Comparative Evaluation of the Effects of Adenotonsillar Hypertrophy on Oral Health in Children

We aimed to investigate the oral health of children in terms of the presence of dental caries, periodontal health, halitosis, and dentofacial changes in patients who had adenotonsillar hypertrophy related to mouth breathing and compared these findings with nasal breathing healthy and adenotonsillectomy-operated children. The patient group comprised 40 mouth-breathing children who were diagnosed with adenotonsillar hypertrophy, while the control group consisted of 40 nasal breathing children who had no adenotonsillar hypertrophy. Forty children who had undergone an adenotonsillectomy operation at least 1 year prior to the study were included in the treatment group. Oral examinations of all children were conducted, and the parents were asked about medical and dental anamnesis, demographic parameters, toothbrushing and nutrition habits, oral health-related quality of life (OHRQoL), and symptoms of their children. Demographic parameters, toothbrushing and nutrition habits, and the presence of bad oral habits did not differ between groups (p > 0.05). Adenotonsillectomy is associated with a remarkable improvement in symptoms; however, some symptoms persist in a small number of children. The salivary flow rate, dmft/s, DMFT/S index, plaque, and gingival index scores did not differ between groups (p > 0.05). The patient group showed higher rates of halitosis when compared with the treatment and control groups (p < 0.001). Mouth breathing due to adenotonsillar hypertrophy caused various dentofacial changes and an increase in Class II division 1 malocclusion (p < 0.001). It was shown that adenotonsillar hypertrophy does not negatively affect OHRQoL, it could be a risk factor for dental caries, periodontal diseases, and halitosis, but by ensuring adequate oral health care, it is possible to maintain oral health in children with adenotonsillar hypertrophy. Also, it is recommended that orthodontic treatment should start as soon as possible if it is required. In this context, otorhinolaryngologists, pedodontists, and orthodontists should work as a team in the treatment of children with adenotonsillar hypertrophy.

Efficacy of Sublingual Administration of Dermatophagoides Farinae Drops for Treatment of Pediatric Allergic Rhinitis Accompanied by Adenoid Hypertrophy and Improvement of Immune Function

BACKGROUND The aim of this study was to determine the efficacy of sublingual administration of Dermatophagoides farinae drops for the treatment of allergic rhinitis (AR) accompanied by adenoid hypertrophy and the effect on immune function in children. MATERIAL AND METHODS Eosinophil counts in peripheral blood before and after treatment were determined; serum levels of immunoglobulin E (IgE), total IgE (T-IgE), immunoglobulin G4 (IgG4), interleukin-2 (IL-2), and interleukin-6 (IL-6) before and after treatment were detected by enzyme-linked immunosorbent assay. RESULTS The total effective rate in the study group was significantly higher than that in the control group (P<0.05). In both the study and control groups, symptom scores, medication scores, eosinophil counts in the peripheral blood, and serum levels of IgE, T-IgE, and IL-6 were significantly lower than those before treatment (P<0.05), while the serum levels of IgG4 and IL-2 were significantly higher than those before treatment (P<0.05). After treatment, symptom scores, medication scores, eosinophil counts in the peripheral blood, and serum levels of IgE, T-IgE, and IL-6 in the study group were significantly lower than those in the control group (P<0.05), while the serum levels of IgG4 and IL-2 were significantly higher in the study group than those in the control group (P<0.05). CONCLUSIONS Sublingual administration of D. farinae drops improved the clinical symptoms of pediatric AR caused by Dermatophagoides mites and improved the immune functions in children.

Clinical application of MRI-respiratory gating technology in the evaluation of children with obstructive sleep apnea hypopnea syndrome

The objective of the present study was to investigate the clinical application of magnetic resonance imaging (MRI)-respiratory gating technology for assessing illness severity in children with obstructive sleep apnea hypopnea syndrome (OSAHS).MRI-respiratory gating technology was used to scan the nasopharyngeal cavities of 51 children diagnosed with OSAHS during 6 respiratory phases. Correlations between the ratio of the area of the adenoid to the area of the nasopalatine pharyngeal cavity (Sa/Snp), with the main indexes of polysomnography (PSG), were analyzed. Receiver operator characteristic (ROC) curve and Kappa analysis were used to determine the diagnostic accuracy of Sa/Snp in pediatric OSAHS.The Sa/Snp was positively correlated with the apnea hypopnea index (AHI) (P < .001) and negatively correlated with the lowest oxygen saturation of blood during sleep (LaSO2) (P < .001). ROC analysis in the 6 respiratory phases showed that the area under the curve (AUC) of the Sa/Snp in the end-expiratory phase was the largest (0.992, P < .001), providing a threshold of 69.5% for the diagnosis of severe versus slight-moderate OSAHS in children. Consistency analysis with the AHI showed a diagnosis accordance rate of 96.0% in severe pediatric OSAHS and 96.2% in slight-moderate pediatric OSAHS (Kappa = 0.922, P < .001).Stenosis of the nasopalatine pharyngeal cavity in children with adenoidal hypertrophy was greatest at the end-expiration phase during sleep. The end-expiratory Sa/Snp obtained by a combination of MRI and respiratory gating technology has potential as an important imaging index for diagnosing and evaluating severity in pediatric OSAHS.

[The morphofunctional prerequisites for the development of exudative otitis media in the children presenting with chronic adenoiditis]

The objective of the present study was to elucidate the structural and functional mechanisms underlying disturbances of the protective nasolaryngeal barrier with special reference to the following histological and immunohistochemical characteristics of the pharyngeal tonsils (CD4, CD20, CD68, IgA, P53, BCL2, Ki67, TGF-beta) in the children aged 3-6 years and presenting with complicated (n=20) or uncomplicated (n=20) chronic adenoiditis (CA). It was shown that adenoids of the patients with complicated chronic adenoiditis less frequently exhibit markers of active inflammation, such as hyperemia, intraepithelial infiltration, and hemosiderophages. Also, they have the smaller mean area of lymphoid follicles and the number of functional intrafollicular macrophages suggesting impaired immunological reactivity. Lymphoid follicles of the pharyngeal tonsils in the children with uncomplicated chronic adenoiditis show up enhanced density of B-lymphocytes (CD20) and CD69-positive cells which may suggest functional tension. However, density of IgA-producing lymphocytes responsible for the protection of nasolaryngeal mucosa is identical in the patients with complicated and uncomplicated chronic adenoiditis. Taken together with the decreased number of T-helpers (CG4), this finding indicates the compromised immunological response in the children with this pathology. It is concluded that the structural characteristics of pharyngeal tonsils revealed in the present study may provide a basis for the disturbances of congenital and adaptive immunity; moreover, they can serve as the predictors of complications of chronic adenoiditis.

[The effectiveness of rinorin introduced in the combined treatment of chronic adenoiditis in the children]

This study was designed to analyse the effectiveness of combined treatment of chronic adenoiditis in the children with the use of rinorin (Orion, Finland) in comparison with the traditional methods for the management of this condition either combined with irrigation therapy or without it. The results of the study indicate that the application of rinorin enhance the effectiveness of the treatment due to the substantial reduction of the manifestation of clinical symptoms and the frequency of relapses. The patients describe rinorin as a modern convenient-to-use preparation superior to the traditional medicines for the treatment of adenoiditis which improved medication compliance.

Paraoxonase and arylesterase activity and total oxidative/anti-oxidative status in patients with chronic adenotonsillitis

OBJECTIVES

The aim of this study was to investigate serum paraoxonase, arylesterase activities along with determination of oxidative status via measurement of total oxidant status (TOS), total antioxidant status (TAS) and oxidative stress index (OSI) in children with recurrent adenotonsillitis during pre- and post-adenotonsillectomy period and to compare results with data from healthy subjects.

METHODS

We performed a prospective controlled trial on adenoidectomy and/or tonsillectomy patients. A total of 47 subjects, including 22 patients with recurrent adenotonsillitis and 25 healthy controls were enrolled in this study. Peripheral venous blood samples were taken from patients before adenotonsillectomy and a second sample was obtained in first month postoperatively. In the control group, blood samples from healthy volunteers were collected for one time only. Serum paraoxonase, arylesterase activities, TOS, TAS and OSI levels were measured.

RESULTS

Paraoxonase, arylesterase activity, TAS and TOS levels were significantly higher in preoperative group compared to control group (P<0.001, P=0.003, 0.003 and 0.005, respectively). However, OSI level was similar in preoperative group compared to control group (P=0.25). In the post-operative group, paraoxonase, arylesterase activities, TAS and OSI levels were lower as compared to preoperative group but differences were statistically insignificant (P=0.483, 0.265, 0.149 and 0.090, respectively). TOS level in post-operative group was significantly lower than the preoperative group (P<0.001). In the post-operative group, paraoxonase and arylesterase activities were significantly higher as compared to control group (P=0.004 and 0.02, respectively). TOS and OSI levels were significantly lower in post-operative group compared to control group (P=0.001 and 0.02, respectively). However, TAS was similar between post-operative and control groups (P=0.464).

CONCLUSIONS

Based on data obtained from this study, we may state that paraoxonase, arylesterase activities with TAS, TOS and OSI levels of patients with chronic adenotonsillitis shows alterations due to oxidant/antioxidant imbalance induced by frequent infections.

[Absence of positional effect in children with moderate-severe obstructive sleep apnea syndrome]

BACKGROUND

Sleep apnea syndrome (SAS] is common in both adults and children (amongst whom it is estimated at 2-3%). This syndrome significantly affects the child's daily activities and development. Research in adults has demonstrated a direct relationship between sleeping supine and the severity of sleep apnea syndrome. Very few studies were conducted among children and the findings were controversial.

AIM

The goal of this study was to continue examining and establishing the relationship between children's sleep position and the severity of sleep apnea syndrome.

METHODS

The study group consisted of 25 children with cLinically suspected obstructive sleep apnea [OSA), referred to the Technion's Sleep Lab for confirmation of this diagnosis. The study course included nocturnal recording of the children and closely monitoring their sleep position. Data analysis included a comparison of the various data regarding the severity of the children's respiratory disturbance, at each stage of sleep and in each sleeping position separately. Analysis of the results was performed using the paired T test.

RESULTS

Sixteen boys and 9 girls aged 5.5 years (range 2-12 years) with various severity of OSA, most of them with moderate-severe degree of sleep apnea, [average respiratory disturbance index of 14.7 +/- 12.3/h) were studied. In most children the recording consisted of all sleep postures, but no statistically significant relationship was found between the various sleeping positions and the severity of OSA, neither in REM sleep nor in NREM sleep.

CONCLUSIONS

We believe that the absence of positional effect in children with moderate-severe obstructive sleep apnea syndrome results from a different mechanism and site of obstruction. While in adults the Location of obstruction is mostly retroglossal or retropalatal, in children it is usually at the levels of tonsils and adenoids.

[A clinical study of the acoustic rhinometry in nasal and nasopharyngeal airway of children with adenoid vegetation]

OBJECTIVE

To investigate the significance of the AR measurement in diagnosis of adenoid vegetation and evaluation of the efficiency of adenoidectomy.

METHOD

Twenty-three healthy children and 27 children with adenoid vegetation were studied by ECCOVISION acoustic rhinometry (AR).

RESULTS

Tthe NAR of the in-patients before adenoidectomy [(0.44 +/- 0.17) kPa x L(-1) x min(-1)] were significantly (P < 0.05) greater than that of the healthy children [(0.33 +/- 0.17) kPa x L(-1) x min(-1)],while the total NPV [(14.74 +/- 5.01) cm3] were significantly (P < 0.01) smaller [(19.77 +/- 5.77) cm3]. The NAR of the in-patients after adenoidectomy [(0.36 +/- 0.21) kPa x L(-1) x min(-1)] were significantly (P < 0.05) smaller than that before adenoidectomy. The total NPV [(17.93 +/- 4.56) cm3] were significantly (P < 0.05) greater than that before adenoidectomy.

CONCLUSION

AR has significant importance in diagnosis of adenoid vegetation and it is also an efficient method to evaluate the efficiency of adenoidectomy.

Atypical streptococcal infection of gingiva associated with chronic mouth breathing

Streptococcal infections of oral tissues are mainly seen in young children who experience a variety of upper respiratory tract infections. The disease is characterized by fever, lymphadenopathy, and ulcers on the gingiva, lips, and tonsils. This case report presents an atypical streptococcal infection of the gingiva in an 18-year-old man. The patient was referred to the periodontology department complaining of a 2-month history of gingival enlargement. He had persistent fever (39.5 degrees C) and general malaise for 2 weeks. Intraoral examination revealed extremely inflamed and enlarged gingiva with spontaneous bleeding and suppuration. Based on the otolaryngologic consultation and the hematologic, immunologic, and microbiologic tests, the final diagnosis was an atypical streptococcal gingivitis with chronic adenoid-related mouth breathing and oral hygiene neglect as contributing factors. Treatment consisted of a broad-spectrum antibiotic regimen, supragingival and subgingival debridement, adenoidectomy, and scaling and root planing. A good response to nonsurgical therapy was achieved despite poor patient compliance, and no recurrence of gingival enlargement was observed after 1 year. Streptococcal gingivitis should be included in the differential diagnosis of suppurative gingival enlargements. Furthermore, chronic mouth breathing may initiate and/or contribute to this disease.

Suction diathermy for adenoidectomy: complications and risk of recurrence

OBJECTIVES

When introduced, suction coagulation was initially utilised for haemorrhage control following curettage of the adenoid pad. More recently the whole procedure has been performed using the technique. This study aims to report post-operative haemorrhage rates and risk of recurrence in adenoidectomy performed solely by suction diathermy in children.

METHODS

A retrospective study of 1411 consecutive paediatric patients. Surgery was performed using suction diathermy. No patients were excluded. All patients were followed up.

RESULTS

There were no cases of post-operative haemorrhage. 1.7% of patients remained symptomatic and underwent revision adenoidectomy. None required a third procedure.

CONCLUSIONS

Re-growth of adenoid tissue may occur despite visualisation of the nasopharynx at the time of surgery. The incidence of re-growth is similar to that reported in patients undergoing conventional adenoidectomy by curettage. Post-operative haemorrhage was not encountered in children having adenoidectomy by suction diathermy. The authors suggest suction diathermy as the most appropriate method for adenoidectomy in children.

The role of topical nasal steroids in the treatment of children with otitis media with effusion and/or adenoid hypertrophy

OBJECTIVES

Topical steroid treatment can be a powerful alternative to surgery in controlling adenoid hypertrophy and otitis media with effusion (OME).

METHODS

A prospective, controlled, randomized, clinical study in an academic tertiary care center. A total of 122 children (3-15-year-old) on the waiting list for an adenoidectomy and/or ventilation tube placement were enrolled into the study and control groups. The study group (67 patients with adenoid hypertrophy, 34 of them with otitis media with effusion) received intranasal mometasone furoate monohydrate 100 mcg/day, and the control group (55 patients with adenoid hypertrophy, 29 of them with otitis media with effusion) was followed up without any treatment. All patients were evaluated at 0 and 6 weeks. The assessment of each patient included history, a symptom questionnaire, a skin prick test, a tympanogram, if possible a pure tone audiogram, and otoscopic and endoscopic examinations. The size of adenoid tissue was graded as a percentage according to obliteration of the choanae. The adenoid/choana ratio (A/C) was recorded for each patient. Symptoms were scored as 0 (absent), 1 (intermittent/periodic), or 2 (continuous). The data were analyzed with the "Statistical Package for the Social Sciences" (SPSS 9.0) using the appropriate nonparametric tests for nominal and ordinal data.

RESULTS

Resolution of otitis media with effusion in the study group (42.2%) was significantly higher than that in the control group (14.5%) (p<0.001). Forty-five patients (67.2%) with adenoid hypertrophy in the study group showed a significant decrease in adenoid size according to the endoscopic evaluation compared to the control group (p<0.001). A significant improvement in obstructive symptoms was seen in the study group (p<0.001). The endoscopically measured adenoid/choana ratio and degree of obstructive symptoms showed a significant correlation (r=0.838 p<0.001, r=0.879 p<0.001, r=0.838 p<0.001, r=0.879 p<0.001). The adenoid/choana ratio improved significantly in atopic patients in the study group (p<0.05), whereas in atopic patients in the control group there was no change (p=0.221).

CONCLUSION

Nasal mometasone furoate monohydrate treatment can significantly reduce adenoid hypertrophy and eliminate obstructive symptoms. It is a useful alternative to surgery, at least in the short term, for otitis media with effusion.

[Treatment of children with chronic adenoiditis in different coagulation status]

Chronic adenoiditis in children is a frequent surgical pathology. To avoid hemorrhagic complications in adenotomy, it is necessary to exclude concomitant hemostatic pathology. Forty-three children were examined before operation. Primarily, vascular-thrombocytic disorders (dysaggregation thrombocytopathies) were found. Chronic focal infection plays an essential role in pathogenesis of systemic disorders in chronic adenoiditis including those provoking coagulatory disorders. A program of a target pre- and intraoperative hemostatic therapy is proposed which has demonstrated its high efficacy.

How do children with adenoid hypertrophy smell and taste? Clinical assessment of olfactory function pre- and post-adenoidectomy

OBJECTIVE

To assess the ability to smell and appreciate food in children with adenoid hypertrophy pre and post-adenoidectomy.

METHODS

A total of 35 children with adenoid hypertrophy admitted for adenoidectomy (aged 5-9.3 years, mean age 5.9 years) were tested preoperatively. In a follow up appointment 3 months postoperatively, 28 of them returned and were tested again. The control group consisted of 30 healthy children (aged 5-10.2 years, mean age 6.1 years). Orthonasal olfactory function was assessed psychophysically using "Sniffin sticks" 12 item odor identification test. Retronasal olfaction was assessed using a collection of 12 grocery available powders applied to the oral cavity.

RESULTS

Both orthonasal and retronasal olfactory function of the study group preoperatively were significantly lower in comparison with the results of the control group (p<0.0001). The difference in retronasal olfaction between groups was significantly higher in comparison with the difference in orthonasal odor identification (p=0.048). There is a strong correlation between adenoid hypertrophy grade and retronasal testing results (t=-5.461, p<0.0001), but not with the orthonasal results (t=-1.677, p=0.9). Significant improvement of orthonasal and retronasal olfaction was observed in the follow-up appointment (p<0.0001). Relative increase postoperatively was higher for the retronasal olfaction compared to orthonasal olfaction (p=0.0029).

CONCLUSIONS

Children with adenoid hypertrophy have a reduced ability to smell, with retronasal olfactory function being more affected. Surgery had a greater impact on retronasal olfaction.

[Aspects of biological activity of T and NK lymphocytes in children with adenoid hypertrophy and concomitant otitis media with effusion]

The aim of this study was to inquire whether it has got an influence on the number and activity of peripheral blood T and NK cells.

MATERIAL AND METHODS

The examined group consisted of 51 children with adenoid hypertrophy. The first group consisted of 17 children with only one episode of otitis media with effusion (ome). The second group consisted of 14 children with more than 4 episodes of ome and the third group consisted of 20 children with adenoid hypertrophy without ome. Evaluation of percentage of CD4+, CD8+ and NK subsets with co-expression of CD69, HLA-DR molecules in peripheral blood was performed by flow cytometry method. In examined groups with ome the decrease of CD4 number was compensated by increase of the number of NK and CD19 cells. In these groups the increase of CD69 and HLA-DR expression on the examined subsets was observed. The results suggest that in recurrent otitis media with effusion may be one of the factors causing T lymphocytes deficiency. Obtained results might be one of the criteria of using adenoidectomy.

Acoustic estimation of voice when incorrect resonance function of the nose takes place

Phonation is a sensitive indicator of palatopharyngeal obstruction and its physiological force. The aim of the study was to evaluate the influence of nasality on the voice quality. The study was carried out on 125 patients divided into three subgroups. The first was created of the patients treated due to allergic rhinitis, the second was composed of patients with adenoids, the third one consisted of patients with cleft palate. The following acoustic parameters were assessed: Fo, Jitter, Shimmer, Fo-tremor, NNE, HNR, SNR. The results of the experimental and control groups were analysed statistically with Student's t-test. The performed acoustic tests of voice confirmed statistically significant elevation of Fo, HNR and SNR frequency in the studied group as compared with the control group.

Anatomy of oral respiration: morphology of the oral cavity and pharynx

The anatomical states of the oral cavity and pharynx during mouth breathing in children with adenoid hypertrophy and in adults confirmed the speculation that mouth breathing is disadvantageous compared with nose breathing. In addition, comparison of the anatomical state between wakefulness and sleep in normal adults showed slight depression of the tongue root and slight narrowing of the oropharynx and hypopharynx during sleep. Obstructive sleep-disordered breathing occurs due to a variety of factors, such as paranasal sinus disease, tonsil and adenoid hypertrophy, hypertrophy and morphological abnormalities of the soft palate and palatine uvula, low-set soft palate, micrognathia, macroglossia, obesity and tongue root depression. Narrowing or obstruction of the middle pharynx and hypopharynx is more marked in patients with obstructive sleep-disordered breathing than in normal people and is especially marked during sleep. Therefore, morphological (i.e. anatomical) changes during mouth breathing may provide useful information for evaluating the pathology of snoring and sleep apnea.

[Functional characteristics of the central nervous system in children with pharyngeal tonsil lesions]

The analysis of the clinical and neurophysiological evidence obtained upon examination of children with adenoids has shown that pharyngeal tonsil affection is often accompanied by neurological disorders. Perinatal pathology does not influence significantly EEG alterations. Surgical treatment leads to positive changes of both general condition and neurophysiological indices, but part of the children with perinatal encephalopathy worsen because of aggravation of brain problems and appearance of epiphenomena. It is thought necessary to consider perinatal history when planning treatment policy for children with affection of the pharyngeal tonsil.

Waldeyer's ring and otitis media: the nasopharyngeal tonsil and otitis media

This overview of the relationship between the nasopharyngeal tonsil and otitis media will review three important concepts: (1) Adenoid inflammation leads to inflammatory obstruction of the Eustachian tube; (2) early colonization of the adenoid with the three major bacterial pathogens of otitis media is the most important factor in the early pathogenesis of otitis media; (3) the local immune system in the adenoid particularly specific secretory IgA directed against both viruses and bacterial pathogens are probably genetically controlled and represent the immunological factor in protecting the host against invasion of these agents in the Eustachian tube and middle ear. This overview of the relationship between the adenoid and the development of otitis media emphasizes that nasopharyngeal colonization with the three major middle ear pathogens is among the most important risk factors in the pathogenesis of otitis media. Inasmuch as these pathogens normally reside in the nasopharynges of most healthy children, the factors which trigger development of otitis media need to be carefully evaluated. Among these two triggers are viral infections and upper respiratory tract allergy.

[The morphofunctional characteristics of the palatine and pharyngeal tonsils in children with chronic tonsillitis and adenoids]

22 palatine and 10 pharyngeal tonsils of 20 children, 4 to 15 years of age, with chronic tonsillitis and adenoids were studied histologically and immunohistochemically. The material was obtained at tonsillectomy, adenotomy and adenotonsillectomy. The expression of LCA, CD20, CD45 RO, CD45 RA, CD68 and HLA DR-antigen was determined immunohistochemically. Functional heterogeneity of the whole lymphoid population in the tonsil tissue is structured by dividing lymphoid tissue into T- and B-regions. However, this subdivision is relative. Interpenetration of T- and B-cells into structurally determined functional zones reflects cooperative cell relations in the immune response the obligatory participant of which are non-lymphoid cells of the microenvironment: antigen-representing macrophages of the follicle germinative centres and reticular epitheliocytes in the regions of lymphoepithelial symbiosis. HLA-DR-antigen expression of the reticulum epithelium cells and the presence of activated T-lymphocytes in the lymphoepithelial symbiosis zones allow one to consider these zones as an immunoregulatory compartment of the tonsils.

[Emergency amygdalectomy and adenoidectomy in children with upper respiratory obstruction]

Hypertrophy of the adenoids and tonsils in children sometimes produces life-threatening upper airway obstruction that requires emergency endotracheal intubation followed by adenotonsillectomy. Four patients, age range 18 months to 3 years, who required emergency treatment in the Pediatric Intensive Care Unit were studied for acute respiratory distress syndrome with cyanosis and use of accessory respiratory muscles. Two had orotracheal intubation to stabilize their cardiorespiratory situation before surgery. One presented cardiomegaly and secondary pulmonary arterial hypertension. The third remained stable and adequately ventilated with naso-hypopharyngeal ventilation. The fourth remained in intensive care for its clinical situation, but did not require exceptional measures.

Pediatric adenotonsillectomy for obstructive sleep apnea

Forty-four children who underwent adenotonsillectomy for obstructive sleep apnea (OSA) were studied. The diagnosis was confirmed polysomnographically. Patients with other medical problems or complications of OSA were excluded. The overall complication rate was 32%. Significant airway complications occurred in 16%. Factors associated with development of statistically significant airway complications were acute airway compromise, age < 3 years, thin body habitus, and both oxygen (O2) desaturation and carbon dioxide (CO2) retention seen polysomnographically. Although many OSA patients can safely have outpatient adenotonsillectomy, perioperative monitoring of patients with these risk factors is needed.

Relapsing infective-phlogistic pathology of Waldeyer's ring and its relationship with secretory otitis media

In our previous studies on the physiopathology of the rhinopharyngeal-tubal unit, we found and reported an unmistakable correspondence between rhinopathy and otitis media. However, we have often asked ourselves how and why severe cases of otitis media were often present in subjects without an evident obstructive naso-tubal pathology. With research that we have already published, we have been able to reveal how alteration of the ventilatory function of the tube is not the only factor that provokes affections of the middle ear. In our opinion, the phlogistic event is the main cause of otitis. Our conviction has recently been confirmed and strengthened by new research to which we wish to refer. A total of 92% of young patients and 65% of adult patients who underwent tonsillectomy in our Institute suffered from otitis media. These results emphasize that it is the infection, with the concomitant inflammation, that alters the function of the tube. Altered functions of drainage and defense cause affections of the middle ear in conditions of non altered ventilation and thus they are not documentable with the routine instrumental tests.

Sleep apnea associated with congenital diseases and moderate hypertrophy of tonsils

In this paper, we studied 3 children with moderate hypertrophy of the palatine tonsils and adenoids and serious congenital diseases. The first patient was a 4-year-old girl with Fallot's tetralogy, the second was a 6-year-old girl with Goldenhar syndrome and ventricular septal defect, aortic stenosis and patent ductus arteriosus, and the third was a 3-year-old boy with cerebral palsy and epilepsy. We examined obstructive apnea during sleep in these patients using all-night polysomnogram or apnomonitor before surgical therapy. After tonsillectomy or adeno-tonsillectomy we confirmed significant improvement of clinical symptoms and obstructive sleep apnea in these patients by all-night polysomnograms or apnomonitor.

Histopathological comparison between tonsil and adenoid responses to allergy

In a previous study of adenoid tissue from allergic and non-allergic patients, we concluded that in allergic children edema of the "chorium" was present in 80.4% and that treatment with antihistamine drugs may reduce this edema. The purpose of the present study was to compare the histopathology of the palatine tonsil and adenoid from allergic patients. Tissue samples were obtained from 153 patients (56 tonsils and 97 adenoids from allergic children). We analysed the intensity of the edema and its cellular components in the chorium of palatine tonsils and adenoids. The frequently seen edema in the adenoids was significantly different from that in the tonsils. The squamous epithelium of the tonsils was thicker and bad stronger intercellular junctions than the columnar epithelium of the adenoids. This fact probably makes difficult the contact of the antigen with the chorium.

Pediatric endoscopic nasal and sinus surgery

A total of 83 children and teenagers underwent endoscopic nasal and sinus surgery. Six patients had surgery for choanal atresia (4) and adenoid hypertrophy (2) and will only be briefly mentioned. Seventy-seven children and teenagers underwent endoscopic sinus surgery for acute and chronic sinusitis, choanal polyposis, and nasal polyposis with a minimum 2-year follow-up. One hundred thirty-three ethmoidectomies, 37 sphenoidotomies, and 119 maxillary antrostomies were performed. Subjective evaluation of the sinus surgery patients indicated that 38% of patients were cured and 55% improved during an average of 3.5 years of follow-up. The number cured and number improved are lower and higher, respectively, than in other reports of results because of the longer follow-up and patient selection. In addition, objective data were obtained on 34 patients with a second- or third-look procedure 2 weeks to 2 months after surgery. These examinations found significant granulation tissue, and almost 50% of patients had at least one maxillary ostia closed. Long-term objective results, however, are not available to determine whether the ostia remained closed. Problems with healing in children's endoscopic sinus surgery are unpredictable compared those in adult surgery because postoperative debridement and examination are often difficult to perform, thus allowing tissue to heal without control. In this series, other factors such as the increased risks of cystic fibrosis, allergy, and immunodeficiency were also more prevalent and compromised healing.(ABSTRACT TRUNCATED AT 250 WORDS)

Juvenile myasthenia gravis with predominant facial weakness in a 7-year-old boy

Myasthenia gravis is the most prevalent of the diseases of the neuromuscular junction in children. The most common clinical finding is ptosis, although ophthalmoplegia and facial weakness are commonly present. This paper reports juvenile myasthenia gravis in a 7-year-old boy with predominant facial muscle weakness without ophthalmoplegia and ptosis. This was detected post-operatively after adenotonsillectomy, as there was severe respiratory distress. Prompt diagnosis and treatment was life saving. A CT scan of the chest revealed thymoma. After the surgical removal of the thymoma, the child has been followed up for a year and is asymptomatic.

Functional-anatomic correlation of eustachian tube obstruction related to the adenoid in a patient with otitis media with effusion: a case report

Prospective randomized clinical trials have shown modest but significant reductions in morbidity from otitis media with effusion following adenoidectomy. However, the precise role of the adenoid in the pathogenesis of otitis media with effusion remains unknown. Some authors have hypothesized that the adenoid may compress or obstruct the Eustachian tube lumen, thereby causing middle ear underpressures and subsequent effusion formation. Functional-anatomic correlation for this theory is lacking. Herein, we present a single case of a pediatric patient with otitis media with effusion and manometrically proven active and passive Eustachian tube obstruction which was relieved by adenoidectomy. Photographic anatomic correlation is presented.

Upper airway collapsibility in children with obstructive sleep apnea syndrome

In adults, the critical nasal pressure (Pcrit) at which the upper airway collapses is higher in patients with the obstructive sleep apnea syndrome (OSAS) than in those with primary snoring. Pediatric OSAS differs clinically from adult OSAS. We therefore compared Pcrit between prepubertal children with OSAS and primary snoring. Pcrit was determined by correlating the maximal inspiratory airflow with the level of positive or negative nasal pressure applied via a nasal mask. As in adults, we found that the maximal inspiratory airflow varied in proportion to the upstream (nasal) rather than the downstream (esophageal) pressure changes. Pcrit was 1 +/- 3 cmH2O in OSAS compared with -20 +/- 9 cmH2O in primary snorers (P < 0.002). In three OSAS patients reevaluated after tonsillectomy and adenoidectomy, Pcrit declined to -7.2 +/- 4.0 cmH2O. We conclude that the pediatric airway behaved as predicted by the Starling resistor model and that Pcrit, a measure of airway collapsibility, correlated with the degree of upper airway obstruction and was reduced postoperatively, consistent with increased upper airway stability.

The assessment of hypertrophy of nasopharyngeal tonsil by acoustical methods

The possibilities for using acoustical analysis as a noninvasive measure of the degree of obstruction created by an enlarged pharyngeal tonsil (adenoid) are discussed. The method capitalizes on the relationship which exists between a specific obstruction of the respiratory tract and the resulting respiratory sound. Results indicate that as the adenoid increases in size relative to the size of the nasopharynx, the dominant components of the respiratory sound spectrum shift towards a higher frequency range. Furthermore, the correlation found between the assessments of the obstruction due to various sizes of the adenoid by radiological methods and acoustical analyses supports the theoretical prediction that information on the size of the constriction is carried by the respiratory sound. Therefore, careful analyses of the acoustic patterns in the respiratory sound can assist in identifying constrictions and monitoring the constriction changes in the upper respiratory tract.

Interactive influence of a pharyngeal flap and an adenoid on maxillofacial growth in cleft lip and palate patients

The aim was to evaluate whether a large adenoid, which aids velopharyngeal function, influences facial growth and if a pharyngeal flap reinforces the effect. Forty cleft palate patients were divided into two groups: adenoid and nonadenoid. Twenty of the patients had a pharyngeal flap operation. All the patients had three cephalograms taken at the same ages over a period of 5 years. At an average age of 4.7 years, i.e., one year before any pharyngoplasty, the mandibular inclination was larger in the adenoid group. This inferioposterior mandibular position was aggravated when a flap was added and with age. The present study suggests that the nasopharyngeal space, which is indicative of nasal airway patency, is influenced by a pharyngeal flap as well as an adenoid which, in turn, influences facial growth direction in the cleft palate population. Airway variables ought to be taken into consideration when the growth effect of cleft palate treatment is evaluated.

Adenoidectomy and otitis media

Adenoid enlargement has traditionally been considered a factor in otitis media; adenoid size, however, does not appear to be correlated with otitis media occurrence. Presence of pathogenic bacteria in the adenoids of children with otitis media has been shown, and adenoidectomy appears to affect the middle ear primarily by removal of the source of infection in the nasopharynx. Three recent randomized, controlled studies showed the efficacy of adenoidectomy in the treatment of chronic secretory otitis media. In one study comparing no treatment, adenoidectomy, and adenotonsillectomy, a significant benefit was seen with adenoidectomy that was not enhanced by tonsillectomy. Another study that compared adenoidectomy, tympanostomy tubes, and a combination of the two showed a significant reduction in effusion time and less surgical retreatment over 2 years in the two adenoidectomy groups. The third study demonstrated the effect of adenoidectomy in children with recurrent chronic otitis media with effusion after failure of tympanostomy tube insertion. All three studies showed that the effect of adenoidectomy was independent of adenoid size. This review discusses current concepts of adenoid physiology and pathology, the major adenoidectomy studies, and indications for the procedure.

Sensitivity and specificity of diagnostic tests for impaired nasal respiration

Diagnostic tests are imperfect and vary in their sensitivity and specificity. The degree of imprecision may be calculated to yield probability estimates of accuracy for both the positive and negative predictions of tests under various conditions. Such information enables clinicians to decide whether to accept or reject test results or the tests themselves. Two pilot studies are reported to establish the diagnostic potential of cephalometric measurements and nasal resistance values for the identification of upper airway impairment. A linear estimate of adenoid size and an area index of adenoid encroachment in the nasopharynx were evaluated as diagnostic tests for increased nasal resistance. The sensitivity of the tests was 31.8% and 18.2%, while specificity was calculated at 83.3% and 66.6%, respectively. In the second study, nasal resistance was evaluated as a test to identify persons whose respiratory mode was equal to or less than 75% nasal airflow. At a NRz value of 5.0 cm H2O per liter per second, the sensitivity of this test was 41.2% and the specificity was 84.0%; with the critical value of NRz at 3.5 H2O per liter per second, the sensitivity was 64.7% and the specificity was reduced to 60.0%. The results suggest that these tests are too imprecise for the reliable identification of either those who might benefit from treatment or those for whom treatment is unlikely to yield benefits.

Ciliary activity on adenoids of patients with otitis media with effusion

Ciliary activity of the adenoidal surface in patients with otitis media with effusion (OME) was evaluated by a photoelectric method. Three groups of patients were compared: a non-OME group whose members had experienced no episode of OME; a middle ear effusion (MEE)-negative OME group whose members had an episode of recurrent OME but no MEE during the month preceding the operation; and an MEE-positive OME group whose members were experiencing an episode of recurrent OME with MEEs when tissue was taken for examination. To serve as a comparison, the ciliary activity in the central pharynx of normal guinea pigs was evaluated using the same technique. The ciliary activity in all patients was significantly lower than that in normal guinea pigs. No significant difference in ciliary activity was apparent between the non-OME group and the MEE-negative OME group. However, both were significantly higher than the ciliary activity of the MEE-positive OME patients. The following findings are drawn from our data: ciliary activity on the surface of hypertrophic adenoids is depressed, and patients with OME have reduced ciliary activity compared with those who have no otitis media or those who have otitis media without effusion.

Reversibility of reduced ciliary activity on adenoids of patients with otitis media with effusion following culture

We have studied the ciliary activity of the pharyngeal epithelium on adenoids obtained from patients with recurrent otitis media with effusion to assess indirectly the ciliary activity in the Eustachian tube. In conclusion, the following has been speculated from the present study: (1) middle ear effusions depress the ciliary activity; and (2) recovery of the reduced ciliary activity can be achieved in an effusion-free environment inasmuch as the ciliated cells have not undergone organic changes. Prompt elimination of the effusion, if present, is of critical importance for the recuperation of tubotympanic drainage, because a positive therapeutic effect resulting from elimination of the effusion can only be possible in early phase of the disease, before irreversible morphological lesions have occurred.

Etiological role of adenoids upon otitis media with effusion

To clarify the etiological role of adenoids in OME, the effects of adenoidectomy on Eustachian tube function and nasal sinusitis were examined. Adenoids were found to exert no influence upon tubal opening pressure, nor patency of the Eustachian tube in a static condition. Active function of the tube during swallowing, however, was improved significantly by the adenoidectomy. In addition, adenoidectomy improved nasal sinusitis, and in such patients, their active tubal function was satisfactory. From these results, adenoidectomy was considered to cure OME, partly via improvement of the pathological condition of the nasopharynx represented by nasal sinusitis.

Mucociliary function and nasal resistance evaluation before and after adenoidectomy

Thirty-four children with clinically and radiologically confirmed adenoid hypertrophy underwent otoscopy, impedance tests, active anterior rhinomanometry and nasal mucociliary clearance evaluation before and 6 months after adenoidectomy. Mucociliary clearance velocity increased significantly while binasal resistances decreased after surgery. The authors conclude that mucociliary evaluation and objective measurements of nasal resistances should be added to impedance tests as indicators to adenoidectomy.

Changes in velopharyngeal valving with age

Variability of velopharyngeal valving between subjects has been a well established fact since the advent of new techniques for the direct viewing of the velopharyngeal sphincter during speech. Multi-view videofluoroscopy and nasopharyngoscopy have shown that there is variable contribution to velopharyngeal closure from the velum, the lateral pharyngeal walls, and posterior pharyngeal wall from person to person. However, to date, there has been no evidence to show if velopharyngeal closure remains unchanged within individuals throughout life. The purpose of this investigation was to observe velopharyngeal closure in normal subjects and subjects with cleft palate from prepubertal to postpubertal life (i.e. pre-adenoid involution to post-adenoid involution). Changes in velopharyngeal closure patterns were observed in 60% of the normals studied and 30% of the cleft subjects.

Adenoid involution and developing hypernasality in cleft palate

Information about the adenoid mass is reviewed, and the phenomenon of gradual development of hypernasality as a result of adenoidal involution is described in two patients selected from a sample of 122 with repaired cleft palate. Three types of radiographically determined closure patterns of the velum against the adenoid pad are presented. Our clinical experience suggests that the results of aerodynamic studies, completed on a longitudinal basis, may identify patients who are at risk in maintaining normal resonance balance one year or more in advance of perceptual or radiographic evidence of velopharyngeal incompetency.

Pulmonary function studies in adenoid hypertrophy

Tests of pulmonary function were performed on children with severe adenoid hypertrophy, before and one month after adenoidectomy. Five types of subjects were selected: (1) normal; (2) cases with isolated increase of residual volume (RV); (3) supernormal type with increased RV; (4) obstructive type of ventilatory defect, and (5) restrictive type of ventilatory defect. Following adenoidectomy there is an objective evidence of improved pulmonary function. The data suggest that 65.7% of clinically normal children with adenoid hypertrophy show pulmonary function abnormalities.

[On the physiopathologic reactions of pharyngeal tonsil from the clinical standpoint (author's transl)]

On the basis of personal experiences the authors isolate two forms of pharyngeal tonsil hypertrophy: a physiological and a pathological one. The first one corresponds to the requirements of the organism which is not completely mature immunologically, it may be quite considerable but causes no disturbances in breathing through the nose or in the function of Eustachian tubes. The pathological hypertrophy of pharyngeal tonsil is due to a parenchymal inflammation caused by viruses with a typical pathogenesis. The authors describe six diagnostic criterias of the pathological hypertrophy of pharyngeal tonsils. Using these criter as they analysed 100 cases of adenotomy from the year 1969 and they have found that in only 38 cases the operation was done for pathological hypertrophy while in 62 cases hypertrophy was physiologic. Adentomy gives good results in cases of pathological hypertrophy but in cases of physiologic hypertrophy it may cause adverse results.