Adenoidectomy and otitis media

Efficacy of tympanostomy tube placement with adjuvant adenoidectomy in children less than 4 years of age

OBJECTIVE

About 8.6 % of children in the United States undergo tympanostomy tube (TT) placement every year. Of these, 24.1 % require a second set of tubes. Adjuvant adenoidectomy in children over 4 years is thought to improve the efficacy of TT. The goal of this study is to characterize the efficacy of adjuvant adenoidectomy at the time of TT placement in children under 4 years, to further improve middle ear function.

METHODS

All patients undergoing TT placement alone or TT placement with adenoidectomy from 2014 to 2016 were reviewed. The primary outcome was need for subsequent tube placement.

RESULTS

A total of 409 patients were included in the study (60.6 % male, 39.4 % female). Median age at initial TT placement was 18 months (range 5-48 months); extreme outliers for age were removed from further analysis. Patients were followed for 1-8 years. 250 patients received TT alone while 159 received TT with adenoidectomy. 120 required a second set of tubes. There was a statistically significant benefit to those undergoing adjuvant adenoidectomy with TT placement: 33.6 % of those receiving TT alone required subsequent tubes, whereas only 22.6 % of patients who underwent TT with adjuvant adenoidectomy required reinsertion (X2 = 5.630, p = 0.018). Adjuvant adenoidectomy in patients 0-48 months was associated with decreased likelihood of requiring subsequent tube placement (OR = 0.578, p = 0.018). There was an increased likelihood of experiencing otorrhea in those receiving TT alone compared to the TT with adenoidectomy group (X2 = 4.353, df = 1, p = 0.0369).

CONCLUSION

Adjuvant adenoidectomy at the time of initial TT placement may have a role in the management of chronic middle ear disease in patients younger than 4 years. However, further studies and prospective randomized studies are needed to explore if this benefit can also be seen in children without chronic rhinosinusitis or nasal obstruction. The benefit-risk ratio from adenoidectomy and modifications in anesthesia technique in the case of adjuvant adenoidectomy should also be further explored.

Association of Adenoid Hypertrophy with Nasal and Middle Ear Pathologies in Adults

A prospective comparative study was carried out in patients attending ENT Out Patient Department of a tertiary care Hospital with an aim to determine the association of adenoid hypertrophy with chronic nasal and middle ear pathologies in those aged 18 years or above. Patients presenting between August 2020 and February 2022 with chronic nasal and middle ear pathologies who underwent diagnostic nasal endoscopy were seen for adenoid hypertrophy and its association was analysed statistically. Adenoid hypertrophy (AH) in 18-25, 26-35, 36-45 and 46-55 years age group are 56.25, 28.12, 12.5, 3.125% respectively with a male:female ratio of 3:1. None of the patients were above 56 years in the study. No statistically significant association could be derived between chronic nasal and middle ear pathologies with AH. AH is a vital cause of nasal obstruction in adult population with a rising frequency these days owing to allergy, chronic infection and increased pollution. The entire of the individuals presenting with nasal obstruction, snoring and other nasal symptoms and chronic middle ear pathologies; AH should at all times be kept in mind as a ground and the patients shall be appraised for adenoid hypertrophy.

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.

Comparison of middle ear function and hearing thresholds in children with adenoid hypertrophy after microdebrider and conventional adenoidectomy: a randomised controlled trial

BACKGROUND

Microdebrider has superior efficacy in clearing the adenoids, compared to curettage. We compared the improvement in middle ear function and hearing thresholds after adenoidectomy, by both methods.

MATERIALS AND METHODS

126 patients (median age-9 years) were randomized into groups A and B, where adenoidectomy was done by microdebrider and curettage, respectively. Middle ear function parameters and hearing thresholds were measured serially.

RESULTS

The mean improvement in middle ear pressure, compliance and hearing thresholds were 92.5 ± 67.6 and 84.2 ± 71.4 daPa; (p = 0.40), 0.19 ± 0.34 and 0.27 ± 0.27 mL; (p = 0.07) and 3.20 ± 4.95 and 2.54 ± 3.98 dB; (p = 0.27), in groups A and B, respectively. Reversal of type B tympanograms was noted in both groups.

CONCLUSIONS

Middle ear function and hearing thresholds improved in both groups after adenoidectomy. More improvement was noted in the microdebrider group, which, however, was not significant.

Effect of topical mometasone furoate on adenoidal lymphoid tissue: a light microscopic study

Background

Adenoid hypertrophy is a common cause of upper airway obstruction, and adenoidectomy is one of the most frequently performed operations in children. Topical nasal steroids can act directly on nasopharyngeal lymphoid tissue to decrease its reactive inflammatory changes and potentially reduce its size.

Objective

To study the light microscopic changes in adenoidal lymphoid tissue after one month of topical steroid use.

Methods

Twenty-six children with adenoid hypertrophy grade 3 scheduled for adenoidectomy were randomly divided into two equal groups: one group received mometasone furoate aqueous nasal spray (Nasonex) 100 mcg/day for four weeks, and a control group received nasal normal saline 0.9 per cent for four weeks. The removed adenoids were examined histopathologically.

Results

Adenoidal tissue from the mometasone group had less reactive germinal centres and less spongiosis compared to the control group. The latter showed proliferating, reactive, variable sized and shaped lymphoid follicles, with congested blood vessels in the interfollicular areas.

Conclusion

The use of intranasal mometasone furoate aqueous nasal spray (Nasonex) for one month reduced adenoidal tissue reactive cellular changes and its vascularity. This is, however, a pilot study; a longer treatment period is needed to assess the effect of treatment on adenoidal size.

Roles of T follicular helper cells in the pathogenesis of adenoidal hypertrophy combined with secretory otitis media

The aim of this study was to investigate the roles of T follicular helper (Tfh) cells in secretory otitis media (SOM) combined with adenoidal hypertrophy (AH).Patients with AH or AH combined with SOM admitted to the Yancheng No. 1 People's Hospital from December 2012 to December 2014 were included. Fourteen age-matched healthy individuals received physical examinations in the hospital served as control. The venous Tfh was determined using flow cytometry, and CD3 + CD4 + CXCR5 + T lymphocytes were defined as Tfh cells. Serum inflammatory factors including IL-8, IL-1b, IL-6, IL-10, TNF, IL-12p70, IL-21, and IgE were determined using commercial kits.Compared with the AH group, the number of CD4 + CXCR5 + T cells in peripheral blood of the AH combined with SOM group showed significant increase. Statistical differences were noticed in the number of the number of CD4 + CXCR5 + T cells in moderate and severe AH groups compared with that of the control group. Statistical differences were identified in the proportion of CD4 + CXCR5 + T cells in the adenoidal tissues between the AH combined with SOM group and AH group (P < .05). For the CD4 + CXCR5 + T cells in adenoidal tissues, no statistical differences were noticed between the moderate and severe AH groups (P > .05). The number of CD4 + CXCR5 + T cells was positively correlated to the serum IL-21. Nevertheless, no correlation was noticed between CD4 + CXCR5 + T cell and serum IL-8, IL-6, IL-10, and IgE.Tfh is involved in the AH combined with SOM in children. Besides, serum IL-21, IL-8, IL-6, IL-10, and IgE may be involved in the onset of SOM in children.

ACE grading-A proposed endoscopic grading system for adenoids and its clinical correlation

OBJECTIVES

To propose a novel endoscopic adenoid grading system using a rigid nasal endoscope and to study its correlation with the clinical diagnosis.

METHODOLOGY

Prerecorded video clips of rigid nasal endoscopy taken during endoscopic adenoidectomy were retrieved. Otolaryngology consultants blinded to the clinical diagnosis of the child were presented these videos and asked to grade the adenoid hypertrophy as per the proposed endoscopic ACE (Airway/Choana/Eustachian tube) grading system. The clinical diagnosis was correlated with the different aspects of the descriptive endoscopic grading system.

RESULTS

152 video clips were presented to the otolaryngology consultants for grading. The average age was 8.6 years (SD-3.48), while the male female ratio was 3:2. The A subcomponent of the ACE grading showed significant correlation with the diagnosis of sleep disordered breathing and chronic adenotonsillitis, C subcomponent with sleep disordered breathing and the E subcomponent with the diagnosis of otitis media.

CONCLUSION

The proposed endoscopic grading is easily applicable and at the same time clearly describes the relation of the adenoids to the nasopharynx, choana and Eustachian tube. Different aspects of the grading system correlated differently with the clinical diagnosis emphasizing that a descriptive scoring rather than a comprehensive scoring is a more relevant clinical tool.

Comparison of benzydamine hydrochloride and Salvia officinalis as an adjuvant local treatment to systemic nonsteroidal anti-inflammatory drug in controlling pain after tonsillectomy, adenoidectomy, or both: an open-label, single-blind, randomized clinical trial

BACKGROUND

Benzydamine hydrochloride (BNZD) is a nonsteroidal anti-inflammatory drug (NSAID) used in an oral rinse formulation as an adjuvant to other NSAIDs in controlling postoperative pain after tonsillectomy, adenoidectomy, or both. Salvia officinalis (SO) is a topically applied herbal preparation frequently used for the same indication. Pain, bleeding, and infection are the most common postoperative complications of tonsillectomy.

OBJECTIVE

The aim of this study was to compare the efficacy and tolerability of BNDZ with those of SO as adjuvant treatments in controlling postoperative pain.

METHODS

This open-label, single-blind, randomized clinical trial was conducted at the Department of Otorhinolaryngology, Clinical Hospital Center "Dr. Dragiša Mišović-Dedinje" (Belgrade, Serbia and Montenegro). Pediatric and adult patients undergoing tonsillectomy, adenoidectomy, or both were enrolled. Patients were randomized to receive BNZD or SO, in addition to ibuprofen 20 mg/kg·d (children) or diclofenac 100 mg/d (adults). The primary end point was the proportion of patients with mild or no pain on postoperative days 1, 2, 4, and 7. Secondary end points were the incidences of infection, hemorrhage, and other adverse events.

RESULTS

A total of 420 patients were enrolled (217 females, 203 males; 278 children, 142 adults; mean [SD] age, 6.2 [2.1] years [children] and 24.1 [9.8] years [adults] [range, 3-45 years]). One hundred thirty-eight children received BNZD; 140 received SO (both in addition to ibuprofen 20 mg/kg·d). Seventy-two adults received BNZD; 70 received SO (both in addition to diclofenac 100 mg/d). A significantly lower proportion of children treated with adjuvant BNZD experienced moderate or severe pain than those treated with SO at each time point (P < 0.01 at days 1 and 4; P < 0.001 at days 2 and 7). In children, the risk for postoperative infection was similar between BNZD and SO (absolute risk reduction [ARR], 6.9%; 95% CI, 6.4%-7.6%); however, the risk was reduced in adults (ARR, 19.0%; 95% CI, 16.5%-21.9%; P = 0.008).

CONCLUSIONS

In this clinical trial of children and adults who underwent tonsillectomy, adenoidectomy, or both, BNZD, as an adjuvant to an NSAID, was more effective than SO in controlling postoperative pain and infection. The pain-reducing effect of BNZD was of quick onset and persisted for 1 week after surgery. The safety profile of BNZD was comparable to that of SO, with the exception of postoperative infection in adults, for which BNZD was more efficacious. In particular, the use of BNZD was not associated with a high risk for early postoperative hemorrhage.

Factors associated with revision adenoidectomy

OBJECTIVE

To determine whether patient factors (eg, indication for initial surgery, medical comorbidity, or age) are associated with adenoid regrowth and subsequent need for revision adenoidectomy and whether surgical factors (eg, surgical technique or level of surgeon's training) are associated with adenoid regrowth and subsequent need for revision adenoidectomy.

STUDY DESIGN

Historical cohort study.

SETTING

Tertiary care academic medical center.

SUBJECTS AND METHODS

Children (≤18 years) who underwent adenoidectomy or adenotonsillectomy between 1980 and May 2009 were identified. Medical and surgical records were reviewed for sex, age at surgery, indication for surgery, training level of surgeon, surgical technique, and history of allergies, asthma, or gastroesophageal reflux disease.

RESULTS

Of 8245 surgical cases (53.8% male), 163 were revision adenoidectomies. Age at initial adenoidectomy was a significant factor for revision adenoidectomy, with younger ages associated with higher increased risk. Indication for adenoidectomy was also a significant risk factor; adjusted for age, patients with ear rather than infectious indications were about 10 times more likely to require revision. A diagnosis of gastroesophageal reflux disease was a significant risk factor (hazard ratio, 2.23; P = .002).

CONCLUSION

Several risk factors are associated with revision adenoidectomy: young age at initial procedure, indication for adenoidectomy, and diagnosis of gastroesophageal reflux disease. Surgical technique, level of experience of the initial surgeon, and diagnosis of asthma or allergies were not significant risk factors for revision adenoidectomy.

Is there any developmental relationship between mastoid pneumatization and adenoid tissue volume?

OBJECTIVE

The aim of this study was to investigate the developmental relationship between adenoid tissue volume and mastoid air cell volume, using a 3D reconstruction technique.

STUDY DESIGN

Cross-sectional retrospective study.

SUBJECTS AND METHODS

Multislice computed tomography (MSCT) images were obtained using three-dimensional (3D) reconstruction and volume-rendering techniques (VRT). The subjects were 63 boys and 37 girls, 3-16 years of age. The volumes of bilateral mastoid air cells and adenoids marked in axial-coronal-sagittal planes were calculated. The patients were grouped into three categories according to adenoid tissue volume, total mastoid volume (TMV), and age.

RESULTS

No significant difference was noted between the right mastoid volume (RMV) and the left mastoid volume (LMV) or between age and sex (p=0.368; p=0.549; p=0.454). The incremental increase in adenoid tissue volume did not correlate with TMV (r=-0.161, r=-0.279, r=0.015). The incremental increase in TMV did not correlate with the volume of adenoid tissue (r=0.024, r=0.148, r=0.017).

CONCLUSIONS

No significant correlation was obtained between the incremental increase in adenoid tissue volume and TMV or the incremental increase in TMV and adenoid tissue volume. There does not seem to be a developmental relationship between adenoid tissue volume and TMV.

Proposed definitive grading system tool for the assessment of adenoid hyperplasia

OBJECTIVES/HYPOTHESIS

To propose a definitive standard grading scale in the assessment of adenoid tissue in relation to size, position, and proximity to surrounding anatomic structures. This will allow for better clinical communications among practitioners when treating this pathology, a better understanding of its relationship and how it effects neighboring structures (eustachian tube and choanae), and allow for a more precise description of this tissue for the purpose of research data collection and analysis.

STUDY DESIGN

A prospective evaluation of adenoid tissue during adenoidectomy was obtained documenting its size and descriptive relationship to adjacent structures (eustachian tube and choanae).

METHODS

A convenience sample of 150 children undergoing adenoidectomy alone or concurrently with tonsillectomy and/or myringotomy and tubes were prospectively evaluated. Mirror nasopharyngeal exam was performed in all cases. Size of the adenoid, as well as its relationship to the choanae and eustachian tube were recorded. A descriptive grading system tool was created accounting for these relationships. Statistical analysis was performed to offer a preliminary validation of the tool.

RESULTS

Adenoid grading scores were assigned to 150 pediatric patients, 74 males and 76 females, who underwent surgery for adenoidectomy with or without tonsillectomy and/or myringotomy and tube placement. Seven patients were found to have no adenoid tissue in the nasopharynx as they had previous adenoidectomy and received a grade of 0A-. The mean age was 5.71 years (range, 1-17 years). Of the 150 scores, 107 patients had an associated diagnosis of chronic hypertrophic adenoids and/or tonsils (CHAT) accounting for 71.3% of the sample. There was a significant increasing trend of CHAT with an increasing size and increasing blocking of the choanae. However, there is no relationship of this morbidity with blocking of the eustachian tube (ET). There is a strong inverse relationship between blocking of the choanae and chronic and recurrent adenotonsillitis. The percentage of patients with this morbidity significantly decreases with increasing blocking of the choanae. A total of nine patients with chronic sinusitis were found to have no relationship between size, blocking of the choanae, and abutting of the eustachian tube. Eustachian tube dysfunction (ETD) was significantly related to blocking of the eustachian tube (ET) in this study, as 54.3% experienced ETD in the presence of blocked ET compared to only 15% in the absence of a blocked ET. Among the components of the adenoid score, the diagnosis given preoperatively, and the surgical treatments performed, there were strong correlations found giving merit to the descriptive nature of this grading tool proposed.

CONCLUSIONS

This grading system is simple, reliable, and easily used. It offers standardization for clinicians and researchers in facilitating communications, and allowing interpretation of adenoid tissue observed with its relationship to and effect on adjacent anatomic structures. This will allow more detailed information of findings during adenoid surgery to assist in future clinical research studies and outcomes analysis.

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

Adenoidal hypertrophy (AH) and adenotonsillar hypertrophy are common disorders in the pediatric population and can cause symptoms such as mouth breathing, nasal congestion, hyponasal speech, snoring, and obstructive sleep apnea (OSA), as well as chronic sinusitis and recurrent otitis media. More serious long-term sequelae, typically secondary to OSA, include neurocognitive abnormalities (e.g. behavioral and learning difficulties, poor attention span, hyperactivity, below average intelligence quotient); cardiovascular morbidity (e.g. decreased right ventricular ejection fraction, left ventricular hypertrophy, elevated diastolic blood pressure); and growth failure. Adenoidectomy (with tonsillectomy in cases of adenotonsillar hypertrophy) is the typical management strategy for patients with AH. Potential complications have prompted the investigation of non-surgical alternatives. Evidence of a pathophysiologic link between AH and allergy suggests a possible role for intranasal corticosteroids (INS) in the management of patients with AH. This article reviews the epidemiology and pathophysiology of AH with a particular focus on evidence of its association with allergy and allergic rhinitis. Current treatment options are briefly considered with discussion on the rationale and evidence for the use of INS.

Comparison between symptoms and endoscopy in children with nasal obstruction

OBJECTIVE

Nasal obstruction is a common symptom in childhood. It may be frequently observed in children with allergic rhinitis and/or adenoidal hypertrophy. However, its assessment is very difficult. The aim of the study was to compare the use of both a Face Related Scale (FRS), recorded by children and their parents, and a simplified Visual Analogue Scales (sVAS) with nasal endoscopy in children complaining nasal obstruction.

METHODS

121 children (75 males, mean age 7.5 years) were studied. FRS and sVAS for nasal obstruction and endoscopy were performed in all patients.

RESULTS

A moderate correlation has been observed between FRS and sVAS and obstruction of nasal anterior segment (r=0.51 for FRS; r=0.52 for sVAS), a strong correlation was observed with nasal posterior segment (r=0.60 for FRS; r=0.61 for sVAS) assessed by endoscopy. However, parents' perception did not relate with objective parameters.

CONCLUSIONS

This study suggests that assessment of FRS and sVAS for nasal obstruction may be used in clinical practice to approximately quantify this symptom in children.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Adenoid hypertrophy in adults: clinical and morphological characteristics

This study compared the aetiology and pathological characteristics of adult and childhood adenoid hypertrophy (AH). Clinical and morphological features and accompanying otolaryngological pathologies were recorded in 40 adults and 23 children undergoing adenoidectomy for obstructive AH. Both AH forms were similar in terms of symptomatology and associated inflammations. There were, however, significant differences in otitis media rate, with effusion and dullness, and retraction in the eardrum both more prevalent in childhood AH. Adult AH was associated with nasal septum deviation in 25.0% of patients. Histopathological features of adenoidal lymphoid tissue were dissimilar in the two groups: numerous lymph follicles with prominent germinal centres was the chief finding in childhood adenoids, whereas adult adenoids showed chronic inflammatory cell infiltration and secondary changes (e.g. squamous metaplasia). These results underline the importance of considering AH as a cause or contributing factor in nasal obstruction and related pathologies in adults and supports the theory that it represents a long-standing inflammatory process rather than being a novel clinical entity.

Intranasal flunisolide treatment in children with adenoidal hypertrophy

Adenoidal hypertrophy (AH) represents one of the most frequent indications for surgery in children and it has been proposed that treatment with intranasal corticosteroids can decrease the size of AH. Therefore, the aim of the study is to evaluate the effect of the use of intranasal flunisolide among children affected by AH. 178 children with AH were evaluated in this randomised and controlled study. Inclusion criteria for the study required that each patient had to have a III or IV degree of AH on the initial endoscopic examination. Children were treated with intranasal flunisolide or isotonic saline solution for 8 weeks. After treatment, endoscopy was performed to re-evaluate AH degree. Flunisolide treatment was associated with significant (p less than 0.04) reduction of AH degree. There was moreover a consistent reduction of children (46 out of 58) proposed to adenoidectomy. No clinically important adverse events were reported. In conclusion, this preliminary study demonstrates that an 8-week treatment with intranasal flunisolide is significantly associated with reduction of AH, thus preventing the recurrence to adenoidectomy, and is safe.

Hypertonic Saline Solution in Children with Adenoidal Hyperytrophy: Preliminary Evidence

Adenoidal hypertrophy (AH) is a frequent problem in children. A preliminary study evidenced that intranasal hypertonic solutions may exert an anti-inflammatory activity. The aim of the study is to evaluate the effect of intranasal hypertonic or isotonic solutions in children affected with AH. For this purpose, 78 children with AH were evaluated in a randomised and controlled study. Inclusion criteria for the study required that each patient had to have a III or IV degree of AH on the initial endoscopic examination. Children were treated with intranasal hypertonic or isotonic saline solution for 8 weeks. After treatment, endoscopy was performed to evaluate AH degree. Hypertonic treatment was associated with significant (p<0.05) reduction of AH degree. There was a consistent reduction of children with III degree of AH. No adverse events were reported. This preliminary study demonstrates that an 8-week treatment with intranasal hypertonic solution is associated with significant reduction of AH. Therefore, this study evidences that hypertonic solution may exert an anti-inflammatory activity and is safe.

Sleep architecture in children with adenoidal hypertrophy

AIM

Adenoidal hypertrophy (AH) in children is associated with obstructive manifestations like mouth breathing, snoring. Unfortunately, little is known regarding sleep architecture of AH in children. The purpose of this study was therefore undertaken to investigate the polysomnographic variables in children with AH.

METHOD

47 children with AH and 11 controls underwent nocturnal polysomnography. Sleep was scored manually according to the standard set by Rechtschaffen.

RESULTS

In AH, stage 1 sleep percentage and rapid eye movement (REM) latency were increased significantly, while the sleep percentage of stage 2 and REM was decreased remarkably compared with that of controls. Arousal index in AH was much more higher than that in controls. Arousal index in REM sleep was higher than that in non-rapid eye movement (NREM) sleep in AH, but the number of arousals in REM sleep was lower than that in NREM sleep. Hypopnea events were the most common type of respiratory events, followed by obstructive events in AH and controls. Apnea/hypopnea index in AH was higher in comparison to controls. No significant difference was found between the children with AH and controls in SaO(2) nadir (%) and base mean SaO(2) (%). Apnea/hypopnea index was related to hypopnea arousal in REM sleep and hypoxemia arousal in NREM sleep.

CONCLUSION

AH is predominantly characterised by a hypopnea with little obstruction in children. Our results clearly and for the first time demonstrated that sleep architecture was abnormal in children with AH. We therefore speculate that hypopnea arousal in REM sleep and hypoxemia arousal in NREM sleep may play an important role in the course of respiratory disturbance.

The Effect of Radiofrequency and Mitomycin C on the Closure Rate of Human Tympanostomy

OBJECTIVES

To conduct a prospective, randomized, controlled trial determining the feasibility of radiofrequency with or without topical mitomycin C application in delaying the closure time of human tympanostomy and screening its efficacy in management of recurrent acute otitis media and otitis media with effusion.

METHODS

From November 2002 to January 2004, 96 patients (180 ears) who were to undergo surgical intervention for recurrent acute otitis media or otitis media with effusion were included in this study. Sixty ears with a diagnosis of recurrent acute otitis media were equally randomized to three procedures: cold knife myringotomy (Group A), radiofrequency tympanostomy (Group B), and radiofrequency tympanostomy with topical mitomycin C application (Group C). One hundred twenty ears diagnosed as having otitis media with effusion were equally randomized to the last two procedures only. Patients were followed-up every week in the first month, every 2 weeks in the second month, and monthly after that until closure of the tympanostomy. A special follow-up setting was designed 3 months after tympanostomy closure where tympanograms and pure-tone audiograms were obtained.

RESULTS

Groups B and C showed a significantly slower rate of closure than Group A. At the same time, Group C demonstrated a slower rate when compared with Group B. The mean closure time of Group B was 3.5 weeks, with no difference between recurrent acute otitis media and otitis media with effusion. In contrast, the mean closure times for Group C were 5.3 and 7 weeks in cases of otitis media with effusion and recurrent acute otitis media, respectively, with the latter demonstrating a significantly slower closure rate. No recurrence of acute otitis media was reported in 10, 45, and 80% of Groups A, B, and C, respectively. Fifty-nine percent of Group C showed no clinical or tympanometric signs of otitis media with effusion 3 months after closure of tympanostomy. In contrast, Group B reported a lower cure rate (28%), with a statistically significant difference between both groups. Absence of recurrence and improvement in tympanometry signs correlated significantly with the duration of patency of tympanostomy (p < 0.01). The success rate was higher in patients who underwent adenoidectomy, but this did not reach statistical significance except in Group C (p < 0.01).

CONCLUSION

Radiofrequency and mitomycin C delay the closure rate of human tympanostomy. The efficacy of mitomycin C seems to be amplified in the presence of an inflamed tympanic membrane. Radiofrequency-assisted mitomycin-enhanced tympanostomy is a precise, safe, and cost-effective procedure that provides a viable approach in the management of recurrent acute otitis media and otitis media with effusion, especially when used in conjunction with adenoidectomy.

Antibody production directed against pneumococci by immunocytes in the adenoid surface secretion

OBJECTIVE

In previous studies of the adenoid surface secretion we revealed the presence of activated T cells, granulocytes engaged in phagocytosis and immunocytes that produce IgG, IgA and IgM. In the present study the objective was to assess the ability of these immunocytes to produce antibodies directed at S. pneumoniae.

METHOD

Nine children subjected to adenoidectomy due to adenoid hypertrophy, secretory otitis media or recurrent otitis media were enrolled in the study. Samples of adenoid surface secretion were obtained by an imprint method and for comparison samples of adenoid tissue and peripheral blood were also obtained as well as a nasopharyngeal culture. Double-colour enzyme-linked immunospot (ELISPOT) assays were performed to detect total and pneumococci-specific IgG- and IgA-antibody secreting cells (ASC). In the adenoid tissue, the presence of H. influenzae type b specific ASC was also examined.

RESULTS

ASC were present in all nine samples of adenoid surface secretion with a dominance of IgG-ASC as compared to IgA-ASC. The proportion of ASC relative to the total number of lymphocytes was always greater in the secretion than in the corresponding adenoid tissue. The adenoid surface secretion samples from three of nine children contained IgG-ASC directed against S. pneumoniae. IgG-ASC directed against S. pneumoniae were detected in six of eight adenoids and IgA-ASC directed against S. pneumoniae were detected in two of eight adenoids. IgA-ASC directed against H. influenzae type b (Hib) were detected in one of seven adenoids.

CONCLUSION

The immunocytes in the adenoid surface secretion and the adenoid tissue itself hold the property to produce antibodies specific for known pathogens of the upper airways. These ASC are probably engaged in the immunologic defence of the nasopharyngeal mucosa and further studies are therefore called upon.

Frequency of surgery among children who have adenotonsillar hypertrophy and improve after treatment with nasal beclomethasone

OBJECTIVE

To describe the long-term outcome of a cohort of children with symptomatic adenotonsillar hypertrophy treated with aqueous nasal beclomethasone.

METHODS

The children enrolled completed a 4-week single-blind, saline solution controlled crossover study of aqueous beclomethasone (total: 400 micro g/d). In a 24-week open-label follow-on study, beclomethasone 200 micro g/d was offered to all patients. During a 100-week follow-up, the degree of nasal obstruction and the frequency of adenotonsillectomy were assessed.

RESULTS

Fifty-three children of the 60 enrolled completed the study. After the 4-week crossover trial, the severity of nasal obstruction of 24 children (45%) significantly decreased during the use of nasal steroids, but no child improved when saline solution was used. At 24, 52, and 100 weeks, the 24 children who had initially improved showed a significant decrease of the severity of nasal obstruction and of the frequency of adenotonsillectomy (54% vs 83%) compared with the 29 children who had not responded after the initial steroidal therapy.

CONCLUSIONS

Evidence from this study suggests that 45% of children with adenoidal hypertrophy improved after 2 weeks of steroidal therapy. Among these children, an additional 24-week treatment at a lower steroid dosage was associated with a significant 52- and 100-week clinical improvement and with reduction of adenotonsillectomy compared with children (55%) who had not responded after the initial 2-week steroidal therapy.

Laser office ventilation of ears with insertion of tubes

OBJECTIVE

Myringotomy with insertion of pressure equalization tubes has proven to be extremely effective in treating persistent serous otitis media (SOM). This study compares the advantages and disadvantages of this procedure when performed in the operating room or with a laser in an office setting.

PATIENTS AND METHODS

Patients selected either traditional myringotomy and tube (M & T; n = 29) done in an operating room under general anesthesia or Laser Office Ventilation of Ears with Insertion of Tubes (LOVE IT; n = 35) done in an office setting with only topical anesthesia. The reasons for selecting either M&T or LOVE IT and satisfaction with the procedure chosen were evaluated by survey, the results of which were compared statistically. Chart review was performed to determine the time and cost of the procedures, time interval from diagnosis to treatment, tube longevity, and complications.

RESULTS

Overall satisfaction was similar with both procedures. Patients and families were more likely to choose LOVE IT based on the anesthetic technique involved (P < 0.001, chi(2)). M&T required less time to perform, whereas the cost of LOVE IT was less. Tube longevity and complication rates were similar between the two procedures, and all complications were minor.

CONCLUSIONS

LOVE IT is a potential alternative to traditional M&T in the treatment of SOM. LOVE IT is most likely to be selected by patients/parents who wish to avoid a general anesthetic and provides a level of satisfaction similar to that of traditional M&T.

Effectiveness of adenoidectomy and laser tympanic membrane fenestration

OBJECTIVE

Adenoidectomy alone or with tonsillectomy (A+/-T) is an effective surgical intervention in the management of otitis media in children, especially when it is performed in conjunction with insertion of pressure equalization tubes (PETs). Otorrhea and persistent tympanic membrane (TM) perforation are frequent complications. This study evaluates the effectiveness of intermediate duration middle ear ventilation using laser tympanic membrane fenestration (LTMF) without tube insertion and as an adjunct to adenoidectomy in resolving middle ear disease within the first 90 days after surgery.

STUDY DESIGN

This pilot study was a multicenter, prospective clinical cohort trial. Institutional review board approval and informed consent were obtained. The study involved four tertiary care pediatric otolaryngology departments. Fifty children (96 ears) were treated with LTMF in conjunction with A+/-T from June 1, 1998, through March 30, 1999. Ages ranged from 9 months to 12 years. Patients undergoing A+/-T who would have been recommended for PET insertion instead underwent middle ear ventilation with LTMF using the Oto-LAM device (ESC/Sharplan, Yokneam, Israel). Patients were seen at 30, 60, and 90 days postoperatively. Resolution of otitis media with effusion was determined by clinical examination, which included pneumatic otoscopy, audiometry, and tympanometry.

RESULTS

Of the treated ears, 88%, 86%, and 83% had clinical resolution of middle ear disease at 30, 60, and 90 days, respectively. Preoperatively, 45% (n = 85) of ears had normal hearing; 92% (n = 49) had normal hearing at 90 days. Eighty-nine percent (n = 92) had type C2 or B tympanograms preoperatively, and 12% (n = 60) had type C2 or B at 90 days.

CONCLUSION

Laser tympanic membrane fenestration in conjunction with adenoidectomy was effective in restoring normal middle ear function at 90 days post-treatment in greater than 80% of children who otherwise may have had placement of PETs.

Classification of otitis media and surgical principles

Otitis media is an important disease of children and adults and is caused by multiple interrelated factors, including infection, eustachian tube dysfunction, allergy, and barotrauma. This article includes a pertinent review of the literature regarding otitis media. The pathogenesis, classification, and treatment of otitis media in children and adults are also reviewed in this article. Additionally, therapy is discussed with emphasis on the surgical options appropriate at each stage.

Tonsillectomy and adenoidectomy. Changing indications

Obstructive sleep apnea and upper airway obstruction (even without complete apnea) from adenotonsillar hypertrophy is either occurring more frequently or is becoming better recognized. Tonsillectomy or adenoidectomy is indicated for these children. Most patients who would benefit from surgery can be identified by a thorough history and physical examination. Occasionally, additional methods of evaluation, such as lateral neck radiographs or polysomnograms, are helpful. The indications for tonsillectomy and adenoidectomy are varied. No review can cogently encompass all clinical scenarios. Tonsillectomy and adenoidectomy remain valuable procedures for carefully selected patients.

How should relative risk estimates for acute otitis media in children aged less than 2 years be perceived?

To determine how the effects of certain risk factors for acute otitis media (AOM) vary according to the values of other risk determinants, and thus to obtain risk estimates more applicable to individual children, the medical records of a random sample of 2,512 children in northern Finland were monitored for the disease for up to an average age of 22 months. Information on determinants of AOM was obtained from parental questionnaires. The risk of the first AOM episode and that of later episodes were modelled separately by logistic regression using time-dependent values for some determinants. The odds ratio (OR) estimates for the alterable risk factors varied markedly over categories of other determinants as follows: nursery day care versus home care (OR from 1.1 to 3.0), parental smoking (OR from 0.9 to 1.5), and breast-feeding (OR from 0.5 to 1.0). Hence, to assess the significance of each risk factor for an individual child, the values for other relevant factors must be considered concurrently.

Methods of selection for adenoidectomy in childhood otitis media with effusion

We have examined the implications of selecting children with otitis media with effusion (OME) for adenoidectomy using different criteria. Data were collected pre-operatively on 125 consecutive cases of OME. Ages 1-13 years, mean = 4.9 years; 68 males and 57 females. The criteria used were: (1) obstructive nasal symptoms, (with three sub-categories); (2) age: and (3) nasopharyngeal airway size. The three sub-categories of obstructive nasal symptoms were based on the clinical practices of colleagues in the UK. Thus we analysed five criterion groups in all. These were: (1) snoring; (2) snoring + mouth breathing; (3) snoring + nasal obstruction; (4) age = 4-8 years and (5) nasopharyngeal airway < 4 mm. We found that applying each criterion separately to the group of children would result in widely differing numbers of children being selected for adenoidectomy. Of the 125 children, the percentage selected by each method varied considerably, ranging from 35-70%. In addition, there was only limited overlap, (43-71%) between the composition of the groups. This helps to explain the variations in surgical rates in different centres. In the absence of any universally acceptable guidelines, therefore, the importance of individual assessment of children can not be overemphasised.

Flow cytometric quantification of lymphocyte subpopulations and immunoglobulin-containing cells in adenoid tissue in relation to secretory otitis media and age

This study was designed to identify differences in the immunological reactions in adenoid tissue between children suffering from chronic secretory otitis media (SOM) and control children without ear disease. Cell populations were identified using monoclonal antibodies and flow cytofluorometry to facilitate quantitative comparisons. A modification of the FOG method was developed to quantify lymphocytes with intracellular IgG and IgA. Immunological screening was done in the first part of the study. No significant differences were found between the groups regarding cells positive for CD3, CD4, CD8, CD20 or CD25. A significantly higher number of PCA-1 positive cells (presumably plasma cells) were found in the SOM group. The second part of the study concentrated specifically on cells containing IgG or IgA. No statistically significant differences in number of positive cells were found between the groups. When we related the percentage of positive cells to age, a statistically significant decrease with age for IgA-positive cells was found in the SOM group but not in the control group. This result supports the hypothesis that SOM is associated with an immunological reaction that influences immunoglobulin production in adenoid tissue.

Possible role of adenoid mast cells in the pathogenesis of secretory otitis media

The distribution of mast cells in the adenoidectomy specimens of 76 children with enlarged adenoids was studied. Forty of the patients had secretory otitis media; the remaining 36 had normally aerated middle ears. The mast cells were identified on the basis of the metachromatic staining of their cytoplasmic granules with toluidine blue. Patients with secretory otitis media had a twofold increase of their mast cell population compared to those without middle ear disease. Statistical analysis confirmed that the difference between the two groups is significant (p = .0001). The results of the study are consistent with the previous finding of increased histamine concentration in adenoids of children with secretory otitis media and lend support to the adenoid mediator release hypothesis, whereby the adenoid mast cells degranulate and release histamine and other inflammatory mediators that induce eustachian tube insufficiency and otitis media with effusion.

Adenoidectomy for otitis media with effusion

The efficacy of adenoidectomy in the surgical treatment of children with otitis media with effusion (OME) persisting after adequate medical therapy has been established in three independent randomized clinical trials. Although each of these studies used a different experimental design, all showed significant reductions in morbidity from OME after adenoidectomy as compared to the control groups. Subsequent application of these findings in formulating clinical guidelines for the use of adenoidectomy has yet to be realized, and recommendations to parents for or against the procedure appear to vary more with the surgeon's philosophy than with the condition of the child. This discussion examines the effectiveness and cost of adenoidectomy for the treatment of children with chronic OME and addresses the question of whether adenoidectomy should be used as a primary or a secondary surgical therapy. The argument is made to use adenoidectomy as a primary therapy in selected cases on the basis of patient age, type of OME, and patient preference, and to base the decision not on the size of the adenoid, but on its known pathophysiology.