lavage where um E. N. T. S. Would actually just puncture the maxillary sinus from underneath from underneath the lip to wash out the sinuses. Um And so this is kind of now the more is a similar, it's a similar concept except you're going through the natural Osti um in the in the nasal cavity. Um The data for this surgery is still very limited in the pediatric population. We do know that this is a low risk procedure um with possible equivalent outcomes. Um The risk of of this balloon sina plasticity is probably equivalent to the same risk. We talked about the regular functional functional sinus surgery, the risk of CSF leak DeFelice orbital complications, bleeding. So I for the for this population I think it's a very reasonable procedure and a lot of and I've personally I have had some positive outcomes with with this procedure. So this is the general treatment algorithm um I do want to touch basically starts with medical management goes down to surgical management. What you know, treatment treating co morbid conditions or rare conditions. I do want to touch base on a little bit of the of the persistent eosinophilic chronic sinusitis. Because a lot of these kids were presented with polyp Asus um where the polyp oid changes. And you know historically this is a surgical disease at that point where you have to really clean out the sinuses. But very very recently was trying to see um that there are some medications that can be used to treat this. This this particular very small population of kids. It's all coming from the adult world and how they manage these kids. So there's no data in Children. But in this population the Luca trying antagonists are quite useful there. Now biologics um such as diplomats that have been used um for the chronic sinusitis or polyp assists, I believe it's also used for the reactive airway disease to um sometimes I start offering topical antibiotics in uh in the ceiling irrigation that we we we recommend for these kids as well as topical steroid and irrigation. So there are some medical um medications that can be used for this small population of kids. So back to my original slide, if you can, this is a take home slide. I think that ultimately if you as as the primary and the primary care world, if you can take care of the mucosa inflammation, which I have a first pass on that, that's very helpful to all of us. But you know of course if there is concerns about persistent symptoms as well as concerns for an atomic obstructions um such as septal deviations, congenital issues like anal atresia nasal masses or tumors or even a foreign body. You really want to send them to the otolaryngologist for further management? This is our team, we are a team of 10 pediatric E. N. T. S across both sides. Um We're going to have 11th starting in october. So we're just expanding trying to accommodate our pediatric population here in the Bay Area. Um we're all accessible by email and phone and pager and so please feel free to reach out. Um and this is how um you can refer your Children to see us. We have a we have an access center that has been really helpful to get these kids in as soon as possible. And of course, you know, I think many of you even have my cell phone number, my patriots to be able to contact me to help help get these kids in sooner. So I think I left enough time for questions. Did I do? Okay. Tabatha. Yes, thank you. So um if any of you have questions, please go ahead and start putting them in the Q. And A. We already have a few that we can start answering while people start putting them in. Okay, so I'll start with the first question at what age do you think allergies contribute to chronic sinusitis? I know a lot of allergists don't believe kids have environmental allergies under three years old. I agree with the allergist. So when I am seeing a child who comes to see me who's under three and he's on Zyrtec and Flonase in my mind? I'm thinking are we treating the adenoids, are we treating maybe some mild inflammation from a recent upper respiratory infection? I'm not thinking about allergy at that point. And I do talk to these families like if they are to make sure they understand that they're not we're not I'm not considering allergies at this at this in this age population. And so in my in my head I'm thinking more of the adenoids being being being the primary issue for that population. So I do agree with that with the allergist and this one and I counsel them the same similarity. Alright. Um I also wanted to do a quick reminder for everybody that there will be a evaluation that will pop up at the end of the lecture. So please don't forget to fill that out so we can send you your your credit. Sorry, I forgot to mention that earlier. Okay perfect. So the next question dr Nadarajah is what about the much advertised new voyage? Is that how you say it? So like it's funny. I don't have cable television so I don't see the commercials but I heard it's pretty popular. Um But I have a few kids who love the Savage. I don't so this is my my thought about sailing all these nasal sprays. Is that especially the younger age group you're already talking to a parent who's gonna probably struggle trying to get those nasal sprays into a kid, you know? And so I'm not even completely convinced when when a kid comes to see me after, I've given them a prescription for nasal steroid sprays or nasal saline, that they actually are doing it either correctly or consistently. So um that's why I like this daily, missed personally. I think that's the most, I think I think has the highest likelihood that a child's going to tolerate it with that said the Savage, I have a few kids who love it. Um So one of them who has Down syndrome and I feel like, you know, some of those kids with really bad chronic sinus type symptoms, especially when there are underlying systemic issues. So, like a kid with Down syndrome has probably some mild immunodeficiency going on. So I think it's great. I think it's it's okay to encourage salient in any manner to me is the best thing. I think there are even studies that show that it reduces the severity of an upper upper respiratory viral infection even for covid, for example. So I think that, like saline saline saline, if I could recommend everybody, even adults, saline is great, of course appropriately may not not your table salt, but um but yes, thank you. Okay, next question is from dr heath. She's asking does perhaps it helped newborn chronic congestion. When do they, when they otherwise do not have um suspicion of GERD, so, you know, the pendulum swing is swinging the other way away from Pepsi and PPS for the newborn. Um So when I see a kid who comes a newborn with chronic congestion, who I'm considering reflux. I start to think of um simple reflux precautions. We talked about spacing out the feeds, keeping the child upright. I don't typically um refer, I don't typically prescribe Pepcid or even a P. P. I. For the new board. Um If you talk to our G. I. Colleagues a lot of them will talk about oral forensic dysplasia being a bigger contributor to this population. So I actually have now kind of veered more towards switching about about thickening the feeds. So we talked about gi colleagues um one teaspoon of rice cereal and the slightly older kid. The four month old onwards in the formula or in the breast milk, one teaspoon per ounce would be my next step before I even consider um P. P. I. Or anti or anti histamine H. two blocker. I'm sorry. So but that's a good question for the G. I. Folks. But you know of course since we see a lot of these kids together, that's kind of my usual rule. Now I don't think I prescribed for um any of my living in Malaysia kids. I think that I it has it takes it takes a lot for me to write a prescription for a pee pee in the newborn. Okay thank you. Okay the next question is please comment on gustatory refineria. I read recently that there is an accessory salvatore salivary gland in the rhino sinus area to cause this also common problem of. Right, So this is a yeah, this is like a diagnosis of exclusion in my head, you know, so you got a really bad news that to be out, you gotta treat the allergies, you got to treat everything and then there's still have had to have a negative allergy testing and even that you can have the caveat. Well are you really testing for every single allergy that's out there in northern California? Um And so it's kind of like my last, my last resort. Um I believe cromelin inhalers have been used for Visa. Motor rhinitis. I rarely prescribed it. There's a few kids I have that I have given it to when we failed everything. Um I think I have heard about the salivary gland and the sinus sinus in the in the sinus cavities. Honestly there's celebrate there's land everywhere right? So hundreds of glands in your mouth. So I'm not surprised there's something there. Um But yeah, I think my next thing will be Cromelin for the lap for the last resort. Perfect. Thank you. Okay we have one more question and it is, do you recommend nasal spray or saline rinse irrigation for older Children. So I'm still saline mist for everybody. Honestly the saline rinses while I think it's great if a child can tolerate it. I usually hold that recommendation personally for those kids who had sinus surgery because I think then you really need to get that saline need that forced to get the sailing into these um surgically treated um sinus cavities. But you know, if a child so saline mist for all kids because I think that's the most likely the highest likelihood you're gonna have somebody has to be compliant with it in my mind. And saline rinse sure. They tolerate it, sure. But they don't I'm not surprised because it is quite, you know, a lot of adults don't even like it. So I think it's even in the younger kids and I'm not I'm not saying I don't think even saline rinses something you only keep for the older kids population if you're gonna consider it. I've heard of four year olds tolerating saline rinses too. So but my general thumbs tried to saline mists can first and do I recommend Afrin story. So I'm gonna jump over because I can see that thing um Afrin spray for I'm guessing you're asking about um for an acute viral infection or an acute bacterial infection. Is that true? If I'm if that's the case sure for three days maximum. Um and but I generally speaking I try not to recommend it because in my experience the parents don't listen to the three day maximum rule and they end up using it for a lot longer than I like. And so um and then you get the risk of rhinitis medicamentos that we have the nasal congestion due to chronic afra news. So I'm not a big difference. I don't I'm not a big fan, I don't recommend it, you know, um all the time only they really need it because of this. The side effect that I see often when I recommend it myself, saline mist is um sailing is the same as saline spray. So sailing. Yes, yes and no. So saline comes in so many different varieties. I think you can get the saline drops, like the ocean spray, which is basically a little tiny bottle where he's kind of squeeze it and that's still like saline drops, the ceiling misses the one that comes in an aerosolized can, like it's like a, like a hairspray can, so that kind of mist in the nose. So I think it's not, I joked that when you start spraying sailing into kids knows you're kind of waterboarding them, you know, you're forcing them down and spraying salt. You know, a lot of saline drops or saline irrigation, it's not, you know, kids don't like it. So the miss can I find it much more tolerable because almost like, you know, it's just like a little mist in there and the main purpose of sailing, this is your washing out the mucus, you're washing out the allergens, You decongestants. I don't think you need a lot of saline um long time. I really do want that. Sailing, you know, in the irrigation is in my personal opinion is when um you have done surgery and you're really trying to keep those nasal passages. This is the sign that the surgically opened austin sinus, austrians um open thank you. And the home saline rinses. I love to get, It consists of table salt, a non I donated table salt water and sodium bicarb. I am happy to give tab it the the actual recipe cause I don't know what else to talk in my head. It's my dot phrase and apex, but I can get that to you if you want that. But the key about making homemade saline is that the water has to be sterile. Um you cannot use tap water. And so once again that I don't offer to families or talk about with families because I'm always never I'm never 100% convinced people, you know, willing to go by or or or boil their water for homemade sailing. But I can give you the recipe perfect. And I can distribute that to everybody who requests it. And any more questions before we wrap up, give it another couple seconds. I just want to say thank you again to dr Nadarajah for taking the time to meet with us and share and once again please do not forget to fill out your form. There's quite another question. Okay, do you want to read it? Yeah. Okay. So the question is, do you think orthodontic intervention? Like palate expanders help kids with chronic rhinitis? I can give a whole talk about palate expanders and orthodontic. That's a very loaded question. So palate expanders the only indication is for for orthodontic work if you're, so if you really if you if you look at even the orthodontic literature or or their society they will say you only do pilot expanders if you're trying to widen the palette so you can get braces put in and you want to straighten the t. We do know that the palette is the floor of the nose. So we do know that if you use a child gets a palate expander for their orthodontic work we will see a widening of the nasal cavity and probably improve nasal nasal um nasal improve ability to breathe through the nose. So less nasal congestion namely increased uh decreased sleep, disordered breathing, decreased snoring. Um Well I treated for rhinitis maybe. I mean so I will never I will never tell a family go to your orthodontist to get a palate expander for your nasal condition. I'd rather treat them treat the turbine is take out their adenoids. Um But I would not recommend that um The reason being is the data is very all the work that's been looking at snoring and nasal congestion as the outcome of pallet expander is all coming from one institution? So it's not been fully reviewed and corroborated by other institutions and so that's why I don't I don't recommend it for that. Um After doing the allergy tests for pollen and trees, what specific instructions would give would you give to kids mask or glasses? I would like them to stay active. Glasses. Tell me more. I'm not sure what glasses mean. Um um So if they're and they're positive to pollen entries, I would say they need to be on saline sprays twice a day. They need to be on Flonase during the allergy season. So pollen, springtime, summertime. Um And then you know if they're if they and then the anti histamines, if you needed to ask Dylan, I would try to kind of get them maximally treated. Do they need singular or not? And then if they're really symptomatic and then you want them to stay active because they want to go play baseball or whatnot, then you've got to start sending them to an allergist to consider um immunotherapy sublingual or um you know, um shocks allergy shots. Um But that would be my my general management of those kids, but like I said, I'm not an allergist, you know, I sometimes feel like I'm an allergist at times because I know that that is one of the especially that's missing in our community here, but that would be the way I manage those kids. Um And then try to find an allergist who can help me. Yeah, my cell phone, I'll give it a tablet that, but if you are if you have a pen and paper it is 5104326005. And if you want to text me that's fine. I'm totally happy to if I don't respond it's because I'm either in the O. R. Or I'm sleeping or you know but like I am I will respond. So if it's an emergency though please call our you know call our nursing line because they will find the hospitalist on call as well as after hours. If you call the operator they will find the E. N. T. Who's on call. But for non urgent stuff that you want me to kind of help help I'm happy to answer by text or call you back. Yes. And we'll make sure that um if you're attending you'll get her phone number for my email email. Yes we'll have a contact her contact information to you. Okay? So there's no more questions. I'm just gonna say give you guys a couple of minutes back of your time and say thank you again. Don't forget to fill out your evaluation. Have a great day everybody. Thanks dr Nadarajah. No problem mm hmm.