Measuring the correlation between adenoidal-nasopharyngeal ratio (AN ratio) and tympanogram in children

Radiological and Audiological Assessment in Patients with Adenoid Hypertrophy Undergoing Adenoidectomy

Enlarged adenoids in children can lead to obstruction of the ET, leading to negative intratympanic pressure and development of Otitis media effusion. Adenoid-nasopharyngeal ratio (ANR) on lateral radiograph of nasopharynx, is one of the most reliable and cost-effective ways of determining the size of adenoids with respect to the nasopharyngeal space. Patients who were clinically diagnosed with adenoid hypertrophy, above the age of 5 years, undergoing adenoidectomy were included in the study. Lateral nasopharynx radiograph, Pure tone audiometry (PTA) and tympanometry were performed. The ANR calculated, graded, and compared with the PTA, tympanograms and size on endoscopic assessment. Taking 0.835 as cut-off value, significant correlation of ANR with PTA and impedance (p = 0.002) was found. 71% abnormal PTA and tympanogram was found with ANR > 0.835 whereas 30.8% with ANR < 0.835. ANR is a useful adjunct as a pre-operative tool for determining the need for adenoidectomy in paediatric patients who are not easily willing to undergo endoscopic evaluation. A major drawback is the lack of identification of lateral extent of adenoids.

Correlative Multicentric Analysis of Dimensions of Nasopharynx and Adenoid Size, and its Burden in Otitis Media with Effusion: An Indian Scenario

Diseases of adenoids are commonly observed in children. It indirectly leads to pathology in the middle ear cleft. It has been demonstrated both by radiological techniques and middle ear pressure studies that adenoids can and do obstruct the Eustachian Tube. The Adenoid-Nasopharyngeal Ratio (ANR), can offer a simple arithmetic measure of nasopharyngeal obstruction. Coupled with tympanometry, it also predicts the degree to which the middle ear is affected. Multicentric study done at two centres in India. 230 patients were studied. Children were in the age group of 5-14 years. The nasopharyngeal and adenoid dimensions were measured separately using the Fujioka method. The adenoid-nasopharyngeal ratio was derived by the arithmetic method. All patients were also subjected to tympanometry. ANR decreased from 0.728 to 0.663 with an increase in age from 5 to 12 years. ANR between 0.701-0.800 had maximum number of Type B (140) and Type C (71) Tympanogram whereas between 0.801 and 0.900, all Tympanogram were found to be of Type B or Type C with none belonging to Type A. Using ANR and Tympanometry, the effects of the adenoids on the middle ear can be quantified indirectly. Both these modalities are easily available, economical, safe and can be performed at the Out Patient Level. This aids in timely and appropriate management thus preventing discomforting symptoms caused by the adenoids locally and also the morbidity caused to the middle ear in the long term.

Clustering upper airway physicals, otitis media with effusion and auditory functions in children

OBJECTIVE

Adenoid hypertrophy (AH) has been identified as a cause of otitis media with effusion (OME), which is the most common cause of childhood hearing loss. Indeed, there may be other upper airway-related predisposing factors such as, location of the adenoid, accompanying tonsillar hypertrophy (TH) and nasal septal deviation (NSD) for the development of OME. In this study, we aimed to evaluate the associations between the upper airway physicals and OME with auditory functions.

METHODS

Eighty-six ears of 43 children, aged 3-11 years were included in this prospective clinical study. Findings of otolaryngologic examinations were noted. Data of pure tone audiometry (PTA), traditional tympanometry (TT) and wideband tympanometry (WBT) parameters were collected. Cluster analysis was performed to the following variables: age, sex; the adenoid choana percentage (ACP), the presences of adenoid around torus tubarius (AATT), TH, NSD and OME; peak pressure (PP) values on TT, resonance frequencies (RF) on WBT, ambient pressure absorbance ratios (APAR) and PTA hearing thresholds.

RESULTS

Two groups of ears revealed by clustering; cluster-1 (n = 46) and cluster-2 (n = 40), at the similarity level of 0.662. The presences of AH, AATT, OME and the medians of ACP, PP, RF, WBT APARs at all frequencies except 5656 Hz and 8000 Hz, all PTA thresholds were significantly different between two clusters (p < 0.05). The lower WBT APARs and higher PTA thresholds were associated with higher levels of ACP and higher frequencies of the presence of AATT and OME in cluster-1.

CONCLUSION

There are associations between AH, AATT and OME together with decline in hearing and SEA. Whereas, TH and NSD are not related to the formation of clusters and they are insignificant factors.

Rising Resonance Frequency Is the Sole Sign of Early Middle Ear Disease in Children With Adenoid Hypertrophy

OBJECTIVE

The present study seeks to estimate the potential of multifrequency tympanometry in the diagnosis of primal otologic disorder in children with adenoid hypertrophy (AH).

STUDY DESIGN

Prospective observational study.

SETTING

Tertiary pediatric institution.

PATIENTS

One hundred thirty-one children presenting consecutively at the otolaryngology clinic were divided on the basis of AH into 98 patients and 33 controls.

INTERVENTIONS

Middle ear status was assessed using pneumatic otoscopy, standard, and wide band tympanometry.

MAIN OUTCOME MEASURES

Tympanogram type/intratympanic pressure, and resonance frequency (RF) were correlated with each other as well as with a set of clinical parameters. Receiver operating characteristic analysis was employed to reveal the diagnostic value of RF.

RESULTS

Mean RF declined in chronic otitis media with effusion by 43.25% (p < 0.001). In our entire cohort, children with AH under the age of 7 years presented with a relative risk = 2.43 of producing "B" tympanogram (p = 0.016) than their older peers. In patients' ears with normal, type "A," tympanogram, RF was the sole tympanometric marker of AH, being elevated by 28.26% in mean value (p = 0.010). On receiver operating characteristic analysis of RF's discriminating capability, the area under the curve was equal to 0.647 (p = 0.010). The optimal cut-off value of RF was set at 899 Hz.

CONCLUSION

AH may induce middle ear stiffening, as RF's increase indicates. Wide band tympanometry output could be a warning sign of ongoing compliance reduction to the sound transmission apparatus, at a time point when physical examination and 226 Hz tympanometry are still unremarkable.

Two-dimensional upper airway normative values in children aged 7 to 17 years

Objective: To develop two-dimensional (2D) upper airway normative values in pediatric patients and correlate upper airway measurements with age.Methods: Cone beam computed tomography scans of 3738 patients were examined, and a sample of 61 patients, divided into two age groups (7-11 and 12-17 years), w used to reconstruct lateral cephalograms.Results: The mean adenoid-nasopharynx (A/N) ratio was 0.45 and 0.44 for age groups 1 and 2, respectively. The mean PNS-ad1 and PNS-ad2 were 24 and 18.7 mm, respectively, for age group 1, and 26.7 and 21.2 mm, respectively, for age group 2. Additional normative values for the hyoid bone, airway space, uvula, and tongue are presented. The highest correlation with age was the upper airway length (r = 0.557, p < 0.001).Conclusion: Although cephalometric radiographs remain 2D reconstructions of three-dimensional structures, they have significant value and can aid clinicians in the screening process for pediatric sleep apnea.

Asymptomatic Otitis Media With Effusion in Children With Adenoid Enlargement

OBJECTIVES

To estimate the burden, and clinical factors associated with development of Otitis media with effusion (OME) in children with enlarged adenoids.

METHODS

Consecutive eligible patients with adenoid (sometimes with tonsillar) enlargement managed operatively in a period of five years. Patients had no complaints suggestive of hearing impairment. Age, sex, clinical diagnosis, and weight of patients were recorded. Otoscopic, audiometric, and radiological examinations findings were recorded. Tympanometry patterns were classified according to Jerger's classification; type B and C tympanograms represented OME. Some patients had Pure Tone Audiometry (PTA). Plain nasopharyngeal X-ray assessed the adenoid: nasopharyngeal (AN) ratio with >0.5 regarded as obstructive adenoid.

RESULTS

216 ears of 108 children were assessed. 49.1% of children were in age range 1-3 years, mean 3.6 ± 2.6 years. 62.0% were males, weight ranged from 7.8 to 31.0 kg, mean was 14.3 ± 5.2 kg. 63.9% had associated tonsillar enlargement. Mean AN ratio was 0.69 ± 0.07. Tympanometric findings showed prevalence of OME in all ears was 63/216 = 29.2%, consisting of 30.5% with unilateral (Right ear 19.4%, Left ear 11.1%), and 13.9% with bilateral OME. Acoustic reflexes were absent in both ears in 32 (29.6%) of the patients. There was normal hearing in 16/38 ears (42.1%), while others had different types of hearing loss. Two factors namely increased age and weight were significantly associated with OME in patients with Adenoid enlargement.

CONCLUSIONS

29.2% of children with adenoid enlargement had a co-morbidity of asymptomatic OME. The factors associated with OME were increased age and weight of the patients.

The effect of adenoid hypertrophy on hearing thresholds in children with otitis media with effusion

INTRODUCTION

Otitis media with effusion is common middle ear mucosa disease that can cause hearing loss in children. Adenoid hypertrophy can cause recurrent acute otitis media in addition to otitis media with effusion as a result of eustachian tube dysfunction and primary infection focus. The aim of this study was to investigate the effect of adenoid hypertrophy on the hearing threshold in children suffering from otitis media with effusion.

METHODS

Children of school age with otitis media with effusion were included in the study. The size and location of the adenoid tissue were determined by examination with a flexible endoscope. Four adenoid size groups were determined according to the percentage of choanal closure. The coverage was 0-25% in the first group, 26-50% in the second group, 51-75% in the third group and 76-100% in the 4th group. The location of the adenoid tissue in the nasopharynx was divided into three groups. In group A, the adenoid tissue was not in contact with torus tubarius. In group B, the adenoid tissue was in contact with the torus tubarius but did not cover it. In group C, the adenoid tissue covered the torus tubarius completely. Bone and air conduction thresholds were determined using standard procedures. The statistical relationship between the size and location of adenoid tissue and the hearing thresholds was investigated.

RESULTS

The study was conducted with the 88 ears of 50 children aged 5-15 years. The median values of mean air conduction thresholds at 500 Hz, 1000 Hz, and 2000 Hz in the adenoid tissue size groups 1-4 were 22 dB HL, 20 dB HL, 15 dB HL, and 20 dB HL respectively. The median values of the mean air conduction thresholds were 20 dB HL, 20 dBHL and 18 dB HL in the adenoid location group A-C, respectively. No significant correlation was found between the groups (p:0.213) and the relevant hearing values (p:0.670). Type B tympanogram was identified in 46 ears and type C tympanogram in 42 ears. The mean hearing thresholds were significantly higher in the ears with a type B tympanogram in the otitis media with effusion cases. (P < 0.001).There was no significant correlation between the duration of effusion and the adenoid size (p:0.931), adenoid location (p:0.626) and hearing threshold (p:0.815).

CONCLUSION

We concluded that adenoid tissue size and location have no effect on hearing thresholds and the duration of effusion in otitis media with effusion. We suggest caution before deciding on adenoidectomy in otitis media with effusion cases. Adenoidectomy should not be performed in children over 4 years of age unless there is a definite indication such as nasal obstruction or chronic adenitis.

The prevalence and impact of otitis media with effusion in children admitted for adeno-tonsillectomy at Dr George Mukhari Academic Hospital, Pretoria, South Africa

INTRODUCTION

Otitis media with effusion (OME) is a leading cause of acquired hearing loss in children worldwide. However, previous South African studies have consistently reported the local paediatric OME prevalence to be lower than typically published in international literature. Furthermore, no South African studies have investigated OME in children with adenotonsillar hypertrophy. The objective of this study was to determine the prevalence of OME in children admitted for adeno-tonsillectomy at our institution in Pretoria, South Africa. In addition, the study sought to gauge the impact of OME on quality of life using a validated questionnaire (OM-6).

METHODS

A cross-sectional, observational study was conducted between July 2015 and May 2016 at the Otorhinolaryngology outpatient department at DGMAH. he study included 109 consecutively sampled children, aged 2-12 years (mean 6.1; 49.7% female). Pneumatic otoscopy and tympanometry were performed on all participants. Adenoid hypertrophy was quantified using he adenoid-nasopharyngeal ratio (ANR) on a lateral post-nasal space radiograph (Fujioka's method). The OM-6 questionnaire was completed for each participant. Pure tone audiometry was performed for participants diagnosed with OME.

RESULTS

The prevalence of bilateral OME was 11.9%. For unilateral OME, the prevalence was 22.9% and 16.5%, for the left and right ears, respectively (p > 0.05). The mean hearing loss (SD) was 19.8 dB (9.4). Clinically significant adenoid hypertrophy (ANR ≥ 0.71) was present in 43% of participants. There was no statistically significant (p > 0.05) correlation between the presence OME and adenoid hypertrophy. The mean total OM-6 survey score was 1.67 (SD ± 0.59) in children with OME, and 1.31 (SD ± 0.45) without OME, showing no statistically significant difference (p > 0.05). There was a significant (P < 0.05) correlation between OME and the presence of atopy.

CONCLUSION

Adeno-tonsillar pathology may play an aetio-pathological role in the development of OME. However, this may be due to the presence of biofilms rather than obstructive adenoid hypertrophy, given the lack of a significant (p > 0.05) correlation between adenoid hypertrophy and OME. Whilst OME was not found to impair quality of life in this population group, the validity of the OM-6 in the South African paediatric population requires further investigation.

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.

Does adenoid hypertrophy really have effect on tympanometry?

OBJECTIVE

The goal of this study is to determine the correlation between the radiographic measurements of adenoid size and tympanometric findings.

STUDY DESIGN

Prospective study.

SETTING

Haydarpasa Numune Research and Education Hospital, Istanbul, Turkey.

SUBJECTS AND METHODS

Nine five consecutive children complaining of one or more of the symptoms of upper airway obstruction (UAO) (presence of snoring, mouth breathing or difficulty in breathing during sleep, obstructive breathing or apnea during sleep) were included in the study. Symptom severity was assessed by a standardized questionnaire. All patients underwent digital lateral soft tissue radiographs. Assessment of nasopharyngeal obstruction in radiographs was done according to four different methods. Tympanometry was used to evaluate the middle ear.

RESULTS

Of 190 ears, 79 were type A, 49 were type B and 62 were type C tympanograms. The symptom severity of 14 patients was graded as mild, 56 patients as moderate and 25 patients as severe. There was no statistically significant difference between UAO symptom severity groups and tympanogram types (p>0,05). Each one of the four methods of radiologic measurements of the adenoid enlargement showed no statistically significant difference between the tympanogram types (p>0,05).

CONCLUSION

The adenoid hypertrophy in both means of radiologic measurements and symptom severity does not correlate with the changes in tympanograms. These findings do not support the hypothesis that adenoidal size plays a major role in the etiopathogenesis of middle ear effusion (MEE).

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.

Laser Eustachian Tuboplasty: Two-Year Results

OBJECTIVE/HYPOTHESIS

Laser eustachian tuboplasty (LETP) combined with appropriate medical management will eliminate the chronic presence of middle ear effusions in selected patients.

METHODS

The study population consisted of 13 adults with otitis media with effusion (OME). Patients underwent slow-motion video endoscopy to identify the location and extent of surgical resection. A diode or argon laser was used to vaporize areas of hypertrophic mucosa and submucosa along the cartilaginous eustachian tube. Patients were evaluated at 6, 12, and 24 months. Successful outcome was defined as absence of OME. Patients with evidence of reflux disease or allergic rhinitis were treated with medical therapy before surgery and throughout the follow-up period as indicated.

RESULTS

LETP combined with medical management eliminated OME in 36% (4 of 11) of patients at 6 months, 40% (4 of 10) at 1 year, and 38% (3 of 8) at 2 years. Failure of LETP correlated with presence of laryngopharyngeal reflux (P = .01) or allergic disease (P = .05) for the results at 1 year but not at 2 years.

CONCLUSIONS

LETP combined with appropriate medical management may be an effective treatment in select patients with chronic persistent eustachian tube dysfunction. A controlled trial with a larger number of subjects will be necessary to determine the efficacy of LETP and identify those factors predictive of successful outcome.

Update on eustachian tube dysfunction and the patulous eustachian tube

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent knowledge on eustachian tube dysfunction and the patulous eustachian tube.

RECENT FINDINGS

A clinically useful test for eustachian tube function is still lacking. Narrowing of the isthmus alone was demonstrated to be an insufficient cause of otitis media. Inflammatory mediators identified within the eustachian tube and middle ear cells were causally linked with otitis media with effusion. Increasing evidence was found that allergic disease and reflux may be two of the most important contributors of tubal inflammation causing otitis media with effusion. The adenoid size and proximity to the torus tubaris may also be important in considering which patients with persistent otitis media with effusion may benefit from adenoidectomy. Computed tomography scan has documented loss of soft tissue within the cartilaginous eustachian tube in patients with patulous eustachian tubes. An endoscopic approach to seal the tubal lumen has been found to be effective in relieving patulous symptoms.

SUMMARY

These studies suggest that allergic rhinitis and gastroesophageal reflux should be investigated in patients with eustachian tube dysfunction. Adenoidectomy should also be considered in patients who have adenoids that obstruct the torus tubaris. Patients with a patulous eustachian tube may benefit from an endoscopic closure. Further research is needed to identify a clinically useful test for eustachian tube dysfunction.