Utility of Nasal Debridement Following Pediatric Functional Endoscopic Sinus Surgery: A Scoping Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors present a litterture search of usefulness of second look in anesthesia in FESS operated children and conclude that studies are so heterogenous that no real conclusion can be drawn.

I agree. A difficult subject, and as the authors discuss, small children are quite different from 17 year olds. 

Paper is ok done, despite no conclusions can be drawn. It is a nice historic exposee. (but watch line 226, not year 1900, right?)

 

Author Response

Comment 1:

The authors present a litterture search of usefulness of second look in anesthesia in FESS operated children and conclude that studies are so heterogenous that no real conclusion can be drawn.

I agree. A difficult subject, and as the authors discuss, small children are quite different from 17 year olds. 

Paper is ok done, despite no conclusions can be drawn. It is a nice historic exposee. (but watch line 226, not year 1900, right?)

Response 1:

Thank you for your review and keen eyes. Previous line 226 (now line 231) has been corrected to say 1990s, not 1900s.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Autors

Thanks a lot for hard work. I read this article with interest. However, I have some concerns.

Kindly incorporate the responses within the manuscript to augment its overall quality.

In their introduction, the authors should emphasise the reduction in quality of life caused by chronic sinusitis.

They should state clear inclusion and exclusion criteria for the study group in the material. Papers based on an analysis of fewer than 50 cases should be excluded from the review group because of the low weight of evidence.

In the study group, the predominance of papers with US 75% is remarkable.  It is true that the USA has a large number of leading medical centres, but such an imbalance is not noticeable when analysing the world literature. The study should therefore be supplemented with articles from outside the USA.

Balloon sinuplasty should be analysed as one of the methods of sinus surgery in children.

The paper should use newer methods of statistical analysis than percentage analysis.

Literature should be supplemented with: https://doi.org/10.3390/jpm13040618; https://doi.org/10.3390/children8121133

This data is fundamental for the impact of this study on clinical practice.

Author Response

Comment 1: 

Dear Autors

Thanks a lot for hard work. I read this article with interest. However, I have some concerns.

Kindly incorporate the responses within the manuscript to augment its overall quality.

In their introduction, the authors should emphasise the reduction in quality of life caused by chronic sinusitis.

Response 1:

Thank you for your review and suggestions. We agree that reduction in quality of life caused by chronic sinusitis is important in children. Please see lines 46-48.

Comment 2:

They should state clear inclusion and exclusion criteria for the study group in the material. 

Response 2:

Thank you for your suggestions. We have included the inclusion and exclusion criteria (see lines 81 - 84): “Studies were included in analysis if and only if they explicitly addressed utilization of second-look endoscopy and debridement following pediatric FESS, or lack thereof. Studies not specifically mentioning or addressing second-look endoscopy and debridement or not involving pediatric population were excluded.”

Comment 3:

Papers based on an analysis of fewer than 50 cases should be excluded from the review group because of the low weight of evidence.

Response 3:

We agree that papers based on analysis of fewer than 50 cases carry low weight of evidence. However, given the paucity of data in this topic, we elected to include them in analysis for completeness.

Comment 4:

In the study group, the predominance of papers with US 75% is remarkable.  It is true that the USA has a large number of leading medical centres, but such an imbalance is not noticeable when analysing the world literature. The study should therefore be supplemented with articles from outside the USA.

Response 4:

We see significant value in world literature and their contribution to the field of pediatric otolaryngology. Unfortunately, we did not come across many world literature pertaining specifically to the utility of second-look endoscopy and debridement following pediatric FESS.

Comment 5:

Balloon sinuplasty should be analysed as one of the methods of sinus surgery in children.

Response 5:

While balloon sinuplasty is an important therapeutic modality of treating pediatric CRS, as this procedure does not often require post-operative debridement, this was not included in our analysis. However, we agree that this would be an interesting topic to investigate in the future.

Comment 6:

The paper should use newer methods of statistical analysis than percentage analysis.

Response 6:

We agree that our method of statistical analysis is rudimentary. However, due to heterogeneity of the reported outcomes, many of which were subjective in nature, we elected to be general and rudimentary in our analysis while focusing on qualitative insights from the included studies.

Comment 7:

Literature should be supplemented with: https://doi.org/10.3390/jpm13040618; https://doi.org/10.3390/children8121133

This data is fundamental for the impact of this study on clinical practice.

Response 7:

This paper is certainly important and should be incorporated in future studies looking at the outcomes of intervention in pediatric FESS. The paper has been cited in the introduction, line 48.

Reviewer 3 Report

Comments and Suggestions for Authors

This is a narrative review of “meticulous” debridement upon FESS in children. Authors conclude that the related studies have several methodological issues and the utility of second-look endoscopy and debridement upon FESS in children remains uncertain.  Although this is a “negative” conclusion, I believe it is useful for the readers, since they make readily available the related studies. Moreover, their writing and the structure of their review, particularly in the discussion, can keep the interest of the reader.   

My only concern is the method of the collection of the studies. Authors report that they used the Boolean method and relevant search term combinations, including “Debridement,” “Second-look,” “Functional endoscopic sinus surgery,” “Pediatric,” “Outcome,” and “Management,”. I believe that they should be more clear on their search terms and method that they have utilized.

I have noticed that all but two of the studies are from north America. Maybe a comment on this is needed e.g Europeans are more reluctant in offering FESS in children? Other reasons?

Author Response

Comment 1:

This is a narrative review of “meticulous” debridement upon FESS in children. Authors conclude that the related studies have several methodological issues and the utility of second-look endoscopy and debridement upon FESS in children remains uncertain.  Although this is a “negative” conclusion, I believe it is useful for the readers, since they make readily available the related studies. Moreover, their writing and the structure of their review, particularly in the discussion, can keep the interest of the reader.   

Response 1:

Thank you for your review and analysis

Comment 2:

My only concern is the method of the collection of the studies. Authors report that they used the Boolean method and relevant search term combinations, including “Debridement,” “Second-look,” “Functional endoscopic sinus surgery,” “Pediatric,” “Outcome,” and “Management,”. I believe that they should be more clear on their search terms and method that they have utilized.

Response 2:

Thank you for your comment. With Boolean method, we tried to convey that we used wide variety of keyword combinations to identify as many potential literature pertaining to second-look endoscopy and debridement in pediatric FESS as possible. More literature were identified when reviewing the reference of the initially identified studies and targeted searches were performed to ensure we were not missing more literature based on our readings and analysis of included studies.

Comment 3:

I have noticed that all but two of the studies are from north America. Maybe a comment on this is needed e.g Europeans are more reluctant in offering FESS in children? Other reasons?

Response 3:

Although it is certainly possible that Europeans are more reluctant to offer FESS in children, lack of more literature outside of North America may be due to narrow scope of our review in which we specifically analyzed studies mentioning intentional use or avoidance of metriculous debridement following pediatric FESS. Thus, we elected not to comment on practice pattern in non-north American countries due to fear of selection bias. But agree that this is certainly an interesting observation that needs more attention.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

I thank the authors for their corrections.

I would like to add to the discussion the limitations of the work, which should include the statements that

There were articles based on the analysis of less than 50 cases with low evidential weight.

The material analysed had a heterogeneity of reported outcomes, many of which were subjective in nature,

Author Response

Comment 1: I thank the authors for their corrections.

I would like to add to the discussion the limitations of the work, which should include the statements that

There were articles based on the analysis of less than 50 cases with low evidential weight.

The material analysed had a heterogeneity of reported outcomes, many of which were subjective in nature,

Response 1:

Thank you for your suggestions. Please see lines 437 - 440 with edits:

When considering the heterogeneity of outcomes, many of which were subjective in nature, drawing any meaningful conclusion becomes even more challenging, not to mention the evidential weight of some studies including less than 50 subjects. Nevertheless, some insights were made possible through this scoping review. For instance, 

Reviewer 3 Report

Comments and Suggestions for Authors

I have no further suggestions. their purpose and their method of the study is more clear now 

Author Response

Comment 1: I have no further suggestions. their purpose and their method of the study is more clear now 

Response 1: Thank you very much!