Endoscopic Sinus Surgery in Pediatric and Adult Patients: Anatomical, Pathophysiological, and Surgical Differences: A Review

Abstract Endoscopic sinus surgery (ESS) is an established treatment for selected sinonasal disorders in both pediatric and adult patients. However, age-related differences in paranasal sinus development, inflammatory mechanisms, disease characteristics, and available medical therapies influence surgical indications, techniques, and outcomes. This review aims to compare pediatric and adult ESS, with particular emphasis on anatomical development, pathophysiology, surgical indications, operative strategies, and clinical outcomes. A literature review was conducted using PubMed, Scopus, and Web of Science. English-language publications from January 2000 to July 2026 addressing pediatric or adult chronic rhinosinusitis (CRS), paranasal sinus anatomy and development, ESS indications and techniques, complications, and clinical outcomes were considered. Pediatric patients have incompletely developed paranasal sinuses, narrower surgical corridors, and age-dependent anatomical relationships that require a more conservative and mucosa-preserving surgical approach. Pediatric CRS is strongly influenced by viral infections, adenoid disease, allergic inflammation, developmental factors, and systemic disorders, whereas adult CRS is increasingly characterized according to inflammatory endotypes, particularly Type 2 and non-Type 2 inflammation. Pediatric ESS generally employs a conservative, mucosa-preserving approach, typically after failure of medical therapy and adenoidectomy, whereas adult procedures are often more extensive. Long-term evidence indicates that ESS does not negatively impact craniofacial growth and is associated with favorable outcomes in appropriately selected pediatric patients. Pediatric ESS should not be regarded as a simple adaptation of adult sinus surgery. Differences in sinus development, disease pathophysiology, treatment algorithms, and emerging targeted therapies require age-specific surgical decision-making. Contemporary management should integrate anatomical development with inflammatory endotyping, systemic disease, and evolving medical therapies when determining the role and extent of ESS.