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Tochigi K, Omura K, Hattori S, Asako M, Tanaka Y. Histological analysis of glucocorticoid receptor and eosinophilic cytokines in the adenoid mucosal epithelium. Int J Pediatr Otorhinolaryngol 2024; 184:112079. [PMID: 39173268 DOI: 10.1016/j.ijporl.2024.112079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 08/07/2024] [Accepted: 08/19/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVE In recent years, the clinical efficacy of medications for adenoid hypertrophy has been demonstrated. Topical nasal steroids have effects to shrink hypertrophic adenoids and improve symptoms of associated diseases. However, the mechanism which topical steroid administrations cause adenoid shrinkage remains unclear, herein, sensitivity for topical steroids in the mucosal epithelium of adenoids was evaluated histologically by comparing with tonsils. METHODS Histological analysis was performed on adenoids and tonsils removed from 32 pediatric patients with adenoid hypertrophy. In hematoxylin-eosin-stained specimens, the morphology of the mucosal epithelium and eosinophil infiltration were evaluated. The expression of the glucocorticoid receptor (GR), interleukin (IL)-4, and IL-25 in the mucosal epithelium was evaluated, and the staining intensity was scored as 0 (none), 1 (weak), and 2 (strong). The number of eosinophils and expression scores of GR, IL-4, and IL-25 were statistically compared between adenoids and tonsils and analyzed correlations with adenoids sizes. RESULTS Adenoids were covered with ciliated epithelium, and eosinophils in the mucosal epithelium and submucosal area was higher than tonsils (p < 0.05). GR expression in the most superficial layer of the mucosal epithelium was observed in adenoids, and the expression intensity score was higher than that in tonsils (p < 0.05). IL-4 and IL-25 were more widely expressed in the mucosal epithelium of adenoids than in tonsils, and their expression intensity scores were also higher than in tonsils (p < 0.05). A correlation was found between adenoid size and the intensity of IL-25 expression in the adenoid epithelium (p < 0.05). CONCLUSION Eosinophilic inflammations in adenoids mucosal epithelium could be one of etiology of adenoid hypertrophy, and the GR and eosinophilic inflammation in the adenoids mucosal epithelium might be target of topical nasal steroids to shrink hypertrophic adenoids.
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Affiliation(s)
- Kosuke Tochigi
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan.
| | - Kazuhiro Omura
- Department of Otorhinolaryngology/Head and Neck Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Saaya Hattori
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Mikiya Asako
- Department of Otolaryngology, Head and Neck Surgery, Kansai Medical University Medical Center, Osaka, Japan
| | - Yasuhiro Tanaka
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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Lv C, Yang L, Ngan P, Xiao W, Zhao T, Tang B, Chen X, He H. Role of the tonsil-oropharynx ratio on lateral cephalograms in assessing tonsillar hypertrophy in children seeking orthodontic treatment. BMC Oral Health 2023; 23:836. [PMID: 37936131 PMCID: PMC10629199 DOI: 10.1186/s12903-023-03573-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/24/2023] [Indexed: 11/09/2023] Open
Abstract
OBJECTIVES To analyze the diagnostic value of the tonsil-oropharynx (T/O) ratio on lateral cephalograms for evaluating tonsillar hypertrophy (TH). METHODS A cross-sectional study was performed on 185 consecutive children (101 males, 84 females; mean age 7.3 ± 1.4 years) seeking orthodontic treatment. The T/O ratios on lateral cephalograms were calculated following Baroni et al.'s method. Tonsil sizes were clinically determined according to the Brodsky grading scale. Spearman correlation coefficients between the T/O ratio and clinical tonsil size were calculated with the total sample and subgroups and then compared between subgroups. Diagnostic value was analyzed using the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive and negative predictive values, and accuracy. RESULTS There was a strong correlation between the T/O ratio and clinical tonsil size in children (ρ = 0.73; P < 0.001). A significantly higher correlation coefficient was found in the Class III children. The ROC curve revealed an area under the curve of 0.90 (95% CI, 0.86-0.94; P < 0.001). The optimal cutoff value of the T/O ratio for predicting TH was 0.58, with a sensitivity of 98.7% and specificity of 64.2%. Employing the cutoff value of 0.5, the sensitivity was 100% and the specificity was 45.9%. CONCLUSIONS Measurement of the T/O ratio on lateral cephalograms may be helpful to initial screening in children for TH. Practitioners may combine the clinical examination of tonsil size with the cephalometric findings for a more comprehensive evaluation.
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Affiliation(s)
- Chenxing Lv
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
- Department of Orthodontics, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Liu Yang
- Department of Stomatology, Hangzhou Traditional Chinese Medicine Hospital, Hangzhou, China
| | - Peter Ngan
- Department of Orthodontics, School of Dentistry, West Virginia University, Morgantown, USA
| | - Wenjie Xiao
- Department of Otorhinolaryngology-Head and Neck Surgery, Guangdong Clifford Hospital, Guangzhou, China
| | - Tingting Zhao
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
- Department of Orthodontics, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Bojun Tang
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China
- Department of Orthodontics, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Xiong Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hong He
- State Key Laboratory of Oral and Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School and Hospital of Stomatology, Wuhan University, Wuhan, China.
- Department of Orthodontics, School and Hospital of Stomatology, Wuhan University, Wuhan, China.
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Senthilvel E, Nguyen QL, Gunaratnam B, Feygin YB, Palani R, El-Kersh K. Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective. J Clin Sleep Med 2023; 19:1027-1033. [PMID: 36727478 PMCID: PMC10235720 DOI: 10.5664/jcsm.10468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/11/2023] [Accepted: 01/11/2023] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES Recurrent/residual adenoid hypertrophy after adenotonsillectomy in children can result in obstructive sleep apnea (OSA). We aimed to assess the role of soft tissue neck X-ray (STN-XR) in evaluating recurrent/residual adenoid tissue hypertrophy. METHODS This was a single-center retrospective study that included children with sleep study-confirmed OSA and a known history of adenotonsillectomy who underwent STN-XR to evaluate for recurrent/residual adenoid tissue hypertrophy. STN-XR nasopharyngeal obliteration and baseline polysomnographic data were analyzed. Multiple linear regression was used to assess the independent relationship between the results of STN-XR and the total apnea-hypopnea index, while controlling for relevant characteristics. RESULTS The study included 160 participants with a median age of 10 years (quartile [Q] 1 = 7, Q3 = 12.25). More than half of the children were male (59.4%) and the median body mass index z-score was 2.11 (Q1 = 1.23, Q3 = 2.54). STN-XR was normal in 39.4%, and it showed mild, moderate, and complete nasopharyngeal obliteration in 20.6%, 32.5%, and 7.5% of the participants, respectively. Multiple regression analysis showed that moderate and complete nasopharyngeal obliteration was associated with an increase in the mean total apnea-hypopnea index by 109% (P = .0002) and 185% (P = .001), respectively, when compared with children without nasopharyngeal obliteration. However, mild nasopharyngeal obliteration, body mass index z-score, age, sex, and race were not significantly associated with an increase in the total apnea-hypopnea index. CONCLUSIONS STN-XR was useful in assessing recurrent/residual adenoid tissue hypertrophy in children with OSA and a history of adenotonsillectomy. Moderate and complete nasopharyngeal obliteration were associated with significantly increased apnea-hypopnea index. Pediatric sleep physicians may consider STN-XR in the evaluation of children with OSA and previous history of adenotonsillectomy. CITATION Senthilvel E, Nguyen QL, Gunaratnam B, Feygin YB, Palani R, El-Kersh K. Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective. J Clin Sleep Med. 2023;19(6):1027-1033.
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Affiliation(s)
- Egambaram Senthilvel
- Department of Pediatrics, University of Louisville and Norton Children Medical Group, Louisville, Kentucky
| | - Quang L. Nguyen
- Deaconess Health, Division of Pulmonary Critical Care and Sleep Medicine, University of Louisville, Louisville, Kentucky
| | | | - Yana B. Feygin
- Department of Pediatrics, University of Louisville and Norton Children Medical Group, Louisville, Kentucky
| | - Rajaneeshankar Palani
- Department of Pediatrics, University of Louisville and Norton Children Medical Group, Louisville, Kentucky
| | - Karim El-Kersh
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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Li P, Li T, Yu L, Chen A, Wu Y, Wan Y, Shi L. Predictive Value of Adenoid-Nasopharyngeal Ratio in the Diagnosis of Secretory Otitis Media. EAR, NOSE & THROAT JOURNAL 2022:1455613221144496. [PMID: 36464777 DOI: 10.1177/01455613221144496] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
OBJECTIVES To explore the associated factors of otitis media with effusion (OME) and analyze the diagnostic value of the adenoid-nasopharyngeal (A/N) ratio to OME. METHODS Patients with adenoid hypertrophy (AH) recently in 2 years were collected, including sex, age, duration, with/without rhinosinusitis, and examination results, including Cone Beam Computerized Tomography (CBCT) sinus imaging, tympanometry, pure tone audiometry (PTA), blood test, and allergen detection. According to Liden/Jerger's classification, the patients were divided into two groups: Type B and type C, which were defined as the tympanometry abnormal group (TAG), and the rest were classified as the tympanometry normal group (TNG). RESULTS A total of 316 children were included in this study. Age and duration were significantly younger and shorter in TAG (6.0(4.0-9.0) vs.5.0(4.0-7.0)); 12.0(4.0-24.0) vs.6.0(2.0-12.0)). Compared to TNG, the allergen test results of fx5 (protein, milk, cod, wheat, peanut, and soybean) in TAG were higher (0.09(0.04-0.25) vs.0.14(0.05-0.45)), but eosinophilia in blood was lower (count: 0.21(0.13-0.35) vs. 0.18(0.12-0.27); ratio: 3.10 (1.90-4.70) vs. 2.50 (1.65-3.80)). A/N ratio and Visual obstruction ratio had a statistical difference (Z = -3.770, P < .01) but the two ratios didn't have too much disparity (0.82(0.74-0.88) VS 0.80(0.75-0.80)), and they had a positive correlation (r = 0.345, P < .01). A/N ratio of TAG was higher than TNG (0.78(0.70-0.85) vs. 0.86(0.82-0.90)) and had a positive correlation with increasing negative middle ear pressure (r = -3.777, P < .01). A/N ratio was an associated factor of OME (OR:1355.611, P = .006), the cut-off value of A/N ratio was 0.815(sensitivity: 75.3%, specificity: 64.3%, area under the curve (AUC): 0.747). CONCLUSIONS A/N ratio indirectly reflected the abnormality of tympanometry in this study. When A/N ratio reaches 0.815, patients are at a higher risk of having OME so it could be a predictor of OME in patients with adenoid hypertrophy.
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Affiliation(s)
- Ping Li
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Tao Li
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
- Department of Allergy, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Liang Yu
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Aiping Chen
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Yisha Wu
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Yuzhu Wan
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
| | - Li Shi
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
- Department of Allergy, Shandong Provincial ENT Hospital, Shandong University, Jinan, P. R. China
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Adenoidal-Nasopharyngeal Ratio in Healthy Adults on Cone Beam Computed Tomography. J Comput Assist Tomogr 2022; 46:836-839. [PMID: 35819911 DOI: 10.1097/rct.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This study aimed to quantify the adenoidal-nasopharyngeal ratio (ANR) in a cohort of healthy adults on cone beam computed tomography (CT) using the Fujioka method, which is a reproducible measure of adenoid size and nasopharyngeal patency. METHODS Electronic health records and maxillofacial cone beam CT in 202 consecutive patients aged 16 years and older were retrospectively reviewed. Patients with a history of adenoidectomy, sinonasal disease, lymphoproliferative disorders, and cleft palate were excluded from the study. The midsagittal reconstructed cone beam CT image was used to determine the ANR. Statistical analysis was conducted using 1-way analysis of variance. RESULTS Of the 202 subjects, 131 were female and 71 were male. The mean ± SD subject age was 45.43 ± 20.79 years (range, 16-91 years). The mean ± SD ANR in all subjects was 0.22 ± 0.13 (range, 0.03-0.75) and in each decade of adult life was as follows: younger than 21 years, 0.39 ± 0.12; 21 to 30 years, 0.29 ± 0.11; 31 to 40 years, 0.21 ± 0.09; 41 to 50 years, 0.20 ± 0.07; 51 to 60 years, 0.16 ± 0.10; 61 to 70 years, 0.13 ± 0.05; 71 to 80 years, 0.12 ± 0.05; 81 to 90 years, 0.11 ± 0.04; and 91 years or older, 0.10 ± 0. The differences in mean ANR among the age subgroups were statistically significant (P < 0.001). CONCLUSIONS The mean ANR gradually decreased from 0.39 in the second decade of life to 0.16 in the sixth decade of life and plateaued at approximately 0.10 thereafter.
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Narang VP, Loroch A, Sambiagio G. Versatility and Benefits of 4.0mm Flexible Nasal Endoscopy in 118 Children up to 10 Years of Age. Cureus 2022; 14:e22656. [PMID: 35371672 PMCID: PMC8963822 DOI: 10.7759/cureus.22656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose This retrospective study looked at the feasibility of using adult 4.0 mm flexible nasendoscopes (FNE) examination under local anesthetic (LA) in children three to 10 years old to diagnose adenoid hypertrophy (AH) and other conditions. We also looked for a correlation between the adenoid size on FNE and a) tonsil size, b) the typical symptoms of snoring, mouth breathing, impaired hearing, and apnoeic episodes c) the management options of otitis media with effusion (OME) and d) the adenoid size intraoperatively. Methods A retrospective, observational study of 118 children in an NHS pediatric otolaryngology clinic led by a single consultant. One hundred ten consecutive patients with suspected AH were divided into two groups of three to five years and six to 10 years. We compared the acceptance rate to FNE in two subgroups (three to five years and six to 10 years old) and examined the correlation between various parameters as outlined above, using the Chi-square test. Eight children underwent FNE for other reasons of change of voice and epistaxis. Results FNE was successfully performed in 86% of the patients without restraint. Thirty-three percent of patients had non-obstructive adenoids (OA) and did not require surgical intervention. The intraoperative adenoid size, symptoms of snoring, mouth-breathing, and apnoeic episodes positively correlated with OA; however, no correlation was seen with the tonsil size (p=0.1143). All patients with OA and type B tympanogram needed adenoidectomy and grommet insertion (p=0.0119), and those with type C curves recovered with adenoidectomy alone. Conclusions 4.0 mm adult scope helped reach a definitive diagnosis for AH in most children above three years of age, thus proving cost-effective. The symptoms of snoring, mouth-breathing, and apnoeic episodes had a positive correlation to the presence of OA; however, the tonsil size was seen to be independent of adenoid size. Primary surgical management can be considered the treatment of choice for all patients with OA and type B tympanogram without a trial of conservative therapy.
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Tepedino M, Montaruli G, Scapato F, Laurenziello M, Suriano C, Chimenti C, Ciavarella D. Long-term effect on adenoid dimensions and craniocervical angulation after maxillary expansion with fixed or functional appliances. J Clin Exp Dent 2021; 13:e594-e600. [PMID: 34188766 PMCID: PMC8223156 DOI: 10.4317/jced.58171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/23/2021] [Indexed: 12/23/2022] Open
Abstract
Background Maxillary expansion is a common orthodontic procedure that could have a positive effect also on airway patency. The aim of the present study was to evaluate the long-term effects of rapid maxillary expansion (RME) on nasopharyngeal area and cranio-cervical angulation in growing patients, compared to controls treated with a function-generating bite appliance (FGB).
Material and Methods Sixty patients aged 6-14 consecutively treated with RME or FGB were selected retrospectively and divided into two groups. Lateral cephalograms taken before and after treatment were retrieved, and the nasopharyngeal area, delimited superiorly by a sella-posterior nasal spine (PNS) line and inferiorly by a basion-PNS line, and the cranio-cervical angulation were measured.
Results The mean observation time was 17.6 ± 8 months. No differences were present between the two groups regarding age and gender. The nasopharyngeal area increased significantly in both groups after treatment, but with no statistically significant difference between them. The cranio-cervical angulation showed no differences within or between groups.
Conclusions Maxillary deficiency treatment with either RME or FGB was followed by a comparable increase in nasopharyngeal area. Key words:Rapid maxillary expansion, Airway, Nasopharyngeal area, Adenoid.
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Affiliation(s)
- Michele Tepedino
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Graziano Montaruli
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Francesco Scapato
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Michele Laurenziello
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Carmela Suriano
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Claudio Chimenti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Domenico Ciavarella
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Thereza-Bussolaro C, Lagravère M, Pacheco-Pereira C, Flores-Mir C. Development, validation and application of a 3D printed model depicting adenoid hypertrophy in comparison to a Nasoendoscopy. Head Face Med 2020; 16:5. [PMID: 32151261 PMCID: PMC7061480 DOI: 10.1186/s13005-020-00216-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 02/12/2020] [Indexed: 11/15/2022] Open
Abstract
Background The exploration of tridimensional (3D) technology of computational tomography and the development of valid 3D printed models may improve the assessment of adenoid obstruction. The identification of an enlarged adenoid in childhood would streamline the referral of appropriately selected cases to an otolaryngologist, leading to early treatment of affected children when indicated. The objective of this study is to validate the use of a 3D printed model depicting adenoid hypertrophy based on the pediatric otolaryngologist, head and neck surgeon (OHNS) participants assessment. Methods A cross-sectional study was performed to develop and validate 3D depictions, including print-outs, of the nasopharynx including different degrees of Adenoidal Hypertrophy (AH). The print-outs were obtained from 14 Cone-beam computed tomography (CBCT) scans of 14 children (12 boys, 2 girls; mean age of 10.61 years) representing grades 1, 2, 3, and 4 nasopharyngeal adenoidal obstructions, according to a previously Nasoendoscopy-graded (NE) classification by a licensed OHNS. The prevalence of AH in this study was 36%. Two OHNS were recruited to assess the print-outs representing two different representations of the nasopharyngeal airway, the lumen (LU) and adenoid mass (AD). LU and AD were visualized in 2D - pictures- and in 3D – printed prototypes. Intraclass correlation was used to assess intra- and inter-reliability. The validity of our depictions was analyzed through comparison (accuracy and correlation) to the reference standard (NE). The data were clustered to calculate the sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). Cross-tab and Pearson’s T-test were performed. Results Overall, the 3D depiction tools showed different diagnostic capabilities. AD representations showed strong (AD 2D, 75%) to almost perfect (AD 3D, 88%) accuracy compared to NE. Excellent sensitivity and specificity were observed for the AD 3D (100, 70%), as well as adequate PPV and NPV (66 and 97% respectively), with only 5% of false-negative cases. Conclusion The use of Dolphin software for the acquisition of a 3D printed prototype of the nasopharyngeal adenoidal region seems promising. These prototypes may be a practical and readily available alternative for the assessment of the nasopharyngeal obstructed area. CBCT in children must be taken under strong solid indications. Early referral to an OHNS for a full assessment remains the main objective in children with unclear symptoms.
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Affiliation(s)
- Claudine Thereza-Bussolaro
- School of Dentistry, University of Alberta, 11405 87Ave NW, 5528 Edmonton Clinic Health Academy,, Edmonton, AB, T6G1C9, Canada.
| | - Manuel Lagravère
- School of Dentistry, University of Alberta, 11405 87Ave NW, 5528 Edmonton Clinic Health Academy,, Edmonton, AB, T6G1C9, Canada
| | - Camila Pacheco-Pereira
- School of Dentistry, University of Alberta, 11405 87Ave NW, 5528 Edmonton Clinic Health Academy,, Edmonton, AB, T6G1C9, Canada
| | - Carlos Flores-Mir
- School of Dentistry, University of Alberta, 11405 87Ave NW, 5528 Edmonton Clinic Health Academy,, Edmonton, AB, T6G1C9, Canada
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Cohen O, Betito HR, Adi M, Shapira‐Galitz Y, Halperin D, Lahav Y, Warman M. Development of the nasopharynx: A radiological study of children. Clin Anat 2019; 33:1019-1024. [DOI: 10.1002/ca.23530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/16/2019] [Accepted: 11/19/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Oded Cohen
- Department of Otolaryngology, Head and Neck Surgery Kaplan Medical Center Rehovot Israel
- Hebrew University‐ Hadassah Medical School Jerusalem Israel
| | - Hadar Rotem Betito
- Department of Otolaryngology, Head and Neck Surgery Kaplan Medical Center Rehovot Israel
- Hebrew University‐ Hadassah Medical School Jerusalem Israel
| | - Meital Adi
- Department of Radiology Kaplan Medical Center Rehovot Israel
- Hebrew University‐ Hadassah Medical School Jerusalem Israel
| | - Yael Shapira‐Galitz
- Department of Otolaryngology, Head and Neck Surgery Kaplan Medical Center Rehovot Israel
- Hebrew University‐ Hadassah Medical School Jerusalem Israel
| | - Doron Halperin
- Department of Otolaryngology, Head and Neck Surgery Kaplan Medical Center Rehovot Israel
- Hebrew University‐ Hadassah Medical School Jerusalem Israel
| | - Yonatan Lahav
- Department of Otolaryngology, Head and Neck Surgery Kaplan Medical Center Rehovot Israel
- Hebrew University‐ Hadassah Medical School Jerusalem Israel
| | - Meir Warman
- Department of Otolaryngology, Head and Neck Surgery Kaplan Medical Center Rehovot Israel
- Hebrew University‐ Hadassah Medical School Jerusalem Israel
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Duan H, Xia L, He W, Lin Y, Lu Z, Lan Q. Accuracy of lateral cephalogram for diagnosis of adenoid hypertrophy and posterior upper airway obstruction: A meta-analysis. Int J Pediatr Otorhinolaryngol 2019; 119:1-9. [PMID: 30658139 DOI: 10.1016/j.ijporl.2019.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Accurate diagnosis of adenoid hypertrophy and posterior upper airway obstruction using a lateral cephalogram is challenging. No universal guidelines for assessing adenoidal enlargement and upper airway obstruction have been established. We performed a meta-analysis to assess the diagnostic accuracy of a lateral cephalogram for adenoid hypertrophy. METHODS After searching a wide range of electronic databases and screening titles and abstracts, we evaluated full papers describing potentially eligible studies according to predefined inclusion criteria. Quality assessment was conducted by adapting the Quality Assessment of Diagnostic Accuracy Studies-2 checklist, and a 2 × 2 contingency table was constructed based on these results. Two authors independently judged the studies and extracted the data. The diagnostic accuracy of a lateral cephalogram for adenoid hypertrophy and posterior upper airway obstruction was calculated using a bivariate meta-analysis model. The Q-test and I2 index were used to test the heterogeneity. RESULTS Nine studies were included in the meta-analysis. The pooled sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio were 0.86 [95% confidence interval (CI): 0.76-0.92], 0.59 (95% CI: 0.42-0.73), 9.00 (95% CI: 5-17), 2.1 (95% CI: 1.5-3.0), and 0.24 (95% CI: 0.15-0.37), respectively. The area under the summary receiver operator characteristic curve was 0.83 (95% CI: 0.80-0.86). Meta-regression analysis revealed that the sample size and study design significantly contributed to the heterogeneity of sensitivity. CONCLUSIONS Our findings suggest that the lateral cephalogram exhibits very good diagnostic accuracy (area under the curve: 0.86) for the diagnosis of adenoid hypertrophy and posterior upper airway obstruction. Nevertheless, the rate of false-positive diagnoses should be further considered.
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Affiliation(s)
- Hanzhong Duan
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, 1055#Sanxiang Road, Suzhou, Jiangsu Province, 215004, PR China; Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Li Xia
- Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Wangfang He
- Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Yongdong Lin
- Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Zhihui Lu
- Department of Otolaryngology, Zhejiang Xiaoshan Hospital, 728#Yucaibei Road, Hangzhou, Zhejiang Province, 311201, PR China.
| | - Qing Lan
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, 1055#Sanxiang Road, Suzhou, Jiangsu Province, 215004, PR China.
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11
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Role of Adenoid-Nasopharyngeal Ratio in Assessing Adenoid Hypertrophy. Indian J Otolaryngol Head Neck Surg 2018; 71:469-473. [PMID: 31742005 DOI: 10.1007/s12070-018-1359-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 04/10/2018] [Indexed: 10/17/2022] Open
Abstract
Most of the time, pediatrician is the first to see children with adenotonsillar hypertrophy (AH) and they mostly rely on clinical assessment with or without some investigation to refer these children to otorhinolaryngologist. Numerous methods have been described for evaluation of AH, but many of these methods are not possible to follow in busy pediatric outpatient unit either because of lack of cooperation from child or due to limited availability of test or due to cost constraints. This study has been conducted to determine the diagnostic accuracy of lateral neck X-ray (LNX) for assessing AH and to assess the correlation between adenoid size in LNX and clinical symptoms in a pediatric unit. Prospective study conducted in Department of ENT, Pathmavathy Medical Foundation, Kollam, Kerala, India from January 2015 to March 2016. 60 consecutive children of both genders, between the age group of 5 to 14 years, attending Department of Pediatrics with a provisional diagnosis of AH were included in the study. The symptom scores, radiographic ratio of adenoid to nasopharynx and endoscopic scorings were calculated. Lateral neck X-ray with calculation of adenoid-to-nasopharynx ratio is found to have significant correlation with patient reported symptoms and findings in nasal endoscopic examination (NE). LNX can be considered as a useful objective tool in evaluation of children with adenoid hypertrophy. Primary care physicians or pediatricians can confidently use lateral neck X-ray for making clinical decisions and can consider nasopharyngoscopy when clinical picture remains unclear or more evaluation is needed.
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Abstract
Purpose of Review Review the current state of the adenoidectomy procedure in the pediatric population with up-to-date indications for surgery, operative techniques, adverse events, non-surgical management of adenoid hypertrophy, and future directions. Recent Findings Adenoidectomy is indicated in children for the treatment of sleep-disordered breathing, nasal airway obstruction, recurrent acute otitis media, and chronic rhinosinusitis. A new recommendation was released in 2016, not supporting adenoidectomy for a primary indication of otitis media in children under 4 years old, including those with prior tympanostomy tubes, unless a distinct indication exists such as nasal obstruction or chronic adenoiditis. Although adenotonsillectomy is the mainstay of treatment for obstructive sleep apnea (OSA), recent studies have identified that non-obese patients with moderate OSA and small tonsils have comparable benefits with adenoidectomy alone with less complications. While conventional approaches such as indirect mirror-assisted curette and suction coagulation are still utilized, direct transnasal endoscope-assisted removal of the adenoids has proven to be a safe technique, with good short- and long-term outcomes. Novel non-surgical therapies including immunotherapy have been evaluated. Summary Adenoidectomy is a safe procedure in the pediatric population and leads to excellent outcomes. Adverse events are rare, and hospitalization is uncommon. Children with sleep disturbance from nasal airway obstruction, ear disease, or chronic rhinosinusitis are the best operative candidates for this procedure.
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Anderson SM, Lim HJ, Kim KB, Kim SW, Kim SJ. Clustering of craniofacial patterns in Korean children with snoring. Korean J Orthod 2017; 47:248-255. [PMID: 28670566 PMCID: PMC5466907 DOI: 10.4041/kjod.2017.47.4.248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/20/2017] [Accepted: 02/07/2017] [Indexed: 11/10/2022] Open
Abstract
Objective The purpose of this study was to investigate whether the craniofacial patterns of Korean children with snoring and adenotonsillar hypertrophy (ATH) could be categorized into characteristic clusters according to age. Methods We enrolled 236 children with snoring and ATH (age range, 5–12 years) in this study. They were subdivided into four age groups: 5–6, 7–8, 9–10, and 11–12 years. Based on cephalometric analysis, the sagittal and vertical skeletal patterns of each individual were divided into Class I, II, and III, as well as the normodivergent, hypodivergent, and hyperdivergent patterns, respectively. Cluster analysis was performed using cephalometric principal components in addition to the age factor. Results Three heterogeneous clusters of craniofacial patterns were obtained in relation to age: cluster 1 (41.9%) included patients aged 5–8 years with a skeletal Class I or mild Class II and hyperdivergent pattern; cluster 2 (45.3%) included patients aged 9–12 years with a Class II and hyperdivergent pattern; and cluster 3 (12.8%) included patients aged 7–8 years with a Class III and hyperdivergent pattern. Conclusions This study found that the craniofacial patterns of Korean children with snoring and ATH could be categorized into three characteristic clusters according to age groups. Although no significantly dominant sagittal skeletal discrepancy was observed, hyperdivergent vertical discrepancy was consistently evident in all clusters.
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Affiliation(s)
| | - Hoi-Jeong Lim
- Department of Orthodontics, Chonnam National University School of Dentistry, Gwangju, Korea
| | - Ki-Beom Kim
- Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St. Louis, MO, USA
| | - Sung-Wan Kim
- Department of Otorhinolaryngology Head and Neck Surgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Su-Jung Kim
- Department of Orthodontics, Kyung Hee University School of Dentistry, Seoul, Korea
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Abstract
Screening for obstructive sleep apnea (OSA) with in-laboratory polysomnography is recommended for children with sleep disordered breathing. Adenotonsillectomy is the first-line therapy for pediatric OSA, although intranasal steroids and montelukast can be considered for those with mild OSA and continuous positive airway pressure for those with moderate to severe OSA awaiting surgery, poor surgical candidates or persistent OSA. Bony or soft tissue upper airway surgery is reasonable for children failing medical management or those with persistent OSA following adenotonsillectomy. Weight loss and oral appliance therapy are also useful. A multi-modality approach to diagnosis and treatment is preferred.
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Affiliation(s)
- Zarmina Ehsan
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA
| | - Stacey L Ishman
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA; Division of Pediatric Otolaryngology - Head & Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229, USA; University of Cincinnati School of Medicine, Department of Otolaryngology - Head & Neck Surgery, 231 Albert Sabin Way, MSB 6503, Cincinnati, Ohio 45267-0528, USA.
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15
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ACE grading-A proposed endoscopic grading system for adenoids and its clinical correlation. Int J Pediatr Otorhinolaryngol 2016; 83:155-9. [PMID: 26968070 DOI: 10.1016/j.ijporl.2016.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/31/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To propose a novel endoscopic adenoid grading system using a rigid nasal endoscope and to study its correlation with the clinical diagnosis. METHODOLOGY Prerecorded video clips of rigid nasal endoscopy taken during endoscopic adenoidectomy were retrieved. Otolaryngology consultants blinded to the clinical diagnosis of the child were presented these videos and asked to grade the adenoid hypertrophy as per the proposed endoscopic ACE (Airway/Choana/Eustachian tube) grading system. The clinical diagnosis was correlated with the different aspects of the descriptive endoscopic grading system. RESULTS 152 video clips were presented to the otolaryngology consultants for grading. The average age was 8.6 years (SD-3.48), while the male female ratio was 3:2. The A subcomponent of the ACE grading showed significant correlation with the diagnosis of sleep disordered breathing and chronic adenotonsillitis, C subcomponent with sleep disordered breathing and the E subcomponent with the diagnosis of otitis media. CONCLUSION The proposed endoscopic grading is easily applicable and at the same time clearly describes the relation of the adenoids to the nasopharynx, choana and Eustachian tube. Different aspects of the grading system correlated differently with the clinical diagnosis emphasizing that a descriptive scoring rather than a comprehensive scoring is a more relevant clinical tool.
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16
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Yildirim YS, Senturk E, Eren SB, Dogan R, Tugrul S, Ozturan O. Efficacy of nasal corticosteroid in preventing regrowth after adenoidectomy. Auris Nasus Larynx 2016; 43:637-40. [PMID: 27036360 DOI: 10.1016/j.anl.2016.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 01/31/2016] [Accepted: 02/03/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE One of the most frequent reasons of nasal obstruction and sleep apnea in pediatrics is adenoid hypertrophy. Remaining adenoid tissue can reoccur following hypertrophied adenoid removal and a second operation may be needed. Nasal corticosteroids are utilized in order to reduce adenoid hypertrophy and eliminate adenoidectomy operation. The purpose of our study is to assess the effect of nasal corticosteroid administration after adenoidectomy on adenoid regrowth and symptom scores. MATERIAL AND METHOD Seventy patients who had adenoidectomy were enrolled in our study. Patients were divided into two groups. Group I (35 patients) received Mometasone furoate (40mcg/day per nostril) intranasal spray for 6 months, starting at postoperative week 3 after wound healing. As for Group II (35 patients), they received intranasal saline spray. Patients were followed up for one year. Every patient had flexible nasal endoscopy at postoperative week 3 and one year after the operation. Choana was scored according to its occlusion level by the adenoid tissue. Additionally, nasal obstruction symptoms (nasal congestion, dry mouth, snoring, nasal speaking, apnea and night coughing) were scored. RESULTS Remaining adenoid tissue in the nasopharynx was comparable in flexible endoscopic assessment and no significant difference was seen between postoperative week 3 nasal obstruction scores. In the flexible endoscopic assessment completed in the twelfth month of the study, significant reduction was found in Group 1 compared to Group 2 in terms of adenoid size. When patients in both groups were compared, statistically significant reduction was observed in nasal obstruction symptom scores at the twelfth month. CONCLUSION This study has demonstrated that the use of steroid nasal spray following adenoidectomy significantly prevents regrowth and reduces nasal obstruction symptoms in the early period.
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Affiliation(s)
- Yavuz Selim Yildirim
- Bezmialem Vakif University, Department of Otorhinolaryngology, Fatih, Istanbul, Turkey
| | - Erol Senturk
- Bezmialem Vakif University, Department of Otorhinolaryngology, Fatih, Istanbul, Turkey.
| | - Sabri Baki Eren
- Bezmialem Vakif University, Department of Otorhinolaryngology, Fatih, Istanbul, Turkey
| | - Remzi Dogan
- Bezmialem Vakif University, Department of Otorhinolaryngology, Fatih, Istanbul, Turkey
| | - Selahattin Tugrul
- Bezmialem Vakif University, Department of Otorhinolaryngology, Fatih, Istanbul, Turkey
| | - Orhan Ozturan
- Bezmialem Vakif University, Department of Otorhinolaryngology, Fatih, Istanbul, Turkey
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Kar M, Altıntoprak N, Muluk NB, Ulusoy S, Bafaqeeh SA, Cingi C. Antileukotrienes in adenotonsillar hypertrophy: a review of the literature. Eur Arch Otorhinolaryngol 2016; 273:4111-4117. [DOI: 10.1007/s00405-016-3983-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
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18
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Kang KT, Weng WC, Lee CH, Hsiao TY, Lee PL, Hsu WC. Clinical risk assessment model for pediatric obstructive sleep apnea. Laryngoscope 2016; 126:2403-9. [PMID: 26973061 DOI: 10.1002/lary.25912] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 12/21/2015] [Accepted: 01/14/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To develop a clinical risk prediction model that identifies children with obstructive sleep apnea (OSA) in a clinical setting by examining the symptoms, physical status, and OSA-18 questionnaire results. DESIGN Single institutional, cross-sectional study. METHODS Children aged 2 to 18 years with symptoms of OSA were enrolled. Pediatric OSA was diagnosed through full-night polysomnography. Clinical data, namely demographics, symptoms, OSA-18 survey results, tonsil and adenoid sizes, and the weight of each child, were examined for constructing a simple point-based clinical model for OSA prediction. Variables for the risk model were selected using multivariable logistic regression analyses. RESULTS Of the 310 participants (mean age, 7.6 ± 3.7 years; boys, 67%), 170 (55%) experienced OSA. Modeling variables were determined using several univariate logistic regression analyses, followed by multivariable logistic regression analyses. A point-based clinical model incorporating the age, tonsil size (5 points maximum), adenoid size (5 and 20 points for age > 6 years and < 6 years, respectively), obesity (5 points for age > 6 years), and breathing pauses (5 points) was developed (area under the curve = 0.832). Moreover, the optimal cutoff points for predicting the apnea-hypopnea index of > 1 and > 5 were 10 (sensitivity, 72.9%; specificity, 65.0%) and 12 (sensitivity, 77.5%; specificity, 56.9%), respectively. Internal validation using the bootstrap method revealed no apparent overfitting problem. CONCLUSION A novel clinical prediction model was developed for determining the risk of pediatric OSA; the model can be useful in identifying high-risk patients among those with sleep disturbances. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2403-2409, 2016.
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Affiliation(s)
- Kun-Tai Kang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University Hospital, Taipei.,Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Wen-Chin Weng
- Sleep Center, National Taiwan University Hospital, Taipei.,Department of Pediatrics, National Taiwan University Hospital, Taipei
| | - Chia-Hsuan Lee
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University Hospital, Taipei.,Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Tzu-Yu Hsiao
- Department of Otolaryngology, National Taiwan University Hospital, Taipei
| | - Pei-Lin Lee
- Sleep Center, National Taiwan University Hospital, Taipei.,Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei. .,Sleep Center, National Taiwan University Hospital, Taipei.
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Torretta S, Marchisio P, Succo G, Capaccio P, Pignataro L. Nasopharyngeal fiberendoscopy in children: a survey of current Italian pediatric otolaryngological practices. Ital J Pediatr 2016; 42:24. [PMID: 26931408 PMCID: PMC4774007 DOI: 10.1186/s13052-016-0234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/23/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Sara Torretta
- Otolaryngology Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
| | - Paola Marchisio
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giovanni Succo
- Academic Oncologic Department, Otolaryngology Service, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy.
| | - Pasquale Capaccio
- Otolaryngology Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
| | - Lorenzo Pignataro
- Otolaryngology Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
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20
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Abstract
Nasal obstruction is a very frequent symptom in children, with numerous etiologies. Clinical diagnosis is straightforward, but general impact and rare etiologies should be explored for. Complementary examinations are guided by diagnostic orientation. Although not usually a severe condition, nasal obstruction may be life-threatening in neonates and infants. An exhaustive list of etiologies is impossible and would not be useful, but it is worth distinguishing infantile nasal obstruction and nasal obstruction in older children, as causes differ greatly. This is the topic of the present update.
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Affiliation(s)
- N Leboulanger
- Service d'ORL et de chirurgie cervico-faciale, hôpital universitaire Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France.
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22
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Feng X, Li G, Qu Z, Liu L, Näsström K, Shi XQ. Comparative analysis of upper airway volume with lateral cephalograms and cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2015; 147:197-204. [PMID: 25636553 DOI: 10.1016/j.ajodo.2014.10.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 10/01/2014] [Accepted: 10/01/2014] [Indexed: 12/01/2022]
Abstract
INTRODUCTION In this study, we aimed to evaluate the adenoidal nasopharyngeal ratio (ANR) on lateral cephalograms by assessing upper airway volumes using cone-beam computed tomography (CBCT) images as the validation method. METHODS Fifty-five patients were included in the study, and it was essential that the lateral cephalograms and CBCT images taken at their examinations were not more than 1 week apart. There were 32 subjects in group A (age ≤15 years) and 23 subjects in group B (age >15 years). The ANR was measured on the lateral cephalograms. The area and volumetric measurements of the nasopharynx and the total upper airway were obtained from CBCT images. Repeated measurements of the ANR and airway volume were performed on 10 subjects by 2 observers. RESULTS Group A had a higher correlation (r = -0.78) between the ANR and the nasopharynx volume than did group B (r = -0.57). The ANR had a weak correlation with the total upper airway volume (group A, r = -0.48; group B, r = -0.32). Both measurements made on lateral cephalograms and CBCT were highly reproducible in terms of intraobserver and interobserver agreement. CONCLUSIONS Based on our results, the measurement of the ANR on lateral cephalograms can be used as an initial screening method to estimate the nasopharynx volumes of younger patients (age ≤15 years).
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Affiliation(s)
- Xin Feng
- Radiologist, Department of Oral and Maxillofacial Radiology, Stomatological Hospital, Dalian, China; guest researcher, Oral Maxillofacial Diagnostics and Surgery, Karolinska Institutet, Huddinge, Sweden
| | - Gang Li
- Professor, Department of Oral and Maxillofacial Radiology, School and Hospital of Stomatology, Peking University, Beijing, China
| | - Zhenyu Qu
- Associate professor, Department of Oral and Maxillofacial Radiology, Stomatological Hospital, Dalian, China
| | - Lin Liu
- Professor, Department of Orthodontics, Stomatological Hospital, Dalian, China
| | - Karin Näsström
- Chair, Oral Maxillofacial Diagnostics and Surgery, Karolinska Institutet, Huddinge, Sweden
| | - Xie-Qi Shi
- Associate professor, Oral Maxillofacial Diagnostics and Surgery, Karolinska Institutet, Huddinge, Sweden.
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Feres MFN, Hermann JS, Sallum AC, Pignatari SSN. Radiographic adenoid evaluation: proposal of an objective parameter. Radiol Bras 2015; 47:79-83. [PMID: 25741053 PMCID: PMC4337152 DOI: 10.1590/s0100-39842014000200008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 10/17/2013] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
| | - Juliana Sato Hermann
- Master, Fellow PhD degree of Pediatric Otorhinolaryngology, Department of Otorhinolaryngology and Head & Nerck Surgery, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | | | - Shirley Shizue Nagata Pignatari
- PhD, Professor, Division of Pediatric Otorhinolaryngology and Head & Neck Surgery, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
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Feres MF, Hermann JS, Sallum AC, Pignatari SS. Radiographic adenoid evaluation – suggestion of referral parameters. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2013.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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25
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Feres MFN, Hermann JS, Sallum AC, Pignatari SSN. Radiographic adenoid evaluation--suggestion of referral parameters. J Pediatr (Rio J) 2014; 90:279-85. [PMID: 24508014 DOI: 10.1016/j.jped.2013.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/21/2013] [Accepted: 09/04/2013] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE this study aimed to evaluate the usefulness of current radiographic measurements, which were originally conceived to evaluate adenoid hypertrophy, as potential referral parameters. METHODS children aged from 4 to 14 years, of both genders, who presented nasal obstruction complaints, were subjected to cavum radiography. Radiographic examinations (n = 120) were evaluated according to categorical and quantitative parameters, and data were compared to gold-standard videonasopharyngoscopic examination, regarding accuracy (sensitivity, negative predictive value, specificity, and positive predictive value). RESULTS radiographic grading systems presented low sensitivity for the identification of patients with two-thirds choanal space obstruction. However, some of these parameters presented relatively high specificity rates when three-quarters adenoid obstruction was the threshold of interest. Amongst the quantitative variables, a mathematical model was found to be more suitable for identifying patients with more than two-thirds obstruction. CONCLUSION this model was shown to be potentially useful as a screening tool to include patients with, at least, two-thirds adenoid obstruction. Moreover, one of the categorical parameters was demonstrated to be relatively more useful, as well as a potentially safer assessment tool to exclude patients with less than three-quarters obstruction, to be indicated for adenoidectomy.
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Affiliation(s)
- Murilo F N Feres
- Faculdade de Odontologia, Universidade São Francisco (USF), Bragança Paulista, SP, Brazil.
| | - Juliana S Hermann
- Department of Otorhinolaryngology, Head and Neck Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Ana C Sallum
- Department of Otorhinolaryngology, Head and Neck Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Shirley S N Pignatari
- Department of Otorhinolaryngology, Head and Neck Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Kang KT, Weng WC, Lee CH, Lee PL, Hsu WC. Discrepancy between Objective and Subjective Outcomes after Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome. Otolaryngol Head Neck Surg 2014; 151:150-8. [DOI: 10.1177/0194599814529534] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 03/07/2014] [Indexed: 11/16/2022]
Abstract
Objective Adenotonsillectomy (T&A) is the first line therapy for pediatric obstructive sleep apnea (OSA); however, inconsistency between objective and subjective outcomes perplexes physicians. This study investigates changes of objective and subjective outcomes in children with OSA after T&A, in particular, to elucidate correlations and discrepancies between these 2 measures. Study Design Case series with record review. Setting Tertiary referral medical center. Subjects and Methods Symptomatic children with polysomnographic diagnosis of OSA (apnea-hypopnea index [AHI] > 1) were included. All children underwent T&A to treat OSA, along with completely objective (polysomnography) and subjective (Obstructive Sleep Apnea 18-Item Quality-of-Life Questionnaire [OSA-18]) measures before and 3 months after surgery. Results One hundred nineteen children were included (mean age, 6.9 ± 3.3 years; 76% boys). Adenotonsillectomy significantly reduced AHI from 15.4 ± 21.2 per hour to 1.6 ± 2.5 per hour ( P < .001). The OSA-18 scores were significantly improved after surgery ( P < .001). A weak but statistically significant positive correlation was found between AHI and OSA-18 scores preoperatively (ρ = 0.22, P = .016) but not postoperatively (ρ = 0.04, P = .677). Among those cases with residual OSA after surgery, only 6% (3/54) had a residual effect on quality of life (OSA-18 score > 60). Conclusion Adenotonsillectomy improves both objective and subjective outcomes. After surgery, quality of life significantly improved subjectively, despite an incomplete resolution of OSA objectively, leading to a better correlation between objective and subjective measures before as opposed to after surgery. Discrepancy between the 2 measures warrants an evaluation of a child both objectively and subjectively when treating OSA.
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Affiliation(s)
- Kun-Tai Kang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Wen-Chin Weng
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hsuan Lee
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Otolaryngology, China Medical University Hospital, Taipei Branch, Taiwan
| | - Pei-Lin Lee
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
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Gomaa MA, Mohammed HM, Abdalla AA, Nasr DM. Effect of adenoid hypertrophy on the voice and laryngeal mucosa in children. Int J Pediatr Otorhinolaryngol 2013; 77:1936-9. [PMID: 24100003 DOI: 10.1016/j.ijporl.2013.08.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 08/24/2013] [Accepted: 08/29/2013] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The adenoids, or pharyngeal tonsils, are lymphatic tissue localized at the mucous layer of the roof and posterior wall of nasopharynx. Dysphonia defined as perceptual audible change of a patient's habitual voice as self judged or judged by his or her listeners. The diagnosis of dysphonia relies on clinical judgment based on phoniatric symptoms, auditory perceptual assessment of voice (APA) and full laryngeal examination. PATIENTS AND METHODS Our study was conducted to evaluate the effect of adenoid hypertrophy on voice and laryngeal mucosa. The study sample composed of sixty children, forty of them had adenoid hypertrophy (patient's group) and twenty healthy children (control group). Patient's group composed of 17 boys (42.5%) and 23 girls (57.5%), while control group consists of 8 males (40%) and 12 females (60%). All patients and control group subjected to history taking, clinical examination, lateral soft tissue X-ray on the nasopharynx, APA based on the modified GRBAS scale and full laryngeal examination. The data are collected and analyzed statistically by using software SPSS. RESULTS Our results showed that there is a significant association between adenoid hypertrophy and, degree of dysphonia, leaky voice, pitch of voice and laryngeal lesion. Adenoid hypertrophy did not associate with loudness of voice, as well as character (irregular, breathy and strained). Laryngeal lesions were detected in thirteen children from patient group (32.5%): nodules (n = 6), thickening (n = 5), congestion (n = 2), while one child only out of 20 children of the control group had congestion (5.0%). CONCLUSION Our results showed the importance of the assessment of voice and laryngeal examination in patients with adenoid hypertrophy, also treating the minimal mucosal lesions that results from adenoid hypertrophy should be taken in consideration.
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Affiliation(s)
- Mohammed A Gomaa
- Department of Otorhinolaryngology, Faculty of Medicine, Minia University, Egypt.
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Kang KT, Chou CH, Weng WC, Lee PL, Hsu WC. Associations between adenotonsillar hypertrophy, age, and obesity in children with obstructive sleep apnea. PLoS One 2013; 8:e78666. [PMID: 24205291 PMCID: PMC3808373 DOI: 10.1371/journal.pone.0078666] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 09/14/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To investigate the contributions of adenoid and tonsil size to childhood obstructive sleep apnea (OSA) and the interactions between adenotonsillar hypertrophy, age, and obesity in children with OSA. METHODS In total, 495 symptomatic patients were recruited. The patients were assigned to four groups according to age: toddler (age 1-3, n=42), preschool (age 3-6, n=164), school (age 6-12, n=200), and adolescence (age 12-18, n=89). All subjects had tonsil size graded by otolaryngologists, adenoid size determined on lateral radiographs (Fujioka method), and a full-night polysomnography. The apnea-hypopnea index (AHI), adenoid size, and tonsil size were compared in obese and non-obese children in the four age groups. Adjusted odds ratios (ORs) and 95% confidence interval (CI) of adenotonsillar hypertrophy and OSA risk were estimated by multi-logistic regression. RESULTS The AHI was positively related to tonsil grade (r=0.33, p <0.001) and adenoid size (r=0.24, p <0.01) in all patients. Tonsil grade was positively related to AHI in all four age groups. Adenoid size was positively related to AHI in the toddler, preschool, school groups, but not in the adolescent group (r=0.11, p=0.37). Tonsil grade and adenoid size were both positively related to AHI in obese and non-obese children. In the regression model, obesity (OR=2.89; 95% CI 1.47-5.68), tonsillar hypertrophy (OR=3.15; 95% CI 2.04-4.88), and adenoidal hypertrophy (OR=1.89; 95% CI 1.19-3.00) significantly increased OSA risk. CONCLUSIONS Adenotonsillar hypertrophy and obesity are the major determinants of OSA in children. However, the influence of adenoid size decreases in adolescence.
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Affiliation(s)
- Kun-Tai Kang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
- Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan, R.O.C.
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan, R.O.C.
| | - Chen-Han Chou
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
| | - Wen-Chin Weng
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
| | - Pei-Lin Lee
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
- Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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Baldassari CM, Choi S. Assessing adenoid hypertrophy in children: X-ray or nasal endoscopy? Laryngoscope 2013; 124:1509-10. [PMID: 24105739 DOI: 10.1002/lary.24366] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/02/2013] [Accepted: 07/25/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Cristina M Baldassari
- Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Norfolk, Virginia
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Kim SY, Lee WH, Rhee CS, Lee CH, Kim JW. Regrowth of the adenoids after coblation adenoidectomy: Cephalometric analysis. Laryngoscope 2013; 123:2567-72. [DOI: 10.1002/lary.23984] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 11/03/2012] [Accepted: 12/18/2012] [Indexed: 11/06/2022]
Affiliation(s)
- So Young Kim
- Department of Otorhinolaryngology; Seoul, National University College of Medicine; Seoul; South Korea
| | - Woo-Hyun Lee
- Seoul National University Bundang Hospital; Seongnam; South Korea
| | | | - Chul Hee Lee
- Department of Otorhinolaryngology; Seoul, National University College of Medicine; Seoul; South Korea
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Waters K, Kol-Castro C, Varghese A, Lam LT, Prelog K, Cheng A. Correlations between polysomnographic and lateral airway radiograph measurements in paediatric obstructive sleep apnoea. J Paediatr Child Health 2013; 49:445-51. [PMID: 23621401 DOI: 10.1111/jpc.12212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2013] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Karen Waters
- Department of Respiratory Support Service, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
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Feres MFN, Hermann JS, Pignatari SSN. Cephalometric evaluation of adenoids: an analysis of current methods and a proposal of a new assessment tool. Am J Orthod Dentofacial Orthop 2012; 142:671-8. [PMID: 23116508 DOI: 10.1016/j.ajodo.2012.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 07/01/2012] [Accepted: 07/01/2012] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Although the scientific literature recognizes that lateral cephalometric radiographs might be clinically useful, there is no consensus in relation to the best parameter available. Therefore, this research was aimed at evaluating current radiographic assessment methods designed to investigate adenoid hypertrophy and nasopharyngeal obstruction. METHODS Children from 4 to 14 years old with nasal obstruction or oral breathing complaints, suspected to be caused by adenoid hypertrophy, received cephalometric examinations. One hundred twenty radiographic records were evaluated according to several current methods, and data were compared with respective gold-standard videonasopharyngoscopic examinations, in relation to the percentage of choanal obstruction. RESULTS Groups derived from a grading system had significantly different percentages of choanal obstruction. However, this parameter showed low sensitivity. Significant but moderate correlations were observed between most of the quantitative radiographic parameters and the percentage of choanal obstruction. Alternatively, a regression model was introduced; it demonstrated satisfactory ability to predict choanal obstruction percentage. Despite limitations, this model could also distinguish patients who might benefit from referral to otolaryngologic care. CONCLUSIONS Current adenoid assessment methods have significant limitations. A novel assessment method introduced here might be clinically useful.
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Affiliation(s)
- Murilo Fernando Neuppmann Feres
- Division of Pediatric Otolaryngology, Department of Otolaryngology, Head and Neck Surgery, Federal University of São Paulo, São Paulo, Brazil.
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James AL. The practical implications of TARGET for adenoidectomy in children with otitis media with effusion. Clin Otolaryngol 2012; 37:174-5. [PMID: 22708935 DOI: 10.1111/j.1749-4486.2012.02475.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Analysing lateral soft tissue neck radiographs. Emerg Radiol 2012; 19:255-60. [DOI: 10.1007/s10140-012-1026-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2011] [Accepted: 01/24/2012] [Indexed: 10/14/2022]
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