Meta-Analysis of Outcomes of Pediatric Functional EndoscopicSinus Surgery

Abstract

Hebert RL, Bent JPLaryngoscope.1081998796799Functional endoscopic sinus surgery (FESS) has been accepted as a useful treatment or children with chronic sinusitis refractory to medical therapy. The authors attempted to create a consensus of published outcomes of pediatric FESS, assessing the effectiveness and safety of this surgery in children.Eight articles on pediatric sinus surgery were analyzed, which reported on 832 children (age range, 11 months–18 years) who underwent FESS for computed tomography-proven chronic sinusitis. These articles were published between 1986 and 1996. An additional 50 children underwent FESS at the authors' institution between 1991 and 1996. Patients were followed for an average of 3.7 years. Two of the eight articles reported separately on FESS in children with underlying medical conditions such as cystic fibrosis or immunodeficiency.A retrospective review was performed to determine the outcome of pediatric FESS at the authors' institution using a telephone survey. This series was used as unpublished data in the meta-analysis to control for the tendency towards overrepresentation of positive findings in the published literature.The meta-analysis included articles retrieved from a MEDLINE search that reported new patient data on outcomes in pediatric FESS. Articles were rated by a scoring system that assessed number of patients per study, length of follow-up, prospective versus retrospective design, and exclusion or separation of patients with severe underlying systemic diseases. Eight articles, as well as the unpublished data, met the rating criteria for inclusion. Outcome was categorized simply as “positive” or “not positive” based on questionnaire responses or clinic visit documentation of overall satisfaction and degree of improvement.Positive outcomes of pediatric FESS in the eight publications chosen for the meta-analysis ranged from 77% to 100% with a “pooled” positive outcome in 88.4% of children. The positive outcome for FESS in the unpublished series of children was 92%. The two papers that separately analyzed FESS in children with immunodeficiency or cystic fibrosis reported less favorable outcomes, with 0% and 57% positive outcomes reported. These patients tended to require multiple procedures. The major complications of FESS in children in the pooled analysis were hemorrhage requiring blood transfusion (n= 2) and meningitis (n = 2), yielding a complication rate of 0.6%.Endoscopic sinus surgery is a safe and effective treatment of refractory chronic sinusitis in children, with >88% of children having a positive outcome and <1% of children experiencing a major complication. Children with sinusitis accompanied by chronic illnesses such as cystic fibrosis and immunodeficiency have poorer outcomes with FESS, and often require multiple surgical procedures.The authors used meta-analysis to assess outcomes of children with refractory chronic sinusitis treated with FESS. They report a positive outcome of 88.4% and a major complication rate of 0.6%. In the absence of a large prospective trial, this approach enables the pooling of data from multiple studies. However, one must note that 500 out of 882 patients included in this meta-analysis were derived from a single large series.As medical literature tends to be dominated by positive results, the authors have included an unpublished retrospective series of 50 patients from their own institution to control against “publication bias.” The results of FESS assessed in this unpublished series agree with those of the eight published studies that were analyzed.The meta-analysis in this article has several limitations. Eight of 9 of the patient series included in the analysis used a retrospective design. Objective, standardized measurements of surgical outcomes have not been used. The patient population being treated with FESS may be heterogeneous, as each series varies with regard to patient selection criteria, severity of sinusitis (no staging system has been uniformly used), and presence of underlying systemic disease. The type of surgery performed varies from child to child and from series to series, as most children are treated with middle meatal antrostomy and anterior ethmoidectomy, while other children may have more extensive sinus surgery. Few studies have prospectively compared FESS with prolonged medical therapy. A prospective study of long-term surgical outcomes of pediatric FESS is needed, as well as a better understanding of the natural history of chronic sinusitis in children.