The role of mometasone furoate nasal spray in the treatment of adenoidal hypertrophy in the adolescents: a prospective, randomized, cross-over study

Eustachian Tube Dysfunction in Children with Adenoid Hypertrophy: The Effect of Intranasal Azelastine-Fluticasone Spray Treatment on Middle Ear Ventilation and Adenoid Tissue

OBJECTIVES

Eustachian tube dysfunction (ETD) is frequent in children with adenoid hypertrophy (AH). Although the most common treatment of AH is surgical removal of adenoid tissue, numerous studies have reported the efficacy of intranasal steroids. The effects of the intranasal steroid and azelastine combination on AH and ETD have not been reported before. In this study, we tried to determine the effects of 3-month intranasal Azelastine-Fluticasone dipropionate combination (Aze-Flu) treatment in children with ETD and AH.

MATERIALS AND METHODS

100 children who had open mouth sleep, snoring, and sleep apnea and were diagnosed with AH and ETD participated in this study. The mean age was 7.73 ± 2.37 (4-14 years). The rates of adenoid tissue hypertrophy and choanal occlusion were evaluated using a rigid pediatric nasal endoscope and reassessed after 3 months of Aze-Flu nasal spray treatment. The function of the Eustachian tube (ET) was evaluated before and after medical treatment using the Eustachian tube score, the Eustachian dysfunction test-7 (ETS-7) and tubomanometry (TMM).

RESULTS

The results were evaluated in 100 patients with AH and ETD. The adenoid tissue to choana rate was 82% before treatment and decreased to 37% after treatment. The ETS-7 test score was 6.36 before treatment and increased to 9.72 at the end of 3 months. Both the regression of the adenoid tissue and the improvement in the Eustachian function scores were statistically significant (p < 0.05).

CONCLUSIONS

AH significantly increases the frequency of ETD. In this study, it was observed that Aze-Flu treatment was significantly effective in both regression of the adenoid tissue and Eustachian tube dysfunction. We believe that it can be applied as an initial therapy in children with AH and associated ETD.

Role of Allergy in Eustachian Tube Dysfunction

PURPOSE OF REVIEW

Eustachian tube dysfunction (ETD) presents with symptoms of aural fullness and pressure, muffled hearing, tinnitus, and otalgia. When severe, it can lead to many common ear disorders such as otitis media with effusion, tympanic membrane retraction/perforation, and cholesteatoma. These diseases are prevalent in both the pediatric and adult population and significantly impact quality of life. The pathophysiology of ETD in the absence of an obstructive lesion has long been debated but is thought to be related to functional obstruction (i.e., inefficient tensor veli palatini muscle) and/or nasal cavity and nasopharyngeal inflammation. In the acute setting, the most common cause of nasal inflammation is an upper respiratory infection. When symptoms become chronic, however, the inflammation is thought to be associated with nasal irritants such as nasal allergens, i.e., allergic rhinitis (AR). The purpose of this review is to summarize our current understanding of the relationship between allergy and ETD.

RECENT FINDINGS

Past studies are either lacking or have reported equivocal findings regarding the relationship between allergy and ETD, and the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis has deemed the current level of evidence linking AR and ETD as low quality. A more recent study using a large adult population dataset did support an association between AR and ETD, but did not find that all cases of ETD are related to allergies. Furthermore, current evidence suggests that the use of medications that can decrease intranasal inflammation, such as intranasal corticosteroids or oral antihistamines, does not result in significant symptomatic improvement in patients with ETD. However, these studies included all patients with ETD, and evidence is lacking regarding the treatment effect of these medications on the subset of patients with concurrent AR and ETD. Current best evidence does support an association between AR and ETD; however, not all patients with ETD suffer from AR, and vice versa. Further research is necessary to understand the mechanism behind this positive association and to elucidate the cause of chronic ETD in patients without associated allergies.

The Proposed Usage of Intranasal Steroids and Antihistamines for Otitis Media with Effusion

PURPOSE OF REVIEW

To examine the role of allergy medications in the treatment of otitis media with effusion (OME), focusing on use of intranasal steroids and antihistamines.

RECENT FINDINGS

There has been ongoing controversy regarding the role of allergy in the development of OME. Treatment of OME with medications commonly used for allergic symptomatology has been studied. Proposed treatment options include decongestants, mucolytics, oral steroids, topical steroids, antihistamines, and antibiotics. We begin by evaluating the proposed association between allergy and OME, and then evaluate intranasal steroids and oral antihistamine therapy in the treatment of OME. The role of the adenoid and concurrent nasal symptomatology is also addressed. The preponderance of data suggests that neither intranasal steroids nor antihistamines improve the long-term clearance of isolated OME and are therefore not recommended. However, data are notably limited with regard to improvement rates in OME in patients specifically with concurrent allergy and/or adenoid hypertrophy. Future studies of medications for OME would ideally incorporate study designs controlling for both allergic rhinitis and adenoid hypertrophy, to better understand the impact of these medications on OME in these subgroups of patients.

Mometasone furoate intranasal spray is effective in reducing symptoms and adenoid size in children and adolescents with adenoid hypertrophy

INTRODUCTION

The use of mometasone furoate (MF) intranasal spray in treating adenoid hypertrophy (AH) has a variable outcome due the different methods of adenoid size evaluation. The aim of our study was to evaluate the effect of MF intranasal spray in children and adolescents with AH using a reliable and consistent endoscopic evaluation.

MATERIAL AND METHOD

A prospective interventional study was conducted. Evaluation took place during the first visit (week 0) and second visit (week 12). Symptoms of nasal obstruction, rhinorrhoea, cough and snoring were assessed, and an overall total symptoms score was obtained. A rigid nasoendoscopic examination using a four-grading system of adenoid size from 1 to 4 was performed. Patients were treated with MF intranasal spray for 12 weeks. Patients' aged 7-11-years old used 1 spray in each nostril once daily, while patients aged 12-17 used two sprays in each nostril once daily. Reassessment was carried out during the second visit (week 12).

RESULTS

A total of 74 patients was recruited. There were significant improvements from week 0 to week 12 in the symptoms' score for nose obstruction, rhinorrhoea, cough, snoring including the total nasal symptoms' score (p<0.001). AH significantly reduced in size from week 0 (2.89±.87) to week 12 (1.88±.83) (p<0.001).

CONCLUSION

MF intranasal spray is effective in improving the symptoms attributed to AH as well as reducing the adenoid size. MF intranasal spray is advocated as a treatment option before adenoidectomy is considered.

Evaluation of the effects of montelukast, mometasone furoate, and combined therapyon adenoid size: a randomized, prospective, clinical trial with objective data

Background/aim: The incidence of adenoid hypertrophy is 2%-3% in children. Adenoidectomy is a commonly performed procedure in children that may cause complications such as early or late bleeding (4%-5%), recurrence of adenoid tissue (10%-20%), and postoperative respiratory problems (27%). Therefore, medical therapy alternatives to adenoidectomy are important and must be tried before surgery. In this study, we investigated the efficacy of mometasone furoate, montelukast, and a combination of these drugs in pediatric patients with adenoid hypertrophy who were scheduled for reduction with medical therapy after not being recommended for surgery.Materials and methods: The study included 120 children with adenoid hypertrophy aged between 4 and 10 years. The patients were randomized into 4 separate groups, with 30 in each group. Group 1 received 100 μg of mometasone furoate per day, group 2 received 4/5 mg (for age) montelukast per day, and group 3 received mometasone furoate + montelukast. Medical therapy continued for 3 months in the treatment groups. Group 4, which comprised patients with mild symptoms, received no treatment and was the control group. The pre- and posttreatment adenoid tissue ratios in lateral neck radiographs were recorded in the four groups. Results: When radiologic measurements of adenoid-to-air passage were calculated, an improvement of 21.76% was observed in group 1 after treatment. The rate of improvement was 22.51% in group 2. There was a 21.79% reduction in adenoid size in group 3 after 3 months? treatment and 12.46% in the control group. There were statistically significant differences between pre- and posttreatment values in every single group administered corticosteroids, montelukast, and combined therapy (P < 0.05).Conclusion: According to our results, both montelukast and mometasone furoate therapies were similarly successful in treating adenoid hypertrophy. Combined therapy has no superiority over single-therapy treatment.

Intranasal Steroid Use for Otitis Media with Effusion: Ongoing Opportunities for Quality Improvement

Objectives Our objectives were (1) to assess patterns of intranasal steroid administration when otitis media with effusion (OME) has been diagnosed in children, (2) to investigate whether usage varies according to visit setting, and (3) to determine if practice gaps are such that quality improvement could be tracked. Study Design Cross-sectional analysis of an administrative database. Subjects and Methods National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005 to 2012; univariate, multivariate, and stratified analyses of intranasal steroid usage were performed. The primary outcome was intranasal steroid administration, and the primary predictor was a diagnosis of OME. The impact of location of service was also analyzed. Results Data representing 1,943,177,903 visits demonstrated that intranasal steroids were administered in 10.0% of visits in which OME was diagnosed, in comparison to 3.5% of visits in which OME was not diagnosed (univariate odds ratio, 3.07; 95% confidence interval [CI], 1.85-5.08; P < .001). After adjusting for age, sex, race/ethnicity, and other confounding conditions, multivariate analysis demonstrated that OME remained associated with an increase in intranasal steroid usage (odds ratio, 3.58; 95% CI, 1.60-8.01; P = .002). This practice pattern was more prevalent in the ambulatory office setting (risk difference 6.6%, P < .001) and less seen in a hospital-based office or emergency department. Conclusion Despite randomized controlled trials showing a lack of efficacy for isolated OME, nasal steroids continue to be used in treating children with OME in the United States. Related quality improvement opportunities to prevent usage of an ineffective treatment exist.

Combination of mometasone furoate and oxymetazoline for the treatment of adenoid hypertrophy concomitant with allergic rhinitis: A randomized controlled trial

In the clinic, approximately 30% of children with adenoid hypertrophy (AH) concomitant with allergic rhinitis (AR) report poor responses to intranasal steroids. To determine whether the combination of mometasone furoate (MF) and oxymetazoline (OXY) is more effective than either agent alone, we performed a two-stage, parallel, randomized, double-blind, double-dummy, clinical trial with 240 AH children with concomitant perennial AR. During the first stage, all children were randomly assigned to the MF or control group for six weeks of treatment. During the second stage, the non-responders from stage one were randomly assigned to 4 groups for 8 weeks of treatment that involved receiving the following treatments: MF/OXY, MF/placebo, placebo/OXY, or placebo/placebo. During the first stage of treatment, 39% of the responders treated with MF achieved greater reductions in total and individual symptom scores than did those on placebo. During the second stage of treatment, the nasal congestion scores of the MF/OXY group significantly decreased. The adenoid/choana ratio of the MF/OXY-treated group decreased and the nasal volume increased significantly. Our results suggest that the combination of OXY and MF is effective and safe for the treatment of AH children with concomitant AR and has a rapid onset of action.

Systematic review and meta-analysis of randomized controlled trials on the role of mometasone in adenoid hypertrophy in children

OBJECTIVES

Mometasone has been reported to improve the symptoms of nasal obstruction in children with adenoidal hypertrophy. This systematic review and meta-analysis were conducted to evaluate the role of mometasone on different nasal symptoms, otitis media with effusion, adenoid size, and quality of life in children with adenoidal hypertrophy.

METHODS

A comprehensive search of MEDLINE, EMBASE, CINAHL and COCHRANE Collaboration databases was undertaken. We identified all the randomized controlled trials (RCTs) in children with adenoidal hypertrophy that compared the effects of mometasone nasal spray and normal saline nasal spray on different outcomes. The deadline of the search was April 2015. The search was supplemented by hand searching of cross-references in the studies and reviews and by contacting the authors of various studies. Only English language RCTs were considered for the systematic review. The primary outcomes were improvement in symptoms of nasal obstruction, mouth breathing, rhinorrhea, snoring, cough, and total nasal symptoms. The secondary outcomes were improvement in otitis media with effusion, quality of life, and size of adenoid. Quality assessment of RCTs was performed using SIGN 50 and Cochrane risk of bias tools. Risk ratio (RR), weighted mean differences (WMD) and their 95% confidence intervals (CI) were calculated for dichotomous and continuous data, respectively. Random effects model was used for the analyses. Heterogeneity was measured by using the I(2) statistics and p value <0.05.

RESULTS

Our search generated 87 citations, of which eight RCTs met the inclusion criteria. The methodological quality of all the RCTs was poor. There was no significant difference between mometasone and control groups for the patient's characteristic and grades of different nasal symptoms, otitis media with effusion, obstructive sleep apnea, and quality of life at the basal level. There was also no significant difference in the number of patients with different symptoms at the basal level. After the administration of mometasone, there were significant improvements in grades of nasal obstruction, 0.8±0.5 versus 2.0±0.6, WMD -1.16 [-2.09, -0.23], snoring 0.3±0.4 versus 1.6±0.6, WMD -1.07 [-2.09, -0.05], total nasal symptoms 2.9±1.3 versus 6.9±1.5, WMD -4.09 [-6.64, -1.53], obstructive sleep apnea, 0.6±0.3 versus 1.4±0.4, WMD -0.95 [-1.74, -0.16], as well as the percentage of patients with nasal obstruction, snoring, obstructive sleep apnea, compared to control. There was tendency of improvement in rhinorrhea, and cough with mometasone. Compared to control, mometasone nasal spray significantly improved adenoid size or adenoid/choana ratio 50.9±8.8 versus 74.2±12.6, WMD -21.2 [-34.0, -8.4], change in adenoid/choana obstruction from the basal level (p=0.01), and percentage of patients with adenoid hypertrophy, 26% versus 92%, RR 0.29 [0.18, 0.48]. There was improvement in otitis media with effusion, 40% versus 72%, pure tone audiometry 5.2±11 versus 11.6±11dB, WMD -6.40dB [-12.65, -0.15], and quality of life with mometasone. Subgroup analyses showed that RCTs that followed blinding showed significantly less response compared to RCTs that did not follow it for most of the outcomes.

CONCLUSIONS

Mometasone caused improvements in outcomes of nasal obstruction, snoring, total nasal symptoms, pure tune audiometry, otitis media with effusion, adenoid size, and quality of life. The data is based on meta-analysis of RCTs of poor methodological quality. A high methodological quality, placebo controlled RCT of different doses and duration of administration of mometasone is required to evaluate its clear efficacy and safety in children with adenoid hypertrophy.

Does Atopy Influence the Effectiveness of Treatment of Adenoid Hypertrophy with Mometasone Furoate?

Background

The effect of topical mometasone for adenoid hypertrophy treatment is well established. Nevertheless, the influence of atopy on this treatment remains ill defined.

Objective

This study aims to compare the effects of topical mometasone furoate treatment on the adenoid tissue between atopic and nonatopic children.

Methods

Fifty-one children with obstructive respiratory complaints underwent a semistructured clinical questionnaire on nasal symptoms, prick test, and nasoendoscopy. Nasoendoscopic images were digitalized, and both adenoid and nasopharyngeal areas were measured in pixels; the relative adenoid/ nasopharyngeal area was calculated. Patients were initially treated for 40 days with nasal saline solution. In a subsequent 40-day period, topical mometasone furoate (total dose, 100 μg/day) was used.

Results

Topical mometasone significantly improved nasal obstruction, snoring, and apnea and also significantly reduced the adenoid tissue area related to the nasopharynx (p < 0.0001). Treatment with this glucocorticoid was not influenced by atopy, neither for symptoms nor for adenoid area.

Conclusion

Topical mometasone furoate significantly reduced the adenoid tissue area and led to a supplementary improvement ofnasal symptoms. This improvement was similar for atopic and nonatopic patients.