Montelukast combined with intranasal mometasone furoate versus intranasal mometasone furoate; a comparative study in treatment of adenoid hypertrophy

Comparative efficacy of intranasal mometasone furoate monotherapy or combination therapy with montelukast in pediatric adenoid hypertrophy: A systematic review and meta-analysis of randomized clinical trials

PURPOSE

Adenoid hypertrophy (AH) is a prevalent pediatric condition associated with nasal obstruction, sleep-disordered breathing, and related comorbidities. This study evaluated comparative efficacies of Mometasone Furoate (MF) monotherapy and MF-Montelukast combination therapy in pediatric AH.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Web of Science, Google Scholar, and Ovid MEDLINE were searched from their inception to August 22, 2024, and five randomized clinical trials (RCTs) with pediatric patients (age <15 years, n = 416) with clinically diagnosed AH, managed with MF monotherapy or MF-montelukast combination therapy, were identified. Outcomes included changes in x-ray adenoids/nasopharynx ratio, endoscopic adenoid obstruction, total symptom score, and individualized symptoms scores of nasal obstruction, rhinorrhea, mouth breathing, and snoring. Although safety data, including neuropsychiatric adverse effects of montelukast, were of interest, they were not reported in the included studies.

RESULTS

Compared to MF-monotherapy, MF-montelukast combination therapy significantly improved (mean difference [95 % confidence interval], p-value) adenoids/nasopharynx ratio (-7.01 [-8.96 to -5.07], <0.001), total symptom score (-1.05 [-1.51 to -0.59], <0.001), rhinorrhea (-0.92 [-1.50 to -0.34], 0.002), mouth breathing (-0.67 [-1.27 to -0.08], 0.02), and endoscopic Grade 4 adenoid obstruction (relative risk 0.25 [0.07-0.84], 0.03); no intergroup differences were noted in nasal obstruction (-0.06 [-0.26 to 0.14], 0.56), snoring (-0.56 [-1.19 to 0.08], 0.08), and endoscopic Grade 3 adenoid obstruction (relative risk 0.70 [0.45-1.09], 0.11).

CONCLUSION

MF-montelukast combination therapy is superior to MF monotherapy in reducing AH symptoms. However, Montelukast has an FDA black box warning due to potential neuropsychiatric side effects, including suicidal thoughts, depression and behavioral changes. None of the included studies systematically assessed these adverse effects highlighting a critical gap in safety evaluation. High-quality RCT-based research is required to evaluate long-term efficacy, safety, dosage, and cost-effectiveness.

Adenoid hypertrophy detection inventory in children for primary care physicians and pediatricians

OBJECTIVE

Adenoid tissue consists of clusters of lymphoid tissue within the nasopharynx and can cause symptoms due to obstruction when hypertrophied. The gold standard for diagnosis is endoscopic nasopharyngoscopy, but it is not always readily available. This study aims to develop an inventory that primary care physicians and pediatricians can use to predict the degree of adenoid hypertrophy clinically, facilitating the planning of patient follow-up and treatment.

STUDY DESIGN

A diagnostic test study.

SETTINGS

tertiary referral hospital.

METHODS

The study involved 123 cases, with 82 in the patient group and 41 in the control group. Evaluation encompassed demographic characteristics, history, and physical examination findings. Additionally, a child psychiatrist assessed cases neurocognitively, behaviorally, and psychologically. Finally, cases underwent endoscopic nasopharyngoscopy by an ENT specialist, recording adenoid sizes and choanae narrowing. Multinomial Logistic Regression (MLR) analysis determined the most suitable model for the clinical inventory.

RESULTS

Snoring, restless sleep, noisy breathing, recurrent throat infections, and recurrent rhinosinusitis constitute the items of the clinical inventory. The average score of relevant items categorized patients into absent and mild, moderate, and severe groups. The area under the ROC curve for average scores of the inventory was 0.67, significantly surpassing the probability of random assignment (0.17). The inventory's accuracy rate was 70%.

CONCLUSION

This user-friendly and highly accurate inventory aids in predicting obstruction degree in patients. Primary care physicians and pediatricians can effectively manage follow-up and treatment, referring cases requiring surgery to an ENT specialist based on the inventory results.

A rat model of adenoid hypertrophy constructed by using ovalbumin and lipopolysaccharides to induce allergy, chronic inflammation, and chronic intermittent hypoxia

BACKGROUND

Adenoid hypertrophy (AH) is a common pediatric disease that significantly impacts the growth and quality of life of children. However, there is no replicable and valid model for AH.

METHODS

An AH rat model was developed via comprehensive allergic sensitization, chronic inflammation induction, and chronic intermittent hypoxia (CIH). The modeling process involved three steps: female Sprague-Dawley rats (aged 4-5 weeks) were used for modeling. Allergen sensitization was induced via intraperitoneal administration and intranasal provocation using ovalbumin (OVA); chronic nasal inflammation was induced through intranasal lipopolysaccharide (LPS) administration for sustained nasal irritation; CIH akin to obstructive sleep apnea/hypopnea syndrome was induced using an animal hypoxia chamber. Postmodel establishment, behaviors, and histological changes in nasopharynx-associated lymphoid tissue (NALT) and nasal mucosa were assessed. Arterial blood gas analysis and quantification of serum and tissue levels of (interleukin) IL-4 and IL-13, OVA-specific immunoglobulin E (sIgE), eosinophil cationic protein (ECP), tumor necrosis factor (TNF-α), IL-17, and transforming growth factor (TGF)-β were conducted for assessment. The treatment group received a combination of mometasone furoate and montelukast sodium for a week and then was evaluated.

RESULTS

Rats exhibited notable nasal symptoms and hypoxia after modeling. Histopathological analysis revealed NALT follicle hypertrophy and nasal mucosa inflammatory cell infiltration. Elevated IL-4, IL-13, IL-17, OVA-sIgE, ECP, and TNF-α levels and reduced TGF-β levels were observed in the serum and tissue of model-group rats. After a week of treatment, the treatment group exhibited symptom and inflammatory factor improvement.

CONCLUSION

The model effectively simulates AH symptoms and pathological changes. But it should be further validated for genetic, immunological, and hormonal backgrounds in the currently used and other strains and species.

Efficacy of combination therapy with mometasone and montelukast versus mometasone alone in treatment of adenoid hypertrophy in children: A systematic review and meta-analysis

INTRODUCTION

Intranasal mometasone and oral montelukast have been found to be effective for adenoid hypertrophy in children. We aimed to compare the efficacy of combination therapy of mometasone and montelukast versus mometasone alone for adenoid hypertrophy in children.

METHODS

Following PRISMA guidelines, we systematically searched PubMed, Embase, Cochrane CENTRAL, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing combination therapy of mometasone and montelukast with mometasone alone for adenoid hypertrophy in children. The outcomes of interest were rhinorrhea, snoring, mouth breathing, and adenoid/nasopharynx ratio. Data were pooled using a random effects model to generate mean differences (MD).

RESULTS

3 RCTs comprising a total of 207 patients were included; (combination therapy n = 104 (50.2 %). Rhinorrhea (MD -1.47; 95 % CI -1.85 to -1.09; p < 0.01; I2 = 0 %), snoring (MD -1.33; 95 % CI -1.65 to -1.00; p < 0.01; I2 = 0 %), and mouth breathing (MD -1.06; 95 % CI -1.40 to -0.71; p < 0.01; I2 = 0 %) were significantly lower in patients treated with combination therapy. No difference was observed in the adenoid/nasopharynx ratio between the groups. However, analysis excluding the study with a high risk of bias showed a significant reduction in the adenoid/nasopharynx ratio (MD -10.73; 95 % CI -13.56 to -7.90; p < 0.01; I2 = 0 %) in the combination therapy group. During the 3-month follow-up period after cessation of treatment, adenoid/nasopharynx ratio, rhinorrhea, snoring, and mouth breathing were significantly lower in the combination therapy group.

CONCLUSION

In children with adenoid hypertrophy, combination therapy reduced rhinorrhea, snoring, mouth breathing, and adenoid/nasopharynx ratio at the end of the treatment period and 3 months after treatment cessation.

Clinical study of the effect of mometasone furoate nasal spray treatment on hearing and in secretory otitis media in children

OBJECTIVE

To investigate the effect of Mometasone furoate (Elocon Cream) Nasal Spray (MFNS) treatment on hearing secretory Otitis Media (SOM) in younger children.

METHODS

Seventy-six children with SOM (ages 5 to 10 years-old) were selected as study subjects and divided into two groups of 38 cases each using a randomized numerical table. The control group was given conventional treatment, and the observation group was treated with MFNS based on the control group. Both groups were treated for 12 weeks. The improvements in clinical symptoms and hearing were compared between the two groups at weeks 4, 8 and 12 of treatment, respectively.

RESULTS

The total effective rate of treatment in the observation group was higher than that in the control group. The middle ear resonance frequency of the children in the observation group was higher than that of the control group at weeks 4, 8 and 12 of treatment, and the air-conduction hearing threshold was lower than that of the control group. The total effective rate of the observation group after 12-weeks of treatment was 92.11 %, which was significantly higher than that of the control group (73.68 %). In addition, the T-ETDQ score of the observation group was lower than that of the control group after treatment.

CONCLUSION

MFNS has clinical efficacy in the treatment of SOM in young children, which can improve clinical symptoms, promote the recovery of hearing and eustachian tube function, reduce the local inflammatory response, and improve immune function.

Allergen Immunotherapy for a Year Can Effectively Reduce the Risk of Postoperative Recurrence of Adenoid Hypertrophy in Children with Concurrent Allergic Rhinitis (IMPROVEII)

Background

Adenoid hypertrophy (AH) and allergic rhinitis (AR) are common pediatric diseases, seriously affecting the quality of life and growth of children. The recurrence rate of AH is higher for patients with than for those without concurrent AR. Allergen specific immunotherapy (AIT) is the only effective therapy for modifying the course of allergic diseases. This study sought to investigate the efficacy of AIT in preventing AH recurrence in patients with AR who underwent adenoidectomy.

Methods

This study included 134 children aged 5-12 years with concurrent AH and AR. They were separated into the subcutaneous immunotherapy (SCIT) group treated with a double-mite allergen preparation or the non-AIT group treated symptomatically with only medications. The adenoid/nasopharyngeal ratio at one year after adenoidectomy was used to assess AH recurrence. The Obstructive Sleep Apnoea Questionnaire (OSA-18), Paediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ), and Visual Analogue Scale (VAS) were used to assess the severity of the sleep disorders and AR.

Results

This study included 62 and 72 children with concurrent AH and AR in the SCIT and non-AIT groups, respectively. The rate of recurrence in the SCIT group was significantly lower than that in the non-AIT group (4.84% vs.16.67%; P=0.030). The OSA-18, PRQLQ, and VAS scores were significantly lower for the SCIT than (P<0.001) for the non-AIT group after one year of treatment.

Conclusion

The findings suggest that AIT should be considered the preferred therapy for reducing postoperative recurrence of AH in children with concurrent AR following adenoidectomy, but further research is needed to confirm these findings in a larger population.

Efficacy of montelukast for adenoid hypertrophy in paediatrics: A systematic review and meta-analysis

INTRODUCTION

Leukotrienes play a significant role in the pathogenesis of adenoid hypertrophy (A.H.). Therefore, we aimed to analyse the role of montelukast, a leukotriene receptor antagonist, alone or in combination with mometasone, a potent local intranasal steroid, for the treatment of A.H.

METHODS

Participants were children with A.H. were treated with montelukast alone or montelukast and mometasone furoate. The main outcome measures were effect of montelukast on clinical symptoms of A.H. A literature review was conducted using online search engines, Cochrane Library, PubMed, Web of Science and Scopus, for randomized clinical trials assessing children with A.H. treated with montelukast alone or montelukast and mometasone furoate. Seven randomized clinical trials (RCTs) were included with 742 children.

RESULTS

Our study reveals that montelukast alone or in combination with intranasal mometasone furoate significantly improves clinical symptoms of adenoid hypertrophy such as snoring, sleeping disturbance, mouth breathing and A/N ratio. Montelukast was superior to placebo in decreasing snoring (SMD = -1.00, 95% CI [-1.52, -0.49]), sleep discomfort (SMD = -1.26, 95% CI [-1.60, -0.93]), A/N ratio (MD = -0.11, 95% CI [-0.14, -0.09]) and mouth breathing (SMD = -1.36, 95% CI [-1.70, -1.02]). No difference was detected between montelukast and mometasone versus mometasone alone in snoring (SMD = -0.21, 95%CI [-0.69, 0.27]); however, the combination group was superior to the mometasone alone in mouth breathing (SMD = -0.46, 95% CI [-0.73, -0.19]).

CONCLUSIONS

The limitation of studies included a small sample size, with an overall low to medium quality. Thus, further larger, higher-quality RCTs are recommended to provide more substantial evidence.

Maximal medical treatment of adenoid hypertrophy: a prospective study of preschool children

PURPOSE

This study aimed to examine the effectiveness of the combined maximal medical treatment for adenoid hypertrophy in preschool children.

METHODS

Sixty-four children underwent one-year combined therapy with intranasal mometasone furoate, oral desloratadine, nasal saline irrigation, and bacteriotherapy. Additionally, decongestion drops were applied during scheduled breaks.

RESULTS

Of the 64 treated children, 72% showed clinical improvement in adenoid symptoms while 28% did not improve and underwent surgery. These groups differed significantly in terms of the overall reduction in ailments after treatment (p < 0.001), infection rate (p < 0.001), catarrh severity (p < 0.001) and nasal patency (p < 0.001). Endoscopic examination confirmed that responders experienced, on average, a decrease of 8.4% in the adenoid/choana ratio and an improvement in mucosal coverage of the adenoid. These effects were not observed in the group of children whose parents opted for surgery after nine months of conservative treatment.

CONCLUSIONS

The proposed new schema of long-term maximal medical treatment with the use of combined intermittent treatment of intranasal mometasone furoate and decongestion drops, oral desloratadine, nasal saline irrigation, and bacteriotherapy can be attempted in patients with adenoid hypertrophy symptoms, and responders may avoid the need for surgery. The applied treatment breaks resulted in a low number of therapeutic side effects.

Inflammatory endotypes of adenoidal hypertrophy based on a cluster analysis of biomarkers

OBJECTIVE

To identify adenoid inflammatory endotypes based on inflammatory markers, match endotypes to phenotypes, and predict endotypes.

METHODS

This cross-sectional study included 72 children with adenoid hypertrophy. Thirteen inflammatory markers and total immunoglobulin E (TIgE) in adenoid tissue were analyzed using Luminex and enzyme-linked immunosorbent assay (ELISA) for performing cluster analysis. Correlation analysis was used to examine the characteristics of each cluster. Receiver operating characteristic (ROC) curve analysis was performed to screen for preoperative characteristic data with predictive value for adenoid inflammation endotype.

RESULTS

The patients were divided into four clusters. Cluster 1 exhibited non-type 2 signatures with low inflammatory marker concentrations, except for the highest expression of Th1-related cytokines. Cluster 2 showed a non-type 2 endotype with the highest concentration of interleukin (IL)-17A and IL-22. Cluster 3 exhibited moderate type 2 inflammation, with the highest concentration of neutrophil factors. Cluster 4 demonstrated significant type 2 inflammation and moderate neutrophil levels. The proportions of AR and serum TIgE levels increased from clusters 1 to 4, and there was a gradual increase in the prevalence of chronic sinusitis from low to high neutrophilic inflammation. The area under the ROC curve for serum TIgE was higher than those for combined or other separate preoperative characteristics for predicting non-type 2 and type 2 inflammation in the adenoid tissue.

CONCLUSIONS

The evaluation of cytokines in adenoid tissue revealed four endotypes. Serum TIgE level was an important indicator of the endotype of adenoid inflammation. Identification of adenoid inflammatory endotypes can facilitate targeted treatment decisions.

Medical treatment does not reduce surgery rates in children with adenoid hypertrophy

OBJECTIVE

We sought to study adenoidectomy rates in children with adenoid hypertrophy (AH) who were either treated with medical therapy or not during a 2-year follow-up period in a longitudinal population-based study.

METHODS

We retrospectively identified healthy children aged 1-18 years between 2014 and 2020 with AH diagnosis from the Clalit Health Services database, the largest healthcare maintenance organization in Israel. The main outcome was adenoidectomy alone or in combination with other procedures performed within 2 years after diagnosis. The treatment group consisted of children who received medical therapy, defined as a pharmacy purchase of montelukast, nasal steroid sprays and/or antihistamines (medical therapy aimed to reduce AH) for ≥2 consecutive months, while the control group consisted of untreated children.

RESULTS

We identified 68,356 unique children with AH, of them 56 % were boys, with a mean age of 4.9 ± 3.3 years. Of them, 5310 (7.7 %) received medical therapy. Overall, 6633 (9.7 %) underwent adenoidectomy within 2 years following diagnosis. There was no significant difference in surgery referral rates between the treatment and the control groups, 10 % vs. 9.7 %, respectively (p = 0.3). When adjusted for age and sex, the likelihood of undergoing adenoidectomy was similar in both groups (HR = 0.98, 95 % CI = 0.90-1.07, p = 0.6). Among operated children, the average time from diagnosis to surgery was statistically significantly longer in the treatment group than in the control group, 346 ± 180 vs 311 ± 175 days (p < 0.001).

CONCLUSION

Prescribing montelukast, nasal steroids and/or oral antihistamines was not associated with a reduction in adenoidectomy rates and was associated with an average surgery delay of 35 days.

150th Anniversary of global adenoid investigations: unanswered questions and unsolved problems

Although the problem of adenoid hypertrophy (AH) has been diagnosed and treated by doctors and scientists from around the world for the last 150 years, there is still no consensus regarding appropriate diagnosis, conservative treatment options, and qualification for surgery. This manuscript presents current knowledge on these issues and compares diagnostic methods and the effectiveness of treatment options. Factors that may influence the obtained treatment results are also described, and a questionnaire is proposed to compare the results of treatment. The objective of drawing attention to this problem is to obtain better results from conservative treatment in the future and better-qualified patients for surgical treatment.

Cause analysis and reoperation effect of failure and recurrence after epiblepharon correction in children

BACKGROUND

In children, it is common to see failure and recurrence in the correction of epiblepharon and to have reoperation due to obvious irritation symptoms and corneal injury.

AIM

To explore the causes of failure and recurrence after epiblepharon correction in children, to remove accurately redundant epiblepharon and orbicularis oculi muscle in patients via the cilia-everting suture technique combined with lid margin splitting in some patients due to inverted lashes in the medial part of the eyelid, and to observe the therapeutic effect.

METHODS

From 2015 to 2019, in the Outpatient Department of Ophthalmology of Beijing Tongren Hospital, 22 children (40 eyes) with epiblepharon, aged 5-12 years, were treated due to correction failure and recurrence. Fourteen patients (28 eyes) underwent the full-thickness everting suture technique, and eight patients (16 eyes) underwent incisional surgery. They were treated by reviewing the previous surgical methods and observing epiblepharon, eyelash direction, and corneal injury. During reoperation, a subciliary incision was made 1 mm below the inferior lash line. Incisional surgery for the lower eyelid was used to remove accurately redundant epiblepharon and part of the pretarsal orbicularis muscle. Subcutaneous tissue and the orbicularis muscle of the upper skin-muscle flap were anchored to the anterior fascia of the tarsal plate by rotational sutures. Lid margin splitting was used only for patients who had seriously inverted lashes located in the medial part of the eyelid. All patients were followed for 6-12 mo after reoperation to observe the lower eyelid position, skin incision, eyelash direction, corneal damage, and recurrence.

RESULTS

After reoperation, all the patients were corrected. Photophobia, rubbing the eye, winking, and tearing disappeared. There was no lower eyelid entropion, ectropion, or retraction. There was no obvious sunken scar or lower eyelid crease. The eyelashes were far away from the cornea, and when the patients looked down, the eyelashes on the lower eyelid did not contact the cornea or conjunctiva. The corneal injuries were repaired. Follow-up observation for 6 mo showed no recurrence of epiblepharon.

CONCLUSION

The type of suture method, the failure to remove accurately redundant skin and orbicularis muscle, the lack of cilia rotational suture use, and excessive reverse growth of eyelashes are the main causes of failure and recurrence after epiblepharon correction in children.