Non-surgical treatment of adenoidal hypertrophy: the role of treating IgE-mediated inflammation

Changes in the pharyngeal and nasal microbiota in pediatric patients with adenotonsillar hypertrophy

The present study aimed to investigate the pharyngeal and nasal microbiota composition in children with adenotonsillar hypertrophy (AH) and assess longitudinal alterations in both microbiota after a probiotic oral spray treatment. A cohort of 57 AH patients were enrolled and randomly assigned to the probiotic and placebo groups for a 5-month treatment course. Pharyngeal and nasal swabs were collected before and after treatment and analyzed by 16S rRNA-based metataxonomics and axenic cultures for pathobiont identification. 16S rRNA sequences from pharyngeal and nasal swabs of 65 healthy children (HC) were used as microbiota reference profiles. We found that the pharyngeal and nasal microbiota of AH children were similar. When compared to HC, we observed an increase of the genera Rothia, Granulicatella, Streptococcus, Neisseria, and Haemophilus, as well as a reduction of Corynebacterium, Pseudomonas, Acinetobacter, and Moraxella in both microbiota of AH patients. After probiotic treatment, we confirmed the absence of adverse effects and a reduction of upper respiratory tract infections (URTI). Moreover, the composition of pharyngeal microbiota was positively influenced by the reduction of potential pathobionts, like Haemophilus spp., with an increase of beneficial microbial metabolic pathways. Finally, the probiotic reduced the abundance of the pathobionts Streptococcus mitis and Gemella haemolysans in relation to AH severity. In conclusion, our results highlight the alterations of the pharyngeal and nasal microbiota associated with AH. Moreover, probiotic administration conferred protection against URTI and reduced the presence of potential pathobionts in patients with AH.

IMPORTANCE

Adenotonsillar hypertrophy (AH) is considered the main cause of breathing disorders during sleep in children. AH patients, after significant morbidity and often multiple courses of antibiotics, often proceed to tonsillectomy and/or adenoidectomy. Given the potential risks associated with these procedures, there is a growing interest in the use of nonsurgical adjuvant therapies, such as probiotics, that could potentially reduce their need for surgical intervention. In this study, we investigated the pharyngeal and nasal microbiota in patients with AH compared with healthy children. Furthermore, we tested the effects of probiotic spray administration on both disease symptoms and microbiota profiles, to evaluate the possible use of this microbial therapy as an adjuvant for AH patients.

Serum leptin and adiponectin function as indicators of allergic sensitization in pediatric adenotonsillar hypertrophy

PURPOSE

Obesity is commonly linked to both adenotonsillar hypertrophy (ATH) and allergic disorders, in which the roles of adipokines are not fully illuminated. This study aims to investigate the levels of leptin and adiponectin and their associations with allergic sensitization in pediatric ATH.

METHODS

Serum levels of specific immunoglobulin E (IgE), leptin and adiponectin were quantified in 35 controls and 111 ATH children, in which 54 were non-atopic and 57 were atopic. Spearman's correlation analysis and polynomial linear trend test were conducted. The odds ratios and 95% confidence intervals were calculated by binary logistic regression after multivariable adjustment.

RESULTS

The serum level of leptin and leptin/adiponectin (L/A) ratio was significantly increased in children with ATH. An increase in leptin level and L/A ratio and a decrease in adiponectin level were observed in atopic children compared with non-atopic children. Among ATH children, the level of adiponectin was negatively while L/A ratio was positively correlated with specific IgE. After multivariable adjustment, leptin was significantly associated with increased risk of atopy to D. pteronyssinus and D. farina, and adiponectin was significantly associated with decreased risk of atopy to willow and mugwort. Leptin was associated with higher odds while adiponectin was associated with lower odds of overall atopy. Besides, significant multiplicative interactions of obesity with leptin and adiponectin on atopy were observed respectively.

CONCLUSION

Leptin and adiponectin were both associated with allergic sensitization and function differently in pediatric ATH. Mechanistic studies are needed to elucidate the involvement of adipokines in allergic sensitization of pediatric ATH.

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.

Correlation Between Nasal Allergy and the Number of Eosinophils in Adenoid Tissue

To study adenoid tissue eosinophilia in allergic rhinitis. A single-centre clinical case-control prospective study with 66 subjects enrolled for the study after taking written informed consent from all the participants. All patients underwent adenoidectomy with histopathological evaluation of adenoid tissue samples for eosinophils. 36 patients (cases) with Symptoms for Allergic Rhinitis (SFAR) score indicative of allergic rhinitis. 30 patients (control) with SFAR scores not indicative of allergic rhinitis. All patients were evaluated for serum absolute eosinophil count and total serum immunoglobulin E (Ig-E). There was a significant relationship between allergic rhinitis and serum Ig-E levels using the Kruskal-Wallis rank sum test amongst case and control groups with a p-value of 0.031. Pathologically examined slides of adenoid tissue eosinophil count per 10 random high power fields in these patients showed significant results with a p-value of 0.002432, via the Kruskal-Wallis rank sum test. Statistical analysis, shows that adenoid tissue eosinophil count and serum Ig-E levels can somewhat predict the presence of clinical features of allergic rhinitis. Based on several similar studies with similar results, allergic rhinitis can be gauged with adenoid tissue histopathology and routine evaluation should be considered as a standard of care.

Evaluation of Pre and Post-operative Pulmonary Artery Pressures in Children with Adenotonsillar Hypertrophy and Correlation with Chronicity: A Prospective Study on 50 Children

Children with grade III or IV of adenotonsillar hypertrophy especially of a longer duration, may show cardiovascular changes due to mouth breathing. These changes can be detected on doppler echocardiocardiography which can be used as a screening tool. Fifty paediatric patients of grade 3 and 4 adenotonsillar hypertrophy underwent adenotonsillar resection after a pre-operative work up which included doppler echocardiography to measure pulmonary artery pressures. A post-operative doppler echocardiography was done after three months. 11 children (22%) showed deranged pulmonary artery pressure values with increased mean pulmonary artery pressure (MPAP) and pulmonary artery systolic pressure (PSAP) on preoperative doppler echocardiography, and 2 out of these 11 children had Pulmonary Artery Hypertension. A significant (p < 0.001) improvement was noted in pulmonary artery pressure values (MPAP and PSAP returned to normal) after adenotonsillectomy in 3-month postoperative echocardiography. Also, a statistically significant correlation was obtained between chronicity of symptoms and raised pulmonary artery pressures. Our study concluded that these children with chronic untreated upper airway obstructive symptoms get predisposed to potential cardiac complications. And these grave consequences can be easily prevented by a timely intervention.

Clinical presentation, radiographic findings, and treatment outcomes in children with adenoid hypertrophy in a paediatric outpatient clinic in Enugu, Nigeria

Objectives

To determine the clinical presentation, imaging features and outcomes of children with adenoid hypertrophy in our setting.

Design

A retrospective study.

Setting

The paediatric clinic of a private hospital in Enugu.

Participants

51 children, aged 2 to 108 months, with suggestive clinical features and radiographic report of adenoid hypertrophy who presented over 3 years.

Interventions

Clinical information was obtained from the patient's medical records. Data was analysed for the clinical characteristics of the patients, the relationship between the degree of airway narrowing on a postnasal space (PNS) radiograph and treatment outcomes.

Main outcome measures

Degree of airway narrowing as measured on a PNS radiograph, the type of and outcomes of treatment.

Results

There was an almost equal male (54.7%): female (45.1%) ratio in the occurrence of adenoid hypertrophy, with a mean age of occurrence of 31.50 ± 3.64 months. Noisy breathing was the commonest symptom (94.1%); history of atopic rhinitis in 64.7% of cases and hyperactive airway disease in 45.1% more than 50% of cases with airway narrowing resolved with medical management only.

Conclusion

Adenoid hypertrophy should be considered in evaluating the upper airway in children under five. Paediatricians should be conversant with diagnosing and managing this common cause of upper airway obstruction.

Funding

None declared.

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.

Effect of tonsillectomy in a child with obesity and obstructive sleep apnea: A case report and review of the literature

Obstructive sleep apnea (OSA) is an increasingly recognized disorder in children. Adenotonsillectomy is the primary surgical treatment for OSA in children with adenotonsillar hypertrophy (ATH). We present the case of an obese 4-year-old boy hospitalized for severe desaturation during sleep and severe ATH. Nasal steroid therapy proved ineffective with persistent symptoms. Polygraphy documented severe OSA with an apnea-hypopnea index (AHI) equal to 11. Tonsillectomy resulted in prompt symptom improvement and a substantial reduction of the AHI (2.2). In this case, tonsillectomy alone resulted effective in treating OSA, despite obesity. We concluded that the presence of obesity should not postpone/exclude surgical treatment of preschool children for whom ATH is the most important cause of OSA.

Analysis of Risk Factors for Otitis Media with Effusion in Children with Adenoid Hypertrophy

Objective

This study aimed to explore whether children with AH have a higher obesity prevalence and analyze the risk factors for otitis media with effusion(OME) in AH children.

Methods

AH patients aged 3-12 years old that were hospitalized in our hospital for adenoidectomy from June 2020 to September 2022 were included in this study. Height and weight were measured to calculate the body mass index, weight for height and weight z-score to evaluate the development of AH children. Propensity score matching was applied to minimize patient selection bias and adjust for confounding factors to analyze the risk factors for OME in children with AH.

Results

A total of 887 children with AH were enrolled in this study. The prevalence of overweight or obesity was higher in children with AH than the control group. The size of adenoids is significantly different between AH children with and without OME. For children aged over 5, there are significantly higher counts of white blood cells, neutrophils, and monocytes in the AH children with OME than those without OME. More individuals represent to be atopic in children with OME than those without OME.

Conclusion

The obstruction of the Eustachian tube is the most important factor of OME in AH children. It seems that there is no apparent correlation between OME and atopic conditions in AH children. In addition to surgical resection of adenoids, active control of infection and inflammation are also important to prevent OME for AH children aged over 5.

Pharmacotherapy focusing on for the management of otitis media with effusion in children: Systematic review and meta-analysis

OBJECTIVE

To examine the evidence for treating children with otitis media with effusion with pharmacotherapy.

DATA SOURCES

For the systematic review, data were retrieved from PubMed, Cochrane database, and the Japan Medical Abstracts Society Database (1st January 1995 through 31th May 2019).

STUDY SELECTION

Articles addressing pharmacotherapy for the management of otitis media with effusion in children were selected in English.

DATA EXTRACTION

The database was searched using the keywords "Otitis Media with effusion or secretory otitis media" and the following medical agents: carbocysteine, antihistamines, leukotriene receptor antagonist, and steroid nasal spray.

DATA SYNTHESIS

After a critical review of 18 studies, studies addressing steroid nasal spray were eligible for quantitative synthesis. Intranasal steroids for OME showed no benefit with OR 1.155 (95% CI 0.834-1.598) within one month. Conversely, intranasal steroids have effects for OME with OR 1.858 (95% CI 1.240-2.786) for more than one month.

CONCLUSIONS

We found evidence of benefit from treatment of OME in children with intranasal steroids and S-carboxymethylcysteine at longer-term follow-up.

Anatomy and physiology of the palatine tonsils, adenoids, and lingual tonsils

OBJECTIVE

This review aims to discuss the basic anatomy and physiology of the palatine and pharyngeal tonsils, with reference to how this foundational understanding may affect patient management and surgical procedures in these regions of the upper airway.

METHODS

A literature search was performed using PubMed and Google Scholar using the MeSH terms tonsils, adenoids, anatomy, physiology, and adenotonsillectomy. Primary sources were excluded if they were abstracts only, non-English language, or non-human studies. Thirty-five sources were included in this review.

RESULTS AND CONCLUSIONS

The pharyngeal and palatine tonsils are compact yet physiologically complex mucosa-associated lymphoid tissues that make up a portion of Waldeyer's ring. As part of the mucosal immune system, these structures function in exogenous antigen sampling and stimulation of immune responses. Aberrant immune activation and/or regulation can lead to a myriad of pathologies, with adenotonsillar hypertrophy, chronic tonsillitis/adenoiditis, and recurrent otitis media among the most commonly encountered conditions by otolaryngologists. While the pathophysiology of these conditions is still incompletely understood, current evidence and future investigations may reveal patterns amenable to targeted medical management. When medical management fails, tonsillectomy and/or adenoidectomy may be indicated for patient care. Though routine procedures, the execution of tonsil and/or adenoid removal requires a thorough understanding of the anatomy of these lymphoepithelial organs so as to minimize the risk for rare serious complications that can occur.

Evaluation of the intranasal steroid treatment outcomes in adenoid tissue hypertrophy with or without allergic rhinitis

PURPOSE

To compare the intranasal steroid (INS) treatment outcomes in patients with adenoid tissue hypertrophy (ATH) with or without allergic rhinitis (AR).

MATERIALS AND METHODS

Medical records of 96 children diagnosed with ATH were retrospectively examined. The pediatric version of the Score for Allergic Rhinitis (SFAR) questionnaire was used to determine the AR status of the patients and classify them. The children were divided into two groups based on the questionnaire: Group 1, low probability of AR (SFAR<9); and Group 2, high probability of AR (SFAR≥9). Intranasal mometasone furoate (100 μg/mL) was used to treat ATH for at least 3 months. The severity of nasal obstruction and snoring was evaluated using the visual analog scale (VAS) score, the adenoid/choana (A/C) ratios before and after treatment were compared, and the rate of patient referral to surgery was recorded among groups.

RESULTS

The change in the A/C ratio within the group between before and after treatment was significant (both P < 0.001). However, the reduction in the adenoid size was more significant in Group 1 than in Group 2 (P = 0.025). A significant improvement in the VAS scores was observed between before and after treatment in both groups (P < 0.001). Furthermore, the rate of surgical referral of Group 1 was significantly lower than that of Group 2 (P = 0.035).

CONCLUSIONS

INS treatment was found more successful for reducing A/C ratio in ATH without AR. Related with this, when considering the INS treatment for ATH, AR status should be kept in mind for predicting the treatment success.

The Association Between Obstructive Sleep Apnea and Allergic Rhinitis: Current Literature Review

:

Sleep-disordered breathing (SDB) is now a significant health problem in today's culture. It ranges from a spectrum of abnormal conditions during sleep from the primary snorer to mild, moderate, or severe obstructive sleep apnea (OSA). SDB also comprises other conditions, such as sleep-related hypoventilation, sleep-related hypoxemia, and central sleep apnea syndromes.

:

One of the components of the pathophysiology of OSA that remain unclear is the association of allergic rhinitis (AR) in the evolution of OSA. Several studies relate the co-existence of OSA and AR in the common clinical practice, but its correlation was not clear. This review article aimed to review the pathophysiological relationship between OSA and AR in terms of the role of chemical mediators and the effect of AR treatment in support of OSA.

:

The symptoms of AR further accelerate the clinical progression to OSA development. Inflammatory mediators such as histamine, cysteinyl leukotrienes, and interleukins are found at a high level in AR, which can aggravate AR symptoms such as nasal obstruction, rhinorrhea, and itchiness, which can then lead to sleep disruption in OSA patients. In addition, OSA patients also have increased chemical mediators such as tumor necrosis factor, interleukin 6, and 1, which would activate the T helper 2 phenotypes that can aggravate AR symptoms. This vicious cycle can potentiate each other and worsen the condition. Few studies have shown that treatment of AR can improve OSA, especially the use of intranasal steroid and leukotriene receptor antagonists.

:

A detailed evaluation of rhinitis symptoms should be made for OSA patients so that they can benefit not only from the improvement of AR but also the good sleep quality.

IL-32 exacerbates adenoid hypertrophy via activating NLRP3-mediated cell pyroptosis, which promotes inflammation

Adenoid hypertrophy (AH) is a common pediatric disease caused by inflammatory stimulation. The pro-inflammatory cytokine IL-32 has been reported to promote airway inflammation and also be involved in the pyroptosis pathway. However, whether IL-32 can contribute to AH by mediating pyroptosis remains to be elucidated. The present study aimed to investigate the role of IL-32 in AH and determine the potential underlying mechanisms. Adenoid tissues were collected from healthy children and children with AH, and the expression of IL-32, NACHT LRR and PYD domains-containing protein 3 (NLRP3) and IL-1β in normal and hypertrophic tissues were measured. Human nasal epithelial cells (HNEpCs) were exposed to a series of IL-32 concentrations. HNEpCs with or without IL-32 silencing were stimulated with lipopolysaccharide (LPS), and cell proliferation, cell apoptosis, gasdermin D (GSDMD) activation, production of inflammatory cytokines and the expression levels of proteins related to the potential mechanisms were evaluated by Cell Counting Kit-8, flow cytometry, immunofluorescence staining, ELISA and western blot assays, respectively. The results showed that IL-32, NLRP3 and IL-1β exhibited higher expression in adenoid tissues with AH compared with normal tissues. In HNEpC cells, treatment with IL-32 (2 and 10 ng/ml) promoted cell proliferation, while 50 ng/ml IL-32 inhibited cell proliferation at 12, 24 and 48 h post-treatment. IL-32 (2, 10 and 50 ng/ml) also resulted in differing degrees of apoptosis, GSDMD activation, release of IL-1β, IL-6 and TNF-α, and increased protein expression levels of NLRP3, cleaved-caspase-1, activated GSDMD, nucleotide-binding oligomerization domain-containing protein (NOD) 1/2 and Toll-like receptor (TLR)4 in a concentration-dependent manner. In addition, compared with the LPS group, IL-32 knockdown significantly inhibited LPS-induced enhancement of cell proliferation, cell apoptosis, GSDMD activation and production of inflammatory cytokines, and reversed the increased protein expression of NLRP3, cleaved-caspase-1, activated GSDMD, NOD1/2 and TLR4. In conclusion, IL-32 may play a role in the progression of AH via promoting inflammation, and the potential mechanism may involve the activation of NLRP3-mediated pyroptosis.

Clinical outcome of Montelukast Sodium in Children with Adenoid Hypertrophy

Background & Objectives:

Generally, the blockage of upper respiratory tract in children is seen with the hypertrophy of adenoids and tonsils. Normally for patients with adenoid hypertrophy (AH), Adenoidectomy with or without Tonsillectomy is carried out, however it has its own complications like haemorrhage and recurrence of adenoid tissue. Consequently, therapeutic approach has increased extraordinary consideration rather than surgical procedure. The inflammatory process proposed for AH has prompted the utilization of anti-inflammatory drugs to treat this issue. The objective of this study was to assess the impacts of Montelukast sodium in children with enlarged adenoids.

Methods:

A randomized controlled trail was performed from April 2018 to March 2019 in the Otorhinolaryngology clinic of Dr. Akbar Niazi Teaching Hospital, Islamabad. In this randomized, placebo treatment-controlled trial, 60 children aged 4-12 years meeting inclusion criteria were isolated into two groups. The study group was treated with Montelukast sodium 5mg consistently for three months while the control group got placebo treatment for a similar timeframe. A questionnaire was filled by parents/ guardians of every child before and after the intervention to evaluate the severity of sleep discomfort, snoring and mouth breathing.

Results:

Following 3 months of treatment, significant reduction in size of the adenoids was seen in 76% of study group compared with just 3% of control group getting placebo treatment.

Conclusion:

Montelukast sodium seems to be effective in the reduction of the size of adenoids and improvement in clinical manifestations. It can be viewed as a viable option in contrast to surgical treatment in children with hypertrophy of adenoids.

Eosinophils Are More Strongly Relevant to Allergic Sensitization Than Basophils in Pediatric Adenotonsillar Hypertrophy

The relationship between eosinophils/basophils and allergic sensitization is not clear in pediatric adenotonsillar hypertrophy (ATH). The objective of this study is to investigate the relationship between eosinophil/basophil counts and peripheral specific IgE levels, and identify the common allergens in children with ATH. We initially screened 1,031 consecutive children who underwent adenotonsillectomy in our department from June 2018 to June 2019, and finally included 676 children. The eosinophil count, basophil count, and levels of specific IgE were collected. Correlations between two quantitative variables were assessed using the Pearson or Spearman coefficient. Logistic regression analyses were performed to evaluate the odds ratios (ORs) for atopy after controlling for age, sex, vitamin D, BMI, and visiting season. Both the eosinophil and basophil counts in atopic participants were significantly higher compared to non-atopic participants. The eosinophil count correlated with the levels of IgE specific to all allergens, and eosinophilia was independently associated with all tested atopy allergens other than atopy to dander after multivariate adjustment. Additionally, the basophil count correlated with the IgE levels specific to A. alternate and food mix, and basophilia was still significantly associated with atopy to food mix after multivariable adjustment. Furthermore, among allergic participants, D. farinae was the most prevalent allergen, followed by food mix, D. pteronyssinus, and A. alternata. In conclusion, eosinophils were more relevant to allergic sensitization than basophils, with eosinophils being significantly associated with all tested atopy allergens apart from dander, and basophils being associated with atopy to food mix. Furthermore, D. farinae was the most prevalent allergen and may be indicative of desensitization therapy.

Pediatric Obstructive Sleep Apnea and Neurocognition

Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.

The Atopy Index Inventory: A Brief and Simple Tool to Identify Atopic Patients

INTRODUCTION

Atopy and ear, nose and throat (ENT) diseases are frequently associated; however, no clinical tool has been proposed so far to discriminate which patients could be atopic and therefore deserving of a further immunoallergological evaluation.

OBJECTIVE

The aim of this study was to assess and validate a set of dichotomous responses suitable for predicting the presence of atopy in adult patients.

METHODS

An 11-item questionnaire, i.e., the Atopy Index Inventory (AII), comprised of 4 questions regarding the clinical history for allergic disease and 7 questions evaluating the presence of the most frequent clinical signs affecting allergic patients, was developed and administered to 226 adult subjects (124 atopic subjects and 102 healthy, not atopic subjects). The atopic condition was proven by an immunoallergological evaluation according to the diagnostic criteria of the EAACI guidelines. Internal consistency and clinical validity were tested.

RESULTS

In healthy subjects, the first 4 variables of the AII returned a 100% correct response (all answered "no") and were defined as "decisive" responses. In the logistic regression analysis, when decisive items were negative, the atopic condition was confirmed when answering "yes" to at least 3 "probability" items (cut-off = 2.69). The difference in AII scores between allergic and healthy group was significant using the Mann-Whitney U test (p < 0.0001). The sensitivity and specificity of the AII were 0.97 and 0.91, respectively, with a true predictive value of 0.92 and a false predictive value of 0.97. The ROC curve showed an area of 0.94, with an OR of 0.88 (95% CI 0.87-0.97, p = 0.0001). The internal consistency as determined by the Cronbach α coefficient was 0.88.

CONCLUSION

The AII has been proven to be a brief, simple and sufficiently accurate tool for screening ENT patients in search of atopic individuals and to allow their clinical management.

Topical nasal treatment efficacy on adult obstructive sleep apnea severity: a systematic review and meta-analysis

BACKGROUND

Nasal obstruction is a common complaint in patients with sleep-disordered breathing and obstructive sleep apnea (OSA). Although topical nasal treatments (TNTs) have been shown to reduce nasal resistance and improve nasal obstruction, there is conflicting evidence regarding the role of TNTs in adult OSA. In this systematic review and meta-analysis we aim to evaluate the role of TNTs in adults with OSA. Data sources used included PubMed, Ovid MEDLINE, and Cochrane Central, from January 2001 to July 2019.

METHODS

Inclusion criteria were English-language studies containing original data on TNTs in adults (≥18 years) with OSA (apnea-hypopnea index [AHI] ≥5). Exclusion criteria were case reports, studies without outcome measures, and concurrent non-TNT treatment for OSA. Two investigators independently reviewed all articles and performed quality assessment using validated tools. Meta-analysis and quality assessment were performed.

RESULTS

Of the 2180 abstracts identified, 8 studies met inclusion criteria. TNTs included decongestants (4 of 8 studies), corticosteroids (3 of 8), and antihistamines (1 of 8). Outcome measures included AHI (8 of 8), respiratory distress index (RDI; 1 of 8), oxygen-desaturation index (ODI; 3 of 8), minimum SaO2 (MinSaO₂ ; 4 of 8), nasal resistance (4 of 8), endoscopic sinus surgery (4 of 8 studies) and standardized rhinoconjunctivitis quality of life questionnaire scores (1 of 8 studies). Qualitatively, all studies showed trends toward improving objective and subjective measures of OSA, although the significance of these improvements varied across studies. A meta-analysis was performed in 5 studies, but TNTs did not reveal a significant change in AHI (p > 0.05).

CONCLUSION

TNTs may improve minimum oxygen saturation, ODI, RDI, and subjective/quality-of-life measures. Allergic patients may have more improvement in OSA measures compared with nonallergic patients. Future studies are indicated to accurately determine the efficacy of TNTs.

Ciliary beat frequency in children with adenoid hypertrophy

BACKGROUND

Children with adenoid hypertrophy (AH) have impaired respiratory system defense mechanisms, such as mucociliary clearance. We hypothesized that AH negatively affects one of the most important aspects of mucociliary clearance-ciliary beat frequency (CBF) and that adenoidectomy could potentially restore this essential defence mechanism of the airways. This study evaluated the influence of AH and endoscopic adenoidectomy on the CBF of the nasal respiratory epithelium in children.

METHODS

This prospective study included 64 children with confirmed AH aged 3 to 18 years and 43 age- and sex-matched healthy controls. Nasal CBF was analyzed using a digital high-speed video microscope and the software application Ciliary Analysis (NI LabVIEW). The preoperative adenoid size was assessed according to Cassano. Clinical symptoms of chronic rhinosinusitis were evaluated using the SNOT-20 questionnaire.

RESULTS

Children with AH had a median CBF of 5.35 ± 1.06 Hz. Six months after surgery, the median CBF was significantly higher (6.48 ± 0.88 Hz; P < .001) and reached the values of healthy children (6.37 ± 0.71 Hz; P = .512). The size of the adenoid tissue did not correlate with the CBF. No influence of age or gender on the CBF was found. After adenoidectomy, a significant reduction of the mean total SNOT-20 score was recorded (P < .01).

CONCLUSION

Children with clinically symptomatic AH have impaired mucociliary clearance due to decreased nasal CBF. Removal of hypertrophic adenoid tissue normalizes the CBF and reduces the presence of clinical symptoms of rhinosinusitis.

Atropine toxicity caused by erroneous intranasal administration in a pediatric patient: case report

A 28-month-old boy mistakenly received intranasal atropine sulfate instead of Otrivin (xylometazoline hydrochloride) for the treatment of adenoid hypertrophy. Later on, he came to the emergency department with anticholinergic manifestations after the administration of multiple drops. The child presented with a tonic-clonic seizure lasting for a few minutes, followed by a brief loss of consciousness, vomiting, agitation, and irritability, all of which were stabilized by a dose of intravenous lorazepam. Subsequently, he was admitted to the pediatric intensive care unit for observation. Afterwards, he developed agitation and unsteady gait, both of which resolved after receiving neostigmine. Eventually, the child became asymptomatic and was discharged home. To the best of our knowledge, only one similar case has been reported in the literature. SIMILAR CASES PUBLISHED: 1.

Effectiveness and safety of Chinese herbal medicine for pediatric adenoid hypertrophy: A meta-analysis

OBJECTIVE

Chinese herbal medicine has been gradually used to treat pediatric adenoid hypertrophy. This meta-analysis were conducted to evaluate the clinical efficacy and safety of Chinese herbal medicine in the treatment of pediatric adenoid hypertrophy.

METHODS

Randomized controlled trials involving Chinese herbal medicine in the treatment of pediatric adenoid hypertrophy were identified from Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Chinese National Knowledge Infrastructure, Chinese Biomedical Database, Wanfang Database and VIP Information Database. The methodological quality of trials was evaluated with Cochrane Handbook criteria, and the Cochrane Collaboration's Review Manager 5.3 software was used for Meta-analysis.

RESULTS

A total of 13 valid articles involving 1038 patients were included. The meta-analysis showed that: Compared with western medicine treatment, Chinese herbal medicine significantly improved clinical efficacy (RR = 1.33, 95% CI [1.24,1.43]), and significantly decreased A/N ratio (MD = -0.04,95%CI [-0.05,-0.03]). Chinese herbal medicine also prominently improved the quality of life (MD = -4.77,95%CI [-8.35,-1.20]). Meanwhile, it dramatically improved snoring (MD = -0.46,95%CI [-0.62,-0.30]); mouth breathing (MD = -0.52,95%CI [-0.66,-0.39]); nasal obstruction (MD = -0.56,95%CI [-0.68,-0.45]).

CONCLUSION

Chinese herbal medicine has good clinical efficacy and safety on pediatric adenoid hypertrophy, which need to be confirmed by high quality, multiple-centre, large sample randomized controlled trials.

Association between allergic and nonallergic rhinitis and obstructive sleep apnea

PURPOSE OF REVIEW

Allergic rhinitis and nonallergic rhinitis (NAR) are common disorders, which have been considered as potential risk factors for obstructive sleep apnea (OSA). This review summarizes the proposed underlying pathophysiological mechanisms to provide a better understanding of the relationship between these conditions.

RECENT FINDINGS

In adults, allergic rhinitis and NAR may be considered as symptoms potentiating, rather than risk potentiating factors in the pathophysiology of OSA, whereas in children, these are considered to be independent predictors for sleep-disordered breathing (SDB) and failure of adeno-tonsillectomy, the recommended first-line therapy for children with OSA. Current advances suggest IL-6 may be important in regulating the sleep-wake cycle, and serum soluble IL-6 receptor (sIL-6R) levels may reflect the severity of OSA. Elevated Th17/Treg ratio correlates positively with apnea-hypopnea index of OSA patients, and Th17 and Treg imbalances caused by allergic rhinitis and OSA, respectively, may possibly promote each other, leading to further imbalance. Moreover, obesity is a strong risk factor for OSA, and leptin plays an important role in ventilatory function and upper airway obstruction. The variant trigeminocardiac reflex and nasotrigeminal reflex may also be involved in the association between rhinitis and OSA.

SUMMARY

Allergic rhinitis/NAR and OSA are closely associated, and each condition can be detrimental to the other. Thus, clinicians should pay attention to the potential presence of allergic rhinitis/NAR in OSA patients and vice versa.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Multi-morbidities of allergic rhinitis in adults: European Academy of Allergy and Clinical Immunology Task Force Report

This report has been prepared by the European Academy of Allergy and Clinical Immunology Task Force on Allergic Rhinitis (AR) comorbidities. The aim of this multidisciplinary European consensus document is to highlight the role of multimorbidities in the definition, classification, mechanisms, recommendations for diagnosis and treatment of AR, and to define the needs in this neglected area by a literature review. AR is a systemic allergic disease and is generally associated with numerous multi-morbid disorders, including asthma, eczema, food allergies, eosinophilic oesophagitis (EoE), conjunctivitis, chronic middle ear effusions, rhinosinusitis, adenoid hypertrophy, olfaction disorders, obstructive sleep apnea, disordered sleep and consequent behavioural and educational effects. This report provides up-to-date usable information to: (1) improve the knowledge and skills of allergists, so as to ultimately improve the overall quality of patient care; (2) to increase interest in this area; and (3) to present a unique contribution to the field of upper inflammatory disease.

Use of intranasal corticosteroids in adenotonsillar hypertrophy

Objectives:

This review examined the efficacy of intranasal corticosteroids for improving adenotonsillar hypertrophy.

Method:

The related literature was searched using PubMed and Proquest Central databases.

Results:

Adenotonsillar hypertrophy causes mouth breathing, nasal congestion, hyponasal speech, snoring, obstructive sleep apnoea, chronic sinusitis and recurrent otitis media. Adenoidal hypertrophy results in the obstruction of nasal passages and Eustachian tubes, and blocks the clearance of nasal mucus. Adenotonsillar hypertrophy and obstructive sleep apnoea are associated with increased expression of various mediators of inflammatory responses in the tonsils, and respond to anti-inflammatory agents such as corticosteroids. Topical nasal steroids most likely affect the anatomical component by decreasing inspiratory upper airway resistance at the nasal, adenoidal or tonsillar levels. Corticosteroids, by their lympholytic or anti-inflammatory effects, might reduce adenotonsillar hypertrophy. Intranasal corticosteroids reduce cellular proliferation and the production of pro-inflammatory cytokines in a tonsil and adenoid mixed-cell culture system.

Conclusion:

Intranasal corticosteroids have been used in adenoidal hypertrophy and adenotonsillar hypertrophy patients, decreasing rates of surgery for adenotonsillar hypertrophy.

Role of the Allergist-Immunologist and Upper Airway Allergy in Sleep-Disordered Breathing

BACKGROUND

Sleep-disordered breathing in general and obstructive sleep apnea in particular are commonly encountered conditions in allergy practice. Physiologically, nasal (or nasopharyngeal) obstruction from rhinitis, nasal polyposis, or adenotonsillar hypertrophy are credible contributors to snoring and nocturnal respiratory obstructive events. Nevertheless, existing practice parameters largely relegate the role of the allergist to adjunctive treatment in cases of continuous positive airway pressure intolerance.

OBJECTIVES

To survey active American Academy of Allergy, Asthma & Immunology members regarding their perceptions and practices concerning sleep-disordered breathing in adult and pediatric patients with rhinitis, and to review the medical literature concerning this connection to identify therapeutic implications and research gaps.

METHODS

Members of the Work Group on Rhinitis and Sleep-disordered Breathing composed and distributed a Web-based clinically oriented survey to active American Academy of Allergy, Asthma & Immunology members in mid-2015. The group, in addition, conducted an English-language literature review using PubMed and other sources.

RESULTS

Survey results were returned by 339 of 4881 active members (7%). More than two-third of respondents routinely asked about sleep problems, believed that sleep-disordered breathing was a problem for at least a "substantial minority" (10%-30%) of their adult patients, and believed that medical therapy for upper airway inflammatory conditions could potentially help ameliorate sleep-related complaints. Literature review supported the connection between high-grade nasal congestion/adenotonsillar hypertrophy and obstructive sleep apnea, and at least in the case of pediatric patients, supported the use of anti-inflammatory medication in the initial management of obstructive sleep apnea of mild-to-moderate severity.

CONCLUSIONS

Clinical allergy practice and the medical literature support a proactive role for allergists in the diagnosis and management of sleep-disordered breathing.

Optimal management of allergic rhinitis

Allergic rhinitis (AR), the most common chronic disease in childhood is often ignored, misdiagnosed and/or mistreated. Undertreated AR impairs quality of life, exacerbates asthma and is a major factor in asthma development. It can involve the nose itself, as well as the organs connected with the nose manifesting a variety of symptoms. Evidence-based guidelines for AR therapy improve disease control. Recently, paediatric AR guidelines have been published by the European Academy of Allergy and Clinical Immunology and are available online, as are a patient care pathway for children with AR and asthma from the Royal College of Paediatrics and Child Health. Management involves diagnosis, followed by avoidance of relevant allergens, with additional pharmacotherapy needed for most sufferers. This ranges, according to severity, from saline sprays, through non-sedating antihistamines, oral or topical, with minimally bioavailable intranasal corticosteroids for moderate/severe disease, possibly plus additional antihistamine or antileukotriene. The concept of rhinitis control is emerging, but there is no universally accepted definition. Where pharmacotherapy fails, allergen-specific immunotherapy, which is uniquely able to alter long-term disease outcomes, should be considered. The subcutaneous form (subcutaneous immunotherapy) in children has been underused because of concerns regarding safety and acceptability of injections. Sublingual immunotherapy is both efficacious and safe for grass pollen allergy. Further studies on other allergens in children are needed. Patient, carer and practitioner education into AR and its treatment are a vital part of management.

Rhinitis in children: common clinical presentations and differential diagnoses

Rhinitis is a common presentation in childhood. Acute virally induced rhinitis is generally self-limiting and usually does not require medical attention. Whilst allergic rhinitis is the focus of the paediatric allergist, the presentation of other diseases or comorbidities that can complicate or mimic allergic rhinitis needs to be considered. Effects on the child's quality of life also need to be addressed. Rhinitis can be associated with asthma and other significant comorbidities: importantly, non-allergic rhinitis can sometimes be a consequence of systemic immune impairment. The diagnosis of rhinitis is based on clinical findings with directed investigations. Nasal nitric oxide measurement is an emerging diagnostic tool and helpful particularly in relation to evaluating the differential diagnosis in more difficult rhinitis. Successfully identifying the cause of rhinitis in childhood and associated comorbidities can ensure that the patient is successfully treated as described in the recently published EAACI Pediatric Rhinitis Position Paper.

Clinical application of nasal nitric oxide measurement in pediatric airway diseases

Nitric oxide plays an important role in several physiological and pathophysiological processes in the respiratory tract. Different ways to measure nasal nitric oxide levels in children are currently available. The possibility of obtaining nasal nitric oxide measurement from relatively young children, combined with the availability of portable devices that can be used even in the office setting, opens new perspectives for nasal nitric oxide analysis in the pediatric daily practice. This review presents a synopsis about the current clinical applications of nasal nitric oxide measurement in the pediatric clinical practice. A total of 3,775 articles on the topic were identified, of which 883 duplicates were removed, and 2,803 were excluded based on review of titles and abstracts. Eighty-nine full text articles were assessed for eligibility and 32 additional articles were obtained from the reference lists of the retrieved studies. Since very low nasal nitric oxide levels are found in the majority of patients with primary ciliary dyskinesia, most publications support a central role for nasal nitric oxide to screen the disease, and indicate that it is a very helpful first-line tool in the real-life work-up in all age groups. Decreased nasal nitric oxide concentration is also typical of cystic fibrosis, even though nasal nitric oxide is not as low as in primary ciliary dyskinesia. In other upper airway disorders such as allergic rhinitis, rhinosinusitis, nasal polyposis, and adenoidal hypertrophy, clinical utility of nasal nitric oxide is still critically questioned and remains to be established. Since nNO determination is flow dependent, a general consensus from the major investigators in this area is highly desirable so that future studies will be performed with the same flow rate. A shared nNO methodology will enable to overcome the challenges that lie ahead in incorporating nNO measurement into the mainstream clinical setting of pediatric airway diseases.

A role for Waldeyer's ring in immunological response to allergens

OBJECTIVE

Adenoids, tubal tonsil, palatine tonsil, and lingual tonsil are immunological organs included in the Waldeyer's ring, the basic function of which is the antibody production to common environmental antigens. Adenoidal hypertrophy (AH) is a major medical issue in children, and adenoidectomy is still the most used treatment worldwide. The response of adenoids to allergens is a good model to evaluate their immunological function. This report assessed the immunological changes in adenoid tissues from children with allergic rhinitis (AR) undergoing sublingual immunotherapy (SLIT).

METHODS

Adenoid samples from 16 children (seven males, nine females, mean age 7.12 years) with AH and clinical indication to adenoidectomy were collected. Of them, five children were not allergic and 11 had house dust mite and grass pollen-induced AR. Among allergic children, in four AR was treated by antihistamines while in seven AR was treated by high-dose SLIT during 4-6 months. The evaluation addressed the T helper 1 (Th1), Th2, and Th3 cells by performing a PCR array on mRNA extracted from adenoid samples.

RESULTS

In non-allergic children, a typical Th1 pattern was found. SLIT induced a strong down-regulation of genes involved in Th2 and Th1 activation and function. In particular, in SLIT-treated allergic children IL-4, CCR2, CCR3, and PTGDR2 (Th2 related genes) and CD28, IL-2, and INHA (Th1 related genes) expression was reduced, compared with children treated with antihistamines.

CONCLUSIONS

These preliminary findings warrant investigation in trials including larger numbers of patients, but indicate that hypertrophic adenoids of allergic children have the typical response to the specific allergen administered by SLIT. This should suggest that one should reconsider the immunological role of adenoids.

Effect of adenoid hypertrophy on the voice and laryngeal mucosa in children

INTRODUCTION

The adenoids, or pharyngeal tonsils, are lymphatic tissue localized at the mucous layer of the roof and posterior wall of nasopharynx. Dysphonia defined as perceptual audible change of a patient's habitual voice as self judged or judged by his or her listeners. The diagnosis of dysphonia relies on clinical judgment based on phoniatric symptoms, auditory perceptual assessment of voice (APA) and full laryngeal examination.

PATIENTS AND METHODS

Our study was conducted to evaluate the effect of adenoid hypertrophy on voice and laryngeal mucosa. The study sample composed of sixty children, forty of them had adenoid hypertrophy (patient's group) and twenty healthy children (control group). Patient's group composed of 17 boys (42.5%) and 23 girls (57.5%), while control group consists of 8 males (40%) and 12 females (60%). All patients and control group subjected to history taking, clinical examination, lateral soft tissue X-ray on the nasopharynx, APA based on the modified GRBAS scale and full laryngeal examination. The data are collected and analyzed statistically by using software SPSS.

RESULTS

Our results showed that there is a significant association between adenoid hypertrophy and, degree of dysphonia, leaky voice, pitch of voice and laryngeal lesion. Adenoid hypertrophy did not associate with loudness of voice, as well as character (irregular, breathy and strained). Laryngeal lesions were detected in thirteen children from patient group (32.5%): nodules (n = 6), thickening (n = 5), congestion (n = 2), while one child only out of 20 children of the control group had congestion (5.0%).

CONCLUSION

Our results showed the importance of the assessment of voice and laryngeal examination in patients with adenoid hypertrophy, also treating the minimal mucosal lesions that results from adenoid hypertrophy should be taken in consideration.

Double-blind placebo-controlled randomized clinical trial on the efficacy of Aerosal in the treatment of sub-obstructive adenotonsillar hypertrophy and related diseases

BACKGROUND

Adenotonsillar hypertrophy (ATH) is a frequent cause of upper airways obstructive syndromes associated to middle ear and paranasal sinuses disorders, swallowing and voice disorders, sleep quality disorders, and occasionally facial dysmorphisms. ATH treatment is essentially based on a number of medical-surgical aids including nasal irrigation with topical antibiotics and corticosteroids and/or treatment with systemic corticosteroids, immunoregulators, thermal treatments, adenotonsillectomy, etc.

OBJECTIVES

The aim of the present study is to assess the efficacy of Aerosal halotherapy in the treatment of sub-obstructive adenotonsillar disease and correlated conditions compared to placebo treatment.

METHODS

A total of 45 patients with sub-obstructive adenotonsillar hypertrophy were randomized to receive either Aerosal halotherapy or placebo for 10 treatment sessions. The main outcome was a reduction greater than or equal to 25% from the baseline of the degree of adenoid and/or tonsillar hypertrophy.

RESULTS

In the intention-to-treat analysis, a reduction of the degree of adenoid and/or tonsillar hypertrophy ≥25% from baseline after 10 therapy sessions was found in 44.4% of the patients in the halotherapy arm and in 22.2% of the patients in the placebo arm (P=0.204). Among the secondary outcomes, the reduction of hearing loss after 10 treatment sessions in the halotherapy arm was higher than the placebo arm (P=0.018) as well as the time-dependent analysis showed significantly improved peak pressure in the Aerosal group (P=0.038). No side effects were reported during the trial. In addition, the therapy was well accepted by the young patients who considered it as a time for play rather than a therapy.

CONCLUSIONS

Aerosal halotherapy can be considered a viable adjunct, albeit not a replacement, to conventional medical treatment of sub-obstructive adenotonsillar syndrome and related conditions. Further research is however needed to improve ATH treatment.

Atopy and adenotonsillar hypertrophy in mouth breathers from a reference center

Mouth breathers use the oral cavity as their principal breathing route. The main causes include: adenotonsillar hypertrophy and inflammatory diseases such as allergic rhinitis.

OBJECTIVE

To look for atopy, the main allergens involved and to check for atopy as a comorbidity with the degree of hypertrophy of the tonsils and adenoids in mouth breathers.

METHOD

A historical cohort study with cross-sectional review of 308 medical charts of patients treated at a mouth breather care center of a tertiary hospital in the period of 2008-2010. We collected data on the mouth breather's clinical history and we ran otolaryngological exams, flexible nasal endoscopy and skin prick test to aeroallergens.

RESULTS

Of 308 patients, 36% were positive on allergy testing, with 95 % of atopic patients being positive for mites. Among all patients, 46% had adenoid hypertrophy; of these, 37% were atopic and 47% had tonsillar hypertrophy, and among these, 33% were atopic.

CONCLUSION

We found no direct correlation between atopy and the degree of tonsils and adenoid hypertrophy observed among the mouth-breathing patients assessed. si.

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.

Safety of mometasone furoate nasal spray in the treatment of nasal polyps in children

BACKGROUND

Mometasone furoate nasal spray (MFNS) improves nasal symptoms and reduces polyp size in adults with nasal polyposis. This 4-month, multinational, randomized, double-blind study was conducted to assess the safety of MFNS in pediatric subjects aged 6-17 yr.

METHODS

Subjects aged 6-11 yr with bilateral nasal polyps received MFNS 100 μg once or twice daily or placebo; those aged 12-17 yr received MFNS 200 μg once or twice daily or placebo. End-points included change in 24-h urinary free cortisol (primary), change in 24-h urinary free cortisol corrected for creatinine (key secondary), and adverse events. Efficacy parameters included polyp size, nasal symptoms, and investigator-evaluated therapeutic response, although the study was not powered for statistical analysis of efficacy.

RESULTS

Least squares baseline mean urinary free cortisol level (nmol/24 h) for both age groups combined (N = 127) was 49.5 in the MFNS once-daily group, 39.6 in the MFNS twice-daily group, and 49.8 in the placebo group. Change in 24-h urinary free cortisol did not significantly differ among MFNS- and placebo-treated subjects. Least squares mean 24-h urinary free cortisol levels corrected for creatinine also showed no significant differences among MFNS- and placebo-treated subjects. No safety issues emerged.

CONCLUSIONS

Results of this study confirm the safety profile of MFNS in pediatric patients with bilateral nasal polyps over 4 months, even at double the recommended pediatric dosage for allergic rhinitis.

The association between allergic rhinitis and sleep-disordered breathing in children: a systematic review

BACKGROUND

The objective of this work was to systematically review existing literature on the association between allergic rhinitis (AR) and sleep-disordered breathing (SDB) in children.

METHODS

We performed a literature search encompassing the last 25 years in PubMed, EMBASE, and Cochrane CENTRAL. Inclusion criteria included English-language papers containing original human data, number of subjects ≥7, and age <18 years old. Data was systematically collected on study design, patient demographics, clinical characteristics/outcomes, and level-of-evidence. Two investigators independently reviewed all articles.

RESULTS

The initial search yielded 433 abstracts, of which 18 articles were included. Twelve (67%) of the 18 articles showed a statistically significant association between AR and SDB. All articles were either case-series or case-control studies. Based on the Newcastle-Ottawa scale, the quality of the articles was determined to be fair to good. For characterizing AR, 7 (39%) studies included skin-prick testing and/or in vitro testing. For determining presence of SDB, 7 (39%) of the studies used polysomnographic data, of which 1 study incorporated data from a home polysomnogram. Habitual snoring was the most common form of SDB studied, in 10 (56%) of the articles. Obstructive sleep apnea was studied in 6 (33%) articles.

CONCLUSION

Although the majority of the studies included in this review showed a significant association between AR and SDB, all of the studies were evidence level 3b and 4, for an overall grade of B- evidence (Oxford Evidence-Based Medicine Center). Further higher-quality studies should be performed in the future to better evaluate the relationship between AR and SDB in children.