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

Maximal medical treatment of adenoid hypertrophy: a prospective study of preschool children

PURPOSE

This study aimed to examine the effectiveness of the combined maximal medical treatment for adenoid hypertrophy in preschool children.

METHODS

Sixty-four children underwent one-year combined therapy with intranasal mometasone furoate, oral desloratadine, nasal saline irrigation, and bacteriotherapy. Additionally, decongestion drops were applied during scheduled breaks.

RESULTS

Of the 64 treated children, 72% showed clinical improvement in adenoid symptoms while 28% did not improve and underwent surgery. These groups differed significantly in terms of the overall reduction in ailments after treatment (p < 0.001), infection rate (p < 0.001), catarrh severity (p < 0.001) and nasal patency (p < 0.001). Endoscopic examination confirmed that responders experienced, on average, a decrease of 8.4% in the adenoid/choana ratio and an improvement in mucosal coverage of the adenoid. These effects were not observed in the group of children whose parents opted for surgery after nine months of conservative treatment.

CONCLUSIONS

The proposed new schema of long-term maximal medical treatment with the use of combined intermittent treatment of intranasal mometasone furoate and decongestion drops, oral desloratadine, nasal saline irrigation, and bacteriotherapy can be attempted in patients with adenoid hypertrophy symptoms, and responders may avoid the need for surgery. The applied treatment breaks resulted in a low number of therapeutic side effects.

Individualized Homeopathic Medicines in the Management of Symptomatic Adenotonsillar Hypertrophy in Children: A Prospective Observational Study

BACKGROUND

 Globally, adenotonsillar hypertrophy (ATH) is one of the most prevalent upper respiratory tract disorders of children, with associated troublesome symptoms such as sleep apnea and cognitive disturbances. In this study, we evaluated the potential role of individualized homeopathic medicines in the management of symptomatic ATH in children.

METHODS

 A multicenter prospective observational study was conducted at five institutes under the Central Council for Research in Homoeopathy, India. Primary and secondary outcomes (symptom score for adenoids, other symptoms of ATH, Mallampati score, tonsillar size, Sleep-Related Breathing Disorder of the Paediatric Sleep Questionnaire [SRBD-PSQ]) were assessed through standardized questionnaires at baseline and at 3, 6, 9 and 12 months. Radiological investigations for assessing the adenoid/nasopharyngeal (A/N) ratio were carried out at baseline, 6 and 12 months. All analyses were carried out using an intention-to-treat approach.

RESULTS

 A total of 340 children were screened and 202 children suffering from ATH were enrolled and followed up monthly for 12 months. Each patient received individualized homeopathic treatment based on the totality of symptoms. Statistically significant reductions in adenoid symptom score, Mallampati score (including tonsillar size), SRBD-PSQ sleep quality assessment and A/N ratio were found over time up to 12 months (p < 0.001). Homeopathic medicines frequently indicated were Calcarea carbonicum, Phosphorus, Silicea, Sulphur, Calcarea phosphoricum, Pulsatilla, Lycopodium and Tuberculinum. No serious adverse events were recorded during the study period.

CONCLUSION

 This study suggests that homeopathic medicines may play a beneficial role in the management of symptomatic ATH in children. Well-designed comparative trials are warranted.

Mometasone Furoate Use for Recurrent Adenoid Hypertrophy: Randomized Controlled Clinical Trial

Background& Objective: Adenoid hypertrophy (AH) in children is one of the most causes of nasal obstruction and is associated with many nasal and respiratory symptoms. Till now, surgery is the main option for managing the associated symptom of AH. The intranasal steroid has an effective role in the control of allergic rhinitis and associated AH. This work aimed to assess the effects of local mometasone on recurrent AH in children. Patients& Methods: A randomized controlled trial enrolled 39 patients aged between 2 and 15 years with recurrent AH. Those patients were randomly subdivided into three groups; group (A) received topical mometasone furoate (MF), group (B) did not receive any medication, and group (C) received topical normal saline. All groups were followed up for 8 weeks. Results: Patients who received Mometasone furoate had temporary relief of adenoid hypertrophy-related symptoms (84.6%) in comparison to the control group and placebo group during the duration of treatment. After cessation of treatment with local steroids, all cases experienced symptoms caused by adenoid hypertrophy, and by the end of the third month of follow up all cases underwent adenoidectomy. Conclusion: Mometasone furoate can temporarily reduce the adenoid size, reducing symptoms related to adenoid hypertrophy.

150th Anniversary of global adenoid investigations: unanswered questions and unsolved problems

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.

Efficacy of Topical Azelastine and Fluticasone Dipropionate Combination in Children With Adenoid Hypertrophy

OBJECTIVE

Adenoid hypertrophy (AH) is one of the common childhood diseases. Surgical and non-surgical treatment of AH in children is planned according to the severity of symptoms and associated complications. In recent years, treatment methods with intranasal sprays have been reported quite frequently in uncomplicated cases. We aim to evaluate the effectiveness of a new combination of azelastine - fluticasone (AZE-FLU) (137mcg azelastine and 50mcg fluticasone) nasal spray in children with uncomplicated AH.

METHODS

Sixty-five children diagnosed with AH were included in the study. The mean age of the children was 7.42 ± 2.26 (4-13 years). The cohort consisted of 29 males and 36 females. All children were evaluated clinically and endoscopically. AZE-FLU nasal spray was applied to both nostrils twice a day for three months. Adenoid/choana ratio and symptom scores were evaluated before treatment and at the end of the 12th week.

RESULTS

At the end of 24 weeks of AZE-FLU application, there was a statistically significant decrease in both adenoid/choana ratio and symptom scores. While the initial adenoid/choana (A/C) score was 3.57 ± 0.58, it decreased to 1.74 ± 0.61 following treatment. A dramatic decrease in total symptom scores was observed. The total symptom score average was 15.63 ± 1.28 before treatment, while it was 2.31 ± 1.4 after the treatment with the difference being statistically significant (P < .01).

CONCLUSION

In this study, the effectiveness of AZE-FLU nasal spray on AH was investigated for the first time. This treatment provides an effective alternative to the surgical approach in children with uncomplicated adenoid hypertrophy. Using this protocol, 96% of patients were removed from the surgery list.

LEVEL OF EVIDENCE

is IV.

Effectiveness of Evaluation of Adenoid Hypertrophy in Children by Flexible Nasopharyngoscopy Examination (FNE), Proposed Schema of Frequency of Examination: Cohort Study

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.

The Long-Term Effects of 12-Week Intranasal Steroid Therapy on Adenoid Size, Its Mucus Coverage and Otitis Media with Effusion: A Cohort Study in Preschool Children

BACKGROUND

The purpose of this study is to analyse the long-term effects of a 12-week course of topical steroids on adenoid size and its mucus using endoscopy and on middle ear effusion measured by tympanometry.

METHODS

The study presents an endoscopic choanal assessment of the change in adenoid size (adenoid to choanae ratio, A/C ratio) and its mucus coverage in 165 children with Grade II and III adenoid hypertrophy three to six months after finishing a 12-week course of intranasal steroid treatment with mometasone furoate. Additionally, tympanometry was performed to measure middle ear effusion. Changes in the tympanograms were analysed.

RESULTS

The mean A/C ratio before treatment was 65.73%. Three to six months after finishing a 12-week course of intranasal steroid treatment, the mean A/C ratio decreased to 65.52%, although the change was not statistically significant (p = 0.743). There was no change in adenoid mucus according to the MASNA scale before and three to six months after the end of the steroid treatment (p = 0.894). Long-term observations of tympanograms before and three to six months after the end of the treatment did not show improvement (p = 0.428).

CONCLUSIONS

The results indicate that there was no effect of topical steroids on adenoid size, its mucus and otitis media with effusion (OME) three to six months after finishing a 12-week course of treatment. In the light of performed study, decision of adenoidectomy and tympanostomy should not be procrastinated.

The Impact of the Thermal Seasons on Adenoid Size, Its Mucus Coverage and Otitis Media with Effusion: A Cohort Study

Background: The purpose of this study is to analyze seasonal differences in adenoid size and related mucus levels via endoscopy, as well as to estimate changes in middle ear effusion via tympanometry. Methods: In 205 children with adenoid hypertrophy, endoscopic choanal assessment, adenoid hypertrophy assessment using the Bolesławska scale, and mucus coverage assessment using the MASNA scale were performed in two different thermal seasons, summer and winter. The study was conducted in two sequences of examination, summer to winter and winter to summer, constituting two separate groups. Additionally, in order to measure changes in middle ear effusion, tympanometry was performed. Results: Overall, 99 (48.29%) girls and 106 (51.71%) boys, age 2–12 (4.46 ± 1.56) were included in the study. The first group, examined in summer (S/W group), included 100 (48.78%) children, while the group first examined in winter (W/S group) contained 105 (51.22%) children. No significant relationship was observed between the respective degrees of adenoid hypertrophy as measures by the Bolesławska scale between the S/W and W/S groups in winter (p = 0.817) and in summer (p = 0.432). The degrees of mucus coverage of the adenoids using the MASNA scale and tympanograms were also comparable in summer (p = 0.382 and p = 0.757, respectively) and in winter (p = 0.315 and p = 0.252, respectively) between the S/W and W/S groups. In the total sample, analyses of the degrees of adenoid hypertrophy using the Bolesławska three-step scale for seasonality showed that patients analysed in the summer do not differ significantly when compared to patients analysed in the winter (4.39%/57.56%/38.05% vs. 4.88%/54.63%/40.49%, respectively; p = 0.565). In contrast, the amount of mucus on the adenoids increased in winter on the MASNA scale (p = 0.000759). In addition, the results of tympanometry showed deterioration of middle ear function in the winter (p = 0.0000149). Conclusions: The obtained results indicate that the thermal seasons did not influence the size of the pharyngeal tonsils. The increase and change in mucus coverage of the adenoids and deterioration of middle ear tympanometry in winter may be the cause of seasonal clinical deterioration in children, rather than tonsillar hypertrophy. The MASNA scale was found to be useful for comparing endoscopy results.

Safety and Efficacy of Maxitrol in Pediatric Age Group Below Two Years With Adenoid Hypertrophy: A Retrospective Cohort Study

Introduction Adenoid hypertrophy, a common condition in children, represents one of the common indications for surgery in pediatrics. Medical treatment alone is not effective, and most of the time patients are managed by surgical removal of the adenoid. The aim of this study is to assess the safety and efficacy of intranasal Maxitrol® drops (Novartis Pharmaceuticals, Basel, Switzerland) in pediatric patients with adenoid hypertrophy aged less than two years and to document any side effects during its use. Methods This retrospective cohort study was conducted at King Abdullah Specialist Children's Hospital (KASCH). We reviewed the charts of 86 pediatric patients aged less than two years who were diagnosed with adenoid hypertrophy between 2015 and 2018. Patients were grouped according to the type of intervention (use of Maxitrol®, and no use). The follow-up time was up to one year. Results Out of 86 patients, 55 (63.9%) patients had adenoid hypertrophy alone and 31 (36.1%) had adenoid hypertrophy plus another disease. Patients with obstructive sleep apnea symptoms (p=0.026) and grade of adenoid (p=0.040) showed a significant relationship with surgery booking after one year. The probability of booking for surgery for those who used Maxitrol® was 1.394 times higher than for those who were not using it (odds ratio [OR]=1.394; 95% confidence interval [CI]=0.549-3.537). Suppression of growth and eye complications were not reported in any of our patients. Conclusion In this small sample, the use of Maxitrol® in the pediatric age group below two years with adenoid hypertrophy was safe and effective in relieving nasal symptoms; however, eventually, surgery was needed in most of our patients. Suppression of growth and eye complications were not reported in any of our patients during the follow-up time.

Anti-inflammatory medications for obstructive sleep apnoea in children

BACKGROUND

Obstructive sleep apnoea (OSA) is characterised by partial or complete upper airway obstruction during sleep. Approximately 1% to 4% of children are affected by OSA, with adenotonsillar hypertrophy being the most common underlying risk factor. Surgical removal of enlarged adenoids or tonsils is the currently recommended first-line treatment for OSA due to adenotonsillar hypertrophy. Given the perioperative risk and an estimated recurrence rate of up to 20% following surgery, there has recently been an increased interest in less invasive alternatives to adenotonsillectomy. As the enlarged adenoids and tonsils consist of hypertrophied lymphoid tissue, anti-inflammatory drugs have been proposed as a potential non-surgical treatment option in children with OSA.

OBJECTIVES

To assess the efficacy and safety of anti-inflammatory drugs for the treatment of OSA in children.

SEARCH METHODS

We identified trials from searches of the Cochrane Airways Group Specialised Register, CENTRAL and MEDLINE (1950 to 2019). For identification of ongoing clinical trials, we searched ClinicalTrials.gov and the World Health Organization (WHO) trials portal.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing anti-inflammatory drugs against placebo in children between one and 16 years with objectively diagnosed OSA (apnoea/hypopnoea index (AHI) ≥ 1 per hour).

DATA COLLECTION AND ANALYSIS

Two authors independently performed screening, data extraction, and quality assessment. We separately pooled results for the comparisons 'intranasal steroids' and 'montelukast' against placebo using random-effects models. The primary outcomes for this review were AHI and serious adverse events. Secondary outcomes included the respiratory disturbance index, desaturation index, respiratory arousal index, nadir arterial oxygen saturation, mean arterial oxygen saturation, avoidance of surgical treatment for OSA, clinical symptom score, tonsillar size, and adverse events.

MAIN RESULTS

We included five trials with a total of 240 children aged one to 18 years with mild to moderate OSA (AHI 1 to 30 per hour). All trials were performed in specialised sleep medicine clinics at tertiary care centres. Follow-up time ranged from six weeks to four months. Three RCTs (n = 137) compared intranasal steroids against placebo; two RCTs compared oral montelukast against placebo (n = 103). We excluded one trial from the meta-analysis since the patients were not analysed as randomised. We also had concerns about selective reporting in another trial. We are uncertain about the difference in AHI (MD -3.18, 95% CI -8.70 to 2.35) between children receiving intranasal corticosteroids compared to placebo (2 studies, 75 participants; low-certainty evidence). In contrast, children receiving oral montelukast had a lower AHI (MD -3.41, 95% CI -5.36 to -1.45) compared to those in the placebo group (2 studies, 103 participants; moderate-certainty evidence). We are uncertain whether the secondary outcomes are different between children receiving intranasal corticosteroids compared to placebo: desaturation index (MD -2.12, 95% CI -4.27 to 0.04; 2 studies, 75 participants; moderate-certainty evidence), respiratory arousal index (MD -0.71, 95% CI -6.25 to 4.83; 2 studies, 75 participants; low-certainty evidence), and nadir oxygen saturation (MD 0.59%, 95% CI -1.09 to 2.27; 2 studies, 75 participants; moderate-certainty evidence). Children receiving oral montelukast had a lower respiratory arousal index (MD -2.89, 95% CI -4.68 to -1.10; 2 studies, 103 participants; moderate-certainty evidence) and nadir of oxygen saturation (MD 4.07, 95% CI 2.27 to 5.88; 2 studies, 103 participants; high-certainty evidence) compared to those in the placebo group. We are uncertain, however, about the difference in desaturation index (MD -2.50, 95% CI -5.53 to 0.54; 2 studies, 103 participants; low-certainty evidence) between the montelukast and placebo group. Adverse events were assessed and reported in all trials and were rare, of minor nature (e.g. nasal bleeding), and evenly distributed between study groups. No study examined the avoidance of surgical treatment for OSA as an outcome.

AUTHORS' CONCLUSIONS

There is insufficient evidence for the efficacy of intranasal corticosteroids for the treatment of OSA in children; they may have short-term beneficial effects on the desaturation index and oxygen saturation in children with mild to moderate OSA but the certainty of the benefit on the primary outcome AHI, as well as the respiratory arousal index, was low due to imprecision of the estimates and heterogeneity between studies. Montelukast has short-term beneficial treatment effects for OSA in otherwise healthy, non-obese, surgically untreated children (moderate certainty for primary outcome and moderate and high certainty, respectively, for two secondary outcomes) by significantly reducing the number of apnoeas, hypopnoeas, and respiratory arousals during sleep. In addition, montelukast was well tolerated in the children studied. The clinical relevance of the observed treatment effects remains unclear, however, because minimal clinically important differences are not yet established for polysomnography-based outcomes in children. Long-term efficacy and safety data on the use of anti-inflammatory medications for the treatment of OSA in childhood are still not available. In addition, patient-centred outcomes like concentration ability, vigilance, or school performance have not been investigated yet. There are currently no RCTs on the use of other kinds of anti-inflammatory medications for the treatment of OSA in children. Future RCTs should investigate sustainability of treatment effects, avoidance of surgical treatment for OSA, and long-term safety of anti-inflammatory medications for the treatment of OSA in children and include patient-centred outcomes.

No impact on the incidence rate of adenoidectomy 1998-2014 on a national level in Denmark by the use of nasal steroid and the introduction of pneumococcal vaccines

OBJECTIVE

To describe trends in incidence rates of adenoidectomy in children in Denmark from 1998-2014 and to look for possible explanatory factors such as intranasal steroids and pneumococcal vaccination.

DESIGN

A nationwide, population-based, retrospective, interrupted time-series analysis, using data from Danish registries.

SETTING

Hospitals and private Ear, Nose and Throat clinics.

PARTICIPANTS

Children who underwent adenoidectomy from 1998 to 2014 in Denmark.

MAIN OUTCOME MEASURE

Adenoidectomy.

METHODS

The National Patient Register and the National Health insurance Service Register were used to identify all adenoidectomies performed in children. The National Prescription Register supplied data on intranasal steroids.

RESULTS

A total of 174,557 adenoidectomies were identified, distributed among 153 022 children. The annual incidence rate was stable at around 11 per 1000 person-years from 1998 to 2004. A decrease was seen from 2004 reaching 7.9 in 2009, followed by an increase to 9.1 in 2014. The highest age-specific incidence rates were seen at 2-3 years of age. An estimated 14% of children born in 2014 will have had adenoidectomy performed before turning 16 years old. The proportion of adenoidectomies performed in private clinics compared with hospitals was 90%.

CONCLUSION

From 1998 to 2004 the incidence rate of adenoidectomy in children in Denmark was among the highest in the world with around 11 per 1000 person-years. A decrease to 7.9 was seen from 2004 to 2009. We found no inverse correlation on a national level between the incidence rates of adenoidectomy and intranasal steroid, nor the introduction of the pneumococcal vaccine. The amount of intranasal steroids used in children in Denmark was negligible compared with adenoidectomy.

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

INTRODUCTION

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

MATERIAL AND METHOD

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

RESULTS

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

CONCLUSION

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

Apnea hypopnea indices categorized by REM/NREM sleep and sleep positions in 100 children with adenotonsillectomy for obstructive sleep apnea disease

OBJECTIVES

In pediatric obstructive sleep apnea (OSA), the relationship between rapid eye movement sleep and upper airway collapse, and between sleep position and airway dimensions are well known. However, the interrelations between these factors and the obstructive apnea hypopnea index (O-AHI) have not been thoroughly investigated.

METHODS

A retrospective study including 100 children who underwent adenotonsillectomy between March 2010 and July 2017. Total O-AHI was divided into four subcategories by sleep stage and position.

RESULTS

Preoperatively 14 of 47 mild cases of OSA (1 ≤ total O-AHI) and 17 of 18 moderate (5 ≤ total O-AHI) had time showing severe apnea (10 ≤ subcategorized O-AHI). Twenty-two of 24 severe cases (10 ≤ total O-AHI) exhibited very severe apnea (30 ≤ subcategorized O-AHI). All 11 very severe cases (30 ≤ total O-AHI) experienced more than 50 apnea events per hour in at least one of the O-AHI subcategories. After surgery, 23 of 70 cases classified as completely resolved (total O-AHI < 1) still had mild apnea in the O-AHI subcategories, and six of 13 cases who continued to experience apnea events had moderate-to-severe apnea. Seventeen cases worsened in the O-AHI subcategories, and total O-AHI deteriorated in two cases of the 17. The amount of REM sleep and use of the supine position increased significantly postoperatively in the quartile groups with the lowest baseline values (p < 0.0001).

CONCLUSIONS

When an unexpected AHI value is encountered, the O-AHI subcategories may be informative regarding the indications for surgery and evaluating the efficacy thereof.

Adenoidectomy in Children: What Is the Evidence and What Is its Role?

Purpose of Review

Review the current state of the adenoidectomy procedure in the pediatric population with up-to-date indications for surgery, operative techniques, adverse events, non-surgical management of adenoid hypertrophy, and future directions.

Recent Findings

Adenoidectomy is indicated in children for the treatment of sleep-disordered breathing, nasal airway obstruction, recurrent acute otitis media, and chronic rhinosinusitis. A new recommendation was released in 2016, not supporting adenoidectomy for a primary indication of otitis media in children under 4 years old, including those with prior tympanostomy tubes, unless a distinct indication exists such as nasal obstruction or chronic adenoiditis. Although adenotonsillectomy is the mainstay of treatment for obstructive sleep apnea (OSA), recent studies have identified that non-obese patients with moderate OSA and small tonsils have comparable benefits with adenoidectomy alone with less complications. While conventional approaches such as indirect mirror-assisted curette and suction coagulation are still utilized, direct transnasal endoscope-assisted removal of the adenoids has proven to be a safe technique, with good short- and long-term outcomes. Novel non-surgical therapies including immunotherapy have been evaluated.

Summary

Adenoidectomy is a safe procedure in the pediatric population and leads to excellent outcomes. Adverse events are rare, and hospitalization is uncommon. Children with sleep disturbance from nasal airway obstruction, ear disease, or chronic rhinosinusitis are the best operative candidates for this procedure.

Efficacy of nasal corticosteroid in preventing regrowth after adenoidectomy

OBJECTIVE

One of the most frequent reasons of nasal obstruction and sleep apnea in pediatrics is adenoid hypertrophy. Remaining adenoid tissue can reoccur following hypertrophied adenoid removal and a second operation may be needed. Nasal corticosteroids are utilized in order to reduce adenoid hypertrophy and eliminate adenoidectomy operation. The purpose of our study is to assess the effect of nasal corticosteroid administration after adenoidectomy on adenoid regrowth and symptom scores.

MATERIAL AND METHOD

Seventy patients who had adenoidectomy were enrolled in our study. Patients were divided into two groups. Group I (35 patients) received Mometasone furoate (40mcg/day per nostril) intranasal spray for 6 months, starting at postoperative week 3 after wound healing. As for Group II (35 patients), they received intranasal saline spray. Patients were followed up for one year. Every patient had flexible nasal endoscopy at postoperative week 3 and one year after the operation. Choana was scored according to its occlusion level by the adenoid tissue. Additionally, nasal obstruction symptoms (nasal congestion, dry mouth, snoring, nasal speaking, apnea and night coughing) were scored.

RESULTS

Remaining adenoid tissue in the nasopharynx was comparable in flexible endoscopic assessment and no significant difference was seen between postoperative week 3 nasal obstruction scores. In the flexible endoscopic assessment completed in the twelfth month of the study, significant reduction was found in Group 1 compared to Group 2 in terms of adenoid size. When patients in both groups were compared, statistically significant reduction was observed in nasal obstruction symptom scores at the twelfth month.

CONCLUSION

This study has demonstrated that the use of steroid nasal spray following adenoidectomy significantly prevents regrowth and reduces nasal obstruction symptoms in the early period.

Is the effect of topical intranasal steroids on obstructive adenoids transient or long-lasting? Case series and systematic review of literature

Objectives:

To study and review the short- and long-term effects of intranasal steroids on obstructive adenoids.

Methods:

In this prospective cohort study, 19 children previously treated with mometasone furoate for 3 months were contacted at 3, 6 and 12 months after cessation of treatment. Main outcome measures included: change in severity of nasal obstruction, allergic rhinitis and obstructive symptoms. A systematic review of literature was also performed.

Results:

By one year, 25 per cent of patients required adenoidectomy; the remaining children had no significant change in clinical score (p = 0.464), obstruction severity (p = 0.191) or allergic symptoms (p = 0.284). Fourteen pertinent studies were identified; all but one study showed improvement in the patients’ symptoms and/or degree of obstruction. Two studies with follow up reaching 25 months showed positive effects.

Conclusion:

The short-term positive effect of some intranasal steroids on obstructive adenoids seems to persist in a significant number of patients after the cessation of treatment.

Topical drug delivery systems: a patent review

INTRODUCTION

Topical administration is the favored route for local delivery of therapeutic agents due to its convenience and affordability. The specific challenge of designing a therapeutic system is to achieve an optimal concentration of a certain drug at its site of action for an appropriate duration.

AREAS COVERED

This review summarizes innovations from the past 3 years (2012-2015) in the field of topical drug delivery for the treatment of local infections of the vagina, nose, eye and skin. The review also throws some light on the anatomy and physiology of these organs and their various defensive barriers which affect the delivery of drugs administered topically.

EXPERT OPINION

Topical administration has been gaining attention over the last few years. However, conventional topical drug delivery systems suffer from drawbacks such as poor retention and low bioavailability. The successful formulation of topical delivery products requires the careful manipulation of defensive barriers and selection of a soluble drug carrier. Extensive research is required to develop newer topical drug delivery systems aiming either to improve the efficacy or to reduce side effects compared to current patented systems.

Adenoid Vegetation in Children with Allergic Rhinitis

Objective

Pediatric patients with nasal obstruction due to adenoid vegetation (AV) can also encounter allergic rhinitis (AR) as a comorbidity. The aim of the study was to estimate the incidence of mite sensitization and its effect on adenoid size in children who underwent adenoidectomy.

Methods

This prospective randomized study conducted between August and September 2014 included 84 children. Skin Prick Test (SPT) for inhalant allergens was preoperatively applied to all children who underwent adenoidectomy for nasal obstruction. Children were divided into two study groups: AV only (Group I) (n=52) and AV with Dermatophagoides Pteronyssinus and/or D. farinae allergy (Group II) (n=32). Postoperative specimen volumes, visual analogue scale (VAS) scores, and adenoid volumes measured using flexible fiberoptic nasopharyngolaryngoscopy were compared between the two groups.

Results

Postoperative specimen volume measures were higher in Group II compared with those in Group I (p<0.05). Furthermore, in preoperative endoscopic examination, adenoid volume measures were higher in Group II compared with those in Group I (p<0.05). Pre and postoperative VAS scores in SPT+ group were higher in the Group II (p<0.05) than those in Group I.

Conclusion

We observed that children with AR tend to have an early onset of symptoms of adenoid hypertrophy. We believe that focusing on the management of role of allergy regarding these early symptoms will reduce the need for surgery in a large number of cases. We suggest that SPT must be performed in all children with AV and adenoid examination should not be neglected in children with AR.

Role of mometasone furoate aqueous nasal spray for management of adenoidal hypertrophy in children

Objectives:

To study the role of mometasone furoate aqueous nasal spray for the management of adenoidal hypertrophy in children with more than 50 per cent obstruction, and to assess its impact on change in quality of life.

Methods:

A prospective, randomised, double-blind, interventional placebo-controlled study was conducted. A total of 100 children aged 2–12 years completed treatment and follow up. The symptoms and degree of obstruction were evaluated by nasopharyngoscopy conducted pre-treatment and 24 weeks post-treatment. Subjects received mometasone furoate nasal spray at a daily dose of 200 µg for 8 weeks, followed by a dose of 200 µg on alternate days for 16 weeks. Results were compared with those of a matched control group who were given saline nasal spray.

Results:

With mometasone treatment, there was an 89.8 per cent reduction in clinical symptom score, and the degree of obstruction dropped from 87 to 72 per cent (p < 0.0001). A statistically significant change in quality of life scores was seen in patients treated with the mometasone nasal spray (score change of 37.47) as compared with those given saline nasal spray (score change of 11.25) (p = 0.0001).

Conclusion:

Mometasone nasal spray appears to be effective in treating children with obstructive adenoids.

The use of large volume low pressure nasal saline with fluticasone propionate for the treatment of pediatric acute rhinosinusitis

OBJECTIVES

Fluticasone propionate and nasal saline irrigation have been used in the treatment of sinonasal diseases for a long time. Our study investigates the effect of the combination of large volume low pressure nasal saline irrigation and fluticasone propionate for the treatment of pediatric acute rhinosinusitis.

METHODS

Ninety-one pediatric patients with acute rhinosinusitis were included in our study. The patients were randomized into two groups. The first group (n=45) was treated with standard therapy (antibiotherapy+nasal decongestant) for 2 weeks, the second group was treated with the large volume low pressure nasal saline+fluticasone propionate combination for 3 weeks. The clinical scores, radiologic evaluations (X-ray Waters view), peak nasal inspiratory flow (PNIF) measurements, total symptom scores and hematologic parameters (WBC, CRP, ESR) of the patients were evaluated and compared.

RESULTS

There were no significant differences in between the two groups regarding age, gender, height and weight. Even though the clinical scores of Group 2 improved more rapidly, there were no significant differences in between groups regarding clinical scores by the 21st day. There were no significant differences in post treatment radiologic evaluations (Waters graphy). Both groups had significant improvement of their post treatment PNIF values, yet the improvement was more marked in Group 2 than in Group 1. The rhinorrhea, nasal congestion, throat itching and cough symptoms improved more rapidly in Group 2 than in Group 1. Post-treatment nose itching and sneezing symptoms were significantly less in Group 2. The values of hematologic parameters were significantly reduced at the end of the 3rd week in both groups.

CONCLUSIONS

Our study is a first in investigating the combined use of large volume low pressure nasal saline and fluticasone propionate in acute pediatric rhinosinusitis, and the results reveal that the combination therapy was effective. Low pressure large volume nasal saline+fluticasone propionate combination can be employed as a new line of therapy for the treatment of pediatric acute rhinosinusitis, either by itself or combined with standard therapy.

[Medicinal treatment of breathing disorders in adenotonsillar hyperplasia]

BACKGROUND

Adenotonsillar hyperplasia (ATH) can lead to severe breathing disorders, such as impaired nasal breathing, mouth breathing, snoring and obstructive sleep apnea. In such cases ATH should be treated mostly by performing adenoidectomy and/or adenotonsillectomy. There is increasing evidence that anti-inflammatory medication (AIM) is effective in treating ATH-related breathing disorders.

OBJECTIVES

The aim of this study was to provide evidence and recommendations for the use of AIM in the treatment of ATH-related breathing disorders.

METHODS

In this study 12 national pediatric sleep experts were included into a Delphi process and formulated indications and recommendations.

RESULTS

The use of AIM in the treatment of ATH-related breathing disorders is sufficiently supported by the results of randomized controlled trials and systematic reviews. Nasal beclometason and nasal mometason have been studied for the treatment of enlarged adenoids and nasal fluticason and oral montelukast for the treatment of obstructive sleep apnea. The use of AIM for first-line treatment should be restricted to selected indications, such as a characteristic patient age and exclusion of an acute upper respiratory tract infection. Evidence-based recommendations are given concerning indications, dosage, treatment duration and correct administration of AIM.

CONCLUSIONS

Anti-inflammatory medications are simple and effective alternatives for the treatment of ATH-related breathing disorders. These guidelines are intended to promote the use of AIM by pediatricians in ambulatory care settings.

Role of intranasal steroid in the prevention of recurrent nasal symptoms after adenoidectomy

Background. Intranasal steroid provides an efficient nonsurgical alternative to adenoidectomy for theimprovement of adenoid nasal obstruction. Objective. To demonstrate the role of intranasal steroid in the prevention of adenoid regrowth after adenoidectomy. Methods. Prospective randomized controlled study. Two hundred children after adenoidectomy were divided into 2 groups. Group I received postoperative intranasal steroid and group II received postoperative intranasal saline spray. Both medications were administered for 12 weeks postoperatively. Patients were followed up for 1 year. Followup was done using the nasopharyngeal lateral X-rays, reporting the degree of the symptoms. Results. Significant difference between both groups after 6 months and after 1 year. The intranasal steroid group had significantly lower score after 6 months and after 1 year as regards nasal obstruction, nasal discharge, and snoring than the intranasal saline group. 2 weeks postoperatively, there was no difference between both groups as regards nasal obstruction, discharge, or snoring. As regards lateral radiographs, there was statistically significant difference between both groups 1 year but not 6 months postoperatively. Conclusion. Factors influencing the outcome of intranasal steroids therapy in the prevention of adenoid regrowth have not been identified. However, this treatment may obtain successful results in children to avoid readenoidectomy.

Drug therapy for obstructive sleep apnoea in adults

BACKGROUND

The treatment of choice for moderate to severe obstructive sleep apnoea (OSA) is continuous positive airways pressure (CPAP) applied via a mask during sleep. However, this is not tolerated by all individuals and its role in mild OSA is not proven. Drug therapy has been proposed as an alternative to CPAP in some patients with mild to moderate sleep apnoea and could be of value in patients intolerant of CPAP. A number of mechanisms have been proposed by which drugs could reduce the severity of OSA. These include an increase in tone in the upper airway dilator muscles, an increase in ventilatory drive, a reduction in the proportion of rapid eye movement (REM) sleep, an increase in cholinergic tone during sleep, an increase in arousal threshold, a reduction in airway resistance and a reduction in surface tension in the upper airway.

OBJECTIVES

To determine the efficacy of drug therapies in the specific treatment of sleep apnoea.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials. Searches were current as of July 2012.

SELECTION CRITERIA

Randomised, placebo controlled trials involving adult patients with confirmed OSA. We excluded trials if continuous positive airways pressure, mandibular devices or oxygen therapy were used. We excluded studies investigating treatment of associated conditions such as excessive sleepiness, hypertension, gastro-oesophageal reflux disease and obesity.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by The Cochrane Collaboration.

MAIN RESULTS

Thirty trials of 25 drugs, involving 516 participants, contributed data to the review. Drugs had several different proposed modes of action and the results were grouped accordingly in the review. Each of the studies stated that the participants had OSA but diagnostic criteria were not always explicit and it was possible that some patients with central apnoeas may have been recruited.Acetazolamide, eszopiclone, naltrexone, nasal lubricant (phosphocholinamine) and physiostigmine were administered for one to two nights only. Donepezil in patients with and without Alzheimer's disease, fluticasone in patients with allergic rhinitis, combinations of ondansetrone and fluoxetine and paroxetine were trials of one to three months duration, however most of the studies were small and had methodological limitations. The overall quality of the available evidence was low.The primary outcomes for the systematic review were the apnoea hypopnoea index (AHI) and the level of sleepiness associated with OSA, estimated by the Epworth Sleepiness Scale (ESS). AHI was reported in 25 studies and of these 10 showed statistically significant reductions in AHI.Fluticasone in patients with allergic rhinitis was well tolerated and reduced the severity of sleep apnoea compared with placebo (AHI 23.3 versus 30.3; P < 0.05) and improved subjective daytime alertness. Excessive sleepiness was reported to be altered in four studies, however the only clinically and statistically significant change in ESS of -2.9 (SD 2.9; P = 0.04) along with a small but statistically significant reduction in AHI of -9.4 (SD 17.2; P = 0.03) was seen in patients without Alzheimer's disease receiving donepezil for one month. In 23 patients with mild to moderate Alzheimer's disease donepezil led to a significant reduction in AHI (donepezil 20 (SD 15) to 9.9 (SD 11.5) versus placebo 23.2 (SD 26.4) to 22.9 (SD 28.8); P = 0.035) after three months of treatment but no reduction in sleepiness was reported. High dose combined treatment with ondansetron 24 mg and fluoxetine 10 mg showed a 40.5% decrease in AHI from the baseline at treatment day 28. Paroxetine was shown to reduce AHI compared to placebo (-6.10 events/hour; 95% CI -11.00 to -1.20) but failed to improve daytime symptoms.Promising results from the preliminary mirtazapine study failed to be reproduced in the two more recent multicentre trials and, moreover, the use of mirtazapine was associated with significant weight gain and sleepiness. Few data were presented on the long-term tolerability of any of the compounds used.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the use of drug therapy in the treatment of OSA. Small studies have reported positive effects of certain agents on short-term outcomes. Certain agents have been shown to reduce the AHI in largely unselected populations with OSA by between 24% and 45%. For donepezil and fluticasone, studies of longer duration with a larger population and better matching of groups are required to establish whether the change in AHI and impact on daytime symptoms are reproducible. Individual patients had more complete responses to particular drugs. It is possible that better matching of drugs to patients according to the dominant mechanism of their OSA will lead to better results and this also needs further study.

Adenoid Hypertrophy in Adults: A case Series

Adenoid hypertrophy is common in children. Size of the adenoid increases up to the age of 6 years, then slowly atrophies and completely disappears at the age of 16 years. Adenoid hypertrophy in adults is rare. Present study shows that adenoid hypertrophy is now increasing in adults because of various causes. Study has been conducted in the Department of ENT and Head & Neck Surgery, Alluri Sitarama Raju Academy of Medical science, Eluru, Andhra Pradesh, India. Study shows that incidence of adenoid hypertrophy is increasing as the cause of nasal obstruction in adults. This study identified the different causes of adenoid hypertrophy in adult patients. The common causes of adenoid hypertrophy in adults are chronic infection and allergy. Pollution and smoking are also important predisposing factors. Sometimes it is also associated with sinonasal malignancy, lymphoma and HIV infection. Study shows that 21 % of adult nasal obstruction is due to adenoid hypertrophy. But in case of the patient with chronic tonsillitis only 9 % were associated with adenoid hypertrophy. Males are more commonly involved (70 %) then female, may be because of out door activities and more commonly exposed to pollutants. And most commonly involved age group is 16-25 years (60 %). Majority of the cases with adenoid hypertrophy are associated with infection and allergy i.e. descending infection in 33.3 % cases, ascending infection in 20 % cases and allergic rhinitis in 30 % cases. Association of malignant sinonasal tumors, non Hodgkin's lymphoma and HIV infections are rare i.e. 3.3 % each. So any cases of adult adenoid hypertrophy should be treated seriously to exclude the dangerous causes.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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