Diagnostic accuracy of the nasal obstruction index in detecting adenoid hypertrophy in children without allergy

Biofilm Production and Its Implications in Pediatrics

Biofilms, aggregates of bacteria enclosed in a self-produced matrix, have been implicated in various pediatric respiratory infections, including acute otitis media (AOM), otitis media with effusion (OME), adenoiditis, protracted bacterial bronchitis, and pulmonary exacerbations in cystic fibrosis. These infections are prevalent in children and often associated with biofilm-producing pathogens, leading to recurrent and chronic conditions. Biofilms reduce antibiotic efficacy, contributing to treatment failure and disease persistence. This narrative review discusses biofilm production by respiratory pathogens such as Streptococcus pneumoniae, non-typeable Haemophilus influenzae, Pseudomonas aeruginosa, and Staphylococcus aureus. It examines their mechanisms of biofilm formation, antibiotic resistance, and the challenges they present in clinical treatment. Various antibiofilm strategies have shown promise in vitro and in animal studies, including the use of N-acetylcysteine, enzymes like dispersin B, and agents disrupting quorum sensing and biofilm matrix components. However, their clinical application, particularly in children, remains limited. Traditional treatments for biofilm-associated diseases have not significantly evolved, even with biofilm detection. The transition from experimental findings to clinical practice is complex and requires robust clinical trials and standardized biofilm detection protocols. Addressing biofilms in pediatric respiratory infections is crucial for improving treatment outcomes and managing recurrent and chronic diseases effectively.

The Role of Telemedicine in Children with Obstructive Sleep Apnea Syndrome (OSAS): A Review of the Literature

The advent of telemedicine marked a significant turning point in the healthcare landscape, introducing a revolutionary approach to the delivery of medical care. Digital technologies easily connect health professionals and patients, overcoming geographical and temporal barriers. Telemedicine has been used for sleep disorders including obstructive sleep apnea syndrome (OSAS) since the mid-1990s. In adult patients with OSAS, telemedicine is helpful both for consultation and diagnosis, the latter obtained through remote recordings of oxygen saturation and further parameters registered with telemonitored respiratory polygraphy or polysomnography. Remote monitoring can be used to follow up the patient and verify adherence to daily treatments including continuous positive airway pressure (CPAP). In children, studies on the role of telemedicine in OSAS are scarce. This narrative review aims to describe the application of telemedicine in children with obstructive sleep apnea syndrome (OSAS), assessing its advantages and disadvantages. In patients with OSA, telemedicine is applicable at every stage of patient management, from diagnosis to treatment monitoring also in pediatric and adolescent ages. While telemedicine offers convenience and accessibility in healthcare delivery, its application in managing OSAS could be associated with some disadvantages, including limitations in physical examination, access to diagnostic tools, and education and counseling; technology barriers; and privacy concerns. The adoption of a hybrid approach, integrating both in-office and virtual appointments, could effectively meet the needs of children with OSAS. However, more studies are needed to fully assess the effectiveness and safety of telemedicine in the pediatric population.

The First-Line Approach in Children with Obstructive Sleep Apnea Syndrome (OSA)

Obstructive sleep apnea syndrome (OSA) is the main manifestation of sleep-disordered breathing in children. Untreated OSA can lead to a variety of complications and adverse consequences mainly due to intermittent hypoxemia. The pathogenesis of OSA is multifactorial. In children aged 2 years or older, adenoid and/or tonsil hypertrophy are the most common causes of upper airway lumen reduction; obesity becomes a major risk factor in older children and adolescents since the presence of fat in the pharyngeal soft tissue reduces the caliber of the lumen. Treatment includes surgical and non-surgical options. This narrative review summarizes the evidence available on the first-line approach in children with OSA, including clinical indications for medical therapy, its effectiveness, and possible adverse effects. Literature analysis showed that AT is the first-line treatment in most patients with adenotonsillar hypertrophy associated with OSA but medical therapy in children over 2 years old with mild OSA is a valid option. In mild OSA, a 1- to 6-month trial with intranasal steroids (INS) alone or in combination with montelukast with an appropriate follow-up can be considered. Further studies are needed to develop an algorithm that permits the selection of children with OSA who would benefit from alternatives to surgery, to define the optimal bridge therapy before surgery, to evaluate the long-term effects of INS +/- montelukast, and to compare the impact of standardized approaches for weight loss.

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.

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.

Update of endoscopic classification system of adenoid hypertrophy based on clinical experience on 7621 children

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.

The role of orthodontics in management of obstructive sleep apnea

Dental sleep medicine is the field of dental practice that deals with the management of sleep-related breathing disorders, which includes obstructive sleep apnea (OSA) in adults and children. Depending on the developmental age of the patient and the cause of the apnea dental treatment options may vary. For adult patients, treatment modalities may include oral appliance therapy (OAT), orthognathic surgery and surgical or miniscrew supported palatal expansion. While for children, treatment may include non-surgical maxillary expansion and orthodontic functional appliances. Many physicians and dentists are unaware of the role dentistry, particularly orthodontics, may play in the interdisciplinary management of these disorders. This review article is an attempt to compile evidence-based relevant information on the role of orthodontists/sleep dentists in the screening, diagnosis, and management of sleep apnea. Oral sleep appliance mechanisms of action, selective efficacy, and the medical physiological outcomes are discussed. The purpose of this review is to provide a comprehensive understanding of how orthodontists and sleep physicians can work in tandem to maximize the benefits and minimize the side effects while treating patients with OSA.

Clinical parameters influencing the results of anterior rhinomanometry in children

BACKGROUND

Nasal obstruction is a frequent symptom in both adults and children and it is a common reason to see an otorhinolaryngologist. Endoscopy of the nasal cavity and the epipharyngeal space along with anterior rhinomanometry is regarded the gold standard since many years to estimate the severity of nasal obstruction in the particular patient. Endoscopy shows anatomical reasons for an obstruction, whereas the nasal flow volume and nasal resistance can be determined using anterior rhinomanometry. Currently, there are only few data available for rhinomanometry results in children. The purpose of the present study was to evaluate the application of this technique in the pediatric population for objective evaluation of nasal flow. Whether it achieves reproducible results and which clinical parameters have some influence on the results were studied.

PATIENTS AND METHODS

427 children (average age of 8.5 years, range 7 months through 17 years) who were admitted to evaluate nasal patency or for allergy testing were examined. After clinical examination and endoscopy of the nasal cavity and epipharyngeal space, anterior rhinomanometry was performed before and after application of decongestant nose drops separately for each nose side in 334 children. The nasal flow with a pressure of 150 Pasc was measured and served for statistical evaluation. Flow values were correlated to clinical and endoscopic parameters along with results of allergy tests (prick tests).

RESULTS

Reproducible rhinomanometric measurements were possible in children age 3 years and older. However, the standard deviation and variation of measurements were significant in this cohort of patients. Statistically highest significant correlations were found between flow measurements and body height along with the age of the children (p < 0.01) and status following adenoidectomy (p < 0.05). No statistically significant correlations were found between rhinomanometry and results of prick tests.

CONCLUSIONS

The study demonstrates that rhinomanometry can be applied in the pediatric population for objective evaluation of nasal obstruction and for determining the effects of decongestant nose drops. The highest correlation was found between nasal flow and children's body height, children's age and status following adenoidectomy. The correlation between nasal flow and clinically/endoscopically determined degree of nasal obstruction was lower. However, definition of normal flow values for particular age groups is challenging since the results showed high variation and standard deviation. Yet with regard to individual patient, the technique achieves reliable results in nasal provocation tests, which are widely used for allergy testing in children. When performed in children it should always be considered that there are age-specific requirements for the examination and interpretation of results in this patient cohort.

Nasopharyngeal fiberendoscopy in children: a survey of current Italian pediatric otolaryngological practices

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.

Adenoids and clinical symptoms: Epidemiology of a cohort of 795 pediatric patients

OBJECTIVE

Adenoid hypertrophy (AH) is very common in children and can cause airway obstruction. The aim of this retrospective study was to investigate the relationship between AH and other factors, including age, possible related symptoms, and allergies.

METHODS

Seven hundred and ninety-five patients (460 males, 335 females; mean age=5.9 years; range age: 1-14 years) were seen in an ENT clinic for nasal symptoms. Nasal endoscopy was performed with a pediatric flexible endoscope. One hundred and sixty-nine patients had documented allergy sensitization. Patients were divided into two groups according to their age: group 1 included children aged 1-7 years, and group 2 included subjects aged 8-14 years.

RESULTS

Adenoid size was related to age (p<0.0001). A logistic regression model - performed to evaluate adenoid grade considering, as dependent variables, age, sex, and the presence or absence of symptoms - was statistically significant (p<0.001). Moreover, AH was more common (p=0.0104) in patients with allergy sensitization, in particular in patients aged 8-14 years (p=0.0043). Nasal obstruction (OR=3.27) significantly predicted AH, whereas major age was not associated with pathological AH (OR=0.81).

CONCLUSIONS

The present retrospective study described the relationship between AH and other demographic and clinical factors. In conclusion, our findings demonstrated a significant association among pathological AH, age, and nasal obstruction.

Nasopharyngeal fiberendoscopy in children: a diagnostic challenge in current clinical practice: how we do it

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.

Evaluation of airway obstruction by adenoid tissue: comparison of measures in the sitting and recumbent

OBJECTIVE

To measure the airway obstruction caused by adenoid hypertrophy in the sitting and recumbent positions in search of hypothesized differences.

METHODS

Forty eight children between the ages of 2 and 12 years who sought the department of otorhinolaryngology spontaneously complaining of snoring and/or nasal obstruction. Children could be either male or female and belong to any social or racial group. Patients underwent nasal videoendoscopy sitting and lying performed by the same investigator. An image of the posterior nasopharynx was obtained from each nasal cavity of each patient for both positions. The free area of the nasopharynx was measured and compared in both positions. Image analysis was performed by two researchers other than that who carried out the examination.

RESULTS

The nasopharynx free area obtained with seated patient is, on average, 53% bigger than the free area obtained with the patient lying down (confidence interval: 95%; p<0.001). Thus, adenoidal obstruction is larger when the examination is performed with the patient lying down.

CONCLUSIONS

Nasal videoendoscopy to evaluate adenoid hypertrophy with the patient lying down makes testing more reliable, better reproducing the patient's position when sleeping. Such accuracy is essential since it influences the decision for surgical intervention in this important and widespread disease in the pediatric population.

Management of chronic rhinosinusitis

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