Pediatric otolaryngologist David Conrad, MD, FAAP, provides keys to diagnosing various types of sinusitis and breaks down the serious complications that may develop in children and especially teens. Learn the signs of abscesses that can impact the eye or brain, first-line treatments, and when to consider surgery.
Thank you for having me. Thanks for your time this afternoon. I'm a pediatric oncologist at UCSF. Uh Senator mostly at Children's Hospital of Oakland and uh have some coverage at Mission Bay and will also be going to record shorts. So I'm going to speak about complications of pediatric sinusitis. Um I think it's very relevant topic, especially for teenagers and adolescents, but also for our younger Children. And I'll speak generally about pediatric sinusitis and what we do about it. And some medical therapies as well, but then also about the complications, which again is in generally older Children. And should we get a topic, hopefully something for everyone. So well, we'll be speaking about the development of the sinuses that's kind of relevant for how sinus disease affects Children by age. And then a review just of the anatomy of the nasal cavities and um differentiate acute acute from chronic sinusitis. And also recurrent acute sinusitis, discussed medical management such as antibiotics, but also nasal irrigation. And so it's a histamines and there's a story, it's usually aren't very helpful. Um, and then we'll talk about our surgical options for recurrent sinusitis. And then I'm through an episode axis as a topic to discuss just because it's so common, it's irrelevant just for the nasal cavity. And so when it's appropriate of of issues of the nasal cavity to discuss. And then uh we'll also, you know, we'll focus most on complications of sinusitis. But I think covering all these, all these things is helpful and then just some conclusions and clinical girls about uh managing this. This issue. I think you should see maybe several cases of bad sinus infections over over the year, maybe. Um, maybe not. Maybe maybe none. But, you know, generally, I think one or two bad sinus infections, either teenagers or maybe someone you have to send to the works the room. I think it's that common at least recently, tend to see a fairly company. So, Um, so development of science is, I think it's relevant because when you're born you just have your maxillary in F1 sinuses. So therefore an infant or one or two year old really can't get frontal sinusitis. It's a maxillary problem mostly. And um if you just take any child who has a cold who's a child killer and I'm not saying to do this, but if you were to get a ct scan of their head, he would likely find sinus of pacification, it would just be fluid. Um, and so the radiologist has always faced with the decision, you know, do I call this sinusitis or do I just say this is scientists of pacification or pan sinus disease. You know, someone who has a cold probably like me um would probably show pants sinus disease just by nature of having that you or I and fluid and the fluid and secretions and the sinuses. So it was a tangent there. But um maxillary and ethnic sinuses are what we're born with. And over time our solenoid sinus starts to build, that's someone kind of kind of in the center of the head and then our frontal sinuses start to develop at puberty, So maybe age 12 or 11, 13 And then all sinuses are fully developed by age 20. Um, and so it's really teenagers that we worry about their frontal sinuses and uh frontal sinusitis as well discuss. It is a pretty big deal. Um, something that we don't, you know, take too lightly isolated signing status is a fairly big deal, but it seems that ages 5 to 10, don't really get it. They can, but it's it's usually more of a teenage teenager issues. So solenoid and frontal sinus disease. Really teenagers, maxillary ethnic sinus disease, really younger Children. But serious sinus infection is generally a disorder of teenagers and adolescents. Okay, um nasal cavity and sinus anatomy. Uh you know, and the nose is a fairly complicated place. We have three turbulence and uh these, the purpose of these are very important that you modify the errors that goes down to our lungs. And they're kind of the drainage pathways for most of our sinuses. And we have this thing called the nasal cycle, which is where alternating every eight hours, one side of our knows our turbine, it's swell and then the other the other side decongest and then it alternates every eight hours or so. And so many patients would say, you know, it's the right side that's on its left side, that's swollen. Um we really try to isolate areas. So if someone just says no, no, it's only my right side that's always swollen. Our parents complain or um that that deserves, you know, I think a referral really awful bad just to make sure that there's nothing isolated going on that area. But congestion generally ultimate sides and some edema or swelling is normal. Some algorithm is normal. The story epithelium is of the nose is um is the same as the airway. You know the trachea. It contains many goblet cells to create because very quickly as we know, the turbines themselves are made of erectile tissue actually so they can swell very quickly and cause nasal congestion. Uh your eyes often cause science pacification as we discussed. And then just looking at this cat scan here. Um just to point out the science is uh this is a criminal view of the skull and sinuses and just looking in the bone window. The chief sinuses are what's black also see this feeling times. But just pointed out that the turbine ethics are fairly large structures and it's really nothing looking at the bottom picture here. This is called interior colonoscopy. We use a nasal spectrum, something too complicated. We just use the headlight and this device that allows us slipping the nostrils. And of course we have the ability to scope um which is not a first line, you know, work out or anything but is used sometimes we can't see well enough or we're going to look at the adenoid area which we need to do with the scope from. Okay, so acute bacterial rhinosinusitis or A BRS Is suggested by the presence of should be three or 3 or more of the following. Uh, so nasal discharge, which is often just one side but can be both nasal discomfort or pressure. Uh fever elevated S. R. C. R. P. Although that's not routinely obtained. Um So three or more of those. Um Right that Bosnia or decrease sense of smell boats and Children often don't report that. Um And the typical story is getting it cold viral. You or I and then that's followed by a sense infection. Most think that the where I set you up because it causes you know congestion and then stays this within the sinuses and then the super infection on top of the viral you or I you know so it's certainly a bacterial infection that doesn't have to be. Um And then there's this kind of double sickening concept which is where someone starts to feel better and then you know they worsen with worsen congestion really just uh uh the horses storing and uh not not doing well. And so it's three more of the following of those nasal discharge I think is really most common. Um Usually they really have to have a kind of pure land discharge. Generally not just clear, so pass out of the nose and then um discomfort is a relative term. She only just congestion and pressure and then fever is usually present to be a true sinusitis, bacterial sinusitis. Then there's recurrence in chronic uh signing size. And um I started to talk about admit that is here a little bit because at nowadays is still in the kind of the same category as sinusitis for Children generally under age 12. So we'll talk about adenoid disease and why we often real the adenoids. But Sinusitis is four more episodes Of what we mentioned. The last slide lasting 10 days suffered by at least one month of the healthy period symptoms overall for 10 days or longer. And uh the patient is having recurrent sinusitis. I generally recommend annually for allergy testing because the two can go ahead and and and just like you are, I allergies can also set us up for sinus infections because they cause this this baseline inflammatory states in the nose and nasal congestion. And then with that there's impaired uh drainage of the sinuses and that's led to a sinus infection. Yes, so there's this admitted sinus relationship, especially with younger Children, not so much older Children, but the advocates can be enlarged and then they can really cause this chronic inflammatory state that uh kind of it starts to involve the front part of the nose and then the entire, you know, Nukus earlier, a lining of the of the nasal cavity. Admins can be very large, just really blocking the entire airway. Uh They have nooks and crannies uh and can harbor bacteria usually strap staff. Um And so we perform an appendectomy often as our first line uh surgical treatment of sinusitis and Children. Surprisingly, I think too many. But it's been shown to really large studies. It's certainly been shown for supporting any Children child receiving their second set of your tubes or over the age of four receiving your tubes and should be very beneficial with that. But also let's just sinusitis, which again, this is general term of uh you know, recurrent uh cough fever, congestion For at least 10 days and then recurrent being four more per year. Um And so we do admit after me rather than an endoscopic sinus surgery which has risked CSF leak um you know, causing scarring to the point where it's uh the problem returns and and it's worse. And then there's been reports of disturbing the maxillofacial growth, the skeleton of the trial. And so sinus disease and young Children is generally avoided. Um And if you have to do it, you remove as little tissue as possible. It's very conservative surgery. Whereas an adult that's much more aggressive, want to talk about nasal polyps just because I think it's relevant. You may come across patients with this. Um I have a subset of patients, probably about eight patients or so that have recurrent nasal polyps. Um You have to be on the lookout for Children who assisted fibrosis. There's a connection between uh nasal polyps and statistics fibrosis. So any travels nasal falls. We generally test them for cf. Um But these are benign polyps. They're very soft. If you look in with the nasal speculum or with a telescope in the nose, you may see them as he's kind of listening uh polyps and they're benign. They're not cancerous in any way. Uh they're related to an allergic response. Um and this can happen usually in adolescence. It's rare that it's in younger Children. Um and so Children with a lot of polyps may have smaller sinuses and be prone to sinus infections. And so a child who gets a lot of infections, if we see them as any anti, will be very open minded and try to rule out these polyps and potentially scope them. And so this is a a video of polyps and seven knows you see, stop because she thinks that grow down from the top down and they couldn't grow like a bunch of grapes. Uh as I said, and uh this is a microchip reader that's used just back in the polyps and then trim them. It's a swiveling blade and it just months is the polyp tissue up. There's always a fair amount of bleeding. You can see how every difficult to do this on a child in the office, but it's done in adults in the office and um it's important to very thorough. These polyps are kind of like mowing the lawn they want to grow back and so many people need, you know, Close to 10 surgeries throughout their life. And like there were just opening the sinus passages and trimming one of the turbulence. And so uh polyps can also grow from maxime sciences that's called. Andrew coyne will follow just one giant paul up. Whereas many patients that's just looking in the maxillary sinus opening here holding out this uh lovely, very thick mucus um it can get very thick. Um Sorry, this is uh not not good during lunchtime but uh yeah, so uh polyps just be on the lookout for any child that gets a lot of sinus infections. Um Just in the same way that you can look up their immune system, kind of uh immune response deficiency. Um So let's talk about complications of sinusitis. Um Now that we've covered adenoid disease and kind of the classification of sinus disease. Talk about complications and also some medical treatments and and how we manage these. Um So let's start with the orbit the eye sockets are uh they straddle or the kind of book and the employed air cells or the appointed sinuses which is kind of in the bridge of the nose back. And many patients first present with a puffy eyelid. It's a very early sign. It doesn't have to be painful. So usually they have a cold although the cold is very severe. Um They just present what they put the island swollen. I lead generally it's swollen shut and and some congestion and sometimes fever it can it can progress really rapidly. Um Either a serious complication or just in Ireland sign. And uh if if you do see a patient with a popular they should be sent to the emergency department for a to an E. N. T. Because usually we obtain imaging that's really the only way to know how deep the infection is whether whether or not going into surgery. And they also need to very thorough eye exam. And so here this is a patient to who had a uh precept of cellulitis. An orbital cellulitis a presented with a very puffy right eyelid. And here you can see that they're swelling. So it grows from the right is the right side, right next to the right. Atmosphere. Cells are all pacified with post and debris. And that's gone across the laminate Patricia, which is the orbital wall, and that's then gone into and starting to affect the fat. And sometimes that progresses into an abscess and such. What's happening is all the eyes getting squeezed and so therefore it goes forward. So the past is acting like a mass and mass is going lateral and pushing the ball forward. And so this can, you know, I think that many people know how to strain on the muscles around the eye. And so if there's gays restriction, um, that there's a lot of days restriction, that's a really big deal. We only operate on that. So, through I think is really important. Um, any child with puffy eyelids should be september State Department for imaging. Where are these two voter geologists? Um, and so this is kind of what I'm talking about. generally just a punk eyelid doesn't hurt necessarily. Um Otherwise usually fine, it's usually one sided process and we would really try to open this as best we can take a look. Usually the contract Tyler are really swollen. Um Sometimes there's kIM Asus or the square itself is really a demetrius. I you know, sometimes doesn't turn well. The patients have blurry vision because uh their eyes can't align properly and so everything they see is double. Uh Those are all really big important things to know that we face a decision to operate on. So we classify orbital complications in different ways, basically from mild to moderate, you know, um If it's pre septal, it's mild, it's a peri orbital. Um it's orbital Silas. It's um more significant to the point where we would operate If it's a cellulitis, there's no fluid collection. We generally give them some antibiotics to see if it improves. We give it 24-48 hours, monitor the I almost always going to ophthalmology consult. And so especially if I am receiving antibiotics which is treated with antibiotics. Um nasal decongestants, although literature is not really support its use. Um steroids which is controversial that will cover And I would say about 75% of patients and three point where we don't need to surgery for those who have overall sales where the infection has already crossed the limit Patricia. Um We tend to operate and then it gets worse as you go as secretary also abscesses this fluid pocket that then pushes the eyeball forward. An orbital abscess is an abscess within the fat around the eye or the irish ball itself very serious. And then lastly, a cavernous sinus thrombosis, which is where the infection is so bad. It's caused inflammation of one of the large drainage pathways at the cavernous sinus, which is behind the orbit. That's a very serious infection. And so these patients are generally need to be integrated very serious life for the infection. So thank you. This is kind of overall progression. Um They can start with a popular island and it can end with uh you know, criminal nerve deficits, integration, um sepsis and septic emboli because the cavernous sinus recently throws subsequently throughout the body. So very serious. Again, much more common in teenagers. A can be seen and slightly older Children. Let's talk about medical therapy. Uh You know, these patients are admitted to our use of institutions. We definitely do a nasal endoscopy at bedside. So in the hospital well do remedial uh uh you know, swab So we'll take a sample of plus directly from its source to regulate from the sinus opening. We usually can do this pretty well and aspirated into a trap. And then that's kind of an isolated culture that we can get rather than putting in a Q tip in the nose and we'll start them on a broad spectrum antibiotics I'd consult and generally will start steroids, assuming there's no communication. We do favorite steroids at our institution tends to work well. Um we're pretty much in agreement with already colleagues and they're generally not opposed to. And so uh if we can we'll start decongestants and sailing irrigation. Uh If they have a cavernous sinus thrombosis which we probably get several a year. Um Sometimes we do start into calculation it's somewhat controversial but we certainly have the ability. Uh huh. And an operative indications for a serious corporal sinusitis issue. It's somewhat controversial but it really depends on the eye exam. So it's very important to get an ophthalmology consult in the house and um we measure prosthesis, orbital pressures rely on on the for that and visual acuity um extra operate movements. Um You know we all assess that but they do a very good job If there's gays restriction. If there's severe prognosis, if there's just no improvement after 48 hours we have to operate and do it athlete ectomy so clean out the air cells that are uh neighboring that area. So in between the eyes are the excellent air cells which we get to antiseptically. Um And then we also generally open up the maxillary sinuses um at the same time. And then depending on the age if there's frontal sinus disease will also do that as well. But really just kind of go to the area that's most involved. It opened those sinuses and um get repeat cultures for excess disease. And it can speed up recovery significantly. Or hopefully thwart any kind of intracranial complication such as abscess or emphysema. Um Okay and um so it it's kind of a finer point but if a the younger the child the more likely we are to not operate. Maybe that's kind of intuitive but it's really the teenagers that we were about the most were about everyone obviously. But um younger Children kind of uh we have a higher threshold to operate so they generally improved with antibiotics and steroids. So whereas maybe half teenagers need to go to the O. R. I would say really less than maybe um You know 10% or so need to go to the operating room through younger than age eight. So it's very optimistic for a young child with sinusitis even with puffy island um It takes a lot for them to go down right room. So they just do better. They don't have any frontal sinuses yet. So that can't really be a factor. It's generally mastery. And F would air cells that are infected and they present with a puffy eyelids. So it's usually two or three days in the hospital home and then better on oral antibiotics. No need for a pick. Um Whereas older Children, it's often a trip to the operating room several days, sometimes a pickling uh and up to about four weeks of I. V. Antibiotics. So there's some would say that's unnecessary but they tend to be pretty aggressive where we are. Um So uh yeah the orbit can progress very certain very quickly. It's a common presentation of an underlying sinus infection and um generally deserves a referral to the local emergency department and consultation with emergency with a little oncologist, infectious disease and ophthalmology. So let's move on to the frontal sinus. Again this does not develop until someone is his started really start puberty or after age 10 or so at least. And it grows rapid expansion as we grow. Um And so there's this thing called Potts puffy tumor which is kind of outdated at this point, it really just it's frontal sinus status with with cellulitis or abscess. But anyways it's stuck around as an old terms. Um And so it's a it's basically frontal sinusitis that's going to ride and it can really get serious. So the frontal sinuses uh kind of in the red line above our eyebrows. And if it gets, if you have a bad sinus infection in that area which is not that large. Plus has nowhere to go. Sometimes it gets so swollen that has nowhere to drain so it has to go somewhere and sometimes it goes out the front. So anti really you know get this thing called a like a pot puppy tuna, right pots with the doctor. Uh That's true. But see famous pots. But anyways uh yeah so emergency department uses terms it's kind of a but anyways presents with this doughy uh swelling over the forehead sometimes with posture image. And this is basically official to that's been created from just a really severe sinus infection. It's gone through the bone. So therefore the osteomyelitis. And so we we take this to the operating room sometimes with neurosurgery. And so by definition this patient would need uh surgery and uh this kind of a mix on this child of a pots coffee and with orbital cellulitis to go hand in hand. And um again the scenes urgent antibiotics, surgical drainage and agreement of democratic realm. Um Sometimes to the point where some bonus lost and affects the contour of their their head. It has to be grafted later neurosurgery. Um But these patients seem close follow up and it's a very big deal to have this and it can be uh it can be kind of initial presentation. So just other in general intracranial complications are meningitis. So a psychogenic source isn't the most common cause, but it can be certainly a cause of meningitis. So I don't have statistics on it, but it's not a common cause a sinus infection but should be considered. Generally patient have a lot of symptoms accompanying that. So it would just be manager dick symptoms without sinus sinusitis symptoms I don't think. But um you know, should be considered as a contributing factor. The frontal epidural abscess um is a frontal sinus infection that's not going out the front like Potts, puffy tumor but got out the back um and collected underneath the dura. I'm sorry on top of the Douro epidural abscess, but then it could have been transgressed, the dura become a subdural emphysema. And then um it can also infect blood vessels until the sinus thrombosis is that cabinet scientists at secure sagittal sinus. And then lastly, brain that test is like the most feared complication is just a very bad prognosis. It's something that develops a brain access from sinusitis. Uh And also that ruptures. It could be uh fatal. And so uh not sure why they show up so pixilated but see her on the left frontal sinuses case by bone and it generally drains down into the nose. Um But if there is such bad you are, i congestion sometimes it just really can't train. And this entire area is filled with puss, sometimes on Kathy and this little air bubble. And here we can see this is a pacified and the post your table which is this thin a saw bone can be eaten away. The puss can then drain through and then collect with an epidural abscess who can go out the front and create a puffy puffy tumor of the trigger. Again, it's just a satisfaction question of puss. But imaging is very important for suspected complicated sinusitis. You have this ability to do a balloon dilation of the frontal scientist. So uh uh in the past it was kind of a big deal to get to the final sinus. You have to make an incision through the eyebrow and it will be very noticeable and it's very effective. But if you miss you, you know, you can enter through into the area of the brain. So it has a lot of risk. Although you know just it's certainly low risk if if you're confident in your enemy everything but everything has a risk. So there's a frontal sinus balloon that's been around for probably about 10 years or so. This balloon can actually go into the maxillary sinuses and the screen with sinus. But we and we do use the Mexico sinuses. Um Excuse me. But we do really like it for the frontal sinus at PCH Oakland and Mission Bay. So whereas we used to have to do sometimes a parental incision, a very large incision or an incision on the eyebrow. And then we can just think a site is balloon up and drain off all the puss and irrigate. Um And so we think this balloon up trans eliminate let's see the the area through the skin and then we inflate the tiny balloon and pressed to mico. So that's inflamed out of the way, suck out the puss and really improves outcomes. I think patients to see very well. Um Again it's usually usually a teenager who was receiving this. Um And so it's become a common part of our practice that you say so yeah. Um Just going back to orbital complications. So epidural abscesses where past collects um superficial to the dura. Um and you can get a subdural hematoma from that. Or brain abscesses kind of the last part of that process. And this is Jonas staph aureus came the other um Bugs. Uh Also stripe is the most common. Yeah, these patients are generally very ill when they present. So it's usually someone who's sleeping a lot more than they really happen teenagers who are just you know, just really very sick fever is almost always common, almost almost present and they generally have headache and it would just be off and on someone just sleeping. Um And so you know, someone has this type of collection will obviously consult neurosurgery. Um and then also playing for combined neurosurgery TNT procedure Marie drain the puss from above the boil. I want to talk about this other thing called allergic fungal sinusitis. Uh This there's this other entity called invasive uh fungal sinusitis that we'll talk about. But there's this other subset of patients who have allergies, but their allergies tend to cause this development of this type of mucus which is very thick and problematic. It's called allergic medicine and it's kind of the consistency of peanut butter. Um and it's the patient's also generally have problems. So this is more common in actually the areas of like Georgia and florida and the Southeast eastern United States. Human climates, other parts of the world. We do see a little bit here, especially in san Joaquin valley in several months. And so uh you know, just just f y there's a city called allergic fungal sinusitis, which is not the invasive type, It's not like music or um uh we'll talk a little bit about that, but oh can occur and needs often needs surgery. And so sometimes we find us on cts were surprised by what we find with the pathology out there, but uh sometimes will be scanning for this regular sinus recurrent sinus issues. And we see something like this where one entire side of the nasal cavities is occupied by this thick uh peanut butter musician we call it, which is like thick mucus. It's almost a tissue though. And they can be calculations within it. And uh these patients need extensive sinus surgery if we find it. Um So that's different than this thing called invasive fungal sinusitis. It maybe you've heard of this through also through recent covid, I believe, particularly in India, maybe brazil. They've had a lot of cases of nucor associated with their new crop psychosis or invasive fungal disease associated with covid exposure. But really this is most common in any child who was given a compromise most commonly from poorly controlled diabetes. So important patients with very poorly controlled diabetes who uh this often presents with a black area or d vitalized tissue. So it can be a spot on the cheek, on the palate. It make cheap numbness because this is essentially think about a rapidly growing to religious force through everything. And um, so we'll destroy nerves. It's not a tumor. You know, obviously it's a new corn psychosis infection. Or sometimes invasive asper jealous. So there's two main from the fungi that caused this but can be caused by others. Uh Anyways this is a surgical emergency. Uh this happened so patients need wide agreement sometimes or blood saturation or removing the eyeball. Um It can be very more but it's very sad but if she really does have this in order to save their life because mortality is just exceptionally high, About 50% only um it's really emergency. So this is really just an aside mostly for patients who are really even a compromise. So very poorly controlled diabetes patients in DK. It's just we've had a strong point. Um but just something to note that can happen. So sinus infections in general just went to operate uh as early oncologist said, uh this is a P. C. H. Oakland and should be, we generally operate for any patient who has an intracranial complications. So whether it be meningitis an epidural abscess central and fema. Um even sometimes many guilt they can eat on ct. So the sign that it's brewing, it's starting to happen where the final sinuses under pressure and you know it looks like it's headed towards that after all access. Uh With a friend of mine is blue, it's very low risk and very effective. So we totally operate for meningitis or any kind of intracranial congregation which is standard of care and um awesome for patients who have had Improvement after 48 hours of by the antibiotics for some sort of steroids. Um 48 hours is about the cut off. Um You know in order to be admitted to the hospital for sinusitis has to be pretty, you know it has to be uh you know I was thinking these changes in labs and um clinically very ill. And so we tend to see many patients but not many get admitted. But anyways um So no during the next 48 hours and then any kind of orbital complications. So um for pre septal cellulitis which is the mildest form of an orbital cellulitis, we do not operate especially the transom but as you go up in the severity of it, so the orbital, so those were pre septal to orbital cellulitis and then um to severe also abscess and then corporal abscess. So as you go up with you generally do operate any child with gays restriction, double vision prosthesis. Um if they have improved it for 48 hours we operate uh the younger the child is less likely we are to operate. So the older the child is more likely we are. It's kind of how it helps how it only works. Um And of course any sinus thrombosis. So again, it's another type of complications uh that can cause increased increased cranial pressure um and some serious issues and they can also shower infected clot and subject and really throughout the body. So uh and then quite anti regulation has been often used actually, but it's more controversial right? Um for medical therapy uh antibiotics are indicated for severe onset and worsening course according to the latest practice guidelines from the ap the first time is very similar to the chinese media amoxicillin with or without. Um club. The limits of Augmentin generally clinton for penicillin allergy And we can consider broadly enough for 72 hours. A saline spray has not been shown to be very impactful but is generally used. There's an insufficient data to support the congestion such as African or megalithic. Story of mine estimates unfortunately, but they are often used, steroids are effective. Um Generally there has, there have been some studies that I was shown to be the case, but in general, if you have a serious orbital infection, steroids have been shown to hasten recovery. Um although the duration of steroids has still not been really radically explored, but it's kind of counterintuitive. But despite this serious infection, we tend to use steroids just decreases the swelling so significantly that things are allowed to train. That really seems to improve outcomes. So good to talk about sex is it really is that we're kind of good to the end of it. Um Just those words are so common and I just wanna make sure that several things are being awkward to the families. First off, most of them happen in the front part of the nose, and that's the reason why I'd be a whole pressure over the nose of the lower part of the nose. Not the bone really. You do not want to hold pressure over the bone but the lower part, that's why you're squishing the nostrils or the lower part of the nose against the symptoms is where the the bleeding is coming from. In almost 80 to 90% cases. And there can be posterior sources. It's really rare, actually, surprisingly rare. And then there can be contributing factors like final events, disease affiliate and H. T. Um But those are those are less common And so really like 80 80 or 90% of the action is happening right in front of the nose. On the septum itself. It's called Selects plexus. And we have a stepwise approach and I hope we deal with nosebleeds. They can be very bothersome to be very scary uh for anyone involved take care of it and uh also for the patient. So the child. So there's a stepwise approach, certainly it go pressure for five minutes by the clock with the chin down the chest and the bug clocks up the middle up in these little cavity and that's following it. Um that's usually effective to stop it right then and there. But I'm preventative measures. You know, Afrin has not been shown to be, you can't use it regularly. Police more than three days. These will you medicate education is really important. So creating a moist environment for the nose rather than a dry environment. And you know the the acute citing songs we used the moment glue and certain things but and nasal packing but it's really necessary. But we do have a lot of packing ability our institutions but and then we offer surgeries. It really takes a lot to need surgery for those bleeds as we really bothers. Some have to, you know we can do in office Kateri that say about age five is the cut off. So any child younger than five, it's hard to kind of coax them into sitting for Qatar the silver nitrate, which is a chemical that we apply to the septum. It hurts of it, it really does blood stains. And so After H. five it's generally possible but longer than that it's hard we try to avoid it. Um And so do it in. The operator was really kind of last resort. I'd say only about 10% of our at this access control to receive cover in the office. Which is look at that. It is in the every single thing. So most of us we can deal with in the office. This is my point and we can do a lot of need in the operating room to help stop it. So just wrapping up general conclusions, uh sinusitis is very common and it's often a continuation of the U. R. I. Um Anyone assessed for underlying allergies and if they're contributing to recurrent sinusitis in Children um please do consider nasal irrigation for Children with just kind of garden variety, nasal congestion. Um We don't have much story, better kind of you know dealing with the korean sinus infections that has been trying to do something helpful. Um. Mhm. And that to me is the first line surgical therapy for Children with recurrent science. Sinusitis. Surprisingly, I think for many it does tend to help and it's less uh lower risk than sinus surgery. Um And I think it's important to split up your tune the sinusitis too. Uh groups younger than age 10 and older than age 10 in the younger age 10. It's certainly self limited out products. Uh true Sinus infections over the age of 10 or more likely to go towards serious complications. So um It's rare to need surgery younger than age 10. It's a bit more complicated surgery older than age 10, especially if you're hospitalized for it. There is much more prone to orbital complications and then from sinus complications. Uh and uh so yeah, generally complications can be very severe and arrived suddenly. Uh teenagers are most susceptible And I would have a very low threshold to refer someone who has more than three episodes of 10 days or more of nasal congestion fever, pure linen nasal discharge because I don't talk to me is very low risk and can really help quite a bit. Um and at the most, you know, at least we can just scope them and see if your adenoids are enlarged or causing certain issues. Uh So it's it's really very simple. Um And you see this up we're very well equipped just for the anti standpoint. But also just all the consultants we have neurosurgery ophthalmology. We really work well as a team for these serious complications. This is how to refer. It's been a lot easier now With this 877 you see child telephone number as our pediatric access center. And there's also separate facts numbers. Um But all of your calls can be addressed through central phone number and we've done a lot better with Just our general access. I think all patients can get an appointment or at least get scheduled within 72 hours now. Mhm. Thank you so much. It's a pleasure to talk to, mm.