Pediatric Balloon Sinuplasty: Our Institutional Experience

Pediatric Balloon Sinuplasty: Our Institutional Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pediatric Balloon Sinuplasty: Our Institutional Experience Ritu Gupta, Jitendra Chauhan, Virendra Kumar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6990998/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Chronic rhinosinusitis (CRS) in the pediatric population is multifactorial condition that significantly affects quality of life, leading to recurrent infections, nasal obstruction, sleep disturbances, and school absenteeism. Balloon sinuplasty has emerged as a minimally invasive alternative.However, its application in the pediatric population, particularly in the Indian context, remains underreported. Material and methods Aim To evaluate the clinical outcomes and safety profile of balloon sinuplasty in pediatric patients with chronic rhinosinusitis unresponsive to prolonged medical management. A prospective observational study was conducted over a 24-month period from 15 January 2023 to 15 January 2025 in a tertiary care teaching hospital. Fifteen pediatric patients (aged 6 to 18 years) diagnosed with CRS, who failed to respond to at least 12 weeks of optimized medical therapy, were enrolled. All patients underwent balloon sinuplasty targeting the maxillary sinus ostia under general anesthesia. A total of 24 maxillary sinuses were dilated. Postoperative follow-up was conducted for 6 months, assessing symptom resolution using the Sinonasal Outcome Test-22 (SNOT-22), SN-5 Score, endoscopic evaluation for ostial patency, Lund Mac Kay CT Scan Score and monitoring for complications. Results Ostial Patency: At 6-month follow-up, 22 out of 24 treated sinuses (92%) remained patent.Symptom Improvement: The mean SNOT-22 score significantly improved from average 43 preoperatively to average 4 postoperatively. Conclusion BSP is a safe, minimally invasive surgical option for managing pediatric CRS, especially in the 12–18 year age group. To the best of our knowledge, this is the first prospective Indian study evaluating balloon sinuplasty in the pediatric population. Pediatric chronic rhinosinusitis Balloon sinuplasty Maxillary sinus Minimally invasive surgery SNOT-22 India. Introduction Chronic rhinosinusitis (CRS) in children is defined as the persistence of two or more symptoms for at least 12 weeks, one of which must include nasal blockage/congestion or anterior/posterior nasal discharge, accompanied by facial pain/pressure or a chronic cough. Diagnosis is confirmed through either endoscopic findings (e.g., mucosal edema, purulent discharge, or nasal polyps) or computed tomography (CT) evidence of sinonasal inflammation [1,2]. CRS affects approximately 10% of the general population, with a reported prevalence of 2–4% in the pediatric age group. Although the prevalence is lower in children compared to adults, the impact on the pediatric population is equally significant in terms of morbidity, including impaired quality of life, recurrent infections, and school absenteeism [3,4,5]. The etiology of pediatric CRS is multifactorial, and certain contributing factors—such as adenoidal hypertrophy and laryngopharyngeal reflux—are more prominent in children than in adults. Surgical Considerations in Pediatric Chronic Rhino sinusitis Despite extensive research on CRS management in adults, children are often excluded from such studies due to anatomical and physiological differences. At birth, only the maxillary and ethmoid sinuses are present and are underdeveloped. The frontal and sphenoid sinuses develop progressively throughout childhood. Additionally, adenoidal hypertrophy, which can obstruct sinonasal drainage and act as a reservoir for infection, is more common in the pediatric population. The pathophysiology of CRS in children differs from that in adults. Pediatric CRS is more frequently associated with allergic rhinitis, recurrent upper respiratory infections, laryngopharyngeal reflux, and adenoid-related obstruction [6–8]. While most pediatric patients respond to appropriate medical management, surgical intervention may be warranted in medically refractory cases. Current guidelines, including the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020), recommend adenoidectomy as the first-line surgical option in children with CRS. This may be combined with adjunct procedures such as antral lavage or balloon sinus ostial dilation. Endoscopic sinus surgery (ESS) is generally reserved for cases unresponsive to initial surgical measures, particularly in children without adenoidal hypertrophy or with underlying mucociliary dysfunction [9,10,11]. For children under 12 years of age, adenoidectomy is widely accepted as the primary surgical approach. However, there is a lack of consensus and established guidelines for the management of CRS in older children and adolescents. In this subset of patients, balloon sinuplasty has emerged as a promising minimally invasive technique for managing medically resistant CRS without nasal polyps (CRSsNP) [11]. Nevertheless, high-quality evidence supporting its efficacy and safety in this age group remains limited, especially in the Indian population. Aim and Objectives Aim To share our institutional experience with pediatric balloon sinuplasty in the management of chronic rhinosinusitis (CRS). Objectives To assess clinical improvement following pediatric balloon sinuplasty. To evaluate intraoperative, immediate postoperative, and late complications associated with the procedure. To determine the overall feasibility, safety, and success rate of balloon sinuplasty in the pediatric population. Materials and Methods This prospective study was conducted at a tertiary care teaching hospital over a period of 24 months, from 15 January 2023 to 15 January 2025. Data collection occurred between January 2023 and January 2024, followed by a 6-month postoperative follow-up for each patient. Data compilation and analysis were performed during the final six months of the study period. A total of 15 pediatric patients (aged ≤ 18 years) with chronic rhinosinusitis unresponsive to 12 weeks of medical therapy were included. A total of 26 maxillary sinuses were addressed using balloon sinuplasty. The diagnosis of CRS was based on the presence of persistent symptoms for at least 8 weeks, non-responsiveness to 12 weeks of appropriate pharmacological therapy, and radiological confirmation of disease on CT of the paranasal sinuses (CT-PNS), performed four weeks after completion of medical treatment. After the balloon Sinuplasty procedure the children were suggested regular twice daily saline nasal washes. They were called for 3 follow ups. The first follow up was at the end of one month. Second follow up at the end of third month and final follow up at the end of the sixth month. The patency of the sinuses were checked at the end of six months after the Balloon Sinuplasty procedure by 30 degree nasal endoscope. Follow up CT Scan was done at end of the six months of the procedure. CT Scan was used to evaluate Lund Mac Kay Scoring. Inclusion Criteria Age ≤ 18 years. Unilateral or bilateral mild to moderate chronic maxillary sinusitis. Absence of nasal polyposis. Failure of 12 weeks of medical management. Exclusion Criteria Severe CRS with nasal polyposis. History of facial trauma or congenital anomalies of the nose/face. Diagnosed cases of ciliary dyskinesia or other congenital mucociliary disorders. Distorted osteomeatal complex anatomy on CT. Inability to comply with 6-month follow-up protocol. Surgical Technique All procedures were performed under general anesthesia. Nasal packing was done using lignocaine with adrenaline (1:100,000) for 15 minutes. No local anesthetic injection was used. The patient was positioned supine with the head elevated at a 15-degree angle on a head ring. A sinus balloon dilation catheter (Meril™, maxillary type, 110° angulation, 16 mm length) was used. After removing the nasal pack, a flexible guidewire was introduced through the nasal cavity into the maxillary sinus under endoscopic visualization. To confirm correct placement, room lights were turned off and transillumination of the maxillary sinus (maxillary glow) was observed. Once the natural ostium was delineated, the balloon catheter was advanced over the guidewire to the ostium and inflated to 12 atmospheres for 10 seconds to achieve dilation. Results Table 1 Demographic Profile of Chronic Rhinosinusitis Patients Undergoing Balloon Sinuplasty (n = 15) Parameter Category n (%) Age Group 6–12 years 1 (6.67%) 13–18 years 14 (93.33%) Mean ± SD 15.80 ± 2.14 Gender Female 8 (53.33%) Male 7 (46.67%) Occupation Student 14 (93.33%) Shopkeeper 1 (6.67%) Side Involved Bilateral (B/L) 11 (73.33%) Left (L) 4 (26.67%) Table 2 Radiological and Procedural Characteristics of Patients Undergoing Balloon Sinuplasty (n = 15) n (%) SINUS Yes 14 (93.33%) No 1 (6.67%) OMU Yes 12 (80.0%) No 3 (20.0%) PROCEDURE B/L 11 (73.33%) L 4 (26.67%) Table 3 Comparison of Clinical Outcome Scores at Baseline and Follow-Up After Balloon Sinuplasty (n = 15) PRE OP 1st follow-up 2nd follow-up 3rd follow-up F p-Value Mean ±SD Mean ±SD Mean ±SD Mean ±SD SNOT SCORE 41.80 9.53 12.27 2.99 7.20 1.57 4.40 1.45 170.70 < 0.001 VAS SCORE 5.33 1.23 2.27 0.46 1.20 0.41 0.93 0.59 108.18 < 0.001 LUND MACKAY CT SCAN SCORE 5.27 1.79 . . . . 1.00 0.53 78.13 < 0.001 SN -5 SCORE 7.00 . 3.00 . . . . . . .- LUND KENNEDY SCORE 4.33 1.29 2.13 0.52 1.13 0.64 0.73 0.96 47.69 < 0.001 Incidence of Postoperative Complications Following Balloon Sinuplasty in Chronic Rhinosinusitis Patient Out of 15 cases operated synechia was noted in two patients. No other complications were noted. Discussion This prospective study evaluates the safety, feasibility, and efficacy of balloon sinuplasty in the pediatric population with chronic rhinosinusitis without nasal polyps (CRSsNP). To our knowledge, this is the first prospective Indian study on this subject, addressing a notable gap in the literature. Demographics and Disease Pattern As depicted in the Table number 1, pediatric chronic sinusitis was more prevalent among the adolescents compared to the younger children.. Most patients (93.33%) in our study were adolescents aged 13–18 years, with a mean age of 15.8 ± 2.14 years. Only one patient was below 12 years of age, reflecting the difficulty in encountering younger candidates meeting both the inclusion criteria and surgical candidacy in a real-world setting. A slightly higher proportion of patients were female (53.33%), and the majority were students (93.33%), as expected in this age group. Bilateral sinus involvement was seen in 73.33% of cases, with 26.67% having unilateral disease, indicating a diffuse disease pattern. As shown in Table number 2, radiologically, maxillary sinus disease was evident in 93.33% of patients, with 80% showing involvement of the ostiomeatal complex (OMC), supporting the theory that OMC obstruction plays a central role in pediatric CRS pathophysiology. Efficacy of Balloon Sinuplasty The subjective and objective success rate after the balloon Sinuplasty is depicted by the Table number 3; multiple validated scoring systems were used to objectively assess outcomes, all of which demonstrated significant improvement: SNOT-22 Score: Mean preoperative score was 41.80 ± 9.53, which reduced to 4.40 ± 1.45 by the final follow-up (p < 0.001), indicating significant symptomatic relief and quality-of-life improvement. VAS Score: Decreased from 5.33 ± 1.23 to 0.93 ± 0.59 (p < 0.001), confirming reduction in perceived symptom severity. Lund-Mackay CT Score: Improved from 5.27 ± 1.79 to 1.00 ± 0.53 postoperatively (p < 0.001), reinforcing radiologic recovery. Lund-Kennedy Endoscopic Score: Showed a significant decline from 4.33 ± 1.29 to 0.73 ± 0.96 (p < 0.001), indicating mucosal healing. SN-5 Score: Reduced from 7.00 to 3.00, reflecting improvement in pediatric sinus-specific quality-of-life, though detailed statistical analysis was not available. Overall, 22 out of 24 sinuses (92%) remained patent at 6 months, confirming a high success rate. The two sinuses which were not patent, they were advised for the conventional endoscopic sinus surgery. The sinuses were addressed by uncinectomy and middle meatal antrostosomy. Careful post operative followup was advised by saline nasal wash for next three months. In one of the child; biopsy of the nasal mucosa showed inflammatory changes. In accordance with the EPOS 2020 guidelines, Clarithromycin 250 mg twice a day was given for next 3 months.[11] Soler ZM et al. reported a significant improvement in SN-5 (mean score = 1.7 postoperatively vs. mean score = 4.8 preoperatively) [12]. In a prospective study conducted by Liu J et al., VAS score was significantly improved after the procedure (preop VAS score = 17.86 ± 7.59 vs. post op VAS score = 1.68 ± 3.53) [13]. Additionally, findings of the two experimental controlled trials supported the aforementioned findings. [14,15] Safety and Complications The procedure was well tolerated, with no major intraoperative or immediate postoperative complications. No cerebrospinal fluid (CSF) leak, orbital complications, or significant hemorrhage occurred. Nasal packing was not routinely used; one patient required packing for minor postoperative bleeding. The most common late complication was the development of synechiae, observed in 1 of the patients. These adhesions were managed with endoscopic release under anesthesia. Although balloon sinuplasty is minimally invasive, the synechiae may be attributed to the narrow nasal anatomy in pediatric patients and mucosal apposition during the healing phase. In reviewing other studies, the complication rates were very low. Only synechia was noted as a complication in the studies. [16,17] Context and Relevance Balloon sinuplasty was approved by the U.S. FDA in 2005 and has since been adopted worldwide, including in India. While it is widely studied in adults, pediatric data, especially from the Indian subcontinent, remain scarce. Clinical guidelines—such as those from the AAO-HNS and EPOS—primarily recommend adenoidectomy as first-line surgical treatment in pediatric CRS unresponsive to medical therapy. Balloon sinuplasty may be added, particularly in children without significant adenoidal hypertrophy. However, clear guidelines for children aged 12–18 years are lacking. In our series, all patients were aged 11–18 years. Despite the inclusion criteria allowing younger children, no patients under 11 years met the criteria during the study period. This highlights the selective nature of balloon sinuplasty in the pediatric cohort. Advantages of Balloon Sinuplasty Balloon sinuplasty is a minimally invasive, anatomy-preserving procedure with several advantages: No mucosal or bony resection. Balloon Sinuplasty can be considered micro minimally invasive procedure which preserves the anatomy and the physiology of the sinuses The operative duration is short. Local anaesthesia is given by lignocaine application in the merocele. No local anaesthesia is injected. Short general anaesthesia is given for the dilation of the sinus. No nasal pack is used post operatively as there is no bleeding during the procedure. Minimal bleeding and tissue trauma. Reduced anesthesia exposure. Same-day or next-day discharge. These benefits are particularly important in the pediatric population, where preserving mucociliary function and minimizing postoperative morbidity is paramount. Postoperatively, patients were advised to continue saline nasal irrigation and topical steroid spray for 12 weeks. Regular follow-up with nasal endoscopy and debridement ensured early detection and management of synechiae. Limitations and Future Scope This study is limited by a small sample size and short-term follow-up. Larger, multicenter studies with longer observation periods are necessary to validate these findings and establish standardized guidelines for pediatric balloon sinuplasty. Conclusion Balloon sinuplasty appears to be a safe, effective, and minimally invasive surgical option for managing chronic rhinosinusitis in selected pediatric patients. Its role is particularly promising in adolescents with CRSsNP who have failed conservative therapy and do not exhibit significant adenoidal hypertrophy or anatomical anomalies. Declarations Ethics Approval and Consent to participate Statement on ethics approval and consent-include the name of the ethics committee that approved the study: Ethical approval was taken by the parent/ guardian of the children. The ethical committee approval no. : 161/2023-24 by Institutional Ethics Committee ( Uttar Pradesh University of Medical Sciences). Funding The research did not receive any specific grant from the funding agencies in the public, commercial or not for profit sectors. Author Contribution RG: designing the studyJC: preparing the manuscriptVK: collecting data References Brietzke SE, Shin JJ, Choi S, et al. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014;151:542–553. Fokkens WJ, Viskens AS, Backer V, et al. EPOS 2020: integrated care pathways and paediatric CRS. Rhinol Suppl. 2020;29(1.7):102–110. Ah-See KW, Evans AS. Sinusitis and its management. BMJ. 2007;334(7589):358–361. Orlandi RR, Kennedy DW. Surgical management of rhinosinusitis. Am J Med Sci. 1998;316(1):29–38. Cultrara A, Goldstein NA, Ovchinsky A, Reznik T, Roblin PM, Hammerschlag MR. The role of Chlamydia pneumoniae infection in children with chronic sinusitis. Arch Otolaryngol Head Neck Surg. 2003;129(10):1094–1097. Lusk R. Pediatric chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. 2006;14:393–396. Mahdavinia M, Grammer LC. Chronic rhinosinusitis and age: is the pathogenesis different? Expert Rev Anti Infect Ther. 2013;11:1029–1040. Sedaghat AR, Gray ST, Chambers KJ, et al. Sinonasal anatomic variants and asthma are associated with faster development of chronic rhinosinusitis in patients with allergic rhinitis. Int Forum Allergy Rhinol. 2013;3:755–761. Fokkens WJ, Lund VJ, Hopkins C et al.European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology. 2020 Feb 20;58(Suppl S29):1-464. doi: 10.4193/Rhin20.600. PMID: 32077450. Gupta R. Balloon Sinuplasty: Our Experience. Indian J Otolaryngol Head Neck Surg. 2024;76(1):141–144. doi:10.1007/s12070-023-04111-7. PMID:38440653; PMCID: PMC10909022. Fokkens WJ, Viskens AS, Backer V, et al. EPOS 2020: integrated care pathways and paediatric CRS. Rhinol Suppl. 2020;29(1.7):102–110. Soler ZM, Rosenbloom JS, Skarada D, Gutman M, Hoy MJ, Nguyen SA. Prospective, multicenter evaluation of balloon sinus dilation for treatment of pediatric chronic rhinosinusitis. Int Forum Allergy Rhinol. 2017;7(3):221–229. doi: 10.1002/alr.21889. [DOI] [PMC free article] [PubMed] [Google Scholar] Liu J, Zhao Z, Chen Y, Xu B, Dai J, Fu Y. Clinical curative effect and safety of balloon sinuplasty in children with chronic rhinosinusitis. 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Int J Pediatr Otorhinolaryngol. 2017;100:204–210. doi: 10.1016/j.ijporl.2017.06.026 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6990998","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":499016922,"identity":"5752e83c-26b4-479a-a65e-288c26f453a9","order_by":0,"name":"Ritu Gupta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYDACZhSejQ2QYGw8gF8LRI8EhJeWBtLSgF8LA6qWw2AKrxbzdv5jkl/b7tTx9x9+9uFHwnm7te2HgbbU2ETj0iJzmJlNWrbtmYTEjTTjmT0Jt5O3nUkEajmWltuAQ4sEM1CLZNthCYYbDMYMvD9uJ5sdAGphbDhMWIv8+eOfGf8knEs2O/+QsBbJj0AtBgdyjJl5Eg7Ymd0gbIuxNcO5Z5Ibb+QUM8skJCeY3QDakoDPL/wHH978UXaHX+788c2MbxLs7M3Opz988KHGBqcWEGDmQYqIRLDKBDzKQYDxB5IWewKKR8EoGAWjYAQCAF7pX6G7HMx5AAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Ritu","middleName":"","lastName":"Gupta","suffix":""},{"id":499016923,"identity":"5429c957-efba-4e07-842b-618f5b0f9041","order_by":1,"name":"Jitendra Chauhan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jitendra","middleName":"","lastName":"Chauhan","suffix":""},{"id":499016924,"identity":"8619f419-6a2d-4454-8627-b2934972e796","order_by":2,"name":"Virendra Kumar","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Virendra","middleName":"","lastName":"Kumar","suffix":""}],"badges":[],"createdAt":"2025-06-27 11:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6990998/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6990998/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106415182,"identity":"2fe6df16-9785-408a-b76f-4f3f24c12922","added_by":"auto","created_at":"2026-04-08 10:33:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":497288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6990998/v1/42828760-f4cf-4c89-8be0-c0a79077cf48.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pediatric Balloon Sinuplasty: Our Institutional Experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic rhinosinusitis (CRS) in children is defined as the persistence of two or more symptoms for at least 12 weeks, one of which must include nasal blockage/congestion or anterior/posterior nasal discharge, accompanied by facial pain/pressure or a chronic cough. Diagnosis is confirmed through either endoscopic findings (e.g., mucosal edema, purulent discharge, or nasal polyps) or computed tomography (CT) evidence of sinonasal inflammation [1,2].\u003c/p\u003e\u003cp\u003eCRS affects approximately 10% of the general population, with a reported prevalence of 2\u0026ndash;4% in the pediatric age group. Although the prevalence is lower in children compared to adults, the impact on the pediatric population is equally significant in terms of morbidity, including impaired quality of life, recurrent infections, and school absenteeism [3,4,5]. The etiology of pediatric CRS is multifactorial, and certain contributing factors\u0026mdash;such as adenoidal hypertrophy and laryngopharyngeal reflux\u0026mdash;are more prominent in children than in adults.\u003c/p\u003e\u003cp\u003eSurgical Considerations in Pediatric Chronic Rhino sinusitis\u003c/p\u003e\u003cp\u003eDespite extensive research on CRS management in adults, children are often excluded from such studies due to anatomical and physiological differences. At birth, only the maxillary and ethmoid sinuses are present and are underdeveloped. The frontal and sphenoid sinuses develop progressively throughout childhood. Additionally, adenoidal hypertrophy, which can obstruct sinonasal drainage and act as a reservoir for infection, is more common in the pediatric population.\u003c/p\u003e\u003cp\u003eThe pathophysiology of CRS in children differs from that in adults. Pediatric CRS is more frequently associated with allergic rhinitis, recurrent upper respiratory infections, laryngopharyngeal reflux, and adenoid-related obstruction [6\u0026ndash;8]. While most pediatric patients respond to appropriate medical management, surgical intervention may be warranted in medically refractory cases.\u003c/p\u003e\u003cp\u003e Current guidelines, including the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020), recommend adenoidectomy as the first-line surgical option in children with CRS. This may be combined with adjunct procedures such as antral lavage or balloon sinus ostial dilation. Endoscopic sinus surgery (ESS) is generally reserved for cases unresponsive to initial surgical measures, particularly in children without adenoidal hypertrophy or with underlying mucociliary dysfunction [9,10,11].\u003c/p\u003e\u003cp\u003eFor children under 12 years of age, adenoidectomy is widely accepted as the primary surgical approach. However, there is a lack of consensus and established guidelines for the management of CRS in older children and adolescents. In this subset of patients, balloon sinuplasty has emerged as a promising minimally invasive technique for managing medically resistant CRS without nasal polyps (CRSsNP) [11]. Nevertheless, high-quality evidence supporting its efficacy and safety in this age group remains limited, especially in the Indian population.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAim and Objectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAim\u003c/p\u003e\u003cp\u003eTo share our institutional experience with pediatric balloon sinuplasty in the management of chronic rhinosinusitis (CRS).\u003c/p\u003e\u003cp\u003eObjectives\u003c/p\u003e\u003cp\u003eTo assess clinical improvement following pediatric balloon sinuplasty.\u003c/p\u003e\u003cp\u003eTo evaluate intraoperative, immediate postoperative, and late complications associated with the procedure.\u003c/p\u003e\u003cp\u003eTo determine the overall feasibility, safety, and success rate of balloon sinuplasty in the pediatric population.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis prospective study was conducted at a tertiary care teaching hospital over a period of 24 months, from 15 January 2023 to 15 January 2025. Data collection occurred between January 2023 and January 2024, followed by a 6-month postoperative follow-up for each patient. Data compilation and analysis were performed during the final six months of the study period.\u003c/p\u003e\u003cp\u003eA total of 15 pediatric patients (aged\u0026thinsp;\u0026le;\u0026thinsp;18 years) with chronic rhinosinusitis unresponsive to 12 weeks of medical therapy were included. A total of 26 maxillary sinuses were addressed using balloon sinuplasty. The diagnosis of CRS was based on the presence of persistent symptoms for at least 8 weeks, non-responsiveness to 12 weeks of appropriate pharmacological therapy, and radiological confirmation of disease on CT of the paranasal sinuses (CT-PNS), performed four weeks after completion of medical treatment.\u003c/p\u003e\u003cp\u003eAfter the balloon Sinuplasty procedure the children were suggested regular twice daily saline nasal washes. They were called for 3 follow ups. The first follow up was at the end of one month. Second follow up at the end of third month and final follow up at the end of the sixth month.\u003c/p\u003e\u003cp\u003eThe patency of the sinuses were checked at the end of six months after the Balloon Sinuplasty procedure by 30 degree nasal endoscope. Follow up CT Scan was done at end of the six months of the procedure. CT Scan was used to evaluate Lund Mac Kay Scoring.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAge\u0026thinsp;\u0026le;\u0026thinsp;18 years.\u003c/p\u003e\u003cp\u003eUnilateral or bilateral mild to moderate chronic maxillary sinusitis.\u003c/p\u003e\u003cp\u003eAbsence of nasal polyposis.\u003c/p\u003e\u003cp\u003eFailure of 12 weeks of medical management.\u003c/p\u003e\u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSevere CRS with nasal polyposis.\u003c/p\u003e\u003cp\u003eHistory of facial trauma or congenital anomalies of the nose/face.\u003c/p\u003e\u003cp\u003eDiagnosed cases of ciliary dyskinesia or other congenital mucociliary disorders.\u003c/p\u003e\u003cp\u003eDistorted osteomeatal complex anatomy on CT.\u003c/p\u003e\u003cp\u003eInability to comply with 6-month follow-up protocol.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical Technique\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll procedures were performed under general anesthesia. Nasal packing was done using lignocaine with adrenaline (1:100,000) for 15 minutes. No local anesthetic injection was used.\u003c/p\u003e\u003cp\u003eThe patient was positioned supine with the head elevated at a 15-degree angle on a head ring. A sinus balloon dilation catheter (Meril\u0026trade;, maxillary type, 110\u0026deg; angulation, 16 mm length) was used. After removing the nasal pack, a flexible guidewire was introduced through the nasal cavity into the maxillary sinus under endoscopic visualization.\u003c/p\u003e\u003cp\u003eTo confirm correct placement, room lights were turned off and transillumination of the maxillary sinus (maxillary glow) was observed. Once the natural ostium was delineated, the balloon catheter was advanced over the guidewire to the ostium and inflated to 12 atmospheres for 10 seconds to achieve dilation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic Profile of Chronic Rhinosinusitis Patients Undergoing Balloon Sinuplasty (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAge Group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u0026ndash;12 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (6.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u0026ndash;18 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14 (93.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8 (53.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (46.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14 (93.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eShopkeeper\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (6.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSide Involved\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBilateral (B/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11 (73.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeft (L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (26.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRadiological and Procedural Characteristics of Patients Undergoing Balloon Sinuplasty (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSINUS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14 (93.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (6.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eOMU\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12 (80.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003ePROCEDURE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB/L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11 (73.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (26.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Clinical Outcome Scores at Baseline and Follow-Up After Balloon Sinuplasty (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePRE OP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1st follow-up\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e2nd follow-up\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e3rd follow-up\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003ep-Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026plusmn;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026plusmn;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026plusmn;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026plusmn;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSNOT SCORE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e170.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVAS SCORE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e108.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLUND MACKAY CT SCAN SCORE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e78.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSN -5 SCORE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e.-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLUND KENNEDY SCORE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e47.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIncidence of Postoperative Complications Following Balloon Sinuplasty in Chronic Rhinosinusitis Patient\u003c/p\u003e\u003cp\u003eOut of 15 cases operated synechia was noted in two patients. No other complications were noted.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective study evaluates the safety, feasibility, and efficacy of balloon sinuplasty in the pediatric population with chronic rhinosinusitis without nasal polyps (CRSsNP). To our knowledge, this is the first prospective Indian study on this subject, addressing a notable gap in the literature.\u003c/p\u003e\u003cp\u003eDemographics and Disease Pattern\u003c/p\u003e\u003cp\u003eAs depicted in the Table number 1, pediatric chronic sinusitis was more prevalent among the adolescents compared to the younger children.. Most patients (93.33%) in our study were adolescents aged 13\u0026ndash;18 years, with a mean age of 15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14 years. Only one patient was below 12 years of age, reflecting the difficulty in encountering younger candidates meeting both the inclusion criteria and surgical candidacy in a real-world setting. A slightly higher proportion of patients were female (53.33%), and the majority were students (93.33%), as expected in this age group.\u003c/p\u003e\u003cp\u003eBilateral sinus involvement was seen in 73.33% of cases, with 26.67% having unilateral disease, indicating a diffuse disease pattern. As shown in Table number 2, radiologically, maxillary sinus disease was evident in 93.33% of patients, with 80% showing involvement of the ostiomeatal complex (OMC), supporting the theory that OMC obstruction plays a central role in pediatric CRS pathophysiology.\u003c/p\u003e\u003cp\u003eEfficacy of Balloon Sinuplasty\u003c/p\u003e\u003cp\u003eThe subjective and objective success rate after the balloon Sinuplasty is depicted by the Table number 3; multiple validated scoring systems were used to objectively assess outcomes, all of which demonstrated significant improvement:\u003c/p\u003e\u003cp\u003eSNOT-22 Score: Mean preoperative score was 41.80\u0026thinsp;\u0026plusmn;\u0026thinsp;9.53, which reduced to 4.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45 by the final follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating significant symptomatic relief and quality-of-life improvement.\u003c/p\u003e\u003cp\u003eVAS Score: Decreased from 5.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23 to 0.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), confirming reduction in perceived symptom severity.\u003c/p\u003e\u003cp\u003eLund-Mackay CT Score: Improved from 5.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79 to 1.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53 postoperatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reinforcing radiologic recovery.\u003c/p\u003e\u003cp\u003eLund-Kennedy Endoscopic Score: Showed a significant decline from 4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29 to 0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating mucosal healing.\u003c/p\u003e\u003cp\u003eSN-5 Score: Reduced from 7.00 to 3.00, reflecting improvement in pediatric sinus-specific quality-of-life, though detailed statistical analysis was not available.\u003c/p\u003e\u003cp\u003eOverall, 22 out of 24 sinuses (92%) remained patent at 6 months, confirming a high success rate.\u003c/p\u003e\u003cp\u003eThe two sinuses which were not patent, they were advised for the conventional endoscopic sinus surgery. The sinuses were addressed by uncinectomy and middle meatal antrostosomy. Careful post operative followup was advised by saline nasal wash for next three months. In one of the child; biopsy of the nasal mucosa showed inflammatory changes. In accordance with the EPOS 2020 guidelines, Clarithromycin 250 mg twice a day was given for next 3 months.[11]\u003c/p\u003e\u003cp\u003eSoler ZM et al. reported a significant improvement in SN-5 (mean score\u0026thinsp;=\u0026thinsp;1.7 postoperatively vs. mean score\u0026thinsp;=\u0026thinsp;4.8 preoperatively) [12]. In a prospective study conducted by Liu J et al., VAS score was significantly improved after the procedure (preop VAS score\u0026thinsp;=\u0026thinsp;17.86\u0026thinsp;\u0026plusmn;\u0026thinsp;7.59 vs. post op VAS score\u0026thinsp;=\u0026thinsp;1.68\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53) [13]. Additionally, findings of the two experimental controlled trials supported the aforementioned findings. [14,15]\u003c/p\u003e\u003cp\u003eSafety and Complications\u003c/p\u003e\u003cp\u003eThe procedure was well tolerated, with no major intraoperative or immediate postoperative complications. No cerebrospinal fluid (CSF) leak, orbital complications, or significant hemorrhage occurred. Nasal packing was not routinely used; one patient required packing for minor postoperative bleeding.\u003c/p\u003e\u003cp\u003eThe most common late complication was the development of synechiae, observed in 1 of the patients. These adhesions were managed with endoscopic release under anesthesia. Although balloon sinuplasty is minimally invasive, the synechiae may be attributed to the narrow nasal anatomy in pediatric patients and mucosal apposition during the healing phase.\u003c/p\u003e\u003cp\u003eIn reviewing other studies, the complication rates were very low. Only synechia was noted as a complication in the studies. [16,17]\u003c/p\u003e\u003cp\u003eContext and Relevance\u003c/p\u003e\u003cp\u003eBalloon sinuplasty was approved by the U.S. FDA in 2005 and has since been adopted worldwide, including in India. While it is widely studied in adults, pediatric data, especially from the Indian subcontinent, remain scarce. Clinical guidelines\u0026mdash;such as those from the AAO-HNS and EPOS\u0026mdash;primarily recommend adenoidectomy as first-line surgical treatment in pediatric CRS unresponsive to medical therapy. Balloon sinuplasty may be added, particularly in children without significant adenoidal hypertrophy. However, clear guidelines for children aged 12\u0026ndash;18 years are lacking.\u003c/p\u003e\u003cp\u003eIn our series, all patients were aged 11\u0026ndash;18 years. Despite the inclusion criteria allowing younger children, no patients under 11 years met the criteria during the study period. This highlights the selective nature of balloon sinuplasty in the pediatric cohort.\u003c/p\u003e\u003cp\u003eAdvantages of Balloon Sinuplasty\u003c/p\u003e\u003cp\u003eBalloon sinuplasty is a minimally invasive, anatomy-preserving procedure with several advantages:\u003c/p\u003e\u003cp\u003eNo mucosal or bony resection. Balloon Sinuplasty can be considered micro minimally invasive procedure which preserves the anatomy and the physiology of the sinuses\u003c/p\u003e\u003cp\u003eThe operative duration is short. Local anaesthesia is given by lignocaine application in the merocele. No local anaesthesia is injected. Short general anaesthesia is given for the dilation of the sinus. No nasal pack is used post operatively as there is no bleeding during the procedure.\u003c/p\u003e\u003cp\u003eMinimal bleeding and tissue trauma.\u003c/p\u003e\u003cp\u003eReduced anesthesia exposure.\u003c/p\u003e\u003cp\u003eSame-day or next-day discharge.\u003c/p\u003e\u003cp\u003eThese benefits are particularly important in the pediatric population, where preserving mucociliary function and minimizing postoperative morbidity is paramount.\u003c/p\u003e\u003cp\u003ePostoperatively, patients were advised to continue saline nasal irrigation and topical steroid spray for 12 weeks. Regular follow-up with nasal endoscopy and debridement ensured early detection and management of synechiae.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and Future Scope\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study is limited by a small sample size and short-term follow-up. Larger, multicenter studies with longer observation periods are necessary to validate these findings and establish standardized guidelines for pediatric balloon sinuplasty.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBalloon sinuplasty appears to be a safe, effective, and minimally invasive surgical option for managing chronic rhinosinusitis in selected pediatric patients. Its role is particularly promising in adolescents with CRSsNP who have failed conservative therapy and do not exhibit significant adenoidal hypertrophy or anatomical anomalies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics Approval and Consent to participate\u003c/h2\u003e\u003cp\u003e Statement on ethics approval and consent-include the name of the ethics committee that approved the study: Ethical approval was taken by the parent/ guardian of the children. The ethical committee approval no. : 161/2023-24 by Institutional Ethics Committee ( Uttar Pradesh University of Medical Sciences).\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe research did not receive any specific grant from the funding agencies in the public, commercial or not for profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRG: designing the studyJC: preparing the manuscriptVK: collecting data\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBrietzke SE, Shin JJ, Choi S, et al. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014;151:542\u0026ndash;553.\u003c/li\u003e\n \u003cli\u003eFokkens WJ, Viskens AS, Backer V, et al. EPOS 2020: integrated care pathways and paediatric CRS. Rhinol Suppl. 2020;29(1.7):102\u0026ndash;110.\u003c/li\u003e\n \u003cli\u003eAh-See KW, Evans AS. Sinusitis and its management. BMJ. 2007;334(7589):358\u0026ndash;361.\u003c/li\u003e\n \u003cli\u003eOrlandi RR, Kennedy DW. Surgical management of rhinosinusitis. Am J Med Sci. 1998;316(1):29\u0026ndash;38.\u003c/li\u003e\n \u003cli\u003eCultrara A, Goldstein NA, Ovchinsky A, Reznik T, Roblin PM, Hammerschlag MR. The role of Chlamydia pneumoniae infection in children with chronic sinusitis. Arch Otolaryngol Head Neck Surg. 2003;129(10):1094\u0026ndash;1097.\u003c/li\u003e\n \u003cli\u003eLusk R. Pediatric chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. 2006;14:393\u0026ndash;396.\u003c/li\u003e\n \u003cli\u003eMahdavinia M, Grammer LC. Chronic rhinosinusitis and age: is the pathogenesis different? Expert Rev Anti Infect Ther. 2013;11:1029\u0026ndash;1040.\u003c/li\u003e\n \u003cli\u003eSedaghat AR, Gray ST, Chambers KJ, et al. Sinonasal anatomic variants and asthma are associated with faster development of chronic rhinosinusitis in patients with allergic rhinitis. Int Forum Allergy Rhinol. 2013;3:755\u0026ndash;761.\u003c/li\u003e\n \u003cli\u003eFokkens WJ, Lund VJ, Hopkins C et al.European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology. 2020 Feb 20;58(Suppl S29):1-464. doi: 10.4193/Rhin20.600. PMID: 32077450.\u003c/li\u003e\n \u003cli\u003eGupta R. Balloon Sinuplasty: Our Experience. Indian J Otolaryngol Head Neck Surg. 2024;76(1):141\u0026ndash;144. doi:10.1007/s12070-023-04111-7. PMID:38440653; PMCID: PMC10909022.\u003c/li\u003e\n \u003cli\u003eFokkens WJ, Viskens AS, Backer V, et al. EPOS 2020: integrated care pathways and paediatric CRS. Rhinol Suppl. 2020;29(1.7):102\u0026ndash;110.\u003c/li\u003e\n \u003cli\u003eSoler ZM, Rosenbloom JS, Skarada D, Gutman M, Hoy MJ, Nguyen SA. Prospective, multicenter evaluation of balloon sinus dilation for treatment of pediatric chronic rhinosinusitis. Int Forum Allergy Rhinol. 2017;7(3):221\u0026ndash;229. doi: 10.1002/alr.21889. [DOI] [PMC free article] [PubMed] [Google Scholar]\u003c/li\u003e\n \u003cli\u003eLiu J, Zhao Z, Chen Y, Xu B, Dai J, Fu Y. Clinical curative effect and safety of balloon sinuplasty in children with chronic rhinosinusitis. Int J Pediatr Otorhinolaryngol. 2017;100:204\u0026ndash;210. doi: 10.1016/j.ijporl.2017.06.026. [DOI] [PubMed] [Google Scholar]\u003c/li\u003e\n \u003cli\u003eWang F, Song Y, Zhang X, Tan G. Sinus balloon catheter dilation in pediatric chronic rhinosinusitis resistant to medical therapy. JAMA Otolaryngol - Head Neck Surg. 2015;141(6):526\u0026ndash;531. doi: 10.1001/jamaoto.2015.0397. [DOI] [PubMed] [Google Scholar]\u003c/li\u003e\n \u003cli\u003eGerber ME, Kennedy AA. Adenoidectomy With Balloon Catheter Sinuplasty: A Randomized Trial for Pediatric Rhinosinusitis. Laryngoscope. 2018;128(12):2893\u0026ndash;2897. doi: 10.1002/lary.27270.\u003c/li\u003e\n \u003cli\u003eSoler ZM, Rosenbloom JS, Skarada D, Gutman M, Hoy MJ, Nguyen SA. Prospective, multicenter evaluation of balloon sinus dilation for treatment of pediatric chronic rhinosinusitis. Int Forum Allergy Rhinol. 2017;7(3):221\u0026ndash;229. doi: 10.1002/alr.21889. [DOI] [PMC free article] [PubMed] [Google Scholar]\u003c/li\u003e\n \u003cli\u003eLiu J, Zhao Z, Chen Y, Xu B, Dai J, Fu Y. Clinical curative effect and safety of balloon sinuplasty in children with chronic rhinosinusitis. Int J Pediatr Otorhinolaryngol. 2017;100:204\u0026ndash;210. doi: 10.1016/j.ijporl.2017.06.026\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric chronic rhinosinusitis, Balloon sinuplasty, Maxillary sinus, Minimally invasive surgery, SNOT-22, India.","lastPublishedDoi":"10.21203/rs.3.rs-6990998/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6990998/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChronic rhinosinusitis (CRS) in the pediatric population is multifactorial condition that significantly affects quality of life, leading to recurrent infections, nasal obstruction, sleep disturbances, and school absenteeism. Balloon sinuplasty has emerged as a minimally invasive alternative.However, its application in the pediatric population, particularly in the Indian context, remains underreported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAim\u003c/p\u003e\n\u003cp\u003eTo evaluate the clinical outcomes and safety profile of balloon sinuplasty in pediatric patients with chronic rhinosinusitis unresponsive to prolonged medical management.\u003c/p\u003e\n\u003cp\u003eA prospective observational study was conducted over a 24-month period from 15 January 2023 to 15 January 2025 in a tertiary care teaching hospital. Fifteen pediatric patients (aged 6 to 18 years) diagnosed with CRS, who failed to respond to at least 12 weeks of optimized medical therapy, were enrolled. All patients underwent balloon sinuplasty targeting the maxillary sinus ostia under general anesthesia. A total of 24 maxillary sinuses were dilated. Postoperative follow-up was conducted for 6 months, assessing symptom resolution using the Sinonasal Outcome Test-22 (SNOT-22), SN-5 Score, endoscopic evaluation for ostial patency, Lund Mac Kay CT Scan Score and monitoring for complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOstial Patency: At 6-month follow-up, 22 out of 24 treated sinuses (92%) remained patent.Symptom Improvement: The mean SNOT-22 score significantly improved from average 43 preoperatively to average 4 postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBSP is a safe, minimally invasive surgical option for managing pediatric CRS, especially in the 12–18 year age group. To the best of our knowledge, this is the first prospective Indian study evaluating balloon sinuplasty in the pediatric population.\u003c/p\u003e","manuscriptTitle":"Pediatric Balloon Sinuplasty: Our Institutional Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 12:34:23","doi":"10.21203/rs.3.rs-6990998/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d4a612d4-91af-4295-bd5e-5f363c6ee3f1","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T06:55:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-19 12:34:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6990998","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6990998","identity":"rs-6990998","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}