The role of topical nasal steroids in the treatment of children with otitis media with effusion and/or adenoid hypertrophy

Management of chronic rhinosinusitis

: Chronic rhinosinusitis (CRS) in children is difficult to treat, with resultant frequent recurrences and failures. There are controversies in the treatment, mirroring the debate over the exact etiology of this disorder. The available medical treatments are antibiotics, topical nasal corticosteroids, and nasal lavage with saline solutions; though, there is no general agreement on the efficacy of the latter. The new technique of balloon sinuplasty allows ventilation to the sinuses to be restored with minimal risk and trauma to the tissues, and initial outcome seems promising, being successful in most treated children. Concerning the surgical approach, adenoidectomy is among the most frequent surgical procedures performed on children, but its therapeutic effect is controversial, because randomized studies have failed to prove that adenoidectomy alone is sufficient in curing CRS. Instead, functional endoscopic sinus surgery is a minimally invasive technique which restores the sinus ostia patency and can re-establish ventilation and drainage through the natural pathways. It is important that the effectiveness of any treatment is also evaluated by patient-reported outcomes (PROs) that refer to all health-related reports coming from the patients, without any involvement or interpretations by physician or others. Among PROs, health-related quality of life (HRQL) is the one most widely known and used. HRQL can be measured by means of validated questionnaires, which provide scores proportional to the degree of well-being perceived by patients. Concerning diseases of the upper airway including RS, there are numerous instruments specifically designed for children and caregivers, which allow to assess the effects of treatments in a more extensive and complete manner.

Objective reduction in adenoid tissue after mometasone furoate treatment

OBJECTIVE

Chronic rhinitis and adenoid hypertrophy are the main causes of nasal obstruction in children and proper treatment of these factors seem essential for controlling nasal obstructive symptoms. This study aims to evaluate the effects of topical mometasone treatment on symptoms and size of adenoid tissue in children with complaints of nasal obstruction and to compare this approach to continuous nasal saline douching plus environmental control alone.

METHODS

Fifty-one children with nasal obstructive complaints were submitted to a semi-structured clinical questionnaire on nasal symptoms, prick test and nasoendoscopy. Nasoendoscopic images were digitalized, and both adenoid and nasopharyngeal areas were measured in pixels. The relation adenoid/nasopharyngeal area was calculated. Patients were subsequently re-evaluated in two different periods: following 40 days of treatment with nasal douching and environmental prophylaxis alone; and after an subsequent 40 day-period, when topical mometasone furoate (total dose: 100μg/day) was superposed.

RESULTS

Nasal symptoms and snoring significantly improved after nasal douching, and an additional gain was observed when mometasone furoate was included to treatment. Saline douching did not influence the adenoid area, whereas a significant reduction on adenoid tonsil was observed after 40 days of mometasone treatment (P<0.0001).

CONCLUSION

Nasal saline douching significantly improved nasal symptoms without interfering in adenoid dimension. In contrast, mometasone furoate significantly reduced adenoid tissue, and led to a supplementary improvement of nasal symptoms.

Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children

BACKGROUND

Otitis media with effusion (OME) is common and may cause hearing loss with associated developmental delay. Treatment remains controversial.

OBJECTIVES

To examine the evidence for treating children with hearing loss associated with OME with systemic or topical intranasal steroids.

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 26 August 2010.

SELECTION CRITERIA

Randomised controlled trials of oral and topical intranasal steroids, either alone or in combination with another agent such as an oral antibiotic. We excluded publications in abstract form only; uncontrolled, non-randomised or retrospective studies; and studies reporting outcomes by ears (rather than children).

DATA COLLECTION AND ANALYSIS

The authors independently extracted data from the published reports using standardised data extraction forms and methods. We assessed the quality of the included studies using the Cochrane 'Risk of bias' tool. We expressed dichotomous results as a risk ratio (RR) and continuous data as weighted mean difference (WMD), both with 95% confidence intervals (CI). Where feasible we pooled studies using a random-effects model and performed tests for heterogeneity between studies. In trials with a cross-over design, we did not use post cross-over treatment data.

MAIN RESULTS

We included 12 medium to high-quality studies with a total of 945 participants. No study documented hearing loss associated with OME prior to randomisation. The follow-up period was generally limited, with only one study of intranasal steroid reporting outcome data beyond six months. There was no evidence of benefit from steroid treatment (oral or topical) in terms of hearing loss associated with OME. Pooled data using a fixed-effect model for OME resolution at short-term follow up (< 1 month) showed a significant effect of oral steroids compared to control (RR 4.48; 95% CI 1.52 to 13.23; Chi² 2.75, df = 2, P = 0.25; I² = 27%). Oral steroids plus antibiotic also resulted in an improvement in OME resolution compared to placebo plus antibiotic at less than one month follow up, using a random-effects model (RR 1.99; 95% CI 1.14 to 3.49; five trials, 409 children). However, there was significant heterogeneity between studies (P < 0.01, I² = 69%). There was no evidence of beneficial effect on OME resolution at greater than one month follow up with oral steroids (used alone or with antibiotics) or intranasal steroids (used alone or with antibiotics) at any follow-up period. There was also no evidence of benefit from steroid treatment (oral or topical) in terms of symptoms.

AUTHORS' CONCLUSIONS

While oral steroids, especially when used in combination with an oral antibiotic, lead to a quicker resolution of OME in the short term, there is no evidence of longer-term benefit and no evidence that they relieve symptoms of hearing loss. We found no evidence of benefit from treatment of OME with topical intranasal steroids, alone or in combination with an antibiotic, either at short or longer-term follow up.

The link between otitis media with effusion and allergy: a potential role for intranasal corticosteroids

We reviewed the evidence linking otitis media with effusion (OME) and atopy, with the goal of clarifying the possible role of intranasal corticosteroids (INSs) in OME treatment. In August 2009, the MEDLINE database was searched for primary studies on OME epidemiology, pathophysiology, and treatment. Relevant clinical guidelines were obtained. Interpreting OME research is complicated by variable disease definitions, patient populations, methodologies, and outcomes assessments, along with the possibility of spontaneous resolution. However, evidence links OME with atopic conditions including allergic rhinitis; observed prevalence of allergic rhinitis in patients with chronic or recurrent OME ranges from 24% to 89%. Such findings have prompted evaluations of common allergy medications for OME treatment. While short-term use of INSs alone or combined with antibiotics has shown benefit in some studies, more prolonged treatment protocols and long-term clinical outcomes will require critical assessment. Evidence suggesting epidemiologic and pathophysiologic links between allergy and OME has prompted investigation into a potential role for INSs in OME management, with promising initial results. Benefits of considering medical treatment in patients with OME prior to surgery include both the potential reductions in allergic inflammation and the naturally occurring spontaneous resolution of OME in these patients.

Role of intranasal topical steroid in pediatric sleep disordered breathing and influence of allergy, sinusitis, and obesity on treatment outcome

Objectives

To evaluate efficacy of short term intranasal corticosteroid (mometasone furoate) treatment in pediatric sleep-disordered breathing (SDB) patients.

Methods

A prospective, observational study was done. A total of 41 children (2-11 years old) were enrolled into this study. All patients received 4-weeks course of mometasone furoate 100 µg/day treatment. They were evaluated at pretreatment and immediately after treatment with obstructive sleep apnea (OSA)-18 quality of life survey and lateral neck X-ray. Also, the assessment of each patients included history, skin prick test or CAP test, and sinus radiography. We compared the OSA-18 survey score and adenoidal-nasopharyngeal (AN) ratio between before and after treatment.

Results

Total OSA-18 score and AN ratio decreased significantly after treatment regardless of allergy, sinusitis, and obesity (P=0.003, P=0.006). There was no complication after treatment of mometasone furoate.

Conclusion

Pediatric SDB patients with adenoid hypertrophy could be effectively treated with 4-weeks course of mometasone furoate. Allergy, obesity, and sinusitis did not affect on the result of treatment.

The effects of methylprednisolone, montelukast and indomethacine in experimental otitis media with effusion

OBJECTIVES

The present study aimed to investigate the effects of indomethacine, montelukast and methylprednisolone in management of experimental otitis media with effusion.

METHODS

Forty Wistar albino rats of which the weights ranged between 310 and 370 g were included in this study. Middle ear effusion was created by transtympanic histamine injection. The presence of effusion was confirmed by otomicroscopic examination. Thirty-seven rats with effusion were divided into 4 groups (methylprednisolone, montelukast, indomethacine and saline-control groups). All agents were administered for a period of consecutive 10 days. At the 11th days of administration, the recovery of effusion was confirmed by otomicroscopic examination. Tympanic bullae of the rats were removed and histopathological examinations were carried out. In the histopathological examination, the neutrophil leukocytes accumulated in the middle ear submucosa were counted.

RESULTS

The mean numbers of submucosal neutrophils in the methylprednisolone, montelukast, indomethacine, and saline groups were 24.6±8.1, 54.1±6.2, 52.3±7.3, 55.7±8.3, respectively. The otomicroscopic recovery rates of effusion in the methylprednisolone, montelukast, indomethacine, and saline groups were 18/18 (100%), 8/18 (44%), 2/14 (14%), 2/18 (11%) respectively.

CONCLUSIONS

Methylprednisolone and montelukast ameliorate the middle ear effusion. However, only methylprednisolone reduces the submucosal infiltration of the neutrophil leukocytes which are the most evident cell of inflammatory process. Montelukast is effective in the resolution of experimental otitis media with effusion.

Non-surgical treatment of adenoidal hypertrophy: the role of treating IgE-mediated inflammation

Adenoidal hypertrophy (AH) and adenotonsillar hypertrophy are common disorders in the pediatric population and can cause symptoms such as mouth breathing, nasal congestion, hyponasal speech, snoring, and obstructive sleep apnea (OSA), as well as chronic sinusitis and recurrent otitis media. More serious long-term sequelae, typically secondary to OSA, include neurocognitive abnormalities (e.g. behavioral and learning difficulties, poor attention span, hyperactivity, below average intelligence quotient); cardiovascular morbidity (e.g. decreased right ventricular ejection fraction, left ventricular hypertrophy, elevated diastolic blood pressure); and growth failure. Adenoidectomy (with tonsillectomy in cases of adenotonsillar hypertrophy) is the typical management strategy for patients with AH. Potential complications have prompted the investigation of non-surgical alternatives. Evidence of a pathophysiologic link between AH and allergy suggests a possible role for intranasal corticosteroids (INS) in the management of patients with AH. This article reviews the epidemiology and pathophysiology of AH with a particular focus on evidence of its association with allergy and allergic rhinitis. Current treatment options are briefly considered with discussion on the rationale and evidence for the use of INS.

Rhino-sinus involvement in children with obstructive sleep apnea syndrome

OBJECTIVE

Obstructive sleep apnea syndrome (OSAS) is commonly associated with adenotonsillar hypertrophy. We hypothesized that respiratory perturbations extend to other regions of the upper respiratory tract in such children, particularly to rhino-sinus regions.

STUDY DESIGN

A prospective case control study using Magnetic Resonance Imaging (MRI) of the upper airway and surrounding tissues of OSAS and controls. Magnetic resonance imaging was used to evaluate radiographic changes within the: paranasal sinuses, middle ear and mastoid air cells, and the nasal passages.

RESULTS

We studied 54 OSAS (age 5.7 ± 3.0 years) and 54 controls (age 6.2 ± 2.0 years, P = NS). Children with OSAS had significantly more opacification of: maxillary sinuses (P < 0.05), sphenoid sinuses (P < 0.01), and mastoid air cells (P < 0.01). They also had significantly more: middle ear effusions, (P < 0.001), prominence of inferior nasal turbinate(s) (P < 0.05), and deviation of the nasal septum (P < 0.05).

CONCLUSIONS

Childhood OSAS is associated with a wide range of upper respiratory tract perturbations and is not limited to adenoid and tonsillar hypertrophy.

Cost-utility analysis of topical intranasal steroids for otitis media with effusion based on evidence from the GNOME trial

OBJECTIVES

To estimate the cost-effectiveness of topical intranasal steroids for the treatment of otitis media with effusion (OME) in primary care from the perspective of the UK National Health Service.

METHODS

An economic evaluation was conducted based on evidence from the double-blind, randomized, placebo-controlled GPRF [General Practice Research Framework] Nasal Steroids for Otitis Media with Effusion (GNOME) trial. Participants comprised 217 children aged 4-11 years who had at least one episode of otitis media or related ear problem in the previous 12 months and had tympanometrically confirmed bilateral OME. Children were randomly allocated to receive either mometasone furoate 50 microg or placebo spray once daily into each nostril for 3 months. The main outcome measure was the incremental cost per quality-adjusted life-year (QALY) gained for topical steroids compared with placebo. The nonparametric bootstrap method was used to present cost-effectiveness acceptability curves at alternative willingness to pay thresholds.

RESULTS

Children receiving topical steroids accrued nonsignificantly higher costs (incremental cost/child: pound11, 95% confidence interval [CI]: - pound199 to pound222) and nonsignificantly fewer QALYs (incremental QALY gain/child: -0.0166, 95% CI: -0.0652 to 0.0320) than those receiving placebo. Topical steroids had a 24.19% probability of being cost-effective at a pound20,000 per QALY gained threshold, a 23.82% probability of being more effective and a 46.25% probability of being less costly. Sensitivity and subgroup analyses showed incremental costs and benefits to be highly sensitive to the methods used and the patient group considered, although differences between groups did not reach statistical significance in any analysis.

CONCLUSIONS

Topical steroids are unlikely to be a cost-effective treatment for OME in general practice.

Medical treatment of adenoid hypertrophy with "fluticasone propionate nasal drops"

BACKGROUND

Adenoid hypertrophy treatment for children is generally planned in accordance with the degree of airway obstruction and related morbidity. If surgical treatment is indicated, the individual risk/benefit analysis of patients should be assessed in terms of anesthetic and postoperative complications. Although there are few alternative treatment options, these may be considered as a nonsurgical approach in less serious cases. Accordingly, studies about intranasal steroid applications under various protocols have been presented.

STUDY DESIGN

The prospective, randomized, placebo-controlled study.

SETTING

Tertiary referral center.

PATIENTS AND METHODS

Patients indicated for surgery were randomly divided into two groups. The study group was treated by fluticasone propionate nasal drops (NSD-nasal steroid drops) of 400 microg/day for 8 weeks. The control group was treated by normal saline (NS) in the same way. All the patients were called for follow-up every 4 weeks.

RESULTS

At the end of 8 weeks, statistically significant improvement (p<0.05) was observed in the NSD treated group compared to the NS treated group in terms of nasal airway obstruction, mouth breathing, speech abnormalities, apnea and night cough. At the end of 8 weeks, the average total symptoms score of the NSD treated group dropped from 13.7 to 2.9 while the NS treated group's score changed from 14.8 to 14.6. After 8 weeks of NSD treatment the initial adenoid/choana (A/C) rate had dropped from 87 to 56% and a total decrease of 35.6% was observed. After 8 weeks of NS treatment the A/C rate dropped from 87 to 85% and a total decrease of 2.2% was observed.

CONCLUSIONS

In this study, the effect of fluticasone propionate nasal drops on adenoid hypertrophy is examined for the first time. This method provides an effective alternative to surgical treatment in children with adenoid hypertrophy. With the protocol applied in this study 76% of the patients were eliminated the surgery and removed from the surgical waiting list.

Allergic rhinitis in the child and associated comorbidities

Allergic rhinitis (AR) typically presents after the second year of life, but the exact prevalence in early life is unknown. AR affects 10-30% of the population, with the greatest frequency found in children and adolescents. It appears that the prevalence has increased in the pediatric population. As the childs' immune system develops between the 1st and 4th yr of life, those with an atopic predisposition begin to express allergic disease with a clear Th(2) response to allergen exposure, resulting in symptoms. In pediatric AR, two or more seasons of pollen exposure are generally needed for sensitization, so allergy testing to seasonal allergens (trees, grasses, and weeds) should be conducted after the age of 2 or 3 years. Sensitization to perennial allergens (animals, dust mites, and cockroaches) may manifest several months after exposure. Classification of AR includes measurement of frequency and duration of symptoms. Intermittent AR is defined as symptoms for <4 days/wk or <4 consecutive weeks. Persistent AR is defined as occurring for more than 4 days/wk and more than 4 consecutive weeks. AR is associated with impairments in quality of life, sleep disorders, emotional problems, and impairment in activities such as work and school productivity and social functioning. AR can also be graded in severity - either mild or moderate/severe. There are comorbidities associated with AR. The chronic effects of the inflammatory process affect lungs, ears, growth, and others. AR can induce medical complications, learning problems and sleep-related complaints, such as obstructive sleep apnea syndrome and chronic and acute sinusitis, acute otitis media, serous otitis media, and aggravation of adenoidal hypertrophy and asthma.

Topical intranasal corticosteroids in 4-11 year old children with persistent bilateral otitis media with effusion in primary care: double blind randomised placebo controlled trial

OBJECTIVE

To determine the clinical effectiveness of topical intranasal corticosteroids in children with bilateral otitis media with effusion.

DESIGN

Double blind randomised placebo controlled trial.

SETTING

76 Medical Research Council General Practice Research Framework practices throughout the United Kingdom, between 2004 and 2007.

PARTICIPANTS

217 children aged 4-11 years who had at least one practice recorded episode of otitis media or a related ear problem in the previous 12 months, and with bilateral otitis media with effusion confirmed by a research nurse using otoscopy plus micro-tympanometry (B/B or B/C2, modified Jerger types).

INTERVENTION

Mometasone furoate 50 microg or placebo spray given once daily into each nostril for three months.

MAIN OUTCOME MEASURES

Proportions of children cured of bilateral otitis media with effusion assessed with tympanometry (C1 or A type) at one month (primary end point), three months, and nine months; adverse events; three month diary symptoms. Results 41% (39/96) of the topical steroid group and 45% (44/98) of the placebo group were cured in one or both ears at one month (difference favouring placebo 4.3% (95% confidence interval -9.3% to 18.1%). Poisson regression was done with adjustment for four pre-specified covariates (clinical severity, P=0.003; atopy, P=0.67; age, P=0.92; season, P=0.71). The adjusted relative risk at one month was 0.97 (95% confidence interval 0.74 to 1.26). At three months, 58% of the topical steroid group and 52% of the placebo group were cured (relative risk 1.23, 0.84 to 1.80). Diary symptoms did not differ between the two groups, and no significant harms were reported.

CONCLUSIONS

Topical steroids are unlikely to be an effective treatment for otitis media with effusion in general practice. High rates of natural resolution occurred by 1-3 months.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38988331; National Research Register NO575123823; MREC 03/11/073.

Correlation between adenoid-nasopharynx ratio and endoscopic examination of adenoid hypertrophy: a blind, prospective clinical study

OBJECTIVE

To determine the reliability of adenoid-nasopharynx (A/N) ratio that is calculated on lateral cephalometric graphies for measuring the adenoid tissue size.

METHODS

85 patients that had been examined in our clinic with a prediagnosis of adenoid hypertrophy between June 2007 and March 2008 were included in the study. Local ethics committee approved the study protocol. Patients who had a previous adenoidectomy history and anatomic anomaly or acute infection in nose, palate or nasopharynx were excluded. Endoscopic nasal examination was done in all patients in addition to the routine ear nose throat examination. Lateral cephalometric graphs were obtained from all patients. Digital images obtained during endoscopic examination were evaluated on computer and obstruction ratios of adenoid tissue to choanal opening were calculated. Each cephalometric graph was evaluated by a blinded author. A/N ratio was calculated by dividing the distance from the outermost point of convexity of adenoid shadow to basiocciput to the distance between sphenobasiocciput and posterior end of hard palate (Fujioka Method). A/N ratio of each patient was then compared with the obstruction ratio obtained in nasal endoscopy. Pearson correlation test was used for statistical analysis and a p-value of <0.05 was accepted as significant.

RESULTS

There were 52 male and 33 female patients between the ages of 2 and 12 years (mean age, 5.0+/-2.2; median, 4.5). In nasal endoscopy, adenoid tissue was determined to obstruct the choanal opening as 88.5+/-12.0% (range, 51-99%) in an average. Mean adenoid nasopharynx ratio was found to be 0.87+/-0.1. There was a statistical significant correlation between A/N ratio and nasal endoscopic examination findings (r=0.511; p<0.0001).

CONCLUSIONS

A/N ratio is an easily applicable, noninvasive method that can correctly measure the size of the adenoid tissue in patients who are suspected to have adenoid hypertrophy.

[Aerosol therapy in treatment of childhood otitis media with effusion]

INTRODUCTION AND OBJECTIVES

We address the efficacy of aerosol therapy in the treatment of otitis media with effusion during childhood. We study audiometric recovery in comparison with other classic treatments.

MATERIAL AND METHODS

This is a retrospective analysis of 37 patients suffering from otitis media with effusion treated with aerosols. We analyze the pure tone audiometry gap results for the whole sample of patients. We also evaluate the characteristics of the group of patients that had previously required surgery and the group withdrawn from aerosol therapy for not responding.

RESULTS

Thirty seven patients with a mean age of 6.8 years met the inclusion criteria. Audiometric tests were performed at the beginning of the treatment and after one month, 3 months and finally 6-12 months. In audiometric terms, 76% of the patients achieved results similar to those obtained after surgery. Seven patients were withdrawn from treatment due to poor or no response to aerosol therapy or due to a lack of collaboration. Two patients developed complications not related to aerosol therapy (tympanic perforation and cholesteatoma pearl).

CONCLUSION

The efficacy of aerosol therapy is comparable to that obtained with classic treatments. We have found no differences in the outcomes obtained in the group previously treated with surgery. We found no indicators of poor response in those patients where the treatment failed.

Mometasone furoate nasal spray is safe and effective for 1-year treatment of children with perennial allergic rhinitis

OBJECTIVE

Perennial allergic rhinitis (PAR) affects children at a young age. Current guidelines recommend intranasal corticosteroids as the first-line treatment in patients with moderate-to-severe or persistent disease or in those who have congestion. In this study, the long-term safety and efficacy of mometasone furoate nasal spray (MFNS) were assessed in children with PAR.

METHODS

In this multicenter, active-controlled, evaluator-blind, 12-month study, 255 children aged 6-11 years with a >or=1-year history of PAR were randomized to receive once-daily MFNS 100 microg (n=166) or the active comparator beclomethasone dipropionate (BDP) 168 microg (n=85). Changes from baseline in overall PAR symptoms and response to treatment were rated at each visit. Cosyntropin stimulation testing, as well as tonometry and slit lamp procedures, were performed. Safety variables were assessed.

RESULTS

A total of 137 subjects in the MFNS group and 68 in the BDP group completed treatment. The mean reductions in physician- and subject-rated overall condition of PAR at week 52 were -42.1% and -39.7%, respectively, for MFNS, compared with -44.0% and -39.0%, respectively, for BDP. A total of 94% and 100% of MFNS and BDP subjects, respectively, reported adverse events (AEs), which were mostly mild or moderate. The most frequently reported treatment-related AEs in both groups were epistaxis, headache, and pharyngitis. Response to cosyntropin was normal and no posterior subcapsular cataracts were observed in either group. Although no significant changes in intraocular pressure were observed with MFNS, one subject receiving BDP demonstrated this effect.

CONCLUSIONS

Treatment with MFNS 100 microg once daily for 1 year was well tolerated in children 6-11 years old, with negligible systemic exposure and no evidence of suppression of the hypothalamic-pituitary-adrenal axis or ocular changes.

Using nasal steroids to treat nasal obstruction caused by adenoid hypertrophy: does it work?

OBJECTIVE

To systematically review the evidence for the usage of nasal steroids to improve symptoms of nasal airway obstruction in children with adenoidal hypertrophy.

DATA SOURCES

Published studies indexed in the MEDLINE (1951 to 2008), EMBASE (1974 to 2008), and the Cochrane databases (Issue 3, 2008).

REVIEW METHODS

Data from the included trials were extracted and trial quality was assessed. Meta-analysis was not applicable and data were summarized in a narrative format. Evidence from excluded studies was also discussed.

RESULTS

Seven studies (six randomized controlled trials and one cohort study) met the inclusion criteria of the review, including a total of 493 patients. Six of these studies demonstrated significant efficacy of various nasal steroids (mometasone, beclomethasone, flunisolide) in improving nasal obstruction symptoms and in reducing adenoid size, as measured with symptom scores and fiber-optic nasopharyngeal endoscopy, respectively. The response appeared to be a group effect and may be maintained longer-term by continuing nasal steroids at a lower maintenance dose. The treatment was safe and well-tolerated with few minor adverse events.

CONCLUSION

The available evidence suggests that nasal steroids may significantly improve nasal obstruction symptoms in children with adenoid hypertrophy. This improvement appears to be associated with a reduction of adenoid size. Evidence of long-term efficacy is limited but suggests that in many children maintenance therapy is needed if symptom-relief is to persist. Further studies are required to support the use of nasal steroids as a first-line approach in these children.

Correlation of diagnostic systems with adenoidal tissue volume: a blind prospective study

OBJECTIVES

To determine the correlation between adenoid tissue volume and three diagnostic methods of deciding whether to perform an adenoidectomy.

METHODS

The study used 152 patients (mean age, 5.8+/-2.5 years; age range, 2-12 years) who underwent an adenoidectomy at our clinic between April 2005 and April 2007. Patients requiring a revision operation and those with a cleft palate were excluded. To estimate the extent to which the adenoid narrowed the choana, an evaluation was made using nasal endoscopy (%), a mirror (%), and palpation (rated from 1 to 5) with the patient in Rose's position just before surgery. Postadenoidectomy tissue volume was measured (in cm(3)). The Spearman rank correlation and stepwise linear regression analyses were used to statistically evaluate the data.

RESULTS

Nasal endoscopy revealed that the choana was narrowed by the adenoid at an average of 86.6+/-13.1% (range, 50-99%). When viewing upward by a mirror, the choana was observed as being narrowed at an average of 44.2+/-30.2% (range, 5-100%). The mean palpation value was 3.2+/-1.4 (range, 1-5). The mean volume of adenoidal tissue measured was 1.8+/-0.8 cm(3) (range, 0.7-4.5 cm(3)). Nasal endoscopy was determined to be the best means of checking by the Spearman rank correlation. Mirror (R=0.64, P<.0001), palpation (R=0.62, P<.0001), and volume (R=0.62, P<.0001) were correlated with the nasal endoscopy; however, regression analysis found that only palpation (P=.003) and volume (P<.001) were independent variables affecting the image of nasal endoscopy, mirror inspection (P=.260) was not.

CONCLUSIONS

Nasal endoscopy is considered the most important tool to indicate adenoidectomy. This study showed that nasal endoscopy and palpation provide the most accurate determination of the volume of adenoidal tissues dissected by adenoidectomy.

Long-term follow-up of children undergoing topical intranasal steroid therapy for adenoidal hypertrophy

BACKGROUND

Encouraging results concerning chronic obstructive nasal symptoms due to adenoid in pediatric population were reported by use of intranasal steroid for short period. Up to now, no data are available about outcomes of such therapy after long-term follow-up. We evaluated the utility of mometasone furoate aqueous nasal spray in children with adenoidal hypertrophy in long-term maintenance therapy.

METHODS

All children affected by adenoidal hypertrophy and undergoing successful mometasone treatment for 4 months in a preceding trial were reassessed after a mean follow-up of 28 months. Based on the duration of maintenance therapy and eventual adenoid surgical treatment, three subgroups were identified: (1) children voluntarily suspending maintenance therapy and requiring surgery (Group A); (2) children continuing maintenance therapy but undergoing surgery (Group B); and (3) children continuing maintenance therapy but not undergoing surgery (Group C). Clinical and endoscopic evaluation in each group was compared to the assessment performed after the first 4 months of treatment.

RESULTS

Six patients (Group A) voluntarily suspended maintenance therapy and underwent adenoidectomy. Either the overall symptom score or choanal obstruction of this group worsened compared to the previous trial. Adenoidal surgery was performed in another three children (Group B) for ear disease. Chronic obstructive nasal symptoms and adenoid size were unchanged compared to the preceding study. Finally, 12 patients were in Group C. The overall symptom score and choanal obstruction of this group showed a further significant improvement at this stage.

CONCLUSIONS

This study describes the first long-term follow-up of children undergoing mometasone furoate aqueous nasal spray treatment for adenoidal hypertrophy. Voluntary suspension of maintenance therapy favors surgery of this disorder, whereas its regular administration may lead to successful results.

Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy

BACKGROUND

Adenoidal hypertrophy is generally considered a common condition of childhood. When obstructive sleep apnoea or cardio-respiratory syndrome occurs, adenoidectomy is generally indicated. In less severe cases, non-surgical interventions may be considered, however few medical alternatives are currently available. Intranasal steroids may be used to reduce nasal airway obstruction.

OBJECTIVES

To assess the effectiveness of intranasal corticosteroids for improving nasal airway obstruction in children with moderate to severe adenoidal hypertrophy.

SEARCH STRATEGY

Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2007), MEDLINE (1951 to 2007) and EMBASE (1974 to 2007). All searches were initially performed in May 2007 and updated in April 2008.

SELECTION CRITERIA

Randomised controlled trials comparing intranasal corticosteroids with placebo or no intervention or other treatment in children aged 0-12 years with moderate to severe adenoidal hypertrophy.

DATA COLLECTION AND ANALYSIS

Data from the included trials were extracted and trial quality was assessed by two authors independently. Meta-analysis was not applicable and data were summarised in a narrative format.

MAIN RESULTS

Five randomised trials, including a total of 349 patients, met the inclusion criteria of the review. All trials except one showed significant efficacy of intranasal corticosteroids in improving nasal obstruction symptoms and in reducing adenoid size. The first eight-week cross-over study showed that treatment with beclomethasone (336 micrograms/day) yielded a greater improvement in mean symptom scores than placebo (-18.5 vs. -8.5, P < 0.05) and a larger reduction in mean adenoid/choana ratio than placebo (right, -14% vs. +0.4%, p=0.002; left, -15% vs. -2.0%, p=0.0006) between week 0 and week 4. The second four-week cross-over study demonstrated that the nasal obstruction index decreased by at least 50% from baseline in 38% of patients treated with beclomethasone (400 micrograms/day) between week 0 and week 2, whereas none of the patients treated with placebo had such improvement (p<0.01). The third randomized, parallel-group trial showed that 77.7% of patients treated with mometasone (100 micrograms/day) for 40 days demonstrated an improvement in nasal obstruction symptoms and a decrease in adenoid size, such that adenoidectomy could be avoided, whereas no significant improvement was observed in the placebo group. The fourth randomized, parallel-group trial showed that eight-weeks of treatment with flunisolide (500 micrograms/day) was associated with a lager reduction in adenoid size than isotonic saline solution (p<0.05). In contrast, one randomised, parallel-group trial did not find significant improvement in nasal obstruction symptoms and adenoid size after eight weeks of treatment with beclomethasone (200 micrograms/day).

AUTHORS' CONCLUSIONS

Limited evidence suggests that intranasal corticosteroids may significantly improve nasal obstruction symptoms in children with moderate to severe adenoidal hypertrophy, and this improvement may be associated with a reduction of adenoid size. The long-term effect of intranasal corticosteroids in these patients remains to be defined.

Intranasal flunisolide treatment in children with adenoidal hypertrophy

Adenoidal hypertrophy (AH) represents one of the most frequent indications for surgery in children and it has been proposed that treatment with intranasal corticosteroids can decrease the size of AH. Therefore, the aim of the study is to evaluate the effect of the use of intranasal flunisolide among children affected by AH. 178 children with AH were evaluated in this randomised and controlled study. Inclusion criteria for the study required that each patient had to have a III or IV degree of AH on the initial endoscopic examination. Children were treated with intranasal flunisolide or isotonic saline solution for 8 weeks. After treatment, endoscopy was performed to re-evaluate AH degree. Flunisolide treatment was associated with significant (p less than 0.04) reduction of AH degree. There was moreover a consistent reduction of children (46 out of 58) proposed to adenoidectomy. No clinically important adverse events were reported. In conclusion, this preliminary study demonstrates that an 8-week treatment with intranasal flunisolide is significantly associated with reduction of AH, thus preventing the recurrence to adenoidectomy, and is safe.

The influence of birch pollination on the adenoid size in children with intermittent allergic rhinitis

INTRODUCTION

Allergic sensitization of the airways occurs not only in the mucosa of the shock organ, but also in the lymphatic stations draining these structures. The lymphatic structure closest to the nasal mucosa in humans is the adenoid. Many researches show that in part of children allergic rhinitis can be a risk factor for adenoid hypertrophy.

MATERIALS AND METHODS

We used acoustic rhinometry and endoscopy to evaluate the influence of the birch pollination on the adenoid size in 67 children between 5 and 12 years old. Four separate groups of children were examined. The study group consisted of 28 children hypersensitive to tree pollen with seasonal allergic rhinitis (interview, positive skin prick test results, presence of sIgE in the serum and positive nasal provocation test with birch pollen allergens). The first control group consisted of 14 atopic children hypersensitive to motherwort pollen. The second control group consisted of 15 non-atopic children. The third control group consisted of 10 children hypersensitive to tree pollen, they have got anti-allergic treatment (topical nasal steroid and antihistaminic) a week before birch pollination. In all of the groups the adenoid size was examined before, during and after birch pollination. In the study group, we examined the influence of specific nasal provocation test on the adenoid size too.

RESULTS

In most children from the study group (71.4%) we observed the significant increase of adenoid size in endoscopic examination and decrease of nasopharyngeal cavity volume in acoustics rhinometry (92.9%) during the birch pollination. The changes returned after pollination period in most children (90%). In the first and the second control group there were almost no changes observed (p>0.05). The medical treatment used in the third control group avoided the increase of adenoid size during birch pollination season. In the study group there was no statistically significant correlation between the changes in nasopharyngeal volume during the pollination period and the results of nasal provocation test (r=0.18).

CONCLUSION

The result of our study suggests that in children with seasonal allergic rhinitis the exposure on the allergenic factor can influence the adenoid size. Properly administered nasal glucocorticoid together with antihistaminic in standard doses can probably avoid this effect.

The role of mometasone furoate aqueous nasal spray in the treatment of adenoidal hypertrophy in the pediatric age group: preliminary results of a prospective, randomized study

OBJECTIVE

We evaluated the efficacy of mometasone furoate aqueous nasal spray in decreasing adenoid size and reducing the severity of chronic nasal obstruction symptoms in children affected by adenoidal hypertrophy.

METHODS

Sixty children were recruited in a 2-stage, randomized, placebo-controlled trial. All patients complained of chronic nasal obstruction symptoms, and nasal endoscopy showed >75% choanal obstruction attributable to adenoid pads. In the first stage, 30 patients (group A) underwent mometasone treatment (50 microg per nostril per day) for 40 days, and 30 children (group B) received placebo. In the second stage, at the end of the first 40-day treatment period, patients in group A who showed subjective and objective clinical improvement were divided into 2 subgroups; group A1 (11 children) received topical intranasal steroid treatment on alternate days for the first 2 weeks per month, whereas group A2 (10 children) continued daily mometasone treatment for the first 2 weeks per month. After 3 months, all children were reassessed.

RESULTS

Fifty-seven children completed the study according to the protocol. After the first treatment period, the severity of symptoms and adenoid size decreased for 21 patients (77.7%) in group A. No improvement was observed in the placebo group. After 3 months of additional therapy, group A2 patients demonstrated a more-pronounced reduction in adenoid size compared with group A1 patients. No statistically significant change in symptoms was identified. Mometasone treatment was well tolerated by all patients.

CONCLUSIONS

Mometasone furoate aqueous nasal spray may be considered useful in decreasing adenoid pad size and the severity of symptoms related to adenoidal hypertrophy. Children with adenoidal hypertrophy that is not associated with tonsillar hypertrophy should be considered for intranasal mometasone treatment before surgery is planned.

The Role of Mometasone Furoate Aqueous Nasal Spray in the Treatment of Adenoidal Hypertrophy in the Pediatric Age Group: Preliminary Results of a Prospective, Randomized Study

OBJECTIVE. We evaluated the efficacy of mometasone furoate aqueous nasal spray in decreasing adenoid size and reducing the severity of chronic nasal obstruction symptoms in children affected by adenoidal hypertrophy.

METHODS. Sixty children were recruited in a 2-stage, randomized, placebo-controlled trial. All patients complained of chronic nasal obstruction symptoms, and nasal endoscopy showed &gt;75% choanal obstruction attributable to adenoid pads. In the first stage, 30 patients (group A) underwent mometasone treatment (50 μg per nostril per day) for 40 days, and 30 children (group B) received placebo. In the second stage, at the end of the first 40-day treatment period, patients in group A who showed subjective and objective clinical improvement were divided into 2 subgroups; group A1 (11 children) received topical intranasal steroid treatment on alternate days for the first 2 weeks per month, whereas group A2 (10 children) continued daily mometasone treatment for the first 2 weeks per month. After 3 months, all children were reassessed.

RESULTS. Fifty-seven children completed the study according to the protocol. After the first treatment period, the severity of symptoms and adenoid size decreased for 21 patients (77.7%) in group A. No improvement was observed in the placebo group. After 3 months of additional therapy, group A2 patients demonstrated a more-pronounced reduction in adenoid size compared with group A1 patients. No statistically significant change in symptoms was identified. Mometasone treatment was well tolerated by all patients.

CONCLUSIONS. Mometasone furoate aqueous nasal spray may be considered useful in decreasing adenoid pad size and the severity of symptoms related to adenoidal hypertrophy. Children with adenoidal hypertrophy that is not associated with tonsillar hypertrophy should be considered for intranasal mometasone treatment before surgery is planned.

Allergic rhinitis and its impact on otorhinolaryngology

Allergic rhinitis (AR) is a disease with growing impact on everyday medical practice, as its prevalence has steadily increased during the last decades. Immunoglobulin-E (IgE)-mediated airway inflammation may manifest itself as AR, asthma or both. Allergic inflammation in upper and lower airways is now considered as one airway disease, with manifestation of symptoms in upper, lower or global airway. This insight into allergic inflammation of the whole respiratory tract has consequences for the diagnostic and therapeutic approach of affected patients, as highlighted in the ARIA document. In contrast to asthma, the link between AR and associated conditions in the upper airways like rhinosinusitis, nasal polyps, recurrent viral infections, adenoid hypertrophy, tubal dysfunction, otitis media with effusion and laryngitis remains less explored. It is however of utmost importance to consider the aetiological role of IgE-mediated inflammation of the nasal mucosa in several diseases of the upper respiratory tract, as they represent a large body of patient population seen by the general practitioner as well as the paediatrician, allergologist and otorhinolaryngologist. We here aim at reviewing the current literature on the relationship between AR and conditions in upper airways frequently encountered in everyday clinical practice, and highlight the need for further studies exploring the role of allergic inflammation in the development of these diseases.