Assessment of adenoidal obstruction in children: clinical signs versus roentgenographic findings

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.

Olfactory disorders in childhood: A comparative study of olfaction in children with adenoid hyperplasia versus a control group and the postoperative effects of adenoidectomy with respect to olfactory ability

PURPOSE

Hyposmia in childhood is poorly characterized. The "U-Sniff Test", validated for children with anosmia, can be used to objectify olfactory impairment but has not been used to distinguish between hyposmia and normosmia. Therefore, we investigated children with enlarged adenoids with respect to hyposmia, its correlation with adenoid size, and the sensitivity of questionnaires to predict olfactory impairment.

METHODS

In a prospective comparison, olfaction was assessed by "U-Sniff Test" (score 0-12; <8 hyposmia) in 41 children (5-18 years) with adenoid hyperplasia and compared with 196 children without any respiratory affection (control) after exclusion of previous SARS-Cov2-infection from December 2020 to December 2021. ENT-related complaints were collected using a self-designed questionnaire. We were able to include 13 children in a follow-up examination to compare preoperative performance in the "U-Sniff Test" with postoperative outcome after adenoidectomy.

STATISTICS

chi-square-test (p < 0.05), odds-ratio, Spearman's rho, ROC-, cluster analysis.

RESULTS

Severe hyposmia was present in 36.6% of children with adenoid-hyperplasia compared to 3.1% of the control-group. Adenoid-children scored significantly more often between 8 and 10 points (58.5%) than the control (31.6%; p < 0.01). Adenoid size and olfactory performance correlate significantly (r: 0.83; CI -0.89 … -0.72). Hyposmia in the adenoid group is characterized predominately by loss of the odors banana, butter and rose. None of children with hyposmia or parents reported impaired olfactory performance. Postoperatively, olfactory function improved significantly in 85% of cases (p 0.01, SD ± 1.71, Δ3.54points).

CONCLUSION

Questionnaires are insufficient to detect hyposmia in this cohort. In contrast, the "U-Sniff Test" detects even reduced olfactory performance without reaching the cut-off value, which represents the majority of test results in the adenoid group. Therefore, we recommend the classification of moderate hyposmia (8-10 points) to be included for our study population.

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.

Postoperative Outcomes in Cold Dissection Versus Bipolar Electrocautery Tonsillectomy: A Randomized Double-Blind Controlled Study

Tonsillectomy is one of the oldest and most common procedures worldwide. This surgery is performed by different methods include cold dissection technique (CDT) and bipolar electrocautery technique (BET). Assessment and comparison of postoperative outcomes in cold dissection and bipolar electrocautery is the aim of present study. This randomized controlled clinical trial study was conducted as double-blind on 534 patients. The enrolled patients underwent tonsillectomy in Vali-e-Asr Hospital of Birjand city from Oct. 2013-Oct. 2015. Al patients systematically allocated into two groups treated with cold dissection or bipolar electrocautery methods. Intensity of throat pain scores, Otalgia, analgesic consumption, resume normal diet, body temperature and also wound healing on 10th day after operation were measured and compared between the two groups. The gathered data were analyzed by SPSS software (Ver-22) and using necessary tests. The differences between studied groups less than 0.5 (p < 0.05) considered significant statically. 51.7 and 50.6% in the CDT and the BET groups were male respectively. In comparison between the groups the mean of pain scores 4 and 24 h after operation in the BET group were higher significantly (p < 0.001). Otalgia only 4 h after surgery was higher significantly in the BET group (p = 0.008). All the other studied parameters were significantly more desirable in the CDT group (p < 0.001). According to the findings of present study it seems that the CDT is safer and more favorable than the BET in tonsillectomy.

Decreased frequency of adenoidectomy by a 12-week nasal budesonide treatment

Objective

There is little evidence on the role of topical budesonide in reducing the frequency of adenoidectomy, although it was reported that topical budesonide can effectively ameliorate the symptoms of adenoid hypertrophy (AH). This study was aimed to investigate the possibility and safety of alternatives to adenoidectomy with a 12-week treatment with nasal budesonide.

Materials and methods

One hundred patients with AH were randomized to receive either a double-blind budesonide (1 mg once daily) or placebo treatment for 2 weeks by transnasal nebulization. A further 12-week open study, budesonide spray (64 μg per nostril at bedtime) was administered to the treatment group. During the final 12 weeks of follow-up, the frequency of adenotonsillectomy, side effects, the degree of nasal obstruction, nasal discharge, and snoring were assessed.

Results

Out of the 100 total enrolled patients, 92 children with AH completed the study. After the 2-week treatment with transnasal budesonide nebulization, the symptoms of AH significantly decreased compared to the control group. Responders (n=26) who had initially improved showed significantly decreased symptoms of AH, and the frequency of adenotonsillectomy during the follow-up (14 and 26 weeks) was compared with that of the control group and non-responders (n=21) who did not respond to the initial 2-week budesonide therapy. The 12-week nasal budesonide treatment did not suppress the growth rate of children’s height or cause other side effects.

Conclusion

AH children who had improved after an initial 2-week budesonide therapy can achieve clinical improvements and decreased frequency of adenoidectomy following the therapy with a 12-week treatment with nasal budesonide.

The effect of vibrissae on subjective and objective measures of nasal obstruction

BACKGROUND

Nasal congestion and/or obstruction represents a prevalent and extensively studied problem. No published research exists that describes the impact of nasal hair (vibrissae) on nasal obstruction.

OBJECTIVE

To assess the impact of nasal vibrissae on subjective and objective measurements of nasal obstruction.

METHODS

In this prospective study, 30 healthy participants without nasal symptoms were assessed for baseline vibrissae density and were treated with a topical decongestant. The subjects were then asked to subjectively assess nasal breathing by using four questions from the Nasal Obstruction Symptom Evaluation instrument before undergoing rhinomanometry. Nasal vibrissae were then trimmed, and the participants repeated the subjective and objective assessments. Pre- and postintervention outcomes, including symptom scores, nasal airflow, and resistance, were compared by using statistical analysis.

RESULTS

Statistically significant improvement was noted in subjects' nasal airway specific symptom scores and in objective measurements of their nasal airway. Patients with moderate or many vibrissae at baseline were noted to have greater likelihood of improvement in subjective and objective obstruction assessments than patients rated with few.

CONCLUSION

In these 30 subjects, statistically significant improvement occurred in both subjective and objective assessments of nasal obstruction, particularly in patients with greater density of vibrissae. These findings support further study of the potential benefit of the reduction of vibrissae density in some patients with nasal obstruction.

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

Background

Nasopharyngeal fiberendoscopy (NFE) is the gold standard diagnostic procedure for adenoidal disease, but there is no consensus concerning the optimal technical approach. The aim of this study was to investigate the attitudes of Italian otolaryngologists towards diagnostic NFE in children, and the most widely used methods.

Methods

Nine hundred randomly selected members of the two largest Italian otolaryngological scientific societies were e-mailed an anonymous web-based questionnaire containing 29 multiple-choice items regarding their opinions about, and use of NFE in children.

Results

Questionnaires were returned by 764 clinicians (84.9 %). About 75 % declared they used NFE, but 35 % said they preferred alternative diagnostic methods. Most of the respondents considered NFE safe, but more than 80 % judged it to be poorly or only fairly well tolerated. Almost all declared that they generally use flexible, small-diameter instruments, with the patient seated on a chair or a parent’s lap; 65 % use gentle restraining methods. Fewer than 50 % reported using a standardised hypertrophy grading system.

Conclusion

Italian otolaryngologists have a generally positive attitude towards using NFE in children. However, some have reservations, and there was no unanimous agreement concerning how it should be done. Given the medical advantages of NFE, it is essential to clarify the many still controversial aspects of the procedure by means of comparative studies and educational programmes.

Correlation between adenoidal nasopharyngeal ratio and symptoms of enlarged adenoids in children with adenoidal hypertrophy

BACKGROUND

Adenoid hypertrophy is one of the most common health problems affecting the paediatric population. This study aims to correlate adenoidal nasopharyngeal ratio (ANR) with symptoms of enlarged adenoids in children with enlarged adenoids.

MATERIALS AND METHODS

It was a year, cross-sectional, hospital-based study conducted at Lautech Teaching Hospital, Osogbo. ANR was determined by dividing adenoidal depth with nasopharyngeal depth on the plain lateral radiographs.

RESULTS

A total of 90 consecutive children consisting of 61 males and 29 females were included in the study with M:F ratio of 2.1:1. Their ages ranged from 8 months to 11 years. All the patients presented with nasal obstruction, mouth breathing and noisy breathing. Majority (64.5%) had severe obstructions with preponderance among children of 3-5 years (39.9%). Linear regression analysis showed significant association between age and ANR (t = 10.447, P < 0.001). There was high significant association (P < 0.05) between presenting symptoms and degree of nasopharyngeal airway obstruction; for snoring (r = 0.251, P = 0.000), sleep apnoea (r = 0.594, P = 0.000), nasal discharge (r = 0.314, P = 0.001), excessive daytime sleepiness (r = 0.219, P = 0.019) and failure to thrive (r = 0.240, P = 0.011).

CONCLUSION

Lateral X-ray of the nasopharynx is an effective tool to evaluate children with suspected adenoid hypertrophy. It correlates well with patients' symptoms and provides objective measures of adenoid hypertrophy.

Method of the diagnosis of adenoid hypertrophy for physicians: adenoid-nasopharynx ratio

OBJECTIVE

We aimed to describe the feasibility of a prediction of adenoid hypertrophy by pediatricians for diagnostic accuracy of nasopharyngeal x-ray in a pediatric unit.

METHODS

Forty-six patients with a history of probable adenoid hypertrophy between January 2013 and August 2013 were included in the study. Participants were excluded from the study if they had previous adenoidectomy; anatomic anomaly in the nose, palate, or nasopharynx; and acute infection. Nasal endoscopy was performed and evaluated adenoid size (choanal obstruction ratio) in all patients by an otorhinolaryngologist who was blinded to the information of other data. Lateral nasopharyngeal x-ray graphs of all patients were evaluated by pediatricians with adenoid-nasopharynx (A-N) ratio, who were blinded to the information of other data. The A-N ratio was calculated by Fujioka method. The A-N ratio of each patient was compared with the choanal obstruction ratio that was determined in the nasal endoscopic examination. Spearman correlation test was used for statistical analysis, and P < 0.05 was described as significant.

RESULTS

Forty-six patients were included in this study. The study sample consisted of 25 male (54.3%) and 21 female (45.7%) patients. The mean age of the patients was 6.17 years (range, 2-14 y). In the nasal endoscopic examination, the mean (SD) choanal obstruction ratio was 64.6% (19.5%) (range, 12.5%-90%). Mean (SD) A-N ratio was found to be 16.7 (14.4). The A-N ratio correlated with nasal endoscopic examination findings (r = 0.334, P = 0.023) CONCLUSIONS: The A-N ratio was found to be a useful, tolerable, and confident diagnostic method in pediatric patients for adenoid hypertrophy. Pediatricians can confidently use this method for decision after follow-up or operation.

Lateral cephalometric radiograph versus lateral nasopharyngeal radiograph for quantitative evaluation of nasopharyngeal airway space

OBJECTIVE

This study compared lateral radiographs of the nasopharynx (LN) and lateral cephalometric radiographs (LC) used to assess nasopharyngeal airway space in children.

MATERIAL AND METHODS

One examiner measured the nasopharyngeal space of 15 oral breathing patients aged between 5 and 11 years old by using LN and LC. Both assessments were made twice with a 15-day interval in between. Intergroup comparison was performed with t-tests (P < 0.05).

RESULTS

Comparison between LN and LC measurements showed no significant differences.

CONCLUSION

Lateral cephalometric radiograph is an acceptable method used to assess nasopharyngeal airway space.

Tonsillectomy, adenoidectomy and adenotonsillectomy rates in school-aged children: Relative contributions of socio-demographic and clinical features

OBJECTIVES

The present study sought to investigate the frequencies of tonsillectomy, adenoidectomy and both adenotonsillectomy (T&A) among 6-12 years old children. In addition, we tried to find out the predictors associated with these previous upper respiratory tract (URT) surgeries.

METHODS

This cross-sectional study consisted of 1900 children educated in 3 different elementary schools in Ankara, Turkey. Data about demographics and health conditions were obtained from survey questionnaires completed by parents.

RESULTS

Of the 1900 children, 15 children (0.8%) previously underwent tonsillectomy, 43 children (2.3%) had adenoidectomy and 80 children (4.2%) had T&A surgical histories. Multiple logistic regression analysis revealed that older students compared to younger ones [odds ratio (OR) = 1.15, p = 0.011], and those who had parent-reported apnea compared to subjects without apnea were more likely to have URT surgery histories [OR = 2.34, p = 0.001]. Those children with surgery histories were more likely to have fathers with a higher educational level [medium level: OR = 2.07, p = 0.012; high level: OR = 2.79, p = 0.001 vs. low level) and the subjects had greater BMI percentiles [overweight: OR = 1.71, p = 0.036; obesity: OR = 2.32, p = 0.003 vs. healthy weight]. Children who had 1-2 URT infections per year [OR = 0.47, p = 0.019] had less probability of URT surgery histories, whereas those children with AOM ≥ 3 times per year [OR = 2.52, p = 0.003] had more probability of URT surgery history.

CONCLUSIONS

We conclude that a reasonable explanation for higher rates of URT surgery among children with a high level of paternal education may originate from their awareness about URT associated diseases and possibly due to the ease of access to health care services.

Evaluation of middle ear pressure in the early period after adenoidectomy in children with adenoid hypertrophy without otitis media with effusion

OBJECTIVE

Our aim was to analyze the changes in middle ear pressure in the early period after adenoidectomy in children with adenoid hypertrophy without otitis media with effusion.

METHODS

This prospective, descriptive study was performed on 64 patients (with normal tympanic membranes and tympanograms) undergoing adenoidectomy or adenotonsillectomy. All patients were operated by single experienced team using curettage technique. First tympanometry was done on the day before surgery. Tympanometry was repeated on the first-, third-, and seventh-day after the operation. Patients are separated into two groups according to age as patients younger than 6 years (Group A) and patients older than 6 years (Group B). All data were separately evaluated for each ear using Jerger Classification.

RESULTS

Of the 64 patients included in the study, 35 were male and 29 were female, and the average age was 91.01 ± 37.4 (35-178) months. Pathological decreases in the middle ear pressures of at least one ear were determined in 48 (75%) patients on the first postoperative day and in 10 (15.6%) patients on the third postoperative day. Middle ear pressures returned to preoperative values by the seventh postoperative day except in two patients. There were statistically significant differences (p<0.0001) among preoperative and first, third, and seventh postoperative day mean middle ear pressure. There were no statistically significant differences between Groups A and B in terms of tympanometry values of both ears obtained preoperatively and on the first, third, and seventh postoperative day.

CONCLUSION

In our study, temporary eustachian dysfunction and aural fullness occur in the early period after adenoidectomy and/or adenotonsillectomy. This situation may be due to post-surgery clots and edema in nasopharynx. We consider that tubal orifice can be exposed to surgical trauma as adenoidectomy surgeries are done by curettage technique. There is a need for comparative studies using microdebrider or laser adenoidectomy accompanied by an endoscope.

Radiographic adenoid evaluation: proposal of an objective parameter

Objective

The objective of the present study was to evaluate current radiographic parameters designed to investigate adenoid hypertrophy and nasopharyngeal obstruction, and to present an alternative radiographic assessment method.

Materials and Methods

In order to do so, children (4 to14 years old) who presented with nasal obstruction or oral breathing complaints were submitted to cavum radiographic examination. One hundred and twenty records were evaluated according to quantitative radiographic parameters, and data were correlated with a gold-standard videonasopharyngoscopic study, in relation to the percentage of choanal obstruction. Subsequently, a regression analysis was performed in order to create an original model so the percentage of the choanal obstruction could be predicted.

Results

The quantitative parameters demonstrated moderate, if not weak correlation with the real percentage of choanal obstruction. The regression model (110.119*A/N) demonstrated a satisfactory ability to "predict" the actual percentage of choanal obstruction.

Conclusion

Since current adenoid quantitative radiographic parameters present limitations, the model presented by the present study might be considered as an alternative assessment method in cases where videonasopharyngoscopic evaluation is unavailable.

Adenoids in children: Advances in immunology, diagnosis, and surgery

Adenoids are strategically located for mediating local and regional immune functions as they are exposed to antigens from both the outside air and the alimentary tract. Recurrent or chronic respiratory infections can induce histomorphological and functional changes in the adenoidal immunological barrier, sometimes making surgical treatment necessary. Our aim in this review is to summarize the crucial points about not only the immunological histopathology of adenoidal tissue, especially in patients with adenoid hypertrophy, but also the most common and useful diagnostic techniques and surgical options.

Effects of body mass index and adenotonsillar size on snoring sound intensity levels at highest power

OBJECTIVES

Snoring during sleep is a major clinical symptom of adenoid and tonsil hypertrophy in paediatric patients. The aim of this study was to determine the effects of adenoid and tonsil size on snoring sound frequency and intensity in children.

METHODS

Twenty-seven patients with adenotonsillar hypertrophy were included the study. Adenoid size was graded from 1+ to 4+ by rigid endoscopy. Patients were staged (I-III) according to body mass index (BMI) and tonsil and adenoid size. Snoring was recorded and analysed. The analysis focused on the highest power frequency (Fmax) and snoring sound intensity levels (SSILs).

RESULTS

SSIL and Fmax values for Stage III were significantly higher than those for Stages I and II. BMI for Stage III was higher than for Stages I and II, and that for Stage II was higher than for Stage I. The BMI, SSIL, and Fmax values increased at each stage and tonsil/adenoid grade.

CONCLUSIONS

SSIL seems to be related to Adenoid and Tonsils size and BMI. As stage increased, both Fmax and SSILs increased proportionally. Also, Fmax values shifted to higher frequencies. Physicians and parents should be aware of snoring, and be informed that a higher frequency and intensity may be related to obesity and/or adenotonsillar hypertrophy. Snoring analysis may be a useful tool for detecting cases of Adenoid and Tonsils hypertrophy and/or upper airway obstruction during sleep.

Psychiatric disorders and symptoms severity in patients with adenotonsillar hypertrophy before and after adenotonsillectomy

OBJECTIVE

The objective of this study was to compare the frequency of psychiatric disorders and the severity of psychiatric symptoms in patients with adenotonsillar hypertrophy with a healthy control group and investigate the potential improvement after adenotonsillectomy.

MATERIALS AND METHODS

The study group consisted of 40 patients with adenotonsillar hypertrophy and a control group consisted of 35 healthy volunteers without adenotonsillar hypertrophy. A routine ear nose throat (ENT) examination, flexible nasopharyngoscopy and tympanometry were carried out. The same procedures were applied to the control group. The parents of all the participants were required to fill out the Early Childhood Inventory-4 form, the Strengths and Difficulties Questionnaire and a personal information form. At postoperative month six, the patients were re-examined, and their parents were required to fill out the same forms.

RESULTS

Attention deficit hyperactivity disorders and sleep disorders determined with the Early Childhood Inventory-4 were more common in the patients with adenotonsillar hypertrophy than in the control group. There was a significant decrease in the rates of both types of disorders at postoperative month six. The total psychiatric symptom severity was higher in the patients with adenotonsillar hypertrophy and the following were more frequent: cases of attention deficit hyperactivity disorder, oppositional defiant disorder, symptom severity of anxiety disorders and sleep disorders determined with the Early Childhood Inventory-4, as well as emotional problems, attention deficit hyperactivity disorder problems, behavioural problems and peer problems determined with the Strengths and Difficulties Questionnaire parent-report form. There was a statistically significant decrease in all the other symptoms at postoperative month six, except for the severity of oppositional defiant disorder symptoms determined with the Early Childhood Inventory-4 and behavioural problems determined with the Strengths and Difficulties Questionnaire parent-report form. There were no differences in the severity of psychiatric disorders or symptoms between the adenotonsillar hypertrophy group and the control group at postoperative month six.

CONCLUSION

Adenotonsillar hypertrophy is associated with psychiatric disorders and symptoms. Adenotonsillectomy ameliorated the symptoms and the severity of these disorders in most cases.

Three-dimensional evaluation of the relationship between nasopharyngeal airway shape and adenoid size in children

Objective

To evaluate the shapes and sizes of nasopharyngeal airways by using cone-beam computed tomography and to assess the relationship between nasopharyngeal airway shape and adenoid hypertrophy in children.

Methods

Linear and cross-sectional measurements on frontal and sagittal cross-sections containing the most enlarged adenoids and nasopharyngeal airway volumes were obtained from cone-beam computed tomography scans of 64 healthy children (11.0 ± 1.8 years), and the interrelationships of these measurements were evaluated.

Results

On the basis of frontal section images, the subjects' nasopharyngeal airways were divided into the following 2 types: the broad and long type and the narrow and flat type. The nasopharyngeal airway sizes and volumes were smaller in subjects with narrow and flat airways than in those with broad and long airways (p < 0.01). Children who showed high adenoid-nasopharyngeal ratios on sagittal imaging, indicating moderate to severe adenoid hypertrophy, had the narrow and flat type nasopharyngeal airway (p < 0.01).

Conclusions

Cone-beam computed tomography is a clinically simple, reliable, and noninvasive tool that can simultaneously visualize the entire structure and a cross section of the nasopharyngeal airway and help in measurement of adenoid size as well as airway volume in children with adenoid hypertrophy.

The prevelance of psichiatric symptoms in preschool children with adenotonsillar hypertrophy

OBJECTIVES

The aim of this study was to determine the prevalence of psychiatric disorders and symptoms in preschool-age children who are indicated for operation due to adenotonsillar hypertrophy.

MATERIALS AND METHODS

Forty-eight patients between the ages of three and five years with indication for adenotonsillectomy were included in the study, as well as 40 control patients. Cases underwent routine ear nose throat (ENT) examination, flexible nasopharyngoscopy and tympanometry. The Early Childhood Inventory-4 (ECI-4) parent form and Strengths and Difficulties Questionnaire (SDQ) parent form were completed by the parent caring for the child. The SPSS for Windows 16.0 program was used for statistical analysis.

RESULTS

Groups were compared according to they received at least one psychiatric diagnosis measured by ECI-4, the group of adenotonsillar hypertrophy was diagnosed more than the control group. Attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and sleep disorders were detected at a higher rate in patients with adenotonsillar hypertrophy. It also was established that in the comparison of the severity of psychiatric symptoms determined by ECI-4, symptom severity of ADHD, ODD, anxiety disorders, and sleep disorders was higher in the adenotonsillar hypertrophy group than in the control group. In the evaluation of the SDQ parent form, it was determined that attention deficit, hyperactivity, behavioral, and peer relations problems occurred more frequently in the adenotonsillar hypertrophy group.

CONCLUSIONS

In addition to oral respiration, snoring, and disordered breathing during sleep, adenotonsillar hypertrophy may also associated with psychiatric disorders and symptoms.

Correlations between polysomnographic and lateral airway radiograph measurements in paediatric obstructive sleep apnoea

AIM

To evaluate the ability of lateral airway radiography (LAR) to assess adenoidal hypertrophy in children and correlate with the severity of obstructive sleep apnoea (OSA).

METHODS

This cohort study was undertaken in 72 children who presented consecutively for evaluation of OSA to the outpatients of the Children's Hospital at Westmead. All children had LAR and overnight polysomnography (PSG). Five assessors, with varying experience, were blinded to the PSG results and independently analysed the LAR. Inter-rater reliability was determined for four published assessment methods; Hibbert, Johannesson, Fujioka and Cohen and Konak. We then compared the four LAR results with PSG-determined criteria for OSA.

RESULTS

Using intraclass correlations, inter-rater correlations were moderate to high for all four standardised evaluations of LAR with values ranging from 0.51 to 0.96. With the radiologist taken as the 'gold standard', individual assessors ranged from 0.05 to 0.91. LAR correlated best with PSG determined obstructive apnoea hypopnea index and minimum oxygen saturation for the anterior airway measurement (Hibbert) with r-values of -0.25 and 0.25 respectively (P < 0.05).

CONCLUSION

Amongst four methods of evaluating adenoid size, the anterior airway size correlated best with PSG variables of obstructive respiratory index and minimum oxygen saturation. However, the methods are not able to be used as a predictor for OSA.

[S1 Clinical guideline"adenoids and adenoidectomy"]

On behalf of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery, a clinical guideline for adenoids and adenoidectomy was developed in 5 consensus meetings after taking into consideration the current literature. This guideline was released by the presidium on 13 April 2011. Anatomy, pathology and pathophysiology, symptoms, diagnosis, therapy, and course are presented.

The relationship between posterior septum deviation and depth of maxillopalatal arch

OBJECTIVE

To investigate the relationship between depth of maxillopalatal arch and deviation of posterior septum.

METHODS

This study is based on paranasal sinus CT (PNSCT) scan in the coronal plane evaluation, and sinus paranasal scans were obtained from the database. One-hundred and fifty PNSCT scans were randomly chosen among the PNSCT scans which belong to adult (18 and older) patients. All scans were divided to three different groups. The first group constituted by those patients who had more convex deviation. The second group had those patients with either crest or spur deviations. The last group (control group) had no septum deviation. The data collected from each group were statistically compared.

EXCLUSION CRITERIA

CT imaging which has a chronic sinusitis, nasal cavity mass, and nasal polyps.

MAIN OUTCOME MEASURES

angle and distance measures were taken on maxillopalatal arch and posterior nasal septum.

RESULTS

Strongly positive correlation between posterior septum deviation and depth of maxillopalatal arch was determined (r=0.479, p=0.001).

CONCLUSION

These findings suggest that posterior septum deviations are considered as a result of increase in maxillopalatal depth.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcome of adenotonsillectomy for sleep and breathing difficulties in nigerian children with obstructive adenotonsillar enlargement

The aim of this study was to examine improvements or otherwise, in sleep disturbance and breathing difficulties after adenotonsillectomy (AT) for chronic upper airway obstruction in children. In a prospective clinical study and tertiary referral center setting, the study population included consecutive children aged 1.5 through 12 years who underwent AT for chronic upper airway obstruction due to adenotonsillar enlargement, without any history of previous AT. The validated "Symptomatology score" (SS) parameters were used to grade the symptoms before and after AT. The extent of improvement of the symptoms after surgery were estimated by a standardized response mean (SRM). The study included 59 children, 40 of whom were males (68%). Their ages ranged from 1.5 to 12 years with a mean of 3.3 years and 63% were <4 years. The results showed that tonsillar size was correlated significantly with a high preoperative SS (P ≤ 0.001). The mean preoperative SS for the study population was 7.2, whereas the mean postoperative SS was 1.7. This change was highly significant (P < 0.001). The symptom domain with the greatest change in mean score was snoring, which improved by 2 points with SRM of 2.2. The changes in total score and in the scores for each symptom domain were highly significant (P < 0.002). We concluded that adenotonsillectomy is associated with remarkable improvement in breathing difficulties and sleep disturbances in children with obstructive adenotonsillar hypertrophy regardless of the condition whether it is mild or severe.

Adenoid assessment in paediatric patients: the role of flexible nasal endoscopy

Adenoid hypertrophy is the most common cause of nasal obstruction in paediatric patients. Over the years, various methods to assess the adenoid size were proposed such as the posterior rhinoscopy and the radiological examination of the nasopharynx. Nasal endoscopy was introduced for children in the 80&#x0027;s, and nowadays this is a known and diffuse method in routine practice. The purpose of this article is to describe the personal experience in the assessment of the adenoid size in children, with a particular regard to the flexible nasal endoscopy, and to analyse the literature reports. The personal technique is described in performing nasal endoscopy in paediatric patients, reporting advantages and possible disadvantages of the procedure. A retrospective analysis was conducted on 6036 children since 1999 to 2010. In most cases children fully collaborated to complete the exam. No major or minor complications (such as nose bleedings or other traumatic injuries) were observed. No topical intranasal decongestant, local or general anaesthesia were used in our series. In our opinion, nasal endoscopy in children is a reliable, safe, accurate, easily tolerated and dynamic diagnostic method to assess the adenoid size.

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

OBJECTIVE

We have previously compared the capacity of the nasal obstruction index (NOI) and nasal fiberoptic endoscopy (NFE) to detect adenoid hypertrophy (AH) in children and found no agreement between them. However, the prevalence of false positive results was significantly higher in children with allergic rhinitis (AR), thus suggesting that AR may be a possible causative factor. The aim of this study was to verify the diagnostic accuracy of the NOI in detecting AH by comparing NOI scores with NFE findings in a selected series of non-allergic children affected by nasal obstruction.

METHODS

This prospective study was carried out at the Outpatient Clinics of the Departments of Specialist Surgical Sciences and Maternal and Pediatric Sciences of the University of Milan, Italy, and involved 154 non-allergic children aged 3-12 years in whom otological diseases and/or perceived nasal obstruction led to the suspicion of adenoid obstruction. The diagnostic accuracy of NOI was tested at all of the thresholds obtained by combining all of the cut-off points of NFE and NOI.

RESULTS

Sixty-two percent of the children had otological diseases. The choanal opening was completely blocked by the adenoids in 40% of the children, whereas NOI indicated severe clinical obstruction in only 16%. The analysis of diagnostic accuracy showed that sensitivity and specificity were respectively 17-96% and 15-91% depending on the threshold, with no simultaneously acceptable sensitivity and specificity values at any threshold and AUC values of ≤0.7 at all thresholds.

CONCLUSIONS

In comparison with NFE, the NOI seems to be inaccurate in detecting AH in non-allergic children with nasal obstruction.

Lateral X-ray view of the skull for the diagnosis of adenoid hypertrophy: a systematic review

OBJECTIVES

Many studies have been developed aiming to reveal the usefulness of cavum X-rays and telerradiographies as diagnostic tools for the detection of upper airway obstruction due to adenoid hypertrophy. However, the scientific literature is diverse and controversial. Therefore, a systematic review is proposed; with the objective to determine the diagnosis value of lateral X-ray view of the skull regarding adenoid hypertrophy.

METHODS

Searching was conducted on Pubmed, Lilacs, Cochrane Library, Embase, and Web of Knowledge databases; and was restricted to studies published in English, Portuguese or Spanish languages, carried out on humans under 18 years of age. All the obtained publications were first submitted to a pre-selection, and then, full-texts (n=66) were analyzed and selected by independent examiners. The resultant studies (n=11) were systematically and critically analyzed, and qualified according to QUADAS (Quality Assessment of Diagnostic Accuracy Studies) questionnaire, an assessment tool designed to qualify diagnostic tests accuracy studies.

RESULTS

Searching and selection procedures generated 11 studies which were considered adequate to be systematically analyzed. Accordingly, large variation was observed concerning the evaluation methods of radiographic and fibronasoendoscopic exams, and the sample characteristics. Additionally, little amount of scientific evidences could be provided, since few radiographic variables were analyzed simultaneously. Moreover, assessment methods were, at most, subjective or poorly described. QUADAS application revealed other significant limitations related to the sampling, such as inadequate spectrum of the investigated "disease" (adenoid hypertrophy), and poor report of the subjects' enrollment and participation process. Further, QUADAS revealed inadequacies regarding methodological features, including poor description of the radiographic exams and assessment methods. In addition, it was also shown that most of the studies did not specify the moment in clinical time when both exams were performed; neither reported a strategy of "blindness" by the examiners.

CONCLUSIONS

Despite such limitations, the majority of the resultant data indicates that lateral X-rays might be considered somewhat useful, even though it could not be clearly demonstrated. Future research should then adhere to greater methodological rigor, in order to investigate the significance of radiographies as a screening test.

Adenotonsillar hypertrophy: Does it correlate with obstructive symptoms in children?

OBJECTIVE

The goal of this study is to determine the correlation of clinical symptoms of UAO (upper airway obstruction) with radiographic evaluation of adenoidal obstruction and tonsil size in children with adenotonsillar hypertrophy and to evaluate the usefulness of lateral neck radiography.

STUDY DESIGN

Prospective study.

SETTING

Haydarpaşa Numune Research and Education Hospital, Istanbul, Turkey.

SUBJECTS AND METHODS

This study analyses 95 children with one or more of the symptoms of UAO. Clinical symptoms were assessed by a standardized questionnaire evaluating the severity of symptoms. All patients underwent otolaryngologic examination and their tonsil sizes were graded. 74 of 95 patients underwent digital lateral soft tissue radiographs. Assessment of nasopharyngeal obstruction in radiographs was done according to four different methods.

RESULTS

We did not find statistically siginificant correlation between symptom scores and radiologic measurements according to Johanneson (r=0.072, p=0.544, p>0.05) and Crepeau (r=0.034, p=0.773, p>0.05). The correlations between OSA score and Cohen and Konak's method and AN ratio were weak and not statistically siginificant (p=0.133, r=0.176; p=0.290, r=0.125 respectively; p>0.05). But, we found a statistically siginificant correlation between the tonsil grade and symptom scores (r=0.216, p=0.036, p<0.05).

CONCLUSION

Our results have demonstrated that radiologic measurements of the nasopharyngeal obstruction do not correlate with clinical symptoms of UAO, but clinical assessment of tonsil size does.

Comparação de duas técnicas radiográficas extrabucais utilizadas para avaliação do espaço aéreo nasofaringeano

OBJETIVO: esta pesquisa teve por objetivo comparar a utilização da radiografia cefalométrica de perfil e da radiografia de cavum na avaliação do espaço aéreo nasofaringeano. MÉTODOS: o estudo foi realizado em 2005 na cidade de Recife/PE, com um grupo de 36 crianças portadoras de respiração bucal, com idades variando de 5 a 12 anos. As crianças selecionadas foram divididas em 6 grupos e, em cada grupo, as tomadas radiográficas foram realizadas em um mesmo dia. A amostra constou de 72 radiografias, 36 cefalométricas de perfil e 36 de cavum. O laudo radiográfico foi baseado no método de Schulhof e, no final do laudo, foi emitido um Índice que representava uma síntese de todas as medidas avaliadas. RESULTADOS: os resultados foram comparados estatisticamente através do teste t de Student pareado, do teste qui-quadrado (X²), do coeficiente de correlação linear de Pearson e do índice Kappa. Apenas na porcentagem da via aérea foi encontrada diferença estatisticamente significativa (p = 0,006). Um alto grau de correlação foi verificado em todas as medidas avaliadas e o grau de concordância dos valores obtidos no Índice foi considerado bom. CONCLUSÃO: concluiu-se que a radiografia cefalométrica de perfil e a radiografia de cavum podem ser utilizadas para a análise do espaço aéreo nasofaringeano.

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

BACKGROUND

Adenoid hypertrophy treatment for children is generally planned in accordance with the degree of airway obstruction and related morbidity. If surgical treatment is indicated, the individual risk/benefit analysis of patients should be assessed in terms of anesthetic and postoperative complications. Although there are few alternative treatment options, these may be considered as a nonsurgical approach in less serious cases. Accordingly, studies about intranasal steroid applications under various protocols have been presented.

STUDY DESIGN

The prospective, randomized, placebo-controlled study.

SETTING

Tertiary referral center.

PATIENTS AND METHODS

Patients indicated for surgery were randomly divided into two groups. The study group was treated by fluticasone propionate nasal drops (NSD-nasal steroid drops) of 400 microg/day for 8 weeks. The control group was treated by normal saline (NS) in the same way. All the patients were called for follow-up every 4 weeks.

RESULTS

At the end of 8 weeks, statistically significant improvement (p<0.05) was observed in the NSD treated group compared to the NS treated group in terms of nasal airway obstruction, mouth breathing, speech abnormalities, apnea and night cough. At the end of 8 weeks, the average total symptoms score of the NSD treated group dropped from 13.7 to 2.9 while the NS treated group's score changed from 14.8 to 14.6. After 8 weeks of NSD treatment the initial adenoid/choana (A/C) rate had dropped from 87 to 56% and a total decrease of 35.6% was observed. After 8 weeks of NS treatment the A/C rate dropped from 87 to 85% and a total decrease of 2.2% was observed.

CONCLUSIONS

In this study, the effect of fluticasone propionate nasal drops on adenoid hypertrophy is examined for the first time. This method provides an effective alternative to surgical treatment in children with adenoid hypertrophy. With the protocol applied in this study 76% of the patients were eliminated the surgery and removed from the surgical waiting list.

Plain radiographic evaluation of the nasopharynx: do raters agree?

BACKGROUND

Subjective plain radiographic evaluation of the nasopharynx has been a widely adopted technique. Although it has its own limitations, its ease of interpretation and simplicity are some of its advantages.

AIM

To investigate the reliability, using kappa, in subjectively reporting plain nasopharyngeal radiographs in children with symptoms suggestive of enlarged adenoids.

METHODS

This was a retrospective study of the clinical records, and plain X-rays of the nasopharynx of paediatric patients with clinical features of adenoid hypertrophy in a Nigerian Tertiary Health Institution from January 2008 to December 2008.

RESULTS

Fifty-one children with a mean age of 3.4 years; standard deviation of 2.772 was studied. They had an age range of 2 months to 12 years. Most (66.6%) of the children studied were in the age bracket 0-4 years. The inter-rater reliability between the two Otolaryngologists, and that between an Otolaryngologist and a Radiologist using kappa statistics were 0.6696, 95% CI (0.5035-0.8357; p<0.05) and 0.8182, 95% CI (0.7073-0.9291; p<0.05) respectively. While the kappa intra-rater reliabilities for the two Otolaryngologists were 0.6931, 95% CI (0.5473-0.8389) and 0.9591, 95% CI (0.9033-1.000).

CONCLUSION

There was a high level of agreement among trained raters, in subjectively interpreting plain nasopharyngeal radiographs in children with suspected adenoidal obstruction.

Does adenoid hypertrophy really have effect on tympanometry?

OBJECTIVE

The goal of this study is to determine the correlation between the radiographic measurements of adenoid size and tympanometric findings.

STUDY DESIGN

Prospective study.

SETTING

Haydarpasa Numune Research and Education Hospital, Istanbul, Turkey.

SUBJECTS AND METHODS

Nine five consecutive children complaining of one or more of the symptoms of upper airway obstruction (UAO) (presence of snoring, mouth breathing or difficulty in breathing during sleep, obstructive breathing or apnea during sleep) were included in the study. Symptom severity was assessed by a standardized questionnaire. All patients underwent digital lateral soft tissue radiographs. Assessment of nasopharyngeal obstruction in radiographs was done according to four different methods. Tympanometry was used to evaluate the middle ear.

RESULTS

Of 190 ears, 79 were type A, 49 were type B and 62 were type C tympanograms. The symptom severity of 14 patients was graded as mild, 56 patients as moderate and 25 patients as severe. There was no statistically significant difference between UAO symptom severity groups and tympanogram types (p>0,05). Each one of the four methods of radiologic measurements of the adenoid enlargement showed no statistically significant difference between the tympanogram types (p>0,05).

CONCLUSION

The adenoid hypertrophy in both means of radiologic measurements and symptom severity does not correlate with the changes in tympanograms. These findings do not support the hypothesis that adenoidal size plays a major role in the etiopathogenesis of middle ear effusion (MEE).

Clinical assessment of adenoidal obstruction based on the nasal obstruction index is no longer useful in children

OBJECTIVE

To evaluate the accuracy of clinical assessment of adenoidal obstruction based on a standardized score of the degree of mouth breathing and speech hyponasality (nasal obstruction index [NOI]) in comparison to nasal fiberoptic endoscopy.

STUDY DESIGN

Cross-sectional study with planned data collection.

SETTING

Outpatient clinics of the Departments of Maternal and Pediatric Sciences and Specialized Surgical Sciences, University of Milan, Italy.

SUBJECTS AND METHODS

Children aged three to 12 years with adenoidal obstruction suspected on the grounds of persistent/recurrent otitis media or perceived obstructive nasal breathing were eligible. Ear, nose, and throat examination, allergy testing, NOI measurement, and nasal fiberoptic endoscopy to assess the degree of adenoidal hypertrophy were performed. Agreement between the NOI and adenoidal hypertrophy grade was assessed in the patients as a whole and by clinical subgroups.

RESULTS

A total of 202 children were enrolled: 54.9 percent had otological diseases and 45.1 percent had perceived obstructive nasal breathing. Most of the children (79.2%) showed mild or moderate clinical nasal obstruction. Adenoidal hypertrophy ranged from no obstruction (18%) to severe obstruction (38%). There was no substantial agreement between the NOI and the degree of adenoidal obstruction in the population as a whole and in all the clinical subgroups. False positive findings were significantly more frequent among allergic children (50%) than non-allergic children (22.4%, P = 0.009).

CONCLUSION

Clinical assessment based on the NOI is incapable of accurately predicting the degree of adenoidal obstruction. In children with clinical nasal obstruction not explainable by adenoidal size, the clinician should consider, among causes of more anterior obstruction, nasal allergy.

Correlation between adenoid-nasopharynx ratio and endoscopic examination of adenoid hypertrophy: a blind, prospective clinical study

OBJECTIVE

To determine the reliability of adenoid-nasopharynx (A/N) ratio that is calculated on lateral cephalometric graphies for measuring the adenoid tissue size.

METHODS

85 patients that had been examined in our clinic with a prediagnosis of adenoid hypertrophy between June 2007 and March 2008 were included in the study. Local ethics committee approved the study protocol. Patients who had a previous adenoidectomy history and anatomic anomaly or acute infection in nose, palate or nasopharynx were excluded. Endoscopic nasal examination was done in all patients in addition to the routine ear nose throat examination. Lateral cephalometric graphs were obtained from all patients. Digital images obtained during endoscopic examination were evaluated on computer and obstruction ratios of adenoid tissue to choanal opening were calculated. Each cephalometric graph was evaluated by a blinded author. A/N ratio was calculated by dividing the distance from the outermost point of convexity of adenoid shadow to basiocciput to the distance between sphenobasiocciput and posterior end of hard palate (Fujioka Method). A/N ratio of each patient was then compared with the obstruction ratio obtained in nasal endoscopy. Pearson correlation test was used for statistical analysis and a p-value of <0.05 was accepted as significant.

RESULTS

There were 52 male and 33 female patients between the ages of 2 and 12 years (mean age, 5.0+/-2.2; median, 4.5). In nasal endoscopy, adenoid tissue was determined to obstruct the choanal opening as 88.5+/-12.0% (range, 51-99%) in an average. Mean adenoid nasopharynx ratio was found to be 0.87+/-0.1. There was a statistical significant correlation between A/N ratio and nasal endoscopic examination findings (r=0.511; p<0.0001).

CONCLUSIONS

A/N ratio is an easily applicable, noninvasive method that can correctly measure the size of the adenoid tissue in patients who are suspected to have adenoid hypertrophy.

Using nasal steroids to treat nasal obstruction caused by adenoid hypertrophy: does it work?

OBJECTIVE

To systematically review the evidence for the usage of nasal steroids to improve symptoms of nasal airway obstruction in children with adenoidal hypertrophy.

DATA SOURCES

Published studies indexed in the MEDLINE (1951 to 2008), EMBASE (1974 to 2008), and the Cochrane databases (Issue 3, 2008).

REVIEW METHODS

Data from the included trials were extracted and trial quality was assessed. Meta-analysis was not applicable and data were summarized in a narrative format. Evidence from excluded studies was also discussed.

RESULTS

Seven studies (six randomized controlled trials and one cohort study) met the inclusion criteria of the review, including a total of 493 patients. Six of these studies demonstrated significant efficacy of various nasal steroids (mometasone, beclomethasone, flunisolide) in improving nasal obstruction symptoms and in reducing adenoid size, as measured with symptom scores and fiber-optic nasopharyngeal endoscopy, respectively. The response appeared to be a group effect and may be maintained longer-term by continuing nasal steroids at a lower maintenance dose. The treatment was safe and well-tolerated with few minor adverse events.

CONCLUSION

The available evidence suggests that nasal steroids may significantly improve nasal obstruction symptoms in children with adenoid hypertrophy. This improvement appears to be associated with a reduction of adenoid size. Evidence of long-term efficacy is limited but suggests that in many children maintenance therapy is needed if symptom-relief is to persist. Further studies are required to support the use of nasal steroids as a first-line approach in these children.

[Acoustic rhinometry evaluation of adenoid hypertrophy and adenoidectomy efficacy]

INTRODUCTION

Adenoid hypertrophy is a problem of more than 1/3 of children and is the predominant reason of otolaryngology consultations in this population. Diagnosis and surgical qualification are based on physical examination and other methods introduced more than 100 years ago. Development of endoscopic techniques has been found this method to be a gold standard in adenoid assessment up to date. However, the method is difficult to performed in some young patient because of their invasiveness. Acoustic assessment of nosopharyngs seems to be a new promising method.

THE AIM OF THE STUDY

Were an assessment of nasal obstruction due to adenoid hypertrophy in group of patients referring to adenoidectomy and an objective evaluation of changes in the volume of the nasopharynx after adenoidectomy.

MATERIAL AND METHODS

The examination was carried on the group of 30 patients aged 5-10 y.o. with adenoid hypertrophy admitted for adenoidectomy. The control group consisted of 10 children free of otolaryngological problems. All studied individuals had acoustic rhinometry performed and additionally, endoscopic method such as rhynofiberoscopy and endoscopy of nasopharyngs were introduced in the patient's group.

RESULTS

The study showed that children with adenoid hypertrophy have statistically significant reduction of nasopharyngeal volume (NPV) vs control group. Adenoidectomy increases the NPV parameter and makes it equal to control group.

CONCLUSIONS

The acoustic rhynometry seems to be a promising method in assessment of nasopharyngeal volume. This and further studies may help to reduce the number of "unnecessary" adenoidectomies, by making standards for NPV in different group of age.

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.

Evaluation of adenoidal obstruction in children: clinical symptoms compared with roentgenographic assessment

BACKGROUND

Obstructive adenoid enlargement is commonly implicated as the major cause of chronic nasal obstruction in children. Although clinical assessment is considered essential, there is little consensus over its reliability. This study was conducted to determine the correlation between graded symptomatology assessment and roentgenographic assessment of adenoidal obstruction.

METHOD

Symptoms assessed included snoring, mouth-breathing and obstructive breathing during sleep. Each symptom was rated on a four-point scale (absent = zero, mild = one, moderate = two and severe = three). We summed the ratings for each child to obtain the symptomatology score. We used an adenoidal-nasopharyngeal ratio parameter to classify roentgenographic assessment into minimal, moderate or marked obstruction.

RESULTS

Sixty-four children, 42 boys and 22 girls, aged one to 12 years were enrolled. The clinical symptomatology scores correlated significantly with the roentgenographic ratings of nasopharyngeal airway obstruction (r = 0.419; p = 0.001). The correlation was significant at roentgenographic ratings of minimal obstruction (p < 0.05) and gross obstruction (p < 0.001). Both the symptomatology score and the roentgenographic rating showed significant correlations with patient age (r = -0.657, p < 0.01 and r = -0.340, p < 0.01, respectively).

CONCLUSION

Clinical rating of adenoidal symptoms in children provides a reasonably reliable assessment of the presence and severity of nasopharyngeal airway obstruction. This technique of assessment is easy to use and is particularly valid when obstruction is either minimal or gross.

Sensitivity and specificity of nasal flexible fiberoptic endoscopy in the diagnosis of adenoid hypertrophy in children

OBJECTIVE

To evaluate nasal flexible fiberoptic endoscopy as a diagnostic test of adenoid hypertrophy in children with nasal obstruction.

METHODS

One hundred and thirty consecutive children aged 2-12 years were examined from May to October 2005. A questionnaire answered by parents or guardians was used to obtain a symptom score. Adenoid size was measured on radiographs of the nasal cavity using the Cohen and Konak method, and by nasal flexible fiberoptic endoscopy using the Wornald and Prescott classification. The criterion standard was the adenoid size demonstrated on radiograph.

RESULTS

The sensitivity of nasal flexible fiberoptic endoscopy was 92% (95% CI, 0.90-0.93), and specificity, 71% (95% CI, 0.70-0.72). The area under the ROC curve was 0.83 (95% CI, 0.76-0.90) at a p<0.001 level of significance. Kappa values were 0.94 (p<0.001) for interobserver agreement, 0.95 (p<0.001) for intraobserver agreement, and 0.54 (p<0.001) for agreement between tests.

CONCLUSIONS

Results suggest that nasal flexible fiberoptic endoscopy is a highly accurate diagnostic method. This examination can be performed easily in cooperative children; it is safe, objective and dynamic, and helps to establish diagnoses in difficult cases.

Nasal symptoms and signs in children suffering from asthma

OBJECTIVE

A link between the upper and lower airways has been convincingly demonstrated both in health and disease. To what extent the nose may be involved in children's asthma, has so far not been thoroughly investigated. In this study, we compared symptoms and signs from the upper airways in children with asthma and in children without to find out more about this.

METHODS

The study group included 27 asthmatic children, the control group 29 age and sex-matched healthy volunteers. The children were investigated by a senior ENT-specialist. Their parents completed questionnaires about symptoms and signs of upper airway disorders. Skin prick tests, total IgE, acoustic rhinometry, and an X-ray of the epipharynx were performed. The data from the groups were compared.

RESULTS

Nasal blockage, mouth breathing, day time sleepiness, apnoeas, itching, sneezing, and hearing impairment were more prevalent in asthmatics compared with controls (p<0.05). For nasal blockage the mean VAS-scores were 52.4 and 30.6 for asthmatics and controls, respectively. For daytime sleepiness the corresponding figures were 34.6 and 23.1. The adenoid-nasopharynx-index was larger, indicating reduced palatal airway in the former compared with the latter (p<0.05).

CONCLUSIONS

As the site of upper airway obstruction in asthmatic children appears to be the epipharynx, the adenoids may play a key-role.