The role of rhinomanometry after nasal decongestant test in the assessment of adenoid hypertrophy in children

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.

Rhinomanometry with and without decongestant used to select children for adenoidectomy: a cohort study

OBJECTIVE

Adenoid hypertrophy may coexist, and often does, with rhinitis. Therefore, in some cases, adenoidectomy alone, despite the fact that it reduces nasal resistance, may be insufficient to restore nasal breathing. Juliusson et al. suggested using rhinomanometry with and without nasal decongestant as a method for selecting patients for adenoidectomy. In this study, we aim to assess whether the decongestant test, when using normative data, is useful to select children for adenoidectomy.

METHODS

Children between 4 and 15 years old undergoing adenoidectomy were selected from two tertiary referral university hospitals. Participants underwent anterior active rhinomanometry with and without nasal decongestant before and after surgery. Parents fill in the sinus and nasal quality-of-life survey (SN5).

RESULTS

47 participants were included, and mean age 6.5 ± 2.15. 2 cohorts were defined according to the result of the nasal decongestant test (> 40% improvement in nasal resistance or not). There is a statistically significant difference between groups, with a higher improvement in nasal resistance and airflow after adenoidectomy in the group with less than 40% improvement in nasal resistance.

CONCLUSIONS

In conclusion, this study supports the use of the decongestant test with rhinomanometry to select children for adenoidectomy; especially as it has proven to be a simple technique, harmless, fast, and easily performed on collaborative children.

Complex Approach to the Diagnosis of Children with Nasal and Nasopharyngeal Pathology. Key Results

Background. Nasal and nasopharyngeal pathology is one of the most important and widespread challenge in pediatrics and pediatric otorhinolaryngology. Prolonged nasal breathing difficulty can be caused by various diseases and their combinations. It requires multidisciplinary approach to diagnosis with the involvement of modern examination methods and pathogenetic treatment. Objective. The aim of the study is to develop complex technology for the management of children with nasal and nasopharyngeal pathologies. Methods. The study included 240 children aged from 6 to 18 years. All patients were divided into 3 groups, comparable by sex and age: Group 1 — 85 patients with confirmed ENT-organ disease, Group 2 — 104 patients with confirmed allergic disease, control group — 51 somatically healthy patients who did not have any ENT-organ or allergic diseases. Examination procedures: diagnostic nasopharyngeal endoscopy, rhinomanometry (RMM), rhinoresistometry (RRM), olfactometry. Results. The obtained results (RRM, RMM) have shown that air flow rate in nasal cavity increased due to nasal resistance decrease. Nasal resistance was higher and air flow rate was lower in all children with various ENT-organs or allergic diseases compared to the control group. Nasal resistance decreased in all study groups (significantly in children with aggravation of allergic diseases of airways and ENT-organs diseases) as well as air flow rate increased in all study groups (significantly in Group 1 and 2) after anemisation of nasal mucosa with decongestants. Apparently, it can be associated not only with anatomical features (nasal septum deviation), but also with inflammatory features of nasal cavity and nasopharynx (adenoid hypertrophy and inflammation, persistent swelling of nasal mucosa at allergic rhinitis). We would like to present the algorithm for diagnosis of children with nasal and nasopharyngeal pathologies according to the study results. The following practical guidelines have been proposed: 1) all patients with complaints on prolonged nasal breathing difficulties require not only otorhinolaryngologist examination, but also diagnostic endoscopy of nasal cavity and nasopharynx; 2) in case of nasal septum deviation and complaints on prolonged nasal breathing difficulties, it is necessary to perform functional methods for nasal breathing evaluating (RRM, RMM) to choose adequate treatment method; 3) the use of RRM, RMM would help to choose the optimal treatment approach in children with complaints on prolonged nasal breathing difficulties and confirmed diagnosis of allergic disease (allergic rhinitis, hay fever, etc.), also associated with adenoid hypertrophy and/or nasal cavity and nasopharynx inflammatory diseases; 4) all patients with confirmed chronic diseases of ENT-organs should be examined by allergist, and, if necessary, should undergo comprehensive allergological examination. Conclusion. The developed complex approach to the management of children with nasal cavity and nasopharynx pathology is innovative and represents the technology of personalized use of modern, objective methods for diagnosing the nasal cavity and nasopharynx state. The presented diagnostic algorithm and practical guidelines allow us to establish diagnosis and choose the treatment tactics within a short time. The use of these studies in clinical practice will allow to monitor the therapy efficacy (including various pharmacotherapeutic strategies) for nasal cavity and nasopharynx diseases in children. Timely examination and pathogenetic treatment will allow to prevent the chronization of pathological process in ENT-organs. This is especially crucial in childhood as it provides children with the best chance of healthy growth and development.

Evaluation of the associations between maxillary sinus dimensions and adenoid hypertrophy using multislice computed tomography

INTRODUCTION

Adenoid hypertrophy is especially common in childhood, raising the concern that such growth might affect maxillary sinus volumes during the developmental period. This study evaluated the developmental relationships between maxillary sinus volumes and adenoid hypertrophy via computed tomography.

MATERIALS AND METHODS

It was examined computed tomographic images of 118 individuals: 61 boys and 57 girls. The participants were divided into a healthy control group (n = 59) and an experimental group (with adenoid hypertrophy) (n = 59). Raw data were recorded in DICOM format and analysed using the ITK-SNA algorithm; it was measured the right, left, and total maxillary sinus volumes and adenoid tissue sizes.

RESULTS

It was found significant between-group differences in the three maxillary sinus volumes and adenoid tissue dimensions (linear maximum anterior and posterior depth; maximum upper and lower height, and maximum width to the right and left) (all p<0.001). On the contrary, there was no significant difference according to sex in terms of either maxillary sinus volumes or linear adenoid tissue measurements. Maxillary sinus volumes increased significantly according to age in both groups.

CONCLUSION

Adenoid hypertrophy decreases the maxillary sinus volumes, regardless of sex. The impacts of adenoid growth on maxillary sinus aeration and sinus disease should be further investigated.

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.

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.

What is the relationship between the size of the adenoids and nasal obstruction? A systematic review

OBJECTIVE

adenoidectomy is one of the most common surgical procedure in pediatric otolaryngology practice. Clinical guidelines (such as the Spanish or American) suggest adenoidectomy when the enlargement of the adenoids is associated with nasal obstruction. Nasal endoscopy and cephalograms are adequate methods to estimate the size of the adenoids. However, they do not measure nasal patency. This systematic review is designed with the objective of exploring the relationship between adenoid size and nasal ventilation through rhinomanometry.

REVIEW METHODS

3 authors members of the YO-IFOS rhinology study group independently analyzed the data sources (Pubmed, the Cochrane Library, EMBASE, SciELO) for papers assessing both nasal resistance and/or nasal airflow in rhinomanometry and adenoid size by any method (endoscopy, cephalogram, direct examination).

RESULTS

A total of 10 studies with a total population of 969 participants met the inclusion criteria. 5 authors explored the size of the adenoids through endoscopy. 4 authors explored the adenoids through lateral cephalograms. Finally, a further 2 authors explored adenoid size studying the resected tissue. Five studies explored the correlation between adenoid size and nasal resistance in rhinomanometry, which ranged from 0.20 to 0.84. Finally, 5 studies used nasal decongestant. It was found higher sensitivity and specificity, a higher area under the curve for the receiver operating characteristic curve, and higher correlation with adenoid size for rhinomanometry under nasal decongestion.

CONCLUSION

Up to now, there is no ideal diagnostic method for adenoid hypertrophy. Therefore, it seems prudent to use a combination of all currently available tools, as they provide complementary, rather than supplementary information. Available evidence suggests that rhinomanometry combined with nasal decongestant could help to elucidate the existence of nasal obstruction in intermediate cases of adenoid hypertrophy, as well as throw light on other possible causes for nasal obstruction, mainly turbinate hypertrophy.

Modified adenoid grading system for evaluating adenoid size in children: a prospective validation study

Nasal endoscopy is the best choice for evaluation of adenoid size, but very few studies published on the endoscopic quantitative assessment. This study aimed to newly propose and validate a modified adenoid grading system (MAGS) with the existing endoscopic scoring methods of adenoid size. A prospective study on children with chronic mouth breathing and having endoscopic nasal examination was conducted. Digital images obtained during endoscopic examination were evaluated with the traditional method and the MGAS. Adenoid size was also evaluated by intraoperative nasal endoscopy among those underwent adenoidectomy. One hundred and thirty patients were enrolled. The MAGS showed high inter-rater reliability with a Kappa score of 0.869. Sixty of 130 patients underwent adenoidectomy and assessed with intraoperative nasal endoscopy. The MAGS significantly correlated to the percentage of nasopharyngeal obstruction of intraoperative endoscopy (Spearman's r = 0.796, gamma coefficient = 0.94), and the percentage of choanal obstruction of preoperative endoscopy (Spearman's r = 0.816, gamma coefficient = 0.859). Our findings suggest that the MAGS has high reliability and validity for assessment of adenoid size. It may be a more suitable and reliable grading system for endoscopic evaluation of adenoid size.

Looking for a cutoff value for the decongestant test in children suffering with turbinate hypertrophy

OBJECTIVE

The main causes for objectively confirmed chronic impaired nasal breathing in children are adenoid and turbinate hypertrophy. Turbinate hypertrophy may be addressed by turbinate surgery. However, specialized guidelines include no specific indications for pediatric patients. The decongestant test consists of simulating the effect of turbinate surgery by means of a nasal decongestant. This project, developed by the YO-IFOS rhinology group, aims to establish a cutoff value for the nasal decongestant test with rhinomanometry to select children for turbinate surgery.

METHODS

Children between 4 and 15 years of age were included. Cases were consecutively selected from children affected by turbinate hypertrophy undergoing turbinate radiofrequency ablation with or without adenoidectomy. Controls were consecutively selected from a sample of healthy children. All the subjects were examined with anterior active rhinomanometry with and without nasal decongestant.

RESULTS

Sample included 72 cases and 24 healthy controls. There was a statistically significant difference in the improvement with the decongestant between cases (57.91%) and controls (15.67%). The ROC curve revealed an area under the curve of 0.97. The highest amount of correctly classified individuals (93.44%) corresponded to the cutoff value of 31.66%. However, the value with the highest specificity and highest Youden's index was the 38.88% improvement in nasal resistance with nasal decongestant.

CONCLUSIONS

In conclusion, a preliminary cutoff value for the decongestant test used with rhinomanometry in children has been established. This test could help identify children for turbinate surgery.

Adenoid hypertrophy affects screening for primary ciliary dyskinesia using nasal nitric oxide

AIM

In patients with primary ciliary dyskinesia (PCD), the release of nitric oxide (NO) is extremely low by epithelia of the nasopharynx and sinuses. Measurement of nasal NO (nNO) is recommended as a screening test for PCD. The study aimed to evaluate if adenoids affects nNO and may deteriorate the performance of the test.

METHODS

In 48 nonallergic patients between 5 and 18 years of age with chronic symptoms of nasal obstruction and indications for adenoidectomy, the measurements of nNO by chemiluminescence analyser and nasal patency by active anterior rhinomanometry were performed both before and after adenoidectomy. Adenoidal tissue size was graded during surgery under general anaesthesia using transoral endoscopy.

RESULTS

Patients were stratified into groups with adenoids grades 1, 2 and 3 (<1/3, 1/3-2/3 and > 2/3 of the choana and post-nasal space covered by adenoids). Before adenoidectomy, the median of nNO decreased with the increasing grade of adenoids (920, 663, and 491 ppb, P < 0.05). The rhinomanometry results were comparable and showed no correlation with nNO. Seven patients (14.6%) were incorrectly classified to have PCD based on a subthreshold value of the volume flow of nNO (FnNO < 77 nL/min). Following adenoidectomy, nNO of the grade 3 patients increased by 107 ppb (P < 0.05) and no differences were found between groups (P = 0.40). All patients had the postadenoidectomy FnNO >77 nL/min.

CONCLUSIONS

nNO and FnNO are reduced in nonallergic children with obstructive adenoids. Adenoid hypertrophy can potentially cause a false positive result of the test for PCD.

Measurements of nasal airflow and patency: a critical review with emphasis on the use of peak nasal inspiratory flow in daily practice

Objective measures can be used to assist the clinician to diagnose and treat nasal obstruction and also to quantify nasal obstruction in research. Objective measurements of nasal obstruction are as important as objective measurements of lung function. peak nasal inspiratory flow (PNIF), acoustic rhinometry (AR) and rhinomanometry (RM), with their specific peculiarity, assess different aspects of nasal obstruction. From the studies available in the literature, it seems that these methods roughly correlate with each other and that all of them can be alternatively utilized very well in research as well as in clinical practice. This review describes the various methods that can be used to measure nasal patency, airflow and resistance, mainly peak nasal inspiratory flow, rhinomanometry and acoustic rhinometry. PNIF has been demonstrated to be reproducible and as good an indication of objective nasal patency as formal rhinomanometry and has the advantage to be cheap, simple and suitable for serial measurements and for home use even in the paediatric population. PNIF normative data are available for children, adults and elderly subjects, and the availability of unilateral PNIF normal values allows evaluation of nasal sides separately. Just as in the lower airways, objective and subjective evaluation gives different information that together optimizes the diagnosis and the treatment of our patients. We argue that PNIF should be used regularly in every outpatient clinic that treats patients with nasal obstruction.