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Onal M, Elsurer C, Duran T, Kocak N, Ulusoy B, Bozkurt MK, Onal O. Possible role of endoplasmic reticulum stress in the pathogenesis of chronic adenoiditis and adenoid hypertrophy: A prospective, parallel-group study. Laryngoscope Investig Otolaryngol 2024; 9:e1240. [PMID: 38596230 PMCID: PMC11002993 DOI: 10.1002/lio2.1240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/22/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024] Open
Abstract
Background Adenoid tissue is a first-line host defense secondary lymphoid organ, especially in childhood. The endoplasmic reticulum (ER) is required to maintain balanced cellular activity. With impaired ER functions, protein accumulation occurs, resulting in ER stress, which plays a role in the etiopathogenesis of many diseases. Objective We aimed to investigate the relationship between ER stress and adenoid tissue disorders, thereby elucidating the mechanisms of immunity-related diseases. Methods Fifty-four pediatric patients (>3 years old) who underwent adenoidectomy for chronic adenoiditis (CA) or adenoid hypertrophy (AH) were enrolled in this prospective, parallel-group clinical study. Adenoids were divided into two groups (CA or AH) based on their size and evaluated for ER stress pathway and apoptosis pathway markers by Real-time PCR and Western blot analysis. Results ER stress pathway markers significantly differed between the CA and AH groups. Children with CA had higher ER stress marker levels than the AH group (p < .001 for ATF-4, ATF-6, and GRP78, and p < .05 for EDEM1, CHOP, EIF2AK3, ERNI, and GRP94). Apoptosis pathway marker levels (BAX and BCL-2) were not different between groups. Conclusions ER stress contributes to the etiopathogenesis of adenoid tissue diseases and the pathogenesis of adenoid tissue disorders, which are part of the immune response. These results may guide the development of new and alternative treatments for immune system disorders.
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Affiliation(s)
- Merih Onal
- Department of OtorhinolaryngologySelcuk University Faculty of MedicineKonyaTurkey
| | - Cagdas Elsurer
- Department of OtorhinolaryngologySelcuk University Faculty of MedicineKonyaTurkey
| | - Tugce Duran
- Department of Medical GeneticsKTO Karatay University Faculty of MedicineKonyaTurkey
| | - Nadir Kocak
- Department of Medical GeneticsSelcuk University Faculty of MedicineKonyaTurkey
| | - Bulent Ulusoy
- Department of OtorhinolaryngologySelcuk University Faculty of MedicineKonyaTurkey
| | - Mete Kaan Bozkurt
- Department of OtorhinolaryngologySelcuk University Faculty of MedicineKonyaTurkey
| | - Ozkan Onal
- Department of Anesthesiology and ReanimationSelcuk University Faculty of MedicineKonyaTurkey
- Outcomes Research ConsortiumCleveland Clinic Main Hospital, Anesthesiology InstituteClevelandOhioUSA
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Jasim M, Nayana VG, Nayaka H, Nayak PS. Effect of Adenotonsillectomy on Spectral and Acoustic Characteristics. Indian J Otolaryngol Head Neck Surg 2023; 75:3467-3475. [PMID: 37974753 PMCID: PMC10646023 DOI: 10.1007/s12070-023-03967-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 06/12/2023] [Indexed: 11/19/2023] Open
Abstract
Acoustic analysis and perceptual analysis has been extensively used to assess the speech and voice among individual with voice disorders. These methods provide objective, quantitative and precise information on the speech and voice characteristics in any given disorder and help in monitoring any recovery, deterioration, or improvement in an individual's speech and also differentiate between normal and abnormal speech and voice characteristics. The present study was carried out to investigate the spectral characteristics (formant frequency parameters and formant centralization ratios) and voice characteristics (Acoustic parameters of voice) changes in individuals following adenotonsillectomy. A total of 34 participants participated in the study with a history of adenotonsillar hypertrophy. Spectral and acoustic voice parameters were analyzed across the three-time domains, before surgery (T0), 30 days (T1), and 90 days (T2) after surgery. Data was analyzed statistically using the SPSS software version-28.0.0.0. Descriptive statistics were used to find the mean and standard deviation. Repeated measures of ANOVA were used to compare the pre and post-experimental measures for spectral and acoustic, voice parameters. The derived parameter of acoustic vowel space (formant centralization ratio 3) was compared across three conditions timelines. The results revealed that acoustic vowel space measure and formant frequency measures were significantly increased in pre and post-operative conditions across the three timelines. A significant difference was obtained across the acoustic parameters across the time domains. Adenotonsillectomy has been proved to be an efficient surgical procedure in treating children with chronic adenotonsillitis. The results obtained have indicated an overall improvement in the spectral and acoustic voice parameters thereby highlighting the need for adenotonsillectomy at the right time and at the right age.
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Affiliation(s)
- Mohammed Jasim
- Department Otorhinolaryngologyogy, Yenepoya Medical College Hospital, Yenepoya Deemed to be University, Deralakatte, Mangalore, Karnataka 575018 India
| | - V. G. Nayana
- Department Otorhinolaryngologyogy, Yenepoya Medical College Hospital, Yenepoya Deemed to be University, Deralakatte, Mangalore, Karnataka 575018 India
| | - Hemaraja Nayaka
- Department of Audiology and Speech-Language Pathology, Yenepoya Medical College Hospital (YMCH), Yenepoya Deemed to be University, Deralakatte, Mangalore, Karnataka 575018 India
| | - Priyanka Suresh Nayak
- Department of Audiology and Speech-Language Pathology, Yenepoya Medical College Hospital (YMCH), Yenepoya Deemed to be University, Deralakatte, Mangalore, Karnataka 575018 India
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Zwierz A, Masna K, Domagalski K, Burduk P. 150th Anniversary of global adenoid investigations: unanswered questions and unsolved problems. Front Pediatr 2023; 11:1179218. [PMID: 37520046 PMCID: PMC10375715 DOI: 10.3389/fped.2023.1179218] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/04/2023] [Indexed: 08/01/2023] Open
Abstract
Although the problem of adenoid hypertrophy (AH) has been diagnosed and treated by doctors and scientists from around the world for the last 150 years, there is still no consensus regarding appropriate diagnosis, conservative treatment options, and qualification for surgery. This manuscript presents current knowledge on these issues and compares diagnostic methods and the effectiveness of treatment options. Factors that may influence the obtained treatment results are also described, and a questionnaire is proposed to compare the results of treatment. The objective of drawing attention to this problem is to obtain better results from conservative treatment in the future and better-qualified patients for surgical treatment.
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Affiliation(s)
- Aleksander Zwierz
- Department of Otolaryngology, Phoniatrics and Audiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Krystyna Masna
- Department of Otolaryngology, Phoniatrics and Audiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Krzysztof Domagalski
- Department of Immunology, Faculty of Biological and Veterinary Sciences, Nicolaus Copernicus University, Torun, Poland
| | - Paweł Burduk
- Department of Otolaryngology, Phoniatrics and Audiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Baruah B, Gupta A, Kumar A, Kumar A. The Role of Montelukast Sodium in Children with Adenoid Hypertrophy - A Comparative Study. Indian J Otolaryngol Head Neck Surg 2023; 75:306-310. [PMID: 37275091 PMCID: PMC10235367 DOI: 10.1007/s12070-022-03167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 09/09/2022] [Indexed: 11/06/2022] Open
Abstract
Background Adenoid Hypertrophy (AH) results in symptoms ranging from mild nasal obstruction to the dangerous obstructive sleep apnoea. Normally for such patients Adenoidectomy with or without Tonsillectomy is carried out. However complications like haemorrhage and recurrence of adenoid tissue are common. Thus, non-surgical therapies have attracted considerable attention as an alternative strategy. The present study is aimed at evaluating the effect of oral Montelukast, a cysteinyl- leukotriene receptor antagonist, in children with AH. Materials and Methods Sixty children aged between 6 and 12 years with adenoid hypertrophy were randomly divided into two groups of thirty each. The study group was prescribed Tablet Montelukast 5 mg daily for 12 weeks while the control group received matching placebo. A questionnaire based upon the severity of the symptoms as well as the Adenoid Nasopharynx ratio (A/N), as measured via X-ray Adenoids and the Nasal endoscopic scores done before and after treatment (at 3 months) in the two groups were taken into consideration . Results The Mann Whitney Test which was used found no distinction in snoring, sleep discomfort and mouth breathing between the two groups before the start of treatment. But a significant difference was indeed observed between the two groups after treatment in case of snoring (P < 0.006), sleep discomfort(P < 0.001) and mouth breathing (P < 0.001). Conclusion Oral Montelukast therapy is seen to be effective not only in the reduction of the size of adenoids but also in improvement of the overall symptoms and can thus be considered as a viable alternative .
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Affiliation(s)
- Binayak Baruah
- Tata Main Hospital, Bistupur, 831001 Jamshedpur, Jharkhand India
| | - Ajay Gupta
- Tata Main Hospital, Bistupur, 831001 Jamshedpur, Jharkhand India
| | - Abhijit Kumar
- Tata Main Hospital, Bistupur, 831001 Jamshedpur, Jharkhand India
| | - Alok Kumar
- Tata Main Hospital, Bistupur, 831001 Jamshedpur, Jharkhand India
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Peedikakkal NT, Prakash DRS, Chandrakiran C, Patil SB, Reddy HN. Endoscopic Grading, Radiological Grading and Clinical Features in Children with Chronic Adenoid Hypertrophy: A Correlational Study. Indian J Otolaryngol Head Neck Surg 2023; 75:725-731. [PMID: 37274952 PMCID: PMC10235224 DOI: 10.1007/s12070-022-03438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023] Open
Abstract
To obtain a correlation between endoscopic findings, radiological findings and clinical features in children with symptomatic Chronic Adenoid hypertrophy. A cross sectional study was conducted in 42 pediatric patients (3-14 years) who visited the Department of Otorhinolaryngology in a tertiary care centre from November 2019 to April 2021 (18 months). The patients were subjected to complete history taking; ENT examination, Rigid nasal endoscopic examination, a lateral X-ray nasopharynx were performed prior to surgery after obtaining consent from the parents of the patients. The endoscopic findings were assessed using ACE grading system and the X-ray nasopharynx was assessed using Adenoid- Nasopharyngeal ratio. A male predominance was noted with mouth breathing, snoring, nasal obstruction and recurrent rhinitis as common presentation. Grade 3 hypertrophy was the most common finding in X-ray Nasopharynx (Mean ANR-0.682). Children with Grade 3 adenoid hypertrophy with more than 50% choanal obstruction and Eustachian tube abutment in nasal endoscopy were noted to be the most symptomatic clinically. A positive correlation between reduced hearing (p value-0.004) and blocked ear sensation (p value- < 0.01) with eustachian tube abutment was noted. The children with more symptoms did not show higher-grade adenoid hypertrophy radiographically in our study. The adenoid- nasopharyngeal ratio on X-ray correlated with endoscopic grading of adenoid hypertrophy (p value-0.006) and degree of choanal obstruction (p value-0.003) but not with the abutment of the eustachian tube. The endoscopic grading correlated with clinical grading, but not the X-ray grading. Hence, endoscopic grading appears to be more accurate in assessing the adenoid size and endoscopic grading is nearer to clinical grading than X-ray grading. Though, the digital X-ray nasopharynx lateral view is a more convenient method, nasal endoscopy is the gold standard method to determine whether the adenoid hypertrophy is clinically significant or not.
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Affiliation(s)
- Nawal Thazhathe Peedikakkal
- Department of Otorhinolaryngology and Head and Neck Surgery, Ramaiah Medical College Hospital, Bangalore, Karnataka 560054 India
| | - D. R. Surya Prakash
- Department of Otorhinolaryngology and Head and Neck Surgery, Ramaiah Medical College Hospital, Bangalore, Karnataka 560054 India
| | - C. Chandrakiran
- Department of Otorhinolaryngology and Head and Neck Surgery, Ramaiah Medical College Hospital, Bangalore, Karnataka 560054 India
| | - Sanjay B. Patil
- Department of Otorhinolaryngology and Head and Neck Surgery, Ramaiah Medical College Hospital, Bangalore, Karnataka 560054 India
| | - Harshavardhan N. Reddy
- Department of Otorhinolaryngology and Head and Neck Surgery, Ramaiah Medical College Hospital, Bangalore, Karnataka 560054 India
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Bilgili AM, Durmaz HÖ, Dilber M. Eustachian Tube Dysfunction in Children with Adenoid Hypertrophy: The Effect of Intranasal Azelastine-Fluticasone Spray Treatment on Middle Ear Ventilation and Adenoid Tissue. EAR, NOSE & THROAT JOURNAL 2023; 102:198-203. [PMID: 36416201 DOI: 10.1177/01455613221140281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Ahmet Mert Bilgili
- School of Health Sciences, 64188Cyprus International University, Lefkoşe, Cyprus
| | - Hacı Ömer Durmaz
- Department of Odiology, 420479Biruni University, İstanbul, Turkey
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Li P, Li T, Yu L, Chen A, Wu Y, Wan Y, Shi L. Predictive Value of Adenoid-Nasopharyngeal Ratio in the Diagnosis of Secretory Otitis Media. EAR, NOSE & THROAT JOURNAL 2022:1455613221144496. [PMID: 36464777 DOI: 10.1177/01455613221144496] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
OBJECTIVES To explore the associated factors of otitis media with effusion (OME) and analyze the diagnostic value of the adenoid-nasopharyngeal (A/N) ratio to OME. METHODS Patients with adenoid hypertrophy (AH) recently in 2 years were collected, including sex, age, duration, with/without rhinosinusitis, and examination results, including Cone Beam Computerized Tomography (CBCT) sinus imaging, tympanometry, pure tone audiometry (PTA), blood test, and allergen detection. According to Liden/Jerger's classification, the patients were divided into two groups: Type B and type C, which were defined as the tympanometry abnormal group (TAG), and the rest were classified as the tympanometry normal group (TNG). RESULTS A total of 316 children were included in this study. Age and duration were significantly younger and shorter in TAG (6.0(4.0-9.0) vs.5.0(4.0-7.0)); 12.0(4.0-24.0) vs.6.0(2.0-12.0)). Compared to TNG, the allergen test results of fx5 (protein, milk, cod, wheat, peanut, and soybean) in TAG were higher (0.09(0.04-0.25) vs.0.14(0.05-0.45)), but eosinophilia in blood was lower (count: 0.21(0.13-0.35) vs. 0.18(0.12-0.27); ratio: 3.10 (1.90-4.70) vs. 2.50 (1.65-3.80)). A/N ratio and Visual obstruction ratio had a statistical difference (Z = -3.770, P < .01) but the two ratios didn't have too much disparity (0.82(0.74-0.88) VS 0.80(0.75-0.80)), and they had a positive correlation (r = 0.345, P < .01). A/N ratio of TAG was higher than TNG (0.78(0.70-0.85) vs. 0.86(0.82-0.90)) and had a positive correlation with increasing negative middle ear pressure (r = -3.777, P < .01). A/N ratio was an associated factor of OME (OR:1355.611, P = .006), the cut-off value of A/N ratio was 0.815(sensitivity: 75.3%, specificity: 64.3%, area under the curve (AUC): 0.747). CONCLUSIONS A/N ratio indirectly reflected the abnormality of tympanometry in this study. When A/N ratio reaches 0.815, patients are at a higher risk of having OME so it could be a predictor of OME in patients with adenoid hypertrophy.
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Affiliation(s)
- Ping Li
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Tao Li
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
- Department of Allergy, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Liang Yu
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Aiping Chen
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Yisha Wu
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Yuzhu Wan
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Li Shi
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
- Department of Allergy, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
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Diksha, Singhal SK, Gupta N, Gupta R, Verma RR. Radiological and Audiological Assessment in Patients with Adenoid Hypertrophy Undergoing Adenoidectomy. Indian J Otolaryngol Head Neck Surg 2022; 74:1527-1531. [PMID: 36452621 PMCID: PMC9702303 DOI: 10.1007/s12070-021-02639-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Diksha
- Department of ENT, Head and Neck Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Surinder Kumar Singhal
- Department of ENT, Head and Neck Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Nitin Gupta
- Department of ENT, Head and Neck Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Rekha Gupta
- Department of Radiology, Government Medical College and Hospital, Chandigarh, India
| | - Ravneet Ravinder Verma
- Department of ENT, Head and Neck Surgery, Government Medical College and Hospital, Chandigarh, India
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Zwierz A, Domagalski K, Masna K, Burduk P. Effectiveness of Evaluation of Adenoid Hypertrophy in Children by Flexible Nasopharyngoscopy Examination (FNE), Proposed Schema of Frequency of Examination: Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12071734. [PMID: 35885638 PMCID: PMC9316505 DOI: 10.3390/diagnostics12071734] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives: To demonstrate the effectiveness of endoscopic assessment of the pharyngeal tonsil in defining the size of the adenoid hypertrophy in endoscopic examination that would be equivalent to intraoperative assessment as a large adenoid, and to determine the lowest necessary frequency of tests to assess the variability of its size. Methods: The study is based on an analysis of two groups of children diagnosed and treated in a children’s ENT outpatient clinic and ENT department. In the first group, adenoid size was assessed based on flexible endoscopy, and then with a consequent adenoid surgery with assessment of the intraoperative size of the adenoid, we compared the size of the adenoid. The second part of the study included a group of 81 children. We analyzed performed flexible nasopharyngoscopy examinations (FNE) of each child, and compared the change of adenoid size in a minimum of two subsequent examinations over a period of 1 year or more. Results: The sensitivity of flexible endoscopic examination in the assessment of the pharyngeal tonsil was determined at 97.3%, and specificity at 72.7%. The ROC curve shows the value of adenoid-to-choana (A/C) ratio as 75% or more in the preoperative FNE, indicating that the tonsil during surgery is assessed as large. Among the children, 26.3% had a change in adenoid size of more than 15% in the A/C ratio in 1 year of observation, and 45% of the children had A/C ratio changed above 15% in a period of 3 years of observation. Conclusions: FNE examination is highly effective in assessing the size of the pharyngeal tonsil. We proposed a schema for frequencies of FNE examinations and treatment dependent on A/C ratio and worsening of ailments.
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Affiliation(s)
- Aleksander Zwierz
- Department of Otolaryngology, Phoniatrics and Audiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, 85-168 Bydgoszcz, Poland; (K.M.); (P.B.)
- Correspondence:
| | - Krzysztof Domagalski
- Department of Immunology, Faculty of Biological and Veterinary Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland;
| | - Krystyna Masna
- Department of Otolaryngology, Phoniatrics and Audiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, 85-168 Bydgoszcz, Poland; (K.M.); (P.B.)
| | - Paweł Burduk
- Department of Otolaryngology, Phoniatrics and Audiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, 85-168 Bydgoszcz, Poland; (K.M.); (P.B.)
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Adenoidal-Nasopharyngeal Ratio in Healthy Adults on Cone Beam Computed Tomography. J Comput Assist Tomogr 2022; 46:836-839. [PMID: 35819911 DOI: 10.1097/rct.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This study aimed to quantify the adenoidal-nasopharyngeal ratio (ANR) in a cohort of healthy adults on cone beam computed tomography (CT) using the Fujioka method, which is a reproducible measure of adenoid size and nasopharyngeal patency. METHODS Electronic health records and maxillofacial cone beam CT in 202 consecutive patients aged 16 years and older were retrospectively reviewed. Patients with a history of adenoidectomy, sinonasal disease, lymphoproliferative disorders, and cleft palate were excluded from the study. The midsagittal reconstructed cone beam CT image was used to determine the ANR. Statistical analysis was conducted using 1-way analysis of variance. RESULTS Of the 202 subjects, 131 were female and 71 were male. The mean ± SD subject age was 45.43 ± 20.79 years (range, 16-91 years). The mean ± SD ANR in all subjects was 0.22 ± 0.13 (range, 0.03-0.75) and in each decade of adult life was as follows: younger than 21 years, 0.39 ± 0.12; 21 to 30 years, 0.29 ± 0.11; 31 to 40 years, 0.21 ± 0.09; 41 to 50 years, 0.20 ± 0.07; 51 to 60 years, 0.16 ± 0.10; 61 to 70 years, 0.13 ± 0.05; 71 to 80 years, 0.12 ± 0.05; 81 to 90 years, 0.11 ± 0.04; and 91 years or older, 0.10 ± 0. The differences in mean ANR among the age subgroups were statistically significant (P < 0.001). CONCLUSIONS The mean ANR gradually decreased from 0.39 in the second decade of life to 0.16 in the sixth decade of life and plateaued at approximately 0.10 thereafter.
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Cassano M, De Corso E, Fiore V, Giancaspro R, Moffa A, Casale M, Trecca EMC, Mele DA, Cassano P, Gelardi M. Update of endoscopic classification system of adenoid hypertrophy based on clinical experience on 7621 children. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:257-264. [PMID: 35396589 PMCID: PMC9330757 DOI: 10.14639/0392-100x-n1832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/29/2021] [Indexed: 11/23/2022]
Abstract
Introduction Nasal endoscopy is likely to be the method of choice to evaluate nasal obstruction and adenoid hypertrophy (AH) in children given its excellent diagnostic accuracy and low risk for the patient. The aim of this study was to update the previous classification of AH to guide physicians in choosing the best therapeutic option. Materials and methods This is a retrospective observational study including 7621 children (3565 females; mean age 5.92; range: 3-14 years) who were managed for adenoid hypertrophy at our institution between 2003 and 2018. All patients were initially treated with medical therapy and then with surgery if not adequately controlled. We performed a specific analysis based on the presence or absence of comorbidities. Results In 1845 (24.21%) patients, adenoid obstruction was classified as Grade I when the fiberoptic endoscopy showed adenoid tissue occupying < 25% of choanal space. In 2829 of 7621 (37.12%) patients, the adenoid tissue was scored as Grade II since it was confined to the upper half of nasopharynx, with sufficiently pervious choana and visualisation of tube ostium. In 1611 of 7621 (21.14%) cases, adenoid vegetation occupied about 75% of the nasopharynx with partial involvement of tube ostium and considerable obstruction of choanal openings, and was classified as Grade III. Finally, 1336 of 7621 (17.53%) patients were scored as Grade IV due to complete obstruction with adenoid tissue reaching the lower choanal border without allowing the visualisation of the tube ostium. Based on resolution of symptoms in Grade III obstruction after medical therapy (that was mostly seen in patients without comorbidities), we divided patients in two subclasses: Grade IIIA was not associated with comorbidities, while Grade IIIB was correlated with important comorbidities. Conclusions These results can be useful to guide medical or surgical therapeutic intervention. In patients with class IIIB AH, surgical treatment offered adequate control not only of nasal symptoms but also of associated comorbidities.
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Narang VP, Loroch A, Sambiagio G. Versatility and Benefits of 4.0mm Flexible Nasal Endoscopy in 118 Children up to 10 Years of Age. Cureus 2022; 14:e22656. [PMID: 35371672 PMCID: PMC8963822 DOI: 10.7759/cureus.22656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose This retrospective study looked at the feasibility of using adult 4.0 mm flexible nasendoscopes (FNE) examination under local anesthetic (LA) in children three to 10 years old to diagnose adenoid hypertrophy (AH) and other conditions. We also looked for a correlation between the adenoid size on FNE and a) tonsil size, b) the typical symptoms of snoring, mouth breathing, impaired hearing, and apnoeic episodes c) the management options of otitis media with effusion (OME) and d) the adenoid size intraoperatively. Methods A retrospective, observational study of 118 children in an NHS pediatric otolaryngology clinic led by a single consultant. One hundred ten consecutive patients with suspected AH were divided into two groups of three to five years and six to 10 years. We compared the acceptance rate to FNE in two subgroups (three to five years and six to 10 years old) and examined the correlation between various parameters as outlined above, using the Chi-square test. Eight children underwent FNE for other reasons of change of voice and epistaxis. Results FNE was successfully performed in 86% of the patients without restraint. Thirty-three percent of patients had non-obstructive adenoids (OA) and did not require surgical intervention. The intraoperative adenoid size, symptoms of snoring, mouth-breathing, and apnoeic episodes positively correlated with OA; however, no correlation was seen with the tonsil size (p=0.1143). All patients with OA and type B tympanogram needed adenoidectomy and grommet insertion (p=0.0119), and those with type C curves recovered with adenoidectomy alone. Conclusions 4.0 mm adult scope helped reach a definitive diagnosis for AH in most children above three years of age, thus proving cost-effective. The symptoms of snoring, mouth-breathing, and apnoeic episodes had a positive correlation to the presence of OA; however, the tonsil size was seen to be independent of adenoid size. Primary surgical management can be considered the treatment of choice for all patients with OA and type B tympanogram without a trial of conservative therapy.
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Feng X, Chen Y, Cai W, Lie SA, Hellén-Halme K, Shi XQ. Aerodynamic characteristics in upper airways among orthodontic patients and its association with adenoid nasopharyngeal ratios in lateral cephalograms. BMC Med Imaging 2021; 21:127. [PMID: 34425762 PMCID: PMC8381502 DOI: 10.1186/s12880-021-00659-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adenoid hypertrophy among orthodontic patients may be detected in lateral cephalograms. The study investigates the aerodynamic characteristics within the upper airway (UA) by means of computational fluid dynamics (CFD) simulation. Furthermore, airflow features are compared between subgroups according to the adenoidal nasopharyngeal (AN) ratios. METHODS This retrospective study included thirty-five patients aged 9-15 years having both lateral cephalogram and cone beam computed tomography (CBCT) imaging that covered the UA region. The cases were divided into two subgroups according to the AN ratios measured on the lateral cephalograms: Group 1 with an AN ratio < 0.6 and Group 2 with an AN ratio ≥ 0.6. Based on the CBCT images, segmented UA models were created and the aerodynamic characteristics at inspiration and expiration were simulated by the CFD method for the two groups. The studied aerodynamic parameters were pressure drop (ΔP), maximum midsagittal velocity (Vms), maximum wall shear stress (Pws), and minimum wall static pressure (Pw). RESULTS The maximum Vms exhibits nearly 30% increases in Group 2 at both inspiration (p = 0.013) and expiration (p = 0.045) compared to Group 1. For the other aerodynamic parameters such as ΔP, the maximum Pws, and minimum Pw, no significant difference is found between the two groups. CONCLUSIONS The maximum Vms seems to be the most sensitive aerodynamic parameter for the groups of cases. An AN ratio of more than 0.6 measured on a lateral cephalogram may associate with a noticeably increased maximum Vms, which could assist clinicians in estimating the airflow features in the UA.
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Affiliation(s)
- Xin Feng
- Department of Clinical Dentistry, Faculty of Medicine, University of Bergen, Årstadveien 19, 5009, Bergen, Norway
| | - Yicheng Chen
- School of Energy Science and Engineering, Harbin Institute of Technology, Xi Da Zhi Street, Nangang, Harbin, 150001, People's Republic of China
| | - Weihua Cai
- School of Energy and Power Engineering, Northeast Electric Power University, Changchun Road 169, Changchun, 132012, People's Republic of China
| | - Stein Atle Lie
- Department of Clinical Dentistry, Faculty of Medicine, University of Bergen, Årstadveien 19, 5009, Bergen, Norway
| | - Kristina Hellén-Halme
- Department of Oral and Maxillofacial Radiology, Faculty of Odontology, Malmö University, 205 06, Malmö, Sweden
| | - Xie-Qi Shi
- Department of Clinical Dentistry, Faculty of Medicine, University of Bergen, Årstadveien 19, 5009, Bergen, Norway. .,Department of Oral and Maxillofacial Radiology, Faculty of Odontology, Malmö University, 205 06, Malmö, Sweden.
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Pisutsiri N, Vathanophas V, Boonyabut P, Tritrakarn S, Vitayaudom N, Tanphaichitr A, Ungkanont K. Adenoid measurement accuracy: A comparison of lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy (gold standard). Auris Nasus Larynx 2021; 49:222-228. [PMID: 34334217 DOI: 10.1016/j.anl.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/21/2021] [Accepted: 07/06/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the accuracy of lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy in assessment of adenoid size. METHODS A cross-sectional study was conducted in 43 pediatric patients undergoing ENT surgery from July 2017 to December 2018. All patients underwent preoperative lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy. RESULTS The average adenoidal-nasopharyngeal (A/N) ratio obtained from lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy was 72.9, 79.5, and 81.6, respectively. There was a moderate correlation between A/N ratio from lateral skull film and intraoperative rigid endoscopy (Pearson's correlation: 0.567, p˂0.001). Whereas, the A/N ratio from flexible endoscopy compared to intraoperative rigid endoscopy showed a stronger correlation (Pearson's correlation: 0.791, p˂0.001). From linear regression analysis, the intraoperative adenoid measurement was estimated from the results of flexible endoscopy (intraoperative rigid endoscopy: 0.72 [flexible endoscopy] +24.47) and lateral skull film (intraoperative rigid endoscopy = 0.65 [lateral skull film] + 34) CONCLUSION: Flexible endoscopy yields the most accuracy in the assessment of adenoid size and nasopharynx visualization, without radiation exposure or anesthesia. Despite less accuracy, lateral skull film is more availability in every hospital. The correlation of adenoid size measurement in this study can also be applied for the actual size of adenoid.
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Affiliation(s)
| | - Vannipa Vathanophas
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Panrasee Boonyabut
- Queen Sirikit National Institute of Child Health, Ministry of Public Health, Bangkok, Thailand
| | - Sirion Tritrakarn
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nichanun Vitayaudom
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Archwin Tanphaichitr
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kitirat Ungkanont
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Masoud AI, Alwadei FH. Two-dimensional upper airway normative values in children aged 7 to 17 years. Cranio 2021; 40:536-543. [PMID: 34176452 DOI: 10.1080/08869634.2021.1943137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Ahmed I Masoud
- Department of Orthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia and University of Illinois at Chicago, Chicago, IL, USA
| | - Farhan H Alwadei
- Department of Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al Kharj, Saudi Arabia
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Manno A, Iannella G, Savastano V, Vittori T, Bertin S, Pasquariello B, Pace A, Rossetti V, Magliulo G. Eustachian Tube Dysfunction in Children With Adenoid Hypertrophy: The Role of Adenoidectomy for Improving Ear Ventilation. EAR, NOSE & THROAT JOURNAL 2021:145561321989455. [PMID: 33470833 DOI: 10.1177/0145561321989455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION To our knowledge, few papers have addressed preoperative evaluation of the impact of adenoid hypertrophy (AH) on the pathogenesis of eustachian tube dysfunction (ETD) in children with otitis media with effusion (OME). AIM The aim of this study was 2-fold: first, to evaluate ETD using tubomanometry and Eustachian Tube Score 7 (ETS-7), in a group of children having AH; second, to assess the clinical impact of adenoidectomy on the ETD of these patients. METHODS Fifty patients, aged 4 to 15 years, underwent adenoidectomy based on various parameters: size of the adenoids causing canal obstruction (grades 1-4), the presence of OME, and recurrent episodes of rhinosinusitis. The function of the eustachian tube was evaluated using ETS-7 before and after surgical treatment. The patients were followed up for 6 months. RESULTS Forty children presented ETD. Of these, 36 had a grade 4 AH. The preoperative mean value for ETS-7 was 6.62. The mean postoperative ETS-7 score showed a value of 9.60 with a statistical difference compared to the preoperative value (P = .0015). CONCLUSIONS Adenoid hypertrophy has a high impact on the frequency of ETD. In the patients observed in the present study, the ETS-7 score appeared to be a valid tool for assessing ETD both preoperatively and postoperatively. Adenoidectomy seemed to be effective in improving ETD as well as middle ear ventilation.
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Affiliation(s)
- Alessandra Manno
- Department of Organi di Senso, 9311University "Sapienza", Rome, Italy
| | | | - Vincenzo Savastano
- Head and Neck Department, Unit of Pediatric Otolaryngology, 9311University "Sapienza", Rome, Italy
| | - Tommaso Vittori
- Head and Neck Department, Unit of Pediatric Otolaryngology, 9311University "Sapienza", Rome, Italy
| | - Serena Bertin
- Head and Neck Department, Unit of Pediatric Otolaryngology, 9311University "Sapienza", Rome, Italy
| | | | - Annalisa Pace
- Department of Organi di Senso, 9311University "Sapienza", Rome, Italy
| | - Valeria Rossetti
- Department of Organi di Senso, 9311University "Sapienza", Rome, Italy
| | - Giuseppe Magliulo
- Department of Organi di Senso, 9311University "Sapienza", Rome, Italy
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Naqi SA, Ashfaq AH, Umar MA, Karmani JK, Arshad N. Clinical outcome of Montelukast Sodium in Children with Adenoid Hypertrophy. Pak J Med Sci 2021; 37:362-366. [PMID: 33679914 PMCID: PMC7931283 DOI: 10.12669/pjms.37.2.2670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background & Objectives: Generally, the blockage of upper respiratory tract in children is seen with the hypertrophy of adenoids and tonsils. Normally for patients with adenoid hypertrophy (AH), Adenoidectomy with or without Tonsillectomy is carried out, however it has its own complications like haemorrhage and recurrence of adenoid tissue. Consequently, therapeutic approach has increased extraordinary consideration rather than surgical procedure. The inflammatory process proposed for AH has prompted the utilization of anti-inflammatory drugs to treat this issue. The objective of this study was to assess the impacts of Montelukast sodium in children with enlarged adenoids. Methods: A randomized controlled trail was performed from April 2018 to March 2019 in the Otorhinolaryngology clinic of Dr. Akbar Niazi Teaching Hospital, Islamabad. In this randomized, placebo treatment-controlled trial, 60 children aged 4-12 years meeting inclusion criteria were isolated into two groups. The study group was treated with Montelukast sodium 5mg consistently for three months while the control group got placebo treatment for a similar timeframe. A questionnaire was filled by parents/ guardians of every child before and after the intervention to evaluate the severity of sleep discomfort, snoring and mouth breathing. Results: Following 3 months of treatment, significant reduction in size of the adenoids was seen in 76% of study group compared with just 3% of control group getting placebo treatment. Conclusion: Montelukast sodium seems to be effective in the reduction of the size of adenoids and improvement in clinical manifestations. It can be viewed as a viable option in contrast to surgical treatment in children with hypertrophy of adenoids.
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Affiliation(s)
- Syed Ali Naqi
- Prof. Dr. Syed Ali Naqi, FCPS (ENT). Professor & HOD ENT, Islamabad Medical and Dental College, Islamabad Pakistan
| | - Ahmad Hassan Ashfaq
- Dr. Ahmad Hassan Ashfaq, FCPS (ENT). Associate Prof., Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Mumtaz Ahmad Umar
- Dr. Mumtaz Ahmad Umar, FCPS (ENT). Assistant Professor, Islamabad Medical and Dental College, Islamabad Pakistan
| | - Jais Kumar Karmani
- Dr. Jais Kumar Karmani, MD (Medicine). Assistant Professor, Islamabad Medical and Dental College, Islamabad Pakistan
| | - Naveed Arshad
- Dr. Naveed Arshad, M.Phil. (Rehabilitation Sciences). Assistant Professor, Islamabad Medical and Dental College, Islamabad Pakistan
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Cengiz AB, Tansuker HD, Ozyilmaz C, Eroglu S, Ogreden S, Oktay MF. Role of Peak Nasal Inspiratory Flow for Measuring the Effectiveness of Surgery in Children with Adenoidal Hypertrophy. Cureus 2020; 12:e12378. [PMID: 33532146 PMCID: PMC7845784 DOI: 10.7759/cureus.12378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Nasal airway obstruction in children is a frequent problem in otolaryngology practice. Adenoidal hypertrophy (AH) is the most common pathology in childhood that requires surgery. Nasal patency can be evaluated by subjective and objective methods. Unlike other methods, peak nasal inspiratory flow (PNIF) is portable and easy to perform. The need for patient compliance is the most important disadvantage of this method. We aimed to analyze the significance of PNIF for measuring the effectiveness of adenoidectomy as well as to compare PNIF with other subjective methods. Methods Two-hundred forty-five (245) patients aged between six and 11 years were evaluated. Seventy-seven (77) of them formed the study group and 168 formed the control group. Pre and post-surgery PNIF measurements, adenoid scores, and simple visual analog scale (sVAS) were recorded. Results The average PNIF value has significantly increased to 70.65 L/min from 33.02 L/min after adenoidectomy (p<0.01). The average PNIF value was 71.66 L/min in control subjects. High PNIF values were significantly correlated with low sVAS and adenoid scores postoperatively in the study group as compared with those of preoperative data (p<0.01). Conclusions PNIF has a satisfying correlation with nasal examination findings and other subjective methods to evaluate nasal obstruction and may provide unique and complementary information helpful for evaluating and improving the effects of adenoidectomy in children.
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Affiliation(s)
- Abdurrahman B Cengiz
- Otolaryngology - Head and Neck Surgery, Bagcilar Training and Research Hospital, Istanbul, TUR
| | - Hasan Deniz Tansuker
- Otolaryngology - Head and Neck Surgery, Bagcilar Training and Research Hospital, Istanbul, TUR
| | - Cemal Ozyilmaz
- Otolaryngology - Head and Neck Surgery, Bagcilar Training and Research Hospital, Istanbul, TUR
| | - Sinan Eroglu
- Otolaryngology - Head and Neck Surgery, Bahcelievler State Hospital, Istanbul, TUR
| | - Sahin Ogreden
- Otolaryngology - Head and Neck Surgery, Basaksehir Cam and Sakura State Hospital, Istanbul, TUR
| | - Mehmet F Oktay
- Otolaryngology - Head and Neck Surgery, Bagcilar Training and Research Hospital, Istanbul, TUR
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Soldatova L, Otero HJ, Saul DA, Barrera CA, Elden L. Lateral Neck Radiography in Preoperative Evaluation of Adenoid Hypertrophy. Ann Otol Rhinol Laryngol 2019; 129:482-488. [DOI: 10.1177/0003489419895035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To assess the value of lateral neck radiographs in quantifying adenoid hypertrophy to help guide treatment decisions in patients with symptoms of nasal obstruction. Study Design: Retrospective review. Methods: Quantitative radiologic grading of adenoids was correlated with the intraoperative grading to select cases in agreement between the two methods. The percent airway obstruction was calculated as a ratio of adenoid size to the size of the nasopharyngeal airway near the level of the choanae on the lateral neck radiographs for adenoidectomy cases in which radiographic and intraoperative grading of adenoid size were in agreement. Results: A total of 426 adenoidectomy cases with preoperative lateral neck radiographs were reviewed (M:F = 254:172 for age range 9 months to 16 years), and only cases in agreement between radiographic and intraoperative adenoid grading were included in radiographic analysis (N = 234). The percent airway obstruction values were significantly different between “severely obstructive” (N = 137, mean = 94.71, SD = 6.55, range [72.00; 100.00]) and “moderately obstructive” adenoid categories (N = 97, mean = 78.53, SD = 6.91, range [63.67; 98.08]), not only within clinically relevant age groups (1-3 years, 4-7 years, 8-15 years), but also for the entire data set (95% CI [14.41; 17.95], P < .0001). “Mildly obstructive” category was omitted due to small sample size (N = 4). Conclusion: Lateral neck radiographs can provide useful supplemental information on the degree of nasopharyngeal airway obstruction when other clinical findings do not clearly point toward adenoid hypertrophy as a primary cause of nasal obstruction. In our data set, a 65% nasopharyngeal airway obstruction represents a value two standard deviations below the mean for “moderately” obstructive adenoid category, and can be viewed as a simplified cut-off to indicate that the degree of adenoid enlargement is clinically relevant. This cut-off value can assist in evaluation of patients with symptoms of nasal obstruction. Level of Evidence: 4
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Affiliation(s)
- Liuba Soldatova
- Department of Otolaryngology—Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hansel J. Otero
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - David A. Saul
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christian A. Barrera
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Elden
- Department of Otolaryngology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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Duan H, Xia L, He W, Lin Y, Lu Z, Lan Q. Accuracy of lateral cephalogram for diagnosis of adenoid hypertrophy and posterior upper airway obstruction: A meta-analysis. Int J Pediatr Otorhinolaryngol 2019; 119:1-9. [PMID: 30658139 DOI: 10.1016/j.ijporl.2019.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Accurate diagnosis of adenoid hypertrophy and posterior upper airway obstruction using a lateral cephalogram is challenging. No universal guidelines for assessing adenoidal enlargement and upper airway obstruction have been established. We performed a meta-analysis to assess the diagnostic accuracy of a lateral cephalogram for adenoid hypertrophy. METHODS After searching a wide range of electronic databases and screening titles and abstracts, we evaluated full papers describing potentially eligible studies according to predefined inclusion criteria. Quality assessment was conducted by adapting the Quality Assessment of Diagnostic Accuracy Studies-2 checklist, and a 2 × 2 contingency table was constructed based on these results. Two authors independently judged the studies and extracted the data. The diagnostic accuracy of a lateral cephalogram for adenoid hypertrophy and posterior upper airway obstruction was calculated using a bivariate meta-analysis model. The Q-test and I2 index were used to test the heterogeneity. RESULTS Nine studies were included in the meta-analysis. The pooled sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio were 0.86 [95% confidence interval (CI): 0.76-0.92], 0.59 (95% CI: 0.42-0.73), 9.00 (95% CI: 5-17), 2.1 (95% CI: 1.5-3.0), and 0.24 (95% CI: 0.15-0.37), respectively. The area under the summary receiver operator characteristic curve was 0.83 (95% CI: 0.80-0.86). Meta-regression analysis revealed that the sample size and study design significantly contributed to the heterogeneity of sensitivity. CONCLUSIONS Our findings suggest that the lateral cephalogram exhibits very good diagnostic accuracy (area under the curve: 0.86) for the diagnosis of adenoid hypertrophy and posterior upper airway obstruction. Nevertheless, the rate of false-positive diagnoses should be further considered.
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Affiliation(s)
- Hanzhong Duan
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, 1055#Sanxiang Road, Suzhou, Jiangsu Province, 215004, PR China; Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Li Xia
- Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Wangfang He
- Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Yongdong Lin
- Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Zhihui Lu
- Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Qing Lan
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, 1055#Sanxiang Road, Suzhou, Jiangsu Province, 215004, PR China.
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Adenoid size by drug induced sleep endoscopy compared to nasopharyngeal mirror exam. Int J Pediatr Otorhinolaryngol 2018; 112:75-79. [PMID: 30055744 DOI: 10.1016/j.ijporl.2018.06.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/16/2018] [Accepted: 06/17/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To establish how assessment of adenoid size is correlated between drug-induced sleep endoscopy (DISE) with indirect mirror nasopharyngoscopy (IMN). STUDY DESIGN Retrospective chart review. SETTING Tertiary care academic hospital. METHODS Over a 6-year period, 154 pediatric patients underwent DISE for obstructive sleep apnea and had IMN. DISE videos were assessed by one reviewer, blinded to results of mirror exams. IMN findings were taken from operative notes recorded by one attending physician. Demographic data, co-morbidities, and sleep study results were also recorded. RESULTS Ninety-three (58.5%) males and 66 (41.5%) females were included. Mean age at DISE was 7.34 ± 3.99 years, with an average of 29 days after DISE until nasopharyngeal mirror examination. The mean initial adenoid size based on DISE assessment was 2.62 + 0.99, and on nasopharyngeal mirror assessment was 2.56 + 0.97. DISE and IMN assessment of adenoid size correlated well (Spearman's Rho = 0.82, P < 0.00001; Kendal tau = 0.764, P < 0.00001). CONCLUSIONS DISE has proven to be an excellent tool to assess adenoid size prior to adenoidectomy in children with OSA.
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Talebian S, Sharifzadeh G, Vakili I, Golboie SH. Comparison of adenoid size in lateral radiographic, pathologic, and endoscopic measurements. Electron Physician 2018; 10:6935-6941. [PMID: 30034661 PMCID: PMC6049977 DOI: 10.19082/6935] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 12/11/2017] [Indexed: 11/23/2022] Open
Abstract
Background Otitis media (OM) is a major health problem that usually results from adenoid hypertrophy. Diagnosis is based on symptoms like mouth breathing and imaging studies like lateral neck radiography (LNR). Adenoid-nasopharyngeal ratio (A/N ratio) is one of the most important and most widely used criteria in LNR study that could estimate the real size of adenoid gland measurements. However, there are huge controversies regarding LNR rules in the management of patients with OM. Objective This study aimed to determine Adenoid Nasopharyngeal Ratio (A/N ratio) in children with otitis media with effusion (OME) and its relation with different factors. Methods This was a cross-sectional study on OME suspected children who needed adenoidectomy. The study was conducted from the fall to winter of 2016 on patients referred to ENT clinics of Mashhad University of Medical Sciences. Before surgery, all children underwent standard LNRs and indirect laryngoscopy to assess adenoidal size, and nasopharyngeal length, and A/N ratio. After adenoidectomy, pathologic analysis was performed for assessment of pathologic size. SPSS 21 was used for data analyzing using Pearson’s correlation, independent t test and Mann-Whitney U test (p<0.05 was considered significant). Results A total of 27 children were enrolled. Most of the patients were male (70.4%, mean age=7.81±2.52 year). All patients in the study were symptomatic and the most frequent symptom was mouth breathing (100%). The mean A/N ratio, pathologic adenoid size, and laryngoscopic adenoid size were 0.825±0.099, 18.22±5.97, and 5.33±19.15 mm. There was a significant correlation between the A/N ratio laryngoscopic adenoid size (r=+0.46, p=0.01) and pathologic adenoid size (r=+0.44, p=0.02). Conclusions The results of this study showed that A/N ratio can be used to estimate the actual size of the adenoid gland and the necessity of adenoidectomy. Considering the reasonable costs and availability of this diagnostic method, researchers recommend using this procedure in assessment of patients with OME.
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Affiliation(s)
- Sina Talebian
- M.D. Student Research Committee, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Gholamreza Sharifzadeh
- M.Sc. of Epidemiology, Assistant Professor, Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Iraj Vakili
- M.D. Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyyed Hassan Golboie
- M.D. in ENT Surgery, Assistant Professor, Department of Thorax Surgery, Faculty of Medicine, Birjand University of Medical Sciences, Vali-e-asr Hospital, Birjand, Iran
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Role of Adenoid-Nasopharyngeal Ratio in Assessing Adenoid Hypertrophy. Indian J Otolaryngol Head Neck Surg 2018; 71:469-473. [PMID: 31742005 DOI: 10.1007/s12070-018-1359-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 04/10/2018] [Indexed: 10/17/2022] Open
Abstract
Most of the time, pediatrician is the first to see children with adenotonsillar hypertrophy (AH) and they mostly rely on clinical assessment with or without some investigation to refer these children to otorhinolaryngologist. Numerous methods have been described for evaluation of AH, but many of these methods are not possible to follow in busy pediatric outpatient unit either because of lack of cooperation from child or due to limited availability of test or due to cost constraints. This study has been conducted to determine the diagnostic accuracy of lateral neck X-ray (LNX) for assessing AH and to assess the correlation between adenoid size in LNX and clinical symptoms in a pediatric unit. Prospective study conducted in Department of ENT, Pathmavathy Medical Foundation, Kollam, Kerala, India from January 2015 to March 2016. 60 consecutive children of both genders, between the age group of 5 to 14 years, attending Department of Pediatrics with a provisional diagnosis of AH were included in the study. The symptom scores, radiographic ratio of adenoid to nasopharynx and endoscopic scorings were calculated. Lateral neck X-ray with calculation of adenoid-to-nasopharynx ratio is found to have significant correlation with patient reported symptoms and findings in nasal endoscopic examination (NE). LNX can be considered as a useful objective tool in evaluation of children with adenoid hypertrophy. Primary care physicians or pediatricians can confidently use lateral neck X-ray for making clinical decisions and can consider nasopharyngoscopy when clinical picture remains unclear or more evaluation is needed.
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Lai D, Qin G, Pu J, Liu L, Yang Y. Pre- and post-operative application of acoustic rhinometry in children with otitis media with effusion and with or without adenoid hypertrophy-a retrospective analysis. Int J Pediatr Otorhinolaryngol 2017; 103:51-54. [PMID: 29224765 DOI: 10.1016/j.ijporl.2017.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/01/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND There is no standardized scheme for preoperative evaluation of adenoid hypertrophy or a consensus on surgical indications for adenoidectomy in children with otitis media with effusion (OME), especially for young children intolerant to nasal endoscopic assessment. The aim of this study was to evaluate the efficacy and reliability of acoustic rhinometry (AR) in evaluating benefits from adenoidectomy in children with OME. METHOD Children with OME who were scheduled for surgical intervention were reviewed and AR tests performed preoperatively and postoperatively. The patients were divided into two groups based on the surgical strategy (Group I: tympanostomy tube placement alone; Group II: tympanostomy tube placement plus adenoidectomy). Correlation and regression analyses were performed to assess the relationship between findings of AR and nasal endoscopy. AR parameters including minimal nasal cross-sectional area (MCA), and nasopharyngeal volume (NPV), as well as scores of subjective symptoms were obtained to evaluate the utility of AR pre- and post-surgery. RESULTS Sixty-five children aged 4-10 years who met the inclusion criteria were included. No significant differences in gender or age distribution were observed between Group I and Group II. MCA, as well as NPV significantly decreased in Group II when compared with Group I (p = 0.000). A significant inverse correlation was observed between NPV and choanal obstruction ratio in both groups I (r = -0.625, p < 0.001) and II (r = -0.570, p < 0.001). A significant difference between preoperative and postoperative NPV and subjective symptom scores was observed in group II after adenoidectomy (p = 0.000). CONCLUSION AR parameters showed a good clinical correlation with findings of nasal endoscopy and thus may be useful for evaluating candidacy for surgical adenoidectomy among children with OME, especially in whom preoperative nasal endoscopic examination is not feasible. Additionally, AR can reveal the changes occurring within the nasopharyngeal passage before and after adenoidectomy.
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Affiliation(s)
- Dan Lai
- Department of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China.
| | - Gang Qin
- Department of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
| | - Junmei Pu
- Department of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
| | - Lu Liu
- Department of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
| | - Yiying Yang
- Department of Otolaryngology Head and Neck Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
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Differential changes in the adenoids and tonsils in Japanese children and teenagers: a cross-sectional study. Sci Rep 2017; 7:9734. [PMID: 28851993 PMCID: PMC5575315 DOI: 10.1038/s41598-017-09893-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/01/2017] [Indexed: 12/24/2022] Open
Abstract
When adenoids (Ad) and tonsils (Tn) become hypertrophied, craniofacial and general body growth is affected. However, there are no objective explicit criteria for evaluating the size of the Ad and Tn, and their respective growth patterns remain unclear. This study determined the average proportions of the Ad and Tn sizes to the upper airway area at various developmental stages in Japanese individuals. Lateral cephalometric radiographs were obtained from 300 Japanese children and teenagers (150 boys and 150 girls, aged 6–20 years), and the respective proportions of Ad to the nasopharynx (Ad/Np) and Tn to the oropharynx (Tn/Op) in the upper airway were determined. Average and standard deviation (SD) were calculated for each of the 5 age groups: lower primary school, upper primary school, junior high school, senior high school, and young adults. We investigated the correlation between age and growth patterns of Ad and Tn, and determined the average Ad/Np and Tn/Op. There was an age-related decrease in Ad and Tn size, and a significant positive correlation between Ad/Np and Tn/Op values in the upper primary school group. Both Ad/Np and Tn/Op decrease as individuals approach adulthood. However, the growth patterns of the Ad/Np and Tn/Op differ from each other.
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Morphometric growth changes of the nasopharyngeal space in subjects with different vertical craniofacial features. Am J Orthod Dentofacial Orthop 2017; 150:451-8. [PMID: 27585773 DOI: 10.1016/j.ajodo.2016.02.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The purpose of this study was to morphometrically investigate the growth pattern of the adenoids in growing subjects with hyperdivergent and hypodivergent vertical craniofacial features. METHODS In this retrospective study, we used a longitudinal sample of lateral cephalometric radiographs of 28 hyperdivergent and 30 hypodivergent subjects from 4 to 13 years of age. The radiographs were obtained from the American Association of Orthodontists Foundation Craniofacial Growth Legacy Collection. Measurements were made using digital tracings of the lateral cephalograms and point distribution models. Mixed-model analyses were used for statistical analysis. RESULTS The mean distance between the sphenoid bone and the posterior nasal spine increased up to 5.3 mm over a 9-year span (95% CI, 4.1-6.5 mm; P <0.001). Furthermore, the mean distance between the sphenoid bone and the posterior nasal spine differed significantly (P = 0.029) between facial types; it was consistently greater (1.8 mm; 95% CI, 0.2-3.3 mm) in the hyperdivergent group. The nasopharyngeal airway area showed a trend to increase with age up to 12-fold (P <0.001). A significant interaction (P = 0.004) was found between age and facial type. Assessment of the adenoid shapes showed greater convexities in the hyperdivergent group, which were observable from an earlier age and for a longer duration. CONCLUSIONS Clear differences in the morphometric growth pattern of the adenoids were found between facial types. Evaluation of adenoid shapes showed more prominent convexities that lasted longer in the long facial types than in the short facial types.
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Abstract
Screening for obstructive sleep apnea (OSA) with in-laboratory polysomnography is recommended for children with sleep disordered breathing. Adenotonsillectomy is the first-line therapy for pediatric OSA, although intranasal steroids and montelukast can be considered for those with mild OSA and continuous positive airway pressure for those with moderate to severe OSA awaiting surgery, poor surgical candidates or persistent OSA. Bony or soft tissue upper airway surgery is reasonable for children failing medical management or those with persistent OSA following adenotonsillectomy. Weight loss and oral appliance therapy are also useful. A multi-modality approach to diagnosis and treatment is preferred.
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Affiliation(s)
- Zarmina Ehsan
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA
| | - Stacey L Ishman
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA; Division of Pediatric Otolaryngology - Head & Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229, USA; University of Cincinnati School of Medicine, Department of Otolaryngology - Head & Neck Surgery, 231 Albert Sabin Way, MSB 6503, Cincinnati, Ohio 45267-0528, USA.
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Pachêco-Pereira C, Alsufyani NA, Major M, Heo G, Flores-Mir C. Accuracy and reliability of orthodontists using cone-beam computerized tomography for assessment of adenoid hypertrophy. Am J Orthod Dentofacial Orthop 2017; 150:782-788. [PMID: 27871704 DOI: 10.1016/j.ajodo.2016.03.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Our objectives were to evaluate the reliability of agreement between orthodontists, with various degrees of cone-beam computed tomography (CBCT) imaging manipulation comfort, in classifying adenoid hypertrophy through CBCT generated images and also to determine how accurate orthodontists are compared with the gold standard diagnosis, nasopharyngoscopy. METHODS This was a cross-sectional study in which a randomized list of board-certified orthodontists evaluated different degrees of adenoid hypertrophy of a stratified sampling of 10 scans. The available pool of CBCT images was from a multidisciplinary airway clinic in which children and adolescents had a CBCT scan and a nasopharyngoscopy (reference standard) by an otolaryngologist (head and neck surgeon) on the same day. The participating orthodontists used the same viewer software and computer, and had access to a previously published visual guideline for evaluating adenoid size. RESULTS Fourteen orthodontists evaluated 10 CBCT reconstructions. Interoperator reliability was excellent (intraclass correlation coefficient [ICC], 0.941; 95% confidence interval, 0.882-0.984). However, the orthodontists' evaluations against the reference standard demonstrated poor accuracy, (ICC mean, 0.39; ICC range, 0.0-0.74). Dichotomous data representing healthy and unhealthy patients were analyzed individually, and the orthodontists' evaluations and the nasopharyngoscopy results (accuracy) showed, on average, poor kappa values (mean, 0.44; range, 0.20-0.80). CONCLUSIONS Different levels of CBCT expertise impacted the assessment accuracy. The participating orthodontists showed excellent consistency among themselves; however, poor agreement between their CBCT assessments compared with nasopharyngoscopy demonstrated that this sample of clinical orthodontists had poor diagnostic accuracy. Together, these findings suggest that orthodontists may make consistent and systematic errors in this type of evaluations.
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Affiliation(s)
- Camila Pachêco-Pereira
- Assistant clinical professor, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
| | - Noura A Alsufyani
- Assistant clinical professor, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Assistant professor, King Saud University, Riyadh, Saudi Arabia
| | - Michael Major
- Director of the Inter-disciplinary Airway Research Clinic and assistant clinical professor, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Giseon Heo
- Associate professor in statistics, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Carlos Flores-Mir
- Professor and Orthodontic Graduate Program Director, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Paulucci BP, Pereira J, Picciarelli P, Levy D, di Francesco RC. Expression of CysLTR1 and 2 in Maturating Lymphocytes of Hyperplasic Tonsils Compared to Peripheral Cells in Children. Inflammation 2017; 39:1216-24. [PMID: 27115897 DOI: 10.1007/s10753-016-0357-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cysteinyl-leukotriene receptors 1 and 2 (CysLTR1 and 2) are related to allergic inflammatory responses. Recent studies demonstrated their role in lymphocyte division and maturation in the bone marrow. Few data are available about CysLTRs function in lymphocyte maturation in tonsils. The objectives of this study are to compare CysLTRs expression in peripheral blood lymphocytes with expression in maturating lymphocytes of hyperplasic tonsil and to check the influence of respiratory allergies in this process. Leukocytes of peripheral blood (PL) and hyperplasic tonsils of children were immunostained for CysLTR1, CysLTR2, CD3 (T cells), and CD19 (B cells) and read in flow cytometer. Lymphocyte of tonsils were divided in differentiating small cells (SC) and mitotic large cells (LC); percentage of B and T cells expressing CysLTRs was determined, and comparison was done using ANOVA and Tukey's tests. Data were analyzed as a whole and categorizing patients according the presence of allergies. Sixty children were enrolled in this study. There was a large expression of CysLTR1 and 2 in CD3+ LC, and such expression decreased progressively in SC and PL. In B cells, the highest expression of CysLTR1 and 2 was found in PL while SC showed the lowest and LC showed the intermediate expression. This pattern kept unchanged in groups of allergic and non-allergic individuals. CysLTRs seem to be involved in lymphocyte maturation that occurs in tonsils, without influence of allergies. New studies aiming the clinic treatment of tonsil hyperplasia must be targeted to the development of drugs capable of blocking both CysLTR1 and 2.
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Affiliation(s)
- Bruno Peres Paulucci
- Department of Otolaryngology of Clinics Hospital, University of Sao Paulo-Brazil, Av. Dr. Eneas de Carvalho Aguiar, 255 - 6° andar - sala 6167, 05403-000, Sao Paulo, SP, Brazil.
| | - Juliana Pereira
- Department of Hematology of Clinics Hospital, University of Sao Paulo-Brazil, Sao Paulo, SP, Brazil
| | - Patricia Picciarelli
- Department of Pathology of Clinics Hospital, University of Sao Paulo-Brazil, Sao Paulo, SP, Brazil
| | - Debora Levy
- Laboratory of Research in Hematology of Clinics Hospital, University of Sao Paulo-Brazil, Sao Paulo, SP, Brazil
| | - Renata Cantisani di Francesco
- Department of Otolaryngology of Clinics Hospital, University of Sao Paulo-Brazil, Av. Dr. Eneas de Carvalho Aguiar, 255 - 6° andar - sala 6167, 05403-000, Sao Paulo, SP, Brazil
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Dawood MR, Khammas AH. Diagnostic Accuracy of Radiology and Endoscopy in the Assessment of Adenoid Hypertrophy. ACTA ACUST UNITED AC 2017. [DOI: 10.5005/jp-journals-10003-1251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
ABSTRACT
Aim
To clarify the diagnostic accuracy of the lateral X-ray of nasopharynx, and the flexible nasopharyngoscopy in the assessment of adenoid hypertrophy, with the preoperative rigid nasal endoscopic observation, as it was considered as a reference standard guide.
Materials and methods
This is a prospective observational study that included 80 children who planned to undergo adenoidectomy due to the symptoms found related to adenoid hypertrophy. All the children underwent a relevant clinical history and full ear, nose, and throat (ENT) examination, and the grading of adenoid hypertrophy was done preoperatively with the lateral X-ray of the nasopharynx and the flexible nasopharyngoscopy. These findings were analyzed and compared with the peroperative rigid nasal endoscopic assessment of adenoid hypertrophy, which was considered as a reference guide.
Results
There were 44 boys (55%) and 36 girls (45%), with mean age of 5.176 (±1.873) years, and the highest frequency of adenoid hypertrophy was found in the age group of 4 to 6 years (62.45%); the most common grade of the adenoid size in all the types of the assessment was grade 3. The assessment of adenoid grading by both flexible and peroperative rigid nasal endoscopy versus radiology was statistically significant, with p value of 0.0001, while the adenoid grading between flexible and peroperative rigid nasal endoscopic assessment was almost comparable, as no significant difference was found, with p value of 0.46.
Conclusion
Flexible nasopharyngoscopy was a more reliable diagnostic tool in the assessment of the adenoid size than lateral nasopharyngeal X-ray, as it correlates well with peroperative rigid nasal endoscopic finding.
How to cite this article
Dawood MR, Khammas AH. Diagnostic Accuracy of Radiology and Endoscopy in the Assessment of Adenoid Hypertrophy. Int J Otorhinolaryngol Clin 2017;9(1):6-9.
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Balaban O, Walia H, Tumin D, Jatana KR, Raman V, Tobias JD. Assessment of adenotonsillar size and caregiver-reported sleep symptoms among 3-6 year old children undergoing adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2016; 91:43-48. [PMID: 27863640 DOI: 10.1016/j.ijporl.2016.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/03/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Adenotonsillectomy remains the accepted first-line treatment for obstructive sleep apnea syndrome (OSAS) in children. Tonsillar size may be especially relevant in risk stratification as it may impact symptoms of sleep disordered breathing (SDB). This study assesses correlations among subjective tonsillar grading, measured tonsillar size, and degree of adenoid obstruction in patients age 3-6 years with caregiver-reported symptoms. METHODS Children 3-6 years old undergoing adenotonsillectomy for OSAS were enrolled prospectively. The subjective tonsillar grade and degree of adenoid obstruction were recorded on physical examination by the otolaryngologist, and the objective tonsillar size was obtained from pathology reports. Spearman's rho was used to assess agreement among measures of tonsillar size and adenoid obstruction; and to correlate these measures with caregiver-reported SDB symptoms obtained from a pre-operative standardized questionnaire. RESULTS The cohort included 103 boys and 97 girls of median age 4.8 (interquartile range [IQR]: 3.9, 5.9) years. Median subjective tonsillar grade was 3+ (IQR: 3+, 4+) while median tonsillar size was 2.7 cm (IQR: 2.5, 3) and median adenoid obstruction was 60% (IQR: 50%, 80%). The subjective tonsillar grade and measured tonsillar size were strongly correlated (ρ = 0.31, p < 0.001), whereas adenoid obstruction was uncorrelated with either subjective tonsillar grade (ρ = 0.01, p = 0.860) or measured size (ρ = -0.05, p = 0.497). Tonsillar grade was positively correlated with 3 common caregiver-reported SDB symptoms (loud snoring, trouble breathing at night, and daytime sleepiness). Objective tonsillar size was positively correlated only with difficulty organizing tasks or activities, and adenoid obstruction was positively correlated only with stopping breathing during sleep. CONCLUSION Subjective tonsillar grading by the otolaryngologist achieved better correlation than measured tonsillar size or degree of adenoid obstruction with caregiver-reported SDB symptoms in children 3-6 years of age undergoing adenotonsillectomy.
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Affiliation(s)
- Onur Balaban
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Hina Walia
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kris R Jatana
- Department of Otolaryngology, Nationwide Children's Hospital and Wexner Medical Center at Ohio State University, Columbus, OH, USA
| | - Vidya Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, OH, USA
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Abstract
INTRODUCTION Dentists can be the first professionals to recognize a patient's potential sleep problem since they typically have more frequent contact with their patients than do physicians. It is important that dentists have a reasonable understanding of sleep disorders and how to assess their patients if they suspect such a problem so that a timely referral can be made or treatment can be provided as appropriate. OBJECTIVE To review the key literature relevant to sleep-disordered breathing (SDB) characteristics and diagnosis, including history, examination, and investigation with an emphasis on radiographic airway analyses. CONCLUSION The authors present a concise explanation of SDB conditions and an outline for thorough patient examination and evaluation, including radiographic airway analyses. Limited two-dimensional and three-dimensional norms exist for adult patients with no SDB and even less so for children. Much more research is needed, particularly in the pediatric population.
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Affiliation(s)
- Ahmed I Masoud
- a Department of Orthodontics, Faculty of Dentistry , King Abdulaziz University , Jeddah , Saudi Arabia.,b Department of Orthodontics , College of Dentistry, University of Illinois , Chicago , IL , USA.,c Graduate Program in Neuroscience , University of Illinois , Chicago , IL , USA
| | - Gregory W Jackson
- b Department of Orthodontics , College of Dentistry, University of Illinois , Chicago , IL , USA
| | - David W Carley
- d Departments of Biobehavioral Health Science, Medicine and Bioengineering , University of Illinois , Chicago , IL , USA
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Paulucci BP, Pereira J, Picciarelli P, Levy D, Di Francesco RC. Expression of cysteinyl leukotriene receptor 1 and 2 (CysLTR1 and CysLTR2) in the lymphocytes of hyperplastic tonsils: comparison between allergic and nonallergic snoring children. Int Forum Allergy Rhinol 2016; 6:1151-1158. [PMID: 27221082 DOI: 10.1002/alr.21798] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/07/2016] [Accepted: 04/21/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cysteinyl leukotriene receptor 1 and 2 (CysLTR1 and CysLTR2) are involved in allergic processes and play a role in adenotonsillar hyperplasia (AH). Clinically, only CysLTR1 may be blocked by montelukast. Our objective was to compare the expression of CysLTR1 and CysLTR2 in the B and T cells of hyperplasic tonsils of sensitized (SE) and control (NS) snoring children. METHODS Sixty children, 5 to 10 years of age, referred for adenotonsillectomy, were divided into SE and NS groups, according to their responses to the skin-prick test. Cells from the removed tissues were stained for CysLTR1, CysLTR2, CD19, and CD3 and counted via flow cytometry. messenger RNA (mRNA) expression of the CysLTRs genes was measured real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR). RESULTS The SE group showed reduced expression of the small CD3+/CysLTR1+ lymphocytes (4.6 ± 2.2 vs 6.5 ± 5.0; p = 0.04). Regarding the large lymphocytes, the SE group showed lower expression of CD3+/CysLTR1+ (40.9 ± 14.5 vs 47.6 ± 11.7; p = 0.05), CD19+/CysLTR1+ (44.6 ± 16.9 vs 54.1 ± 12.4; p = 0.01), and CD19+/CysLTR2+ (55.3 ± 11.3 vs 61.5 ± 12.6; p = 0.05) lymphocytes. Considering the total number of lymphocytes, the SE group had fewer CD3+/CysLTR1+ lymphocytes (11.1 ± 5.5 vs 13.7 ± 6.2; p = 0.04). All other cell populations exhibited reduced expression in the SE group without statistical significance. The expression of CysLTR2 was significantly higher (p < 0.05) than CysLTR1 in most studied cell populations. The mRNA expression did not show significant differences between the groups. CONCLUSION The expression of CysLTR is higher in the lymphocytes of the NS children, and CysLTR2 shows greater expression than CysLTR1 Respiratory allergies do not appear to be a stimulus for AH occurrence. Newer drugs capable of blocking both CysLTRs warrant further study.
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Affiliation(s)
- Bruno Peres Paulucci
- Department of Otolaryngology of Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil. ,
| | - Juliana Pereira
- Department of Hematology of Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Patricia Picciarelli
- Department of Pathology of Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Debora Levy
- Laboratory of Research in Hematology of Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil
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ACE grading-A proposed endoscopic grading system for adenoids and its clinical correlation. Int J Pediatr Otorhinolaryngol 2016; 83:155-9. [PMID: 26968070 DOI: 10.1016/j.ijporl.2016.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/31/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To propose a novel endoscopic adenoid grading system using a rigid nasal endoscope and to study its correlation with the clinical diagnosis. METHODOLOGY Prerecorded video clips of rigid nasal endoscopy taken during endoscopic adenoidectomy were retrieved. Otolaryngology consultants blinded to the clinical diagnosis of the child were presented these videos and asked to grade the adenoid hypertrophy as per the proposed endoscopic ACE (Airway/Choana/Eustachian tube) grading system. The clinical diagnosis was correlated with the different aspects of the descriptive endoscopic grading system. RESULTS 152 video clips were presented to the otolaryngology consultants for grading. The average age was 8.6 years (SD-3.48), while the male female ratio was 3:2. The A subcomponent of the ACE grading showed significant correlation with the diagnosis of sleep disordered breathing and chronic adenotonsillitis, C subcomponent with sleep disordered breathing and the E subcomponent with the diagnosis of otitis media. CONCLUSION The proposed endoscopic grading is easily applicable and at the same time clearly describes the relation of the adenoids to the nasopharynx, choana and Eustachian tube. Different aspects of the grading system correlated differently with the clinical diagnosis emphasizing that a descriptive scoring rather than a comprehensive scoring is a more relevant clinical tool.
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Torretta S, Marchisio P, Succo G, Capaccio P, Pignataro L. Nasopharyngeal fiberendoscopy in children: a survey of current Italian pediatric otolaryngological practices. Ital J Pediatr 2016; 42:24. [PMID: 26931408 PMCID: PMC4774007 DOI: 10.1186/s13052-016-0234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/23/2016] [Indexed: 11/10/2022] Open
Abstract
Background Nasopharyngeal fiberendoscopy (NFE) is the gold standard diagnostic procedure for adenoidal disease, but there is no consensus concerning the optimal technical approach. The aim of this study was to investigate the attitudes of Italian otolaryngologists towards diagnostic NFE in children, and the most widely used methods. Methods Nine hundred randomly selected members of the two largest Italian otolaryngological scientific societies were e-mailed an anonymous web-based questionnaire containing 29 multiple-choice items regarding their opinions about, and use of NFE in children. Results Questionnaires were returned by 764 clinicians (84.9 %). About 75 % declared they used NFE, but 35 % said they preferred alternative diagnostic methods. Most of the respondents considered NFE safe, but more than 80 % judged it to be poorly or only fairly well tolerated. Almost all declared that they generally use flexible, small-diameter instruments, with the patient seated on a chair or a parent’s lap; 65 % use gentle restraining methods. Fewer than 50 % reported using a standardised hypertrophy grading system. Conclusion Italian otolaryngologists have a generally positive attitude towards using NFE in children. However, some have reservations, and there was no unanimous agreement concerning how it should be done. Given the medical advantages of NFE, it is essential to clarify the many still controversial aspects of the procedure by means of comparative studies and educational programmes.
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Affiliation(s)
- Sara Torretta
- Otolaryngology Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
| | - Paola Marchisio
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giovanni Succo
- Academic Oncologic Department, Otolaryngology Service, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy.
| | - Pasquale Capaccio
- Otolaryngology Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
| | - Lorenzo Pignataro
- Otolaryngology Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
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Method of the diagnosis of adenoid hypertrophy for physicians: adenoid-nasopharynx ratio. J Craniofac Surg 2015; 25:e438-40. [PMID: 25153063 DOI: 10.1097/scs.0000000000000952] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE We aimed to describe the feasibility of a prediction of adenoid hypertrophy by pediatricians for diagnostic accuracy of nasopharyngeal x-ray in a pediatric unit. METHODS Forty-six patients with a history of probable adenoid hypertrophy between January 2013 and August 2013 were included in the study. Participants were excluded from the study if they had previous adenoidectomy; anatomic anomaly in the nose, palate, or nasopharynx; and acute infection. Nasal endoscopy was performed and evaluated adenoid size (choanal obstruction ratio) in all patients by an otorhinolaryngologist who was blinded to the information of other data. Lateral nasopharyngeal x-ray graphs of all patients were evaluated by pediatricians with adenoid-nasopharynx (A-N) ratio, who were blinded to the information of other data. The A-N ratio was calculated by Fujioka method. The A-N ratio of each patient was compared with the choanal obstruction ratio that was determined in the nasal endoscopic examination. Spearman correlation test was used for statistical analysis, and P < 0.05 was described as significant. RESULTS Forty-six patients were included in this study. The study sample consisted of 25 male (54.3%) and 21 female (45.7%) patients. The mean age of the patients was 6.17 years (range, 2-14 y). In the nasal endoscopic examination, the mean (SD) choanal obstruction ratio was 64.6% (19.5%) (range, 12.5%-90%). Mean (SD) A-N ratio was found to be 16.7 (14.4). The A-N ratio correlated with nasal endoscopic examination findings (r = 0.334, P = 0.023) CONCLUSIONS: The A-N ratio was found to be a useful, tolerable, and confident diagnostic method in pediatric patients for adenoid hypertrophy. Pediatricians can confidently use this method for decision after follow-up or operation.
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Önal M, Yılmaz T, Bilgiç E, Müftüoğlu S, Sözen T, Bajin MD. Possible role of apoptosis in pathogenesis of adenoid hypertrophy and chronic adenoiditis: Prospective case-control study. Auris Nasus Larynx 2015; 42:449-52. [PMID: 26003878 DOI: 10.1016/j.anl.2015.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/15/2015] [Accepted: 04/27/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Apoptosis is a programmed cell death; it provides an important balance between lymphocytes in adenoid tissue. The aim of this study is to investigate the role of apoptosis in chronic adenoiditis and adenoid hypertrophy. This is the first study in the literature about apoptosis in adenoid hypertrophy and chronic adenoiditis. METHODS Prospective case-control study in a tertiary referral university hospital was conducted. 46 patients who had chronic adenoiditis and adenoid hypertrophy underwent adenoidectomy. Adenoids were evaluated for apoptosis and assembled into groups according to their size. Apoptotic cells were counted in three different microscopic fields and their average was taken for every microcompartment. As a result of immunohistochemical staining, specimens were compared for their apoptotic cell rate. RESULTS The difference in apoptosis of chronic adenoiditis and adenoid hypertrophy groups is statistically significant (p<0.05). The age 6 was used as a cut-off to compare apoptosis in adenoid tissue. The difference was not statistically significant for patients at and below 6 years of age; however, the difference was statistically significant for patients above 6 years of age. The comparison of apoptosis in microcompartments of adenoid tissue (intrafollicular, interfollicular, subepithelial and intraepithelial) between chronic adenoiditis and adenoid hypertrophy groups revealed significant differences for intrafollicular and intraepithelial areas, and insignificant differences for interfollicular and subepithelial areas. CONCLUSION Although apoptosis could not totally explain the pathogenesis of chronic adenoiditis and adenoid hypertrophy, it appeared to play an important role in it. Apoptosis functions to limit adenoid hypertrophy. Adenoid apoptosis appears to be age-dependent.
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Affiliation(s)
- Merih Önal
- Hacettepe University Faculty of Medicine, Department of Otolaryngology-Head & Neck Surgery, Ankara, Turkey
| | - Taner Yılmaz
- Hacettepe University Faculty of Medicine, Department of Otolaryngology-Head & Neck Surgery, Ankara, Turkey.
| | - Elif Bilgiç
- Hacettepe University Faculty of Medicine, Department of Histology and Embryology, Ankara, Turkey
| | - Sevda Müftüoğlu
- Hacettepe University Faculty of Medicine, Department of Histology and Embryology, Ankara, Turkey
| | - Tevfik Sözen
- Hacettepe University Faculty of Medicine, Department of Otolaryngology-Head & Neck Surgery, Ankara, Turkey
| | - Münir Demir Bajin
- Hacettepe University Faculty of Medicine, Department of Otolaryngology-Head & Neck Surgery, Ankara, Turkey
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Feng X, Li G, Qu Z, Liu L, Näsström K, Shi XQ. Comparative analysis of upper airway volume with lateral cephalograms and cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2015; 147:197-204. [PMID: 25636553 DOI: 10.1016/j.ajodo.2014.10.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 10/01/2014] [Accepted: 10/01/2014] [Indexed: 12/01/2022]
Abstract
INTRODUCTION In this study, we aimed to evaluate the adenoidal nasopharyngeal ratio (ANR) on lateral cephalograms by assessing upper airway volumes using cone-beam computed tomography (CBCT) images as the validation method. METHODS Fifty-five patients were included in the study, and it was essential that the lateral cephalograms and CBCT images taken at their examinations were not more than 1 week apart. There were 32 subjects in group A (age ≤15 years) and 23 subjects in group B (age >15 years). The ANR was measured on the lateral cephalograms. The area and volumetric measurements of the nasopharynx and the total upper airway were obtained from CBCT images. Repeated measurements of the ANR and airway volume were performed on 10 subjects by 2 observers. RESULTS Group A had a higher correlation (r = -0.78) between the ANR and the nasopharynx volume than did group B (r = -0.57). The ANR had a weak correlation with the total upper airway volume (group A, r = -0.48; group B, r = -0.32). Both measurements made on lateral cephalograms and CBCT were highly reproducible in terms of intraobserver and interobserver agreement. CONCLUSIONS Based on our results, the measurement of the ANR on lateral cephalograms can be used as an initial screening method to estimate the nasopharynx volumes of younger patients (age ≤15 years).
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Affiliation(s)
- Xin Feng
- Radiologist, Department of Oral and Maxillofacial Radiology, Stomatological Hospital, Dalian, China; guest researcher, Oral Maxillofacial Diagnostics and Surgery, Karolinska Institutet, Huddinge, Sweden
| | - Gang Li
- Professor, Department of Oral and Maxillofacial Radiology, School and Hospital of Stomatology, Peking University, Beijing, China
| | - Zhenyu Qu
- Associate professor, Department of Oral and Maxillofacial Radiology, Stomatological Hospital, Dalian, China
| | - Lin Liu
- Professor, Department of Orthodontics, Stomatological Hospital, Dalian, China
| | - Karin Näsström
- Chair, Oral Maxillofacial Diagnostics and Surgery, Karolinska Institutet, Huddinge, Sweden
| | - Xie-Qi Shi
- Associate professor, Oral Maxillofacial Diagnostics and Surgery, Karolinska Institutet, Huddinge, Sweden.
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Feres MFN, Hermann JS, Sallum AC, Pignatari SSN. Radiographic adenoid evaluation: proposal of an objective parameter. Radiol Bras 2015; 47:79-83. [PMID: 25741053 PMCID: PMC4337152 DOI: 10.1590/s0100-39842014000200008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 10/17/2013] [Indexed: 11/21/2022] Open
Abstract
Objective The objective of the present study was to evaluate current radiographic parameters
designed to investigate adenoid hypertrophy and nasopharyngeal obstruction, and to
present an alternative radiographic assessment method. Materials and Methods In order to do so, children (4 to14 years old) who presented with nasal
obstruction or oral breathing complaints were submitted to cavum radiographic
examination. One hundred and twenty records were evaluated according to
quantitative radiographic parameters, and data were correlated with a
gold-standard videonasopharyngoscopic study, in relation to the percentage of
choanal obstruction. Subsequently, a regression analysis was performed in order to
create an original model so the percentage of the choanal obstruction could be
predicted. Results The quantitative parameters demonstrated moderate, if not weak correlation with
the real percentage of choanal obstruction. The regression model (110.119*A/N)
demonstrated a satisfactory ability to "predict" the actual percentage of choanal
obstruction. Conclusion Since current adenoid quantitative radiographic parameters present limitations,
the model presented by the present study might be considered as an alternative
assessment method in cases where videonasopharyngoscopic evaluation is
unavailable.
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Affiliation(s)
| | - Juliana Sato Hermann
- Master, Fellow PhD degree of Pediatric Otorhinolaryngology, Department of Otorhinolaryngology and Head & Nerck Surgery, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | | | - Shirley Shizue Nagata Pignatari
- PhD, Professor, Division of Pediatric Otorhinolaryngology and Head & Neck Surgery, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
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Onder S, Caypinar B, Sahin-Yilmaz A, Toros SZ, Oysu C. Relation of mean platelet volume with obstructive adenoid hypertrophy in children. Int J Pediatr Otorhinolaryngol 2014; 78:1449-51. [PMID: 24997690 DOI: 10.1016/j.ijporl.2014.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 06/03/2014] [Accepted: 06/05/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Adenoid hypertrophy (AH) is a common etiology of chronic upper airway obstruction. Upper respiratory tract obstruction may cause chronic alveolar hypoventilation and pulmonary vasoconstriction. In one previous study in patients with obstructive sleep apnea (OSA), it has been claimed that mean platelet volume (MPV), an indicator of platelet activation is increased and that MPV has an important role in the pathophysiology of cardiovascular diseases. We investigated in our study if MPV can be used as an indicator of obstruction due to adenoid hypertrophy. METHODS Our study includes 61 children that underwent adenoidectomy with a mean age of 7.12 (± 2.373). White blood cell, platelet count, MPV, platelet crit and platelet distribution width levels were measured before and 3 months after adenoidectomy. Children's symptoms for upper airway obstruction (UAO) (presence of snoring, mouth breathing or difficulty in breathing during sleep, obstructive breathing or apnea during sleep) were questioned in the preoperative and postoperative period by a standardized questionnaire. RESULTS There was no significant difference between preoperative and postoperative mean values of MPV, hemoglobin, platelet count (p > 0.05). White blood cell levels were significantly higher in the preoperative period values compared with postoperative period values (p < 0.05). Preoperative UAO scores were significantly higher than the postoperative UAO scores. After stratification of the degree of obstruction (as mild, moderate and severe) there was no significant difference in between groups in terms of MPV values. CONCLUSION There was no significant relation between MPV levels and obstructive adenoid hypertrophy.
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Affiliation(s)
- Serap Onder
- Umraniye Research and Education Hospital, Department of Otolaryngology, Istanbul, Turkey.
| | - Basak Caypinar
- Umraniye Research and Education Hospital, Department of Otolaryngology, Istanbul, Turkey
| | - Asli Sahin-Yilmaz
- Umraniye Research and Education Hospital, Department of Otolaryngology, Istanbul, Turkey
| | - Sema Zer Toros
- Umraniye Research and Education Hospital, Department of Otolaryngology, Istanbul, Turkey
| | - Cagatay Oysu
- Umraniye Research and Education Hospital, Department of Otolaryngology, Istanbul, Turkey
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Mucopolysaccharidosis: Otolaryngologic findings, obstructive sleep apnea and accumulation of glucosaminoglycans in lymphatic tissue of the upper airway. Int J Pediatr Otorhinolaryngol 2014; 78:944-9. [PMID: 24731921 DOI: 10.1016/j.ijporl.2014.03.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/16/2014] [Accepted: 03/18/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate otolaryngologic problems (upper airway obstruction, obstructive sleep apnea, restriction of mouth opening, middle ear effusion, hearing and breathing problems) and their treatments on mucopolysaccharidoses (MPS) patients and to investigate accumulation of glucosaminoglycans (GAG) in the upper airway biochemically and pathologically. METHODS 76 MPS patients were evaluated. Forty-two MPS patients underwent polysomnography (PSG) for obstructive sleep apnea (OSA). Pre- and postoperative PSG results of 18 patients were compared. The success and complications of treatments for OSA in MPS were evaluated. Biochemical and histopathological accumulation of GAG in tonsil and adenoid tissue and middle ear effusion were analyzed and compared with the control group. RESULTS Forty patients out of 42 tested with PSG had OSA (95%). Adenoid grade, Mallampati grade, restricted mouth opening, rate of difficult intubation were significantly different among MPS subtypes. MPS types III and IV had significantly lower Mallampati scores; type VI had significantly worse mouth opening; and type III had significantly better mouth opening and higher rate of easy intubation when compared to other MPS types. There was no significant difference between MPS subtypes according to tonsil grade, adenoid grade, rate of otitis media with effusion and OSA severity. Statistically significant difference was found between GAG accumulation in adenoid tissue and middle ear effusion of MPS and control group (p<0.05). However, GAG accumulation in tonsil was not significantly different between MPS and control group. There was a statistically significant improvement in postop Apnea-Hypopnea Index (AHI) compared to preop AHI (p<0.05). CONCLUSIONS Most MPS patients have airway obstruction and OSA due to adenotonsillar hypertrophy. Most of these children benefit from adenotonsillectomy, after which OSA significantly improves. They experience high recurrence rate after adenoidectomy; though this is not clinically problematic. They also suffer from conductive hearing loss due to OME, which has to be treated with ventilation tube insertion. However, such operations are usually complicated by difficult endotracheal intubation and restricted mouth opening. Sometimes tracheotomy may be necessary. Tracheotomy is also highly complicated in MPS patients. Significant accumulation of GAG in middle ear fluid and adenoid tissue is present; however, GAG appears not to accumulate in tonsillar tissue.
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Yıldırım YS, Apuhan T, Aksoy F, Veyseller B, Ozturan O. Is transnasal endoscopic examination necessary before and after adenoidectomy? Indian J Otolaryngol Head Neck Surg 2014; 66:257-60. [PMID: 24533394 DOI: 10.1007/s12070-011-0467-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 12/26/2011] [Indexed: 11/26/2022] Open
Abstract
The present study aimed to investigate the amount of residual adenoid tissue following the conventional adenoidectomy as compared with preoperative values. A total of 32 girls and 44 boys (range, 3-15 years) in whom adenoidectomy procedure was planned were included in the study. Adenoid tissue sizes before adenoidectomy and residual tissue sizes after conventional curettage adenoidectomy were measured by transnasal endoscopic examination and were recorded. Adenoid tissue size before and after adenoidectomy was compared. The mean age of the patients was 7.7 years (range, 3-15 years). Before adenoidectomy grade 4 adenoid tissue was noted in 43.4% (n = 33), grade 3 was noted in 28.9% (n = 22), grade 2 was noted in 25% (n = 19), and grade 1 was noted in 2.6% (n = 2) of the patients. Following adenoidectomy, no significant difference was noted with respect to residual adenoid tissue sizes of grade 4 and grade 3 patients (P = 0.75, P = 0.76). Transnasal endoscopic examination is suggested to be the most appropriate method to assess the amount of residual adenoid tissue after conventional curettage adenoidectomy. The residual adenoid tissue with the help of a microdebrider in case of a large residual adenoid tissue located in the choana are necessary for complete adenoidectomy.
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Affiliation(s)
- Yavuz Selim Yıldırım
- Department of Otorhinolaryngology and Head and Neck Surgery, Elbistan State Hospital, 46300 Karaelbistan, Kahramanmaras Turkey
| | - Tayfun Apuhan
- Department of Otolaryngology, Faculty of Izzet Baysal Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Fadlullah Aksoy
- Department of Otorhinolaryngology and Head and Neck Surgery, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
| | - Bayram Veyseller
- Department of Otorhinolaryngology and Head and Neck Surgery, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
| | - Orhan Ozturan
- Department of Otorhinolaryngology and Head and Neck Surgery, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
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Kang KT, Chou CH, Weng WC, Lee PL, Hsu WC. Associations between adenotonsillar hypertrophy, age, and obesity in children with obstructive sleep apnea. PLoS One 2013; 8:e78666. [PMID: 24205291 PMCID: PMC3808373 DOI: 10.1371/journal.pone.0078666] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 09/14/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To investigate the contributions of adenoid and tonsil size to childhood obstructive sleep apnea (OSA) and the interactions between adenotonsillar hypertrophy, age, and obesity in children with OSA. METHODS In total, 495 symptomatic patients were recruited. The patients were assigned to four groups according to age: toddler (age 1-3, n=42), preschool (age 3-6, n=164), school (age 6-12, n=200), and adolescence (age 12-18, n=89). All subjects had tonsil size graded by otolaryngologists, adenoid size determined on lateral radiographs (Fujioka method), and a full-night polysomnography. The apnea-hypopnea index (AHI), adenoid size, and tonsil size were compared in obese and non-obese children in the four age groups. Adjusted odds ratios (ORs) and 95% confidence interval (CI) of adenotonsillar hypertrophy and OSA risk were estimated by multi-logistic regression. RESULTS The AHI was positively related to tonsil grade (r=0.33, p <0.001) and adenoid size (r=0.24, p <0.01) in all patients. Tonsil grade was positively related to AHI in all four age groups. Adenoid size was positively related to AHI in the toddler, preschool, school groups, but not in the adolescent group (r=0.11, p=0.37). Tonsil grade and adenoid size were both positively related to AHI in obese and non-obese children. In the regression model, obesity (OR=2.89; 95% CI 1.47-5.68), tonsillar hypertrophy (OR=3.15; 95% CI 2.04-4.88), and adenoidal hypertrophy (OR=1.89; 95% CI 1.19-3.00) significantly increased OSA risk. CONCLUSIONS Adenotonsillar hypertrophy and obesity are the major determinants of OSA in children. However, the influence of adenoid size decreases in adolescence.
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Affiliation(s)
- Kun-Tai Kang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
- Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan, R.O.C.
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan, R.O.C.
| | - Chen-Han Chou
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
| | - Wen-Chin Weng
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
| | - Pei-Lin Lee
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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Baldassari CM, Choi S. Assessing adenoid hypertrophy in children: X-ray or nasal endoscopy? Laryngoscope 2013; 124:1509-10. [PMID: 24105739 DOI: 10.1002/lary.24366] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/02/2013] [Accepted: 07/25/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Cristina M Baldassari
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Norfolk, Virginia
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Oh KM, Kim MA, Youn JK, Cho HJ, Park YH. Three-dimensional evaluation of the relationship between nasopharyngeal airway shape and adenoid size in children. Korean J Orthod 2013; 43:160-7. [PMID: 24015385 PMCID: PMC3762957 DOI: 10.4041/kjod.2013.43.4.160] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/15/2013] [Accepted: 01/16/2013] [Indexed: 11/29/2022] Open
Abstract
Objective To evaluate the shapes and sizes of nasopharyngeal airways by using cone-beam computed tomography and to assess the relationship between nasopharyngeal airway shape and adenoid hypertrophy in children. Methods Linear and cross-sectional measurements on frontal and sagittal cross-sections containing the most enlarged adenoids and nasopharyngeal airway volumes were obtained from cone-beam computed tomography scans of 64 healthy children (11.0 ± 1.8 years), and the interrelationships of these measurements were evaluated. Results On the basis of frontal section images, the subjects' nasopharyngeal airways were divided into the following 2 types: the broad and long type and the narrow and flat type. The nasopharyngeal airway sizes and volumes were smaller in subjects with narrow and flat airways than in those with broad and long airways (p < 0.01). Children who showed high adenoid-nasopharyngeal ratios on sagittal imaging, indicating moderate to severe adenoid hypertrophy, had the narrow and flat type nasopharyngeal airway (p < 0.01). Conclusions Cone-beam computed tomography is a clinically simple, reliable, and noninvasive tool that can simultaneously visualize the entire structure and a cross section of the nasopharyngeal airway and help in measurement of adenoid size as well as airway volume in children with adenoid hypertrophy.
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Affiliation(s)
- Kyung-Min Oh
- Department of Orthodontics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
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Kim SY, Lee WH, Rhee CS, Lee CH, Kim JW. Regrowth of the adenoids after coblation adenoidectomy: Cephalometric analysis. Laryngoscope 2013; 123:2567-72. [DOI: 10.1002/lary.23984] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 11/03/2012] [Accepted: 12/18/2012] [Indexed: 11/06/2022]
Affiliation(s)
- So Young Kim
- Department of Otorhinolaryngology; Seoul, National University College of Medicine; Seoul; South Korea
| | - Woo-Hyun Lee
- Seoul National University Bundang Hospital; Seongnam; South Korea
| | | | - Chul Hee Lee
- Department of Otorhinolaryngology; Seoul, National University College of Medicine; Seoul; South Korea
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Waters K, Kol-Castro C, Varghese A, Lam LT, Prelog K, Cheng A. Correlations between polysomnographic and lateral airway radiograph measurements in paediatric obstructive sleep apnoea. J Paediatr Child Health 2013; 49:445-51. [PMID: 23621401 DOI: 10.1111/jpc.12212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2013] [Indexed: 11/27/2022]
Abstract
AIM To evaluate the ability of lateral airway radiography (LAR) to assess adenoidal hypertrophy in children and correlate with the severity of obstructive sleep apnoea (OSA). METHODS This cohort study was undertaken in 72 children who presented consecutively for evaluation of OSA to the outpatients of the Children's Hospital at Westmead. All children had LAR and overnight polysomnography (PSG). Five assessors, with varying experience, were blinded to the PSG results and independently analysed the LAR. Inter-rater reliability was determined for four published assessment methods; Hibbert, Johannesson, Fujioka and Cohen and Konak. We then compared the four LAR results with PSG-determined criteria for OSA. RESULTS Using intraclass correlations, inter-rater correlations were moderate to high for all four standardised evaluations of LAR with values ranging from 0.51 to 0.96. With the radiologist taken as the 'gold standard', individual assessors ranged from 0.05 to 0.91. LAR correlated best with PSG determined obstructive apnoea hypopnea index and minimum oxygen saturation for the anterior airway measurement (Hibbert) with r-values of -0.25 and 0.25 respectively (P < 0.05). CONCLUSION Amongst four methods of evaluating adenoid size, the anterior airway size correlated best with PSG variables of obstructive respiratory index and minimum oxygen saturation. However, the methods are not able to be used as a predictor for OSA.
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Affiliation(s)
- Karen Waters
- Department of Respiratory Support Service, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
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Abstract
BACKGROUND AND OBJECTIVES To assess the possibility of adenoid size asymmetry in both nasal sides by nasopharyngoscopy. DESIGN AND SETTINGS This is a prospective study involving 100 children, with age ranging between 1 and 12 years, performed in Saudi Arabia between January 2010 and December 2011. METHODS Adenoid was examined and graded I-IV in relation to posterior choana bilaterally by flexible nasopharyngoscopy. The adenoid grade was compared with the other side in each child. RESULTS The findings from endoscopy were analyzed: there was a high degree of agreement in grading both sides, that was 92% with kappa=0.868. Moreover, there was grade asymmetry in 8% of the cases. CONCLUSION Adenoid grading using flexible nasopharyngoscopy through one side of the nose may not represent the adenoid grade of the other side in all cases.
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Affiliation(s)
- Ahmed Yousif Al-Ammar
- Otolaryngology, H&N Surgery,, King Saud University, Riyadh, Saudi Arabia. ahmedalamma2hotmail.com
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Nasopharyngeal fiberendoscopy in children: a diagnostic challenge in current clinical practice: how we do it. Int J Pediatr Otorhinolaryngol 2013; 77:747-51. [PMID: 23485256 DOI: 10.1016/j.ijporl.2013.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 01/27/2013] [Accepted: 02/01/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Nasopharyngeal fiberendoscopy (NFE) is the gold standard diagnostic procedure in children with suspected adenoidal disease, but it is not always easily feasible in younger children, and there is no consensus on the optimal technical approach according to children's age or disease. This paper aims to report our experience with NFE performed during routine paediatric clinical examination, also with regards to tolerability and patients' satisfaction. METHODS NFE was performed in paediatric patients with suspected adenoidal obstruction by means of a 2.7 mm-diameter flexible endoscope with the child seated in a chair or on parent's knees under outpatients basis and without administering local decongestants, anaesthetic agents, or sedatives. Relationship between possible confounders and patients' satisfaction, NFE tolerability, or needing for restraining was evaluated. RESULTS NFE was successfully performed in all but one syndromic 2-year old patient. Analysis was conducted on 191 children (mean age = 5.58; standard error, SE = 2.52 years). Restraining was required more frequently (p < 0.001) in younger children; NFE tolerability was good, as documented by mean visual analogue scale (VAS) values of 2.06 (SE = 1.58), and a better NFE tolerance was reported more frequently (p < 0.001) in older children. No significant relationship was found between needing for restraining or VAS and gender. No major or minor adverse events occurred. CONCLUSIONS Our results support the feasibility and tolerability of flexible NFE performed by a skilled ENT specialist for nasopharyngeal evaluation in children aged more than 2 years with suspected adenoidal disease.
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