Allergy and the Pharyngeal Lymphoid Tissues

Pollen levels on the day of polysomnography influence sleep disordered breathing severity in children with allergic rhinitis

PURPOSE

Allergic rhinitis (AR) is a common risk factor for sleep disordered breathing (SDB) in children. Allergy to pollen is a trigger for allergic rhinitis, causing nasal inflammation, upper airway congestion and obstruction. We aimed to determine if the pollen count on the day of diagnostic polysomnography for SDB affected the result.

METHODS

Children (3-18 years; n = 90) who participated in research studies between 1 October and 31 December, when daily regional pollen counts were available, in the years 2005-2016 were eligible for inclusion. All children underwent overnight polysomnography for assessment of SDB severity. Pollen was categorised as grass or other pollen. Multiple stepwise linear regression was performed to determine whether the pollen count for that day, a diagnosis of asthma, age, and BMI-z-score were determinants of respiratory parameters measured on polysomnography, including the obstructive apnoea hypopnoea index (OAHI), SpO₂ nadir, average SpO₂ drop, SpO₂ < 90%, oxygen desaturation index > 4% (ODI4), and average transcutaneous CO₂ (TCM).

RESULTS

Sixteen/90 children had AR. In children with AR, an increase in grass pollen of 1 grain/m³ predicted an increase in OAHI of 0.2 events/h, ODI4 of 0.18 times/h, SpO₂ < 90% of 0.03 times/h, and TCM of 0.07 mmHg. None of the factors were determinants of SDB severity in children without AR.

CONCLUSION

Our findings highlight that daily pollen counts may be an important factor influencing the severity of SDB on a single night of polysomnography in children with clinical allergic rhinitis and should be taken into account when determining treatment options.

Medical Treatment for Rhinosinusitis Associated with Adenoidal Hypertrophy in Children: An Evaluation of Clinical Response and Changes on Magnetic Resonance Imaging

Objectives:

The association between adenoidal hypertrophy and rhinosinusitis with upper airway inflammation is increasingly recognized; however, no study has used magnetic resonance imaging (MRI) to assess the changes in adenoid size after medical treatment of rhinosinusitis.

Methods:

Thirteen children referred to a tertiary allergy clinic with symptoms of rhinosinusitis received medical treatment over a 4-month period. All underwent MRI before and after treatment. The medical treatment regimen comprised a short course of oral antibiotics and oral steroids and a longer course of oral antihistamines and intranasal steroids.

Results:

The pretreatment MRI demonstrated enlarged adenoids and rhinosinusitis in all 13 children, with evidence of extensive rhinosinusitis in 9 of the 13. The treatment resulted in an improvement in overall symptom score; the most significant improvement was seen in mouth breathing. The posttreatment MRI showed a statistically significant reduction in adenoid size and adenoid/nasopharynx ratio, which was associated with a significant decrease in sinus involvement on MRI.

Conclusions:

There is a high association between adenoidal hypertrophy and rhinosinusitis in the context of an allergy clinic. Magnetic resonance imaging can document the changes in adenoid size associated with resolution of rhinosinusitis. Further studies are necessary to validate these pilot data and further assess the effects of medical treatment and the role of MRI in adenoidal hypertrophy.

Is obstructive sleep apnea syndrome in children season dependent?

INTRODUCTION

The most common cause of obstructive sleep apnea (OSA) in children is an enlargement of tonsils and/or adenoids. Previous studies have shown that the size of adenoids and tonsils is influenced by upper respiratory tract infections and exposure to allergens. The rate of exposure to bacteria, viruses, and allergens fluctuates from season to season. Therefore, we hypothesized that the rate of polysomnograms positive for OSA may vary according to season.

OBJECTIVE

The objective of this study is to determine whether the prevalence of OSA in children, as determined by polysomnography, is affected by the season during which the study was performed.

METHODS

We retrospectively reviewed polysomnography tests of 296 children, ages 0-12 years, referred for suspected OSA. We compared the Obstructive Apnea Hypopnea Index (OAHI) between the seasons and the rates of abnormal tests in each season according to the degree of severity.

RESULTS

The mean OAHI did not significantly differ among the seasons (winter, 3.0 ± 5.0; spring, 3.0 ± 4.9; summer, 4.0 ± 6.3; fall, 3.4 ± 5.7, p = 0.183). When dividing the OAHI by levels of severity, no seasonality was found in moderate (winter, 13.8 %; spring, 6.7 %; summer, 11.7 %; fall, 14.1 %, p = NS) and severe OSA (winter, 8.8 %; spring, 11.2 %; summer, 10 %; fall, 7.8 %, p = NS). There was a small increase in the frequency of mild OSA diagnoses in the summer compared to the other seasons.

CONCLUSION

In this study, season does not appear to affect the rate of diagnosis of significant OSA in children. Re-evaluation during a different season is unlikely to provide different results and may postpone surgery unnecessarily.

Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy

BACKGROUND

Adenoidal hypertrophy is generally considered a common condition of childhood. When obstructive sleep apnoea or cardio-respiratory syndrome occurs, adenoidectomy is generally indicated. In less severe cases, non-surgical interventions may be considered, however few medical alternatives are currently available. Intranasal steroids may be used to reduce nasal airway obstruction.

OBJECTIVES

To assess the effectiveness of intranasal corticosteroids for improving nasal airway obstruction in children with moderate to severe adenoidal hypertrophy.

SEARCH STRATEGY

Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2007), MEDLINE (1951 to 2007) and EMBASE (1974 to 2007). All searches were initially performed in May 2007 and updated in April 2008.

SELECTION CRITERIA

Randomised controlled trials comparing intranasal corticosteroids with placebo or no intervention or other treatment in children aged 0-12 years with moderate to severe adenoidal hypertrophy.

DATA COLLECTION AND ANALYSIS

Data from the included trials were extracted and trial quality was assessed by two authors independently. Meta-analysis was not applicable and data were summarised in a narrative format.

MAIN RESULTS

Five randomised trials, including a total of 349 patients, met the inclusion criteria of the review. All trials except one showed significant efficacy of intranasal corticosteroids in improving nasal obstruction symptoms and in reducing adenoid size. The first eight-week cross-over study showed that treatment with beclomethasone (336 micrograms/day) yielded a greater improvement in mean symptom scores than placebo (-18.5 vs. -8.5, P < 0.05) and a larger reduction in mean adenoid/choana ratio than placebo (right, -14% vs. +0.4%, p=0.002; left, -15% vs. -2.0%, p=0.0006) between week 0 and week 4. The second four-week cross-over study demonstrated that the nasal obstruction index decreased by at least 50% from baseline in 38% of patients treated with beclomethasone (400 micrograms/day) between week 0 and week 2, whereas none of the patients treated with placebo had such improvement (p<0.01). The third randomized, parallel-group trial showed that 77.7% of patients treated with mometasone (100 micrograms/day) for 40 days demonstrated an improvement in nasal obstruction symptoms and a decrease in adenoid size, such that adenoidectomy could be avoided, whereas no significant improvement was observed in the placebo group. The fourth randomized, parallel-group trial showed that eight-weeks of treatment with flunisolide (500 micrograms/day) was associated with a lager reduction in adenoid size than isotonic saline solution (p<0.05). In contrast, one randomised, parallel-group trial did not find significant improvement in nasal obstruction symptoms and adenoid size after eight weeks of treatment with beclomethasone (200 micrograms/day).

AUTHORS' CONCLUSIONS

Limited evidence suggests that intranasal corticosteroids may significantly improve nasal obstruction symptoms in children with moderate to severe adenoidal hypertrophy, and this improvement may be associated with a reduction of adenoid size. The long-term effect of intranasal corticosteroids in these patients remains to be defined.

An analysis of the incidence of adenoid hypertrophy in allergic children

INTRODUCTION

The adenoidectomy is the most often made operation in small children but the reasons of adenoid hypertrophy are not completely explained. Some researches show that in part of children, allergy can be a risk factor for adenoid hypertrophy. The main aim of this study was the analysis of adenoid hypertrophy in children with different allergic diseases.

MATERIAL AND METHODS

Two separate groups of children were examined. The study group consisted of 436 children between 4 and 9 years old with allergic rhinitis and/or bronchial asthma and/or atopic dermatitis hypersensitive to house dust mites (interview, positive skin-prick test results). The control group consisted of 229 non-atopic children (negative interview and skin-prick tests) in the similar age. In the both groups we examined the incidence of adenoid hypertrophy and its dependence of the kind of allergic disease, age, sex, infections, results of skin-prick test and other sensitization.

RESULTS

The probability of adenoid hypertrophy was statistically more significant (logistic regression analysis) only in children from the study group with allergic rhinitis. There were no differences in adenoid hypertrophy incidence between children with other allergic diseases and the control group. The children from the study group with adenoid hypertrophy were more often hypersensitive to pollen and moulds allergens than the children without adenoid hypertrophy (chi square test). But there were no differences in the incidence of infection, age, sex and results of skin-prick tests.

CONCLUSION

The result of our study suggests that the chance of adenoid hypertrophy in allergic children hypersensitive to dust mites is greater only in them with allergic rhinitis.

Increased rates of ENT surgery among young children: have clinical guidelines made a difference?

OBJECTIVES

To examine the association between introduction of paediatric ear, nose and throat (ENT) surgery guidelines and population procedure rates. To determine changes in children's risk of undergoing ENT surgery.

METHODS

Trend analysis of incidence of myringotomy, tonsillectomy and adenoidectomy among New South Wales (NSW) children aged 0-14 between 1981 and mid 1999. Poisson regression models were used to estimate annual rates of change pre and postguidelines introduction and age/gender specific rates, and lifetable methods to determine risk of undergoing an ENT procedure by age 15.

RESULTS

ENT surgery rates increased by 21% over the study period. Children's risk of surgery increased from 17.9% in 1981 to 20.2% in 1998/99. Guideline introduction was associated with moderate short-term decreases in rates. For tonsillectomy, rates decreased between 1981 and 1983, but then rose continually until the introduction of myringotomy guidelines in 1993, when they fell, only to recommence rising until the end of the study period. For myringotomy, rates rose annually from 1981 to 1992/93 and fell in the 3 years following guideline introduction, after which they rose again. Increases were almost exclusively restricted to children aged 0-4 and correspond with increased use of formal childcare. The prevalence of myringotomy by the age of 5 years rose from 5.6% of children born in 1988/89 to 6.4% of those born in 1994/95, and the prevalence of tonsillectomy from 2.4% to 2.7%.

CONCLUSIONS

The risk of young Australian children undergoing ENT surgery increased significantly over the last two decades despite the introduction of guidelines and no evidence of an increase in otitis media, one condition prompting surgery. Surgery increased most among the very young. We hypothesize this is related to increasing use of childcare.

[Tonsillar mast cell infiltration and allergic tonsillitis]

We report the case of a seven year-old boy bearing of exudative acute tonsillitis after strawberry ingestion with no previous infectious history. After having diagnosed it as hypersensitivity type I, this patient began to suffer repetitive episodes of exudative and purulent tonsillitis, related to cool drinks and direct manipulation of tonsils. These were hyperplastic and Staphylococcus sp. and Streptococcus sp. were isolated in them. The episodes were shortened by the use of corticosteroids. Tonsillectomy was the definitive therapy. Biopsy informed of mast cells infiltration in germinal centers of both palatine tonsils.

Enlarged adenoid and adenoidectomy in adults: endoscopic approach and histopathological study

Adenoid enlargement is uncommon in adults and because examination of the nasopharynx by indirect posterior rhinoscopy is inadequate, many cases of enlarged adenoid in adults are misdiagnosed and accordingly maltreated. This study was conducted on 35 cases of enlarged adenoid aged between 20 and 42 years. The nasal endoscope was utilized to identify the adenoid mass. Adenoidectomy under transnasal endoscopic control was performed and all the excised material was sent for histopathological examination. Adenoidectomy resulted in marked improvement in 94 per cent of cases without major complications. Histopathological examination revealed non-specific inflammatory reaction in 15 cases (43 per cent), pure reactive changes, predominantly follicular hyperplasia, in two cases (6 per cent) and mixed pattern in 18 cases (51 per cent). Endoscopic follow-up for an average 17 months identified recurrence in only two patients. It was concluded that enlarged adenoid tissue in adults has some histopathological differences from that in children and adenoidectomy under transnasal endoscopic control is safe and reliable.