Adenoid tissue rhinopharyngeal obstruction grading based on fiberendoscopic findings: a novel approach to therapeutic management

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Abstract

Objective: A grading into four classes of hypertrophied adenoid rhinopharyngeal obstructions in children on the basis of fiberendoscopic findings to outline an effective therapeutic program according to this classification. Methods: Ninety-eight children with chronic nasal obstruction and oral respiration were examined by anterior rhinoscopy, and fiberendoscopy. During the investigation, the fiberendoscopic images of the choanal openings were divided into four segments from the upper choanal border to the nasal floor. In view of clinical findings, 78 patients also underwent active anterior rhinomanometry. Results: In eight patients (8.2%), the fiberendoscopic imaging revealed that the adenoid tissue occupied only the upper segment in the rhinopharyngeal cavity (<25%). Therefore, choanal openings were free (first degree obstructions). In 20 patients (20.4%), the adenoid tissue was confined to the upper half (<50%) of the rhinopharyngeal cavity (second degree obstructions) and in 63 patients (64.3%) the tissue extended over the rhinopharynx (<75%) with obstruction of choanal openings and partial closure of tube ostium (third degree obstructions). Only in seven cases (7.14%), the obstruction was almost total. As a consequence, both the tube ostium and the lower choanal border could not be observed (fourth degree obstructions). Conclusions: In the first two classes of obstructions, characterized by moderate or discrete adenoid hypertrophy, adenoidectomy should not be performed. In these conditions, the causes of possible nasal obstructions are usually due to either dysmorphic, allergic or phlogistic pathologies. For the fourth degree adenoid obstructions, surgery is always recommended. The most important therapeutic problems occur in the third degree obstructions which include most patients who suffered from hypertrophied adenoids. Moreover, the therapeutic strategy can be conditioned not only by nasal respiratory difficulties but also by frequent concomitant complications such as otitis, sinusitis, sleep apnea, etc. These disorders may be caused by both nasal obstruction and/or phlogistic problems (adenoiditis).

Introduction

Sub-continuous and partial nasal obstruction is a very common condition in children. But it usually causes no significant respiratory difficulties. Therefore, the disorder is usually considered a minor illness which will disappear with puberty.

The obstruction may be due to anatomic, physiologic, and phlogistic factors. The first include incomplete development of nasal cavities, septal deviation, etc., the second and the third nasal respiratory cycle and rhino-sinusitis, respectively. However, the most ascertained recurrent cause is adenoid hypertrophy. This condition, characterized by marked proliferation of lymphoreticular tissue [1], is particularly frequent in 4–6-year-old children (Fig. 1).

In 25% of the cases, nasal obstruction brings about pathologic conditions of such an entity and duration as to produce a series of local phlogistic manifestations such as rhinosinusitis, otitis [2], [3], [4] and/or peripheral diseases including phlogistic and dis-reactive bronchopulmonary disorders. These ailments can influence the patient’s quality of life as well as interfere with their psycho-physical development.

Whether hypertrophic adenoids can cause sleep disorders as snoring and sleep apnoea [5], which, in turn, may generate serious diseases as cardiac, pulmonary affections [6] and even death in sleep in younger children, is still under debate. In fact, other disorders may be the cause of the pathologies often ascribed to sleep disorders [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18].

The influence of adenoid hypertrophy may be less serious on facial block malformations (malocclusion, ogival palate, etc.). These appear related to a series of hereditary skeleton modifications [19]. Nevertheless, it cannot be excluded that oral respiration, if lasting, might be an aggravating factor in the development of maxillary malformations. Therefore, chronic and severe nasal obstructions have to be carefully evaluated and treated as soon as possible.

Clinical diagnosis of adenoid hypertrophy by conventional methods is rather difficult owing to obstacles met in performing the objective examination of the rhinopharyngeal cavity (posterior rhinoscopy) in young children.

Radiological evaluation of the rhinopharynx conformation and contents is often difficult to carry out in infants. The value of this technique should be better studied. In fact, in many cases we found no direct correlation between the entity of the obstruction evidenced by X-ray and the functional ailment.

At present, transnasal fiberendoscopic examination of the nasopharyngeal cavity with a flexible endoscope appears to be a valid diagnostic method. This approach requires little collaboration from the patients. It is risk-free and allows a precise definition of site, nature and entity of obstruction [20], [21], [22], [23], [24]. Small diameter fiberendoscopes allow to examine very young subjects. As well known, full collaboration of a child can only be had at 4–5 years of age.

This technique has been used successfully over the last 10 years for diagnosis of nasal and rhinopharynx pathologies in pediatric age.

In our practice, we studied the obstructions caused by adenoid vegetation and we have drawn up a simple classification that may be very useful for a therapeutic program for pediatricians and otolaryngologists. In this article, we report the results of our experience on nasal obstructions due to adenoid tissue and try to define a reliable diagnostic and therapeutic strategy.

Section snippets

Material and methods

The study includes 98 children, 77 males and 21 females aged 3–14 years (mean age: 5.3 years) with chronic oral respiration and/or nasal obstruction often complicated by nasosinusal, and otologic infections or sleep disorders.

Patients with obstruction due to anatomic malformations (choanal atresias or diaphragms, septal deviations), were excluded. Anterior rhinoscopy was performed on all the patients preliminary.

After washing nasal cavities with a tepid sterile physiologic solution to remove

Anterior rhinoscopy

In 41 subjects (41.8%), the test was normal; a bilateral turbinate hypertrophy was evidenced in 57 subjects (58.2%) with mucous-purulent or clearly purulent exudates in the nasal cavities in 38.

Rhinopharynx fiberendoscopy

In eight patients (8.2%), the fiberendoscopic image appeared more or less normal, evidencing scarce adenoid tissue involvement in rhinopharynx. As a result, choanal opening was free.

In these subjects, the adenoid obstruction was classified as first degree. In this group, one subject was <4 years old and

Discussion

Many years of experience in this field have convinced us that endoscopy by means of a flexible fiberendoscope is the most reliable and easiest test to perform in pediatric age, compared with other methods usually chosen to evaluate anatomic conformation and rhinopharyngeal cavity contents (X-ray, posterior rhinoscopy, CT, telescopy) [20], [21], [22], [23].

Endoscopy is particularly required in the definition of the obstruction degree due to adenoid growth. In fact, we classified hypertrophied

Conclusions

The results of the present study indicate that fiberendoscopy of the rhinopharyngeal cavity appears to be a reliable technique for objective evaluation of adenoid disease. This technique allowed an obstruction grading which can be used as a guide in deciding therapeutic strategy of adenoid tissue nasal obstruction. The grading can be useful in selecting the cases of real obstruction due to adenoid hypertrophy and in deciding different approaches to treatment, follow-up and cure.

Classification

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