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CLINICAL EVALUATION OF OBSTRUCTIVE ADENOID ENLARGEMENT IN UNIVERSITY OF NIGERIA TEACHING HOSPITAL ENUGU.
BY ORJI, FOSTER TOCHUKWU. M.B.B.S. (NIG) DEPARTMENT OF OTOLARYNGOLOGY UNIVERSITY OF NIGERIA TEACHING HOSPITAL ENUGU STATE, NIGERIA.
DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR FELLOWSHIP OF THE MEDICAL COLLEGE IN OTORHINOLARYNGOLOGY F.M.C.O.R.L
NOVEMBER, 2005
CLINICAL EVALUATION OF OBSTRUCTIVE ADENOID ENLARGEMENT IN UNIVERSITY OF NIGERIA TEACHING HOSPITAL (UNTH) ENUGU.
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FOSTER TOCHUKWU ORJI DEPARTMENT OF OTOLARYNGOLOGY UNIVERSITY OF NIGERIA TEACHING HOSPITAL ENUGU.
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DECLARATION
I hereby declare as follows:-
(a) that I am the sole author of this dissertation
(b) that all references cited have been consulted by me,
(c) that I conducted the work reported herein and any assistance
received is duly acknowledged
(d) that I have not previously submitted this dissertation for a higher
degree, or publication, in part or in full.
F. T. ORJI Enugu
June 2005
ATTESTATION
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This is to certify that the dissertation: CLINICAL EVALUATION OF
OBSTRUCTIVE ADENOID ENLARGEMENT IN UNIVERSITY OF
NIGERIA TEACHING HOSPITAL ENUGU was done by the candidate under our supervision.
Name: Prof. B.C Okafor
Status: Consultant ENT Surgeon
Address: Department of ENT, UNTH, Enugu, Nigeria
Signature:
Date:
Name: Dr. B.C Ezeanolue
Status: Consultant ENT Surgeon
Address: Department of ENT, UNTH, Enugu, Nigeria
Signature:
Date:
ETHICAL CERTIFICATION
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ACKNOWLEDGEMENT
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I express my profound gratitude to God almighty for the success of this
Project.
I sincerely thank my Supervisors Dr. BC Ezeanolue and Prof. B.C
Okafor for their directives and encouragement throughout the period of this work. I particularly appreciate all the useful materials and hints I was given which were of great help in carrying out my work. I also appreciate their time and patience in the repeated reading and correction of the work.
I express my heartfelt gratitude to Dr. NC Mgbor Consultant
Otolaryngologist UNTH Enugu and the Management of “Novatone”
Nigeria Limited, for their assistance and discount in the cost of doing tympanometry on the patients, an action that contributed in a large way in completing the work.
I also thank Mrs Ifeyinwa Onugha and Rita Ogwudile for their assistance in the statistical analysis and secretarial work respectively. I thank every other person who contributed in one way or the other to the success of this project.
DEDICATION
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This book is dedicated to my late father Mr. E.I Orji, whose loving support made my Residency Training a reality.
TABLE OF CONTENT
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Title i Declaration ii Attestation iii Ethical Certification iv Acknowledgement v Dedication vi Table of Contents vii List of tables and figures ix Abbreviations x Summary xi
CHAPTER I Introduction 1 1.1 Background 1 1.2 Justification and Significance of the study 3 1.3 Scope and Limitation of the study 4
CHAPTER II Aims and Objectives of the Study 5
CHAPTER III Literature Review 6 3.1 Size of adenoid as a determinant of nasopharyngeal obstruction 6 3.2 Causes of adenoid enlargement 8 3.3 Clinical Effect of adenoid enlargement 9 3.4 Diagnosis of obstructive adenoid enlargement 14
3.5 Diagnosis of otologic complications of enlarged adenoids 19
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CHAPTER IV Patients and Method 21 4.1. Patient selection 21 4.2. Inclusion criteria 21 4.3. Exclusion criteria 22 4.4. Ethical considerations 22 4.5. Study Design 22 4.6. Data Collection and Analysis 25
CHAPTER V Results 27
CHAPTER VI Discussion 37
CHAPTER VII Conclusion and Recommendations 47 References 49 Appendix I 54 Appendix II 57
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LIST OF FIGURES AND TABLES
LIST OF FIGURES Figure 3.1 (a) Picture of lateral soft tissue radiograph of nasopharynx 17
Figure 3.1 (b) Diagram of lateral soft tissue radiograph of nasopharynx 17
LIST OF TABLES
Table 1 Age and Sex Distribution 28
Table 2 Distribution of symptoms of obstructive adenoid enlargement 29
Table 3 Tympanogram types compared with clinical otoscopic findings 31
Table 4 Distribution of mean AN Ratio in relation to Age 33
Table 5 Distribution of Tympanogram in relations to AN ratio 35
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ABBREVIATIONS
UNTH: University of Nigeria Teaching Hospital
OME: Otitis Media With Effusion
OSA: Obstructive Sleep Apnoea
SUMMARY
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BACKGROUND: Obstructive adenoid enlargement is a common ailment encountered in Paediatric-Otolaryngological practice yet there is paucity of information on its clinical presentation and epidemiology in Nigeria. The causal relationship between the size of the adenoids and and development of otitis media with effusion (OME) is still a controversial subject. AIM: The aim of this study is to obtain basic data on the pattern of obstructive adenoid disease among children and to evaluate correlation, if any, between adenoid enlargement and otitis media with effusion. METHODOLOGY: It was 1-year hospital-based, descriptive, cross- sectional study in which consecutive eligible patients aged 0-15 years were recruited from all the new patients aged 0-15 years that attended the ENT clinics of UNTH Enugu between April 2004 and March 2005. RESULTS: The study showed 16.6% prevalence of obstructive adenoid enlargement with a significant male preponderance of 1.9 :1 (X2=4.07; P<0.05). The peak age at presentation was in the age range of 0-3 years. The commonest presenting symptoms were Snoring (98.4%), mouth- breathing (96.9%) and nasal obstruction (78.1%).Prevalence of OME= 39%. CONCLUSION: Obstructive adenoid enlargement was a common clinical presentation mostly among younger children and males. Otoscopy was comparable to tympanometry, though less reliable, in the diagnosing of OME. Obstructive adenoid enlargement was a causative factor of the OME, but there was no correlation between the degree of nasopharyngeal obstruction by the adenoids and the presence of OME (r =0.109; P>0.05 ). Key Words: Adenoid enlargement, Nasopharyngeal obstruction, Otitis media with effusion, Nigeria.
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CHAPTER I
INTRODUCTION
1.1 Background
Although obstructive adenoid disease is a common ailment encountered in Paediatric and Otolaryngological practices1, there is scanty information on the epidemiology and clinical problems of obstructive adenoid enlargement in Nigeria, especially from South
Eastern Nigeria.
It has been common practice to carry out adenoidectomy as part of treatment of otitis media with effusion in children 2. Studies have shown significant curative effect of adenoidectomy or adenotonsillectomy on otitis media with effusion (OME) that were resistant to medical treatment 1,2. However, some other researcher have documented no significant beneficial effect of adenoidectomy on OME3.
There is, therefore, a need to study the prevalence of otitis media with effusion among children presenting with symptoms of obstructive adenoid enlargement and to evaluate a relationship, if any, between the two.
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The adenoid is composed of lymphoid follicles in a delicate reticulum of fibers and is a peripherally placed lymphoid structure from which efferent lymph ducts pass to the cervical group of lymph nodes.4
These lymphoid follicles are capable of considerable hyperplasia when exposed to infection and ultimately lead to gross enlargement of the adenoid with obstruction of the nasopharyngeal airway.
Clinical diagnosis of enlargement of adenoid is made from the history of the presence of nasal obstruction, snoring, and mouth breathing.5 Physical findings are open mouth posture, nasal discharge, stertorous breathing, enlarged adenoid vegetations on postnasal examination and radiological evidence of enlarged adenoids in plain X- ray of the post nasal space.6 0ther useful diagnostic tools are nasopharyngoscopy and computed tomography.
Some of the complications of adenoid enlargement are recurrent attacks of acute otitis media, otitis media with effusion with consequent hearing loss in children and obstructive sleep apnoea especially when there are also enlarged palatine tonsils. The obstructive sleep apnoea when severe can lead to chronic hypoxaemia and ultimately result in cor pulmunale.5 Other complications are orthodontic effects which include high-arched palate, crowded teeth, and pinched underdeveloped nose.
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Traditionally, the initial management of symptoms of adenoid enlargement is non-surgical using antibiotics, local and systemic decongestants, and antihistamine. Surgical treatment by way of adenoidectomy is usually employed when symptoms persist or recur after conservative management, or when complication(s) threaten to occur or are present.
1.2 Justification And Significance Of The Study.
Adenoidal enlargement not only affects the health of the child but also has great social and economic impact on the family and community in general.
The actual incidence of this disease, the pattern of presentation, the complication profile and the outcome of surgical treatment are yet to be studied in children of South Eastern Nigeria.
This study therefore aims to evaluate the clinical profile and prevalence of obstructive adenoid enlargement and also any relationship between the degree of nasopharyngeal obstruction by adenoid and development of otitis media with effusion in our environment.
It is therefore hoped that this study will add to the existing body of knowledge on adenoid enlargement and its effect on the middle ear
16 function in children. It is also hoped to provide basis for comparison with studies from other parts of the world.
1.3 Scope And Limitation Of The Study
The study is prospective, descriptive, cross-sectional and hospital based. The study population is children aged between 0 and 15 years and attending the Ear, Nose and Throat (E.N.T.) Clinics of the University of
Nigeria Teaching Hospital (U.N.T.H), Enugu.
The U.N.T.H. Enugu is a major referral hospital in South-Eastern
Nigeria with a wide catchment area extending to the states of Anambra,
Abia, Akwa Ibom, Benue, Ebony, Kogi, Imo and Enugu. Its ENT clinics have wider catchments areas than the hospital average, because the specialty is not fully developed in the newer teaching/specialist hospitals whose catchments areas overlap with that of the U.N.T.H. Enugu.
There was no significant limitation encountered during the course of the study.
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CHAPTER II
AIMS AND OBJECTIVES OF THE STUDY
Aim
To evaluate the pattern of presentation of obstructive adenoid enlargement among children presenting at the Otolaryngology clinics of
UNTH Enugu.
Objectives
1. To determine the prevalence of obstructive adenoid disease
among children aged 0-15years.
2. To determine the prevalence of otitis media with effusion
among children presenting with obstructive adenoid
enlargement in UNTH Enugu.
3. To evaluate correlation, if any, between the degree of
nasopharyngeal obstruction by adenoid vegetations and
development of otitis media with effusion.
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CHAPTER III
LITERATURE REVIEW:
3.1 Size Of Adenoids As A Determinant Of Nasopharyngeal
Obstruction
The adenoid is a lobulated mass of lymphoid tissue located at the posterosuperior wall of the nasopharynx. It is a structure with a definite function of production of antibodies, namely immunoglobulin A (IgA) locally, immunoglobulin G (IgG), and immunoglobulin M(IgM)6.
The determinants of nasopharyngeal obstruction by adenoid vegetation are; the degree of adenoidal enlargement and the size and shape of the nasopharyngeal space. Both the size and shape of the nasopharyngeal space vary considerably and the major factor in this variation is the shape of the roof of the nasopharynx 7. In some individuals, the arch of the roof of the nasopharynx is flat rather than high thereby having a small supero-inferior dimension. This ultimately decreases the size of nasopharyngeal airway. For these individuals, even adenoid vegetations that are not significantly enlarged cause obstruction of nasopharyngeal airway. On the other hand, individuals with large supero-inferior diameter of the nasopharyngeal space will accommodate even an enlarged volume of adenoid without a significant obstruction of the nasophayngeal airway7.
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The size of the adenoids varies from child to child and also in the same individual as he or she grows. In general, the normal adenoids attain their maximum size between the ages of two and seven (2 -7) years, remain the same from seven to nine years (7-9) and then gradually begin to involute.8 Though it was documented that adenoid tissue is not radiologically demonstrable in infants aged 0- 1 month 9, it is known that adenoids, like the tonsils, are usually present at birth, but small and rudimentary6 .
The adenoids was shown to grow more rapidly than does the nasopharynx from age of 3-5 years with a consequent decrease in size of the nasopharyngeal airway at this period. Subsequently, the size of the adenoid remains relatively constant whilst the nasopharynx increases in size so that the airway progressively enlarges.10
Physiological variations in the size of nasopharyngeal airway occur during sleep, crying, and swallowing due to the movement of the mouth and position of the soft palate.10
3.2 Causes Of Adenoid Enlargement
The main disease processes that cause enlargement of the adenoids are infective although it was suggested that allergic episodes also result in adenoidal enlargement 6.The term “adenotonsillits” is generally
20 accepted as it is logically inconceivable that the adenoids and palatine tonsils can be acutely infected independently of each other. It is easier to directly visualise the palatine tonsils and any signs of acute infection there, than the adenoids which are hidden away form direct view in the nasopharynx. This is probably why the term “acute tonsillitis” is most frequently used, but it is almost certain that the adenoids are involved at the same time. 6
Bacteriological cultures of adenoids, tonsils and nasopharynx yield similar organisms viz: Streptococcal Pneumonia, Haemophilus influenza,
Beta haemolytic streptococcus, and staphylococcal aureus6,11. Similarly, the viral cultures of adenoids and tonsils grew similar organisms namely the adenoviruses, Epstein-Barr virus, herpex simplex virus. 6
A balance between the microbial colonization of the adenoids and the local immune mechanisms available in the nasopharynx are of importance in the maintenance of health and well-being of children in whom otitis media and sinusitis are frequent problems. Available studies suggest that a local immune system exists in the adenoids and plays a critical role in adherence, colonization and spread of bacteria and viruses to the middle ear and paranasal sinuses and this local immune system in the adenoids may modulate and prevent these potential events 12.
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Some researchers concluded, after a study aimed at correlating histological and clinical findings of atopic and non-atopic children using surgical specimens of adenoidectomy, that; in atopic children, there was oedema of the chorium of their adenoids which was not significant in non-atopic children. Also eosinophils and mast cells were present in the oedema within the adenoids thus suggesting allergic aetiology in this group of children with adenoid enlargement 13. They suggested treatment with antihistamines which they proposed would diminish the oedema within the adenoid tissue and in so doing adenoidectomy may not be indicated in children with moderate adenoid hypertrophy and allergic rhinitis presenting with upper airway obstruction 13.
Acute viral and bacterial infections of the adenoids result in hyperplasia and hypertrophy of the lymphoid follicles within the adenoids. These lead to gross increase in the size of the adenoids especially when the infection is recurrent14.
3.3 Clinical Effects Of Adenoid Enlargement
The effects of adenoid enlargement are related to its physical obstruction of the nasopharyngeal airway and the Eustachian tube openings thus impairing their functions.
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3.3.1 Habitual mouth breathing and enlarged adenoid
The experience of most 0tolaryngologists is that large adenoids partially or totally obstruct nasal respiration causing snoring, hyponasal speech and forcing the child to breath through the mouth 5,6.
3.3.2 Obstructive-sleep apnoea caused by enlarged adenoid.
Apnoea occurs when there is cessation of airflow at the nostrils and mouth for at least 10 seconds, while obstructive sleep apnoea syndrome (OSAS) is diagnosed when 30 or more apnoeic episodes during a 7-hour sleep15. Enlarged adenoids have been shown to cause obstructive sleep apnoea 5,15. OSAS may be associated with hypersomnolence during the day which is believed to be the result of interruptions of normal sleep with frequent awakening during the apnoeic episodes 5,6 .
It is widely believed that long-term complication of untreated obstructive sleep apnoea in children with adenoid enlargement is the development of cor pulmonale and right sided ventricular failure 6. Luke et al reported cases of four (4) children with adenoidal enlargement who developed cardio-respiratory changes ranging from moderate cardiac enlargement and right ventricular hypertrophy to cor pulmonale and pulmonary oedema. These complications were completely relieved by adenotonsillectomy (in 3 children) and adenoidectomy alone (in one
23 child).They concluded that cardio-respiratory complications are seen in some children with obstructive adenoid enlargement and advocated adenoidectomy or adenotonsillectomy for these conditions 16.
3.3.3 Effects of adenoid enlargement on the ear.
This has long been and remains a controversial subject 3. The classical concept is that enlargement of the adenoids or recurrent infections of the adenoids result in recurrent acute otitis media and/ or otitis media with effusion 6. It was demonstrated by both radiological and pressure studies that adenoids can and do obstruct the eustachian tube openings at the nasopharynx and that adenoidectomy relieves the obstruction17.
The “exvacuo” theory of otitis media with effusion postulates that chronic negative pressure in the middle ear secondary to eustachian tube malfunction, results in the development of a transudate into the middle- ear space 17.The effusion is sterile and, therefore, therapy should be aimed chiefly at relieving eustachian tube dysfunction 17.
The outcome of adenoidectomy in the treatment of otitis media with effusion was evaluated in a series of 38 children with otitis media with effusion scheduled for adenoidectomy. Evaluation 2 years after surgery showed decreases in recurrence rate of otitis media with effusion,
24 improvement in hearing, and decreases in the negative middle ear pressure 18.
In a study to show the effect of adenoid enlargement on eustachian tubal functionality, it however was concluded that hypertrophy of adenoids was not the only cause of tubal functional impairment as a percentage of the children in the series who had adenoidectomy continued to have types B & C tympanograms. Other causes found were allergy and sinunasal infections19.
Another study that evaluated the significance of adenoidectomy in the treatment of otitis media with effusion (OME), reported that adenoidectomy had a high cure rate only in the children under age of 3 years. Beyond the age of 3 years, there was no significant difference in the cure rate of otitis media with effusion between children that had adenoidectomy and those that did not 20. In a study to determine the aetiology and sequele of otitis media with effusion, it was demonstrated that in two-thirds of the 270 children studied, the adenoids were either not enlarged in the first place or had previously been removed surgically, and that even after surgical removal these children continued to have recurrences, persistence or relapse of the otitis media with effusion. It was therefore concluded that for these children adenoidectomy had little part to play in their management 21.
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Similarly, Okeowo22 reported no significant difference in the observed incidence of secretory otitis media between Nigerian children who had gross adenoid enlargement and normal control group. He documented 4.4% incidence of secretory otitis media for the enlarged adenoid group, and 4.9% for the control group.
Spontaneous resolution of otitis media with effusion should always be considered when evaluating the benefits of various treatment modalities for otitis media with effusion. In a study to assess the sequel of untreated secretory otitis media in Nigerian children, it was concluded that secretory otitis media in Nigerian children resolved spontaneously without significant sequel like tympanosclerosis and hearing impairment 23.
Enlargement of adenoid also impedes mucocilliary flow in the nasopharynx and the stagnant mucus encourages growth of pathogens that would otherwise be washed away. These pathogens lead to ascending infection into the eustachian tube and middle ear and ultimately result in recurrent acute otitis media 6. The adenoid vegetation itself is also regarded as site of infection from where pathogens ascend the eustachian tube. Pus aspirated from the middle ear in acute suppurative otitis media contained the same microorganisms as in the nasopharynx 24.
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3.4 Diagnosis Of Obstructive Adenoid Enlargement
Diagnostic criteria for obstructive adenoid enlargement have been evaluated and are based on the clinical history, physical examination and radiological investigation5,6.Symptoms of mouth breathing, noisy breathing and snoring are suggestive. Other suggestive symptoms are recurrent ear infections, and hearing impairment. However, other causes of hearing impairment like congenital hearing loss, wax impaction in the ears should be excluded. Anterior rhinoscopy may reveal normal nasal cavities or may show nasal congestion or nasal discharge. In some older children that would allow examination of the nasopharynx with postnasal mirror, large adenoid vegetation may be seen. Unfortunately, in most children it is impossible to assess the size of the adenoids in this way 6.
It was stated that a child with enlarged adenoids had a characteristic facial appearance – the so-called “Adenoid facies”6. This was described as :
(a) Open lip posture with prominent upper teeth and short upper
lip, and
(b) A thin nose with hypoplastic maxilla, narrow alveolus and a
high arched palate.
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These findings have also been observed in normal children without adenoid enlargement 6. It was suggested that these findings were merely inherited variation of the normal. It is possible that normal size adenoids in an inherited hypoplastic maxilla may give rise to symptoms whereas this might not occur in a child with normal maxilla. 6
A reliable way of assessing the size of the adenoids is to take a lateral soft tissue radiograph of the nasopharynx. This will measure the relative size of the adenoids to that of the nasopharyngeal airway. In comparing clinical assessment using finger probing of the nasopharynx with radiological assessment, Goldman et al concluded that radiological assessment is a safer, simple and accurate method of assessing the size and shape of adenoid and the degree of nasopharyngeal obstruction than finger probing which is fraught with difficulties 7. Jean et al used lateral cephalometric radiographs of 38 children 3 days before their adenoidectomy to show that there was correlation between radiological measurement/assessment and volume of adenoids removed at adenoidectomy 25. They suggested using linear measurement of the palatal airway at the narrowest point between the outlines of the adenoids and soft palate, and measurement of nasopharyngeal soft tissue area. An earlier study also concluded that lateral radiograph of the soft tissue of postnasal space gave a good measure of the size of the adenoids and the
28 degree of nasopharyngeal airway obstruction than clinical examination of the postnasal space 26.
Other measurements for the size of adenoid and degree of nasopharyngeal obstruction using lateral soft tissue radiograph of the nasopharynx include: i). The adenoidal-nasopharyngeal ratio (AN ratio)
AN ratio was first described by Fujioka et al as a reliable method of expressing the size of the adenoids and patency of the nasopharyngeal airway 27. Subsequently, Elwany modified the AN ratio and used it as a method of selecting patients for adenoidectomy 28. The highest mean value for AN ratio of 0.59 was found in 1,398 normal children 27.
Elwany found mean AN ratio values of 0.59 (range = 0.499 – 0.621),
0.68 (range = 0.652 – 0.742) and 0.73 (range = 0.732 – 0.853) for normal size, moderately enlarged and markedly enlarged adenoids respectively in the 100 children selected for adenoidectomy 28. The AN ratio was shown to reliably express not only the patency of nasopharyngeal airway but also the adenoidal size 27, 28. The validity of the ratio as an indicator of adenoidal size was determined by comparing the AN ratio with visual subjective assessment of the same radiographs made by other experienced observers27; and by comparing with measured adenoid size removed at adenoidectomy28
For practical purposes Elwany suggested a mean AN ratio threshold value of 0.73 above which the diagnosis of pathologically enlarged adenoid
29 was confirmed. This represented two standard deviations (2 S.D) above the mean value of 0.59 for normal adenoid size from his series 28.
Fig 3.1(a) Picture of lateral soft tissue radiograph of nasopharynx.
Fig. 3.1(b) Diagram of lateral soft tissue radiograph of nasophrynx.
B
..
A ...... Pituitary Fossa Hard Palate P S N . ..
.
Soft Palate B
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The AN ratio was calculated from the measurements extracted from a single lateral soft tissue radiograph of nasopharynx. ‘’A’’- adenoidal measurement represented a tangential distance from a point of maximal convexity of the adenoid shadow to a line (B) along the anterior margin of the basi-occiput. ‘’N’’ - the nasopharyngeal measurement was the distance between the posterior border of the hard palate (P) and the antero-inferior edge of the sphenobasioccipital synchrondisis (S)28 (see fig. 3.1 b). The AN ratio was obtained by dividing the adenoidal measurement (A) by the nasopharyneal measurement (N)27, 28; that is ; AN ratio = A/N.
ii) Another technique involves comparing the measurement of nasopharyngeal air strip with that of the thickness of the soft palate. This indicates the amount of airflow through the nasopharynx. When the nasopharyngeal air strip was half, or less than half the size of soft palate, significant obstruction was deemed to have occurs 29.
iii) The size of adenoid was also measured during adenoidectomy by
estimating the degree of choanal obstruction and the size was
graded as 1+, 2+, 3+ or 4+. This grading of the observed size of the
adenoid while the patient was in the supine position during
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surgery corresponded to 25%, 50%,75% or 100% obstruction of
the choanae, respectively 29.
iv) The actual size of the adenoids was determined by measuring the
volume of the adenoids removed at adenoidectomy28.
In a study to determine the best posture when taking plain radiograph of the lateral soft tissue of nasopharynx for assessment of adenoidal size, it was concluded that supine posture gave a more accurate reflection of adenoidal size as opposed to erect posture which was likely to significantly under-estimate the degree of adenoidal enlargement30.
Diagnosis of obstructive adenoids in the nasopharynx may be done using computerized tomographic (CT) scan, magnetic resonance imaging(MRI) and flexible nasopharyngoscopy techniques. These facilities are scarce and therefore not widely used.
3.5 Diagnosis Of Otologic Complications Of Adenoid Enlargement
Otologic complications of obstructive adenoid enlargement are usually diagnosed from the history of hearing impairment, recurrent otalgia, and/or otorrhoea. Otoscopic examination may show hyperaemic tympanic membrane which may be bulging in the case of acute otitis media. Otoscopic appearance of otitis media with effusion varies. The tympanic membrane may look dull red, grey, or amber yellow. It can
32 bulge forward, or be retracted, or even appear normal.17 Existence of chronic middle ear effusion is most easily confirmed when there is a definite fluid level or when bubbles are visualized within the middle ear space on otoscopy especially if micro otoscopy is done 17. In children with otitis media with effusion, pneumatic otoscopy may show impaired mobility of the tympanic membrane 17. Although tympanometry is generally accepted as a reliable diagnostic method for otitis media with effusion, clinical method of diagnosis of OME has also been shown to compare favourably with results of tympanometry 17,31. In comparing simple otoscopic findings with tympanometry results using 785 unselected ears, 85% agreement was found between the two methods 31.
Berry et al found 93% correct prediction value of type B tympanogram for middle ear effusion and concluded that tympanometry can be used reliably as an indicator of middle ear effusion 32. Effusion in the middle ear can be confirmed by doing tympanocentesis but this is considered to be invasive21, 32.
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CHAPTER IV
PATIENTS AND METHOD
4.1 Patient Selection
This is one year prospective study of all children aged (0 –15) years seen and treated at the E. N. T clinics of the U.N.T.H Enugu for obstructive adenoid disease from April 2004 to March 2005.
On attending the clinic, each new patient aged 0-15 years was seen by the author and evaluated for symptoms of obstructive adenoid enlargement. When clinical diagnosis of obstructive adenoid disease was made, the patient was then evaluated further to ascertain eligibility for inclusion in the study.
4.2 Inclusion Criteria
Those included were children who presented with one or more of
the following symptoms:
- Snoring
- Mouth breathing
- Chronic Nasal obstruction
- Recurrent nasal discharge
- Obstructive sleep apnoeic attacks
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4.3 Exclusion Criteria
The following groups of patients were excluded from the study:
- Those that had adenoidectomy prior to the study;
- Those with nasopharyngeal neoplasm.
- Those whose age is outside the range of 0-15 years.
- Those who refuse consent.
4.4 Ethical Consideration
For those who were recruited into the study, the study protocol was explained to the patients and parents or guardian in a language they understood and written informed consent obtained from the parents or responsible guardian (see Appendix 2).
The research protocol was reviewed and approved by the UNTH Hospital Ethical review Committee.
4.5 Study Design
It was prospective hospital-based, descriptive cross-sectional study. When a patient was found eligible and recruited into the study, personal data, clinical history and other data were obtained by filling out the form designed for this purpose (see Appendix 1).
The information/data obtained were:
(a) Names, sex, age and hospital number
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(b) History of symptoms of nasal obstruction, noisy breathing, snoring, mouth breathing, breathlessness, hearing loss, otalgia, otorrhoea, apnoic episodes during sleep, day-time hypersomnolence, and duration of these symptoms. Other symptoms included are: otorrhoea, otalgia, hearing loss in order to assess the otologic complications of obstructive adenoid enlargement.
(c) The severity of the adenoidal obstruction of the nasopharyngeal airway was assessed clinically using a “symptomatology assessment score” of the above symptoms. Presence of each of the above symptoms represents a score of one (1). The total number of score obtained from each child was used to assess the severity of his/her symptoms of adenoidal obstruction (see Appendix). The severity was graded as follows: Total score of 1-3=Mild; 4-6 =Moderate; 7-9 =Severe.
(d) A general physical examination and a detailed Ear, Nose and
Throat examination was then carried out on each patient. In the ear examination, simple otoscopy was carried out using battery-powered otoscope . The appearances of the tympanic membranes were categorized into two groups as follows: (i) “Normal”; representing the tympanic membranes that had normal shinny and intact appearances. (ii)
“Abnormal”; representing tympanic membranes that had appearances
36 consistent with OME – dullness, retraction, discolouration (dull red).
The appearances were compared with the results of tympanometry.
The nasal examination done included anterior rhinoscopy (in all the patients) and mirror nasopharyngoscopy which was attempted in 14 older children aged 5-12 years.
(e) X-ray of lateral soft tissue of postnasal space was obtained for each patient. The x-ray film was taken by standard technique of lateral soft tissue radiograph of the nasopharynx. The beam was centered to the external auditory meatus with the head in true lateral position and child breathing through the nose with mouth closed. The degrees of obstruction of the nasopharyngeal airway were evaluated and analysed using the adenoid-nasopharyngeal ratio 27, 28.
The AN ratio was calculated from measurements obtained from the lateral soft tissue X-ray of the postnasal space as already explained in section 3.4 ( Fig 3.1). The dimensions of the adenoid and nasopharnx were measured with a transparent rule in centimeters. The ratio was obtained by dividing the adenoid dimension by the nasopharyngeal dimension, and the value obtained was approximated to two decimal points.
(f) Tympanometry was requested for all the children but those having active ear discharge, tympanic membrane perforation, otitis externa as well as those that were restless and could not be sedated due to their
37 parents refusal were excluded from tympanometry. The tympanometry was carried out using “SAT 12; Audio Med” impedance meter. The meter automatically measured the compliance of the middle ear system as the pressure swept automatically from + 200 mm of water to – 400 mm of water and was plotted as a curve on a tympanograph. A probe tone of
226hz was used for each patient. Both ears were tested separately. The tympanograms obtained were analysed and categorized into two groups viz: (a) those with type B tympanogram (indicating presence of middle ear effusion) (b) those with types A and C tympanograms (without middle ear effusion). The degree of nasopharyngeal obstruction present in each group was determined by calculating the mean AN ratio and compared with the other group.
4.6 Data Collection And Analysis
4.6.1 Data collection : Information obtained was recorded by the author in a special form designed for this study ( Appendix). 4.6.2 Data analysis : The data obtained was analyzed with statistical tools of mean, mode, standard deviation, student t-test, analysis of variance (ANOVA), Pearson correlation coefficient(r), and chi-square (X2) using “SPSS” computer program .
4.6.3 Determination of terms of variables 1) Tympanogram in relation to the middle ear function was analysed using the modified Jergers 33 classification as follows: - Type A = normal middle ear function.
38
(the maximal compliance ranged from 0.39 ml to 1.30 ml. While middle ear pressure range from +200 mm/water – 99mm of water)
- Also included here are subtypes As (low maximum compliance at
normal pressure) and Ad (very high compliance at normal pressure). - Type C = Eustachian tube dysfunction (point of maximal compliance occurring below – 100 mm of water)
C1 = middle ear pressure of – 100 to – 199mm of water
C2 = middle ear pressure of – 200 to - 400 mm of water - Type B = presence of middle ear effusion. (flat curve of the compliance tracing).
2) The degree of nasopharyngeal obstruction was determined by using AN ratio as already explained in section 3.4 (Fig 3.1) and categorized as follows: - Group I – 0.50 – 0.62 (mild obstruction) - Group II – 0.63 – 0.75 (moderate obstruction) - Group III – 0.76 – 0.88 (severe obstruction)
39
CHAPTER V
RESULTS
A total of 386 new patients aged 0-15 years were seen in the ENT
Clinics of UNTH Enugu between April 2004 and March 2005.The total number of males was 209 while the number of females was 177. Of these
386 new patients,64 consecutive patients presented with symptoms of obstructive adenoid enlargement and met the inclusion criteria of the study and were therefore recruited into the study.
Of the 64 patients studied, 42 (65.6%) were males and 22 (34.4%) were females giving male/female ratio of 1.9:1.0. Using chi square test for significant difference in proportions, the observed male preponderance was found to be statistically significance
(X2=4.07;p<0.05). Their ages ranged from 6 months to 12 years. No patient was older than 12 years. The mean age at presentation was 3 1/3 years with a standard deviation (SD) of 2.3. The peak age at presentation was in the age range of 0-3 years accounting for 62.5% (40 patients) of the total number of patients studied. Only one (1) patient (aged 12 years) was seen in the age range of 10-12 years (see Table 1).
The commonest presenting symptoms were snoring (98.4%), mouth-breathing ( 96.1%) and nasal obstruction (78.1%).
40
TABLE 1 : AGE AND SEX DISTRIBUTION. (n=64)
Sex
Age Groups Males Females Total Percentage
0-3 Years 26 14 40 62.5%
4-6 Years 10 7 17 26.6%
7-9 Years 5 1 6 9.4%
10-12 Years 1 0 1 1.6%
Total 42 22 64 100%
41
TABLE 2: DISTRIBUTION OF SYMPTOM OF OBSTRUCTIVE
ADENOID ENLARGEMENT. ( n=64)
Symptoms No Of Patients Percentage
Snoring 63 98.4%
Mouth Breathing 62 96.9%
Nasal Obstruction 50 78.1%
Obstructive Sleep
Apnoea 48 75.0%
Nasal discharge 38 59.4%
Hearing Impairment 6 9.4%
Otalgia 5 7.8%
Otorrhoea 4 6.3%
Daytime
Hypersomnolence 3 4.7%
42
The least presenting symptoms were daytime hypersomnolence
(4.7%) and otorrhoea (6.3%). See Table 2.
The result of the examinations carried out revealed only 3 patients
(4.7%) presenting with adenoid facie. 26 patients had mucus discharge in one or both nasal cavities. Mirror nasopharyngoscopy was attempted in
14 older children aged 5-12 years but was unsuccessful in all the children examined as they could not stand the mirror examination.
The result of simple otoscopy revealed normal appearance of the tympanic membranes in a total of 43 ears (52.4%), while the total abnormal findings occurred in 39ears (47.6%). Of the abnormal otscopic findings, dullness of tympanic membranes accounted for 71.8%, while red discoloration and retraction accounted for 12.8% and 15.4% respectively. Comparing otoscopic and tympanometric findings, Table 3 shows the number of otoscopically abnormal ears associated with different tympanometric findings. The highest proportions of abnormal tympanic membranes were associated with types B and C tympanograms accounting for 84.4% and 38.9% of the abnormal otoscopic findings respectively, while type A tympanogram was associated with 5 (15%) abnormal ear drums.
43
TABLE 3: PROPORTIONS OF OTOSCOPICALLY ABNORMAL
EARS WITH TYPES OF TYMPANOGRAM. n=82 ears.
______
Tympanogram Types Otoscopic Findings
Normal Abnormal
A 27 5 (15.6%)
B 5 27(84.4%)
C 11 7(38.9%)
Total 43 39(47.6%)
44
The mean symptomatology assessment scores (SAS) of the patients was 4.4. The lowest score of 2 was observed in only one patient while the highest score of 6 was observed in total of 5 patients. The modal score was 5 accounting for 40.6% of the patients. In assessing the severity of the adenoidal symptoms, 52 patients (81.3%) had symptoms of moderate (total SAS of 4-6), while only 12 patients (18.6%) had mildly symptoms (total SAS of 1-3). No patient presented with severe symptoms (SAS of 7-9). There was no significant correlation between the SAS and age of the patients (r = -0.22; p>0.05). There was also no significant correlation between symptomatology assessment score and
AN ratio of the patients. (r = 0.058; P>0.05).
The AN ratio of the patients ranged from 0.50 to 0.88 and had an overall mean of 0.718 with a standard deviation (S.D) of 0.096. The highest mean AN ratio of 0.738 was obtained in the age group of 0-3 years. The mean AN ratio decreased progressively in the older age groups (see Table 4). Using analysis of variance (ANOVA), there was significant difference in the mean AN ratio between the age groups
(F = 4.677; P<0.05). There was also high significant negative correlation between age and AN ratio (r = - 0.340; P<0.01).
45
TABLE 4: DISTRIBUTION OF MEAN AN RATIO IN
RELATION TO AGE GROUPS. n=64
______
Age Groups No of Patients Mean AN Ratio Std. Deviation
0-3 years 40 0.7380 0.09463
4-6 years 17 0.7147 0.07715
7-9 years 6 0.6183 0.08886
10-12 years 1 0.5800 ____
46
The mean AN ratio for the male patients was 0.719 with S.D of
0.101 while that of the females was 0.713 (SD = 0.089). The difference was not statistically significant (t = 0.275; P>0.05).
Tympanometry was obtained from a total of 41 patients (64.1%) with age range of 1-8 years making 82 tympanograms from 82 ears available for analysis (see Table 5 ). Tympanometry was not done on the remaining 23 patients who either had active purulent ear discharge, or tympanic membrane perforation, or otitis externa, as well as those patients that were restless during the test and could not be sedated due to their parents refusal.
Type A tympanogram was found in 32 ears (39.0%) while type C was found in 18 ears (22.0%). This gives a total of 50 ears with types A and C tympanograms. 32 ears (39.0%) from 18 patients had type B tympanogram. 14 of the patients had type B in both ears (28 ears), while each of the remaining 4 patients, had type B in either ear and type C in the other ear. Of the 18 patients with type B tympanograms, 10 (55.6%) were males, while 8 (44.4%) were females. The proportion of the males that developed OME was not significantly different from that of the females (X2=0.015; p>0.05). The types of tympanogram distribution among the AN ratio groups is as presented in Table 5.
47
TABLE 5: DISTRIBUTION OF TYMPANOGRAMS IN
RELATION TO AN RATIO. (n=82)
AN Ratio Groups Types Of Tympanogram
Type A Type C Type B Total
Group 1
(0.50-0.62) 12 3 5 20
Group 11 5 4 9 18 (0.63-0.75)
Group111 15 11 18 44 (0.76-0.88)
Total 32 18 32 82
48
The mean AN ratio for patients with type B tympanogram (middle ear effusion) was 0.727, with S.D of 0.105 and was 0.708 (SD=0.091) for the group of patients with types A and/or C tympanograms (no middle ear effusion). Using t-test for equality of means, there was no significant difference regarding the mean AN ratios between the group of patients with OME and those without OME (t = 0.519; P>0.05).
In the AN ratio group I (0.50-0.62), there were total of 5 ears with type B tympanogram, 12 ears had- type A and 3 ears had type C. For group II (0.63-0.75), a total of 9 ears had type B, while 5 ears and 4 ears had types A and C respectively. And in group III (0.76-0.88), a total of
18 ears had type B, while 15 ears and 11 ears had types A and C respectively. There was no significant difference in the proportion of ears with type B tympanogram among the various AN ratio groups (x2 =
2.630; P>0.05). Also, there was no significant correlation between the degree of nasopharyngeal obstruction by adenoids (AN ratio) and the presence of middle ear effusion (r =0.109; P>0.05 ).
49
CHAPTER VI
DISCUSSION
From the present study the prevalence of adenoidal symptoms among 386 patients with the age range of 0-15 years seen at the
Otolaryngology Clinics of UNTH Enugu was 16.6% . Haapaniemi found
12.7% prevalence of snoring and mouth-breathing among 687 children with age range of 6-15 years in his elementary school community- based study 8. The slightly higher prevalence in the present study may be attributed to the inclusion of younger population of children (0-5 years) in this study and also the fact that the present study was hospital- based which is expected to have a higher prevalence than the community average.
The sex distribution showed significant male preponderance with a male to female ratio of 1.9:1 (X2 =4.07; P >0.05). The reason for the male preponderance is not known .
From the age distribution the peak prevalence of adenoidal symptoms occurred in the age range between 0-3 years. The prevalence thereafter sharply decreased with increasing age. The reason for this observed trend may partly be due to higher incidence of upper respiratory tract infection in younger children which has been shown to cause enlargement of the adenoid and ultimately leads to obstruction of
50 nasopharyngeal airway6. This trend may also be partly explained by the higher growth rate of adenoid tissue relative to the nasopharyngeal growth rate observed in younger children (2-5 years) which subsequently reverses from the age of 7-9 years when the adenoids start to regress while the nasopharynx continues to grow 8,10. The result of the combined effect of the above factors is a relatively smaller nasopharyngeal airway in younger children than the older ones so that even relatively smaller adenoids will cause significant nasopharyngeal obstruction in younger children. Therefore, younger children tend to present more frequently with obstructive adenoidal symptoms than their older counterparts.
Obstructive Adenoidal Symptoms:
Obstructive adenoidal enlargement should be suspected in children with chronic nasal obstruction, hyponasal speech, snoring, mouth– breathing, recurrent nasal discharge, sleep apnoeic attacks, and daytime hypersomnolence 6,8,18.
Snoring and mouth-breathing were by far the commonest presenting symptoms of obstructive adenoid enlargement in the present study. This is in agreement with other studies which found that symptoms of snoring and mouth breathing were important predictors of obstructive adenoid enlargement 8,18. Hibbert reported that 80% of a sample of 10% of Otolaryngologists in the United Kingdom thought a history of nasal
51 obstruction and Snoring important in pre-operative assessment for adenoidectomy, while 65% thought evidence of mouth breathing important34.
In the present study, hearing impairment was not a common presentation of obstructive adenoid enlargement even among the patients with middle ear effusion. Only 11.1% of patients with middle ear effusion presented with hearing impairment. The reason for the apparent low frequency of complaint of hearing impairment among patient with middle ear effusion may be due to the observed difficult of parent in recognizing the hearing impairment of their children especially when mild35.
Degree of Nasopharyngeal obstruction by adenoid
A single lateral soft-tissue radiograph of the nasopharynx was used in this study to evaluate the degree of nasopharyngeal obstruction. The adenoid-nasopharyngeal (AN) ratio as designed by Fujioka and modified by Elwany which was used in the study has been shown to reliably measure the relative size of the adenoid 27,28. The ratio determines the degree of nasopharyngeal airway obstruction by the adenoid tissue. This in turn is directly proportional to the adenoidal size and inversely proportional to the nasopharyngeal dimensions.
52
The mean AN ratio in the present study was found to be 0.718 (SD
= 0.096). Elwany found mean AN ratio of 0.713 (SD = 0.105) among 100 symptomatic adenoidal patient aged 3-7 years selected for adenoidectomy 28. Despite the different racial groups and age ranges in both study populations, the mean AN ratios are similar. This suggest that
AN ratio is reliable index in assessing the degree of nasopharyngeal obstruction by adenoids.
The degree of nasopharyngeal obstruction was not related to the severity of adenoidal symptoms as no significant correlation was found between the AN ratios and the symptomatology assessment scores of the patients in the study. This is similar to the finding in another related study36 which showed that snoring was significant indicator of adenoidal enlargement but lacked correlation with weight of adenoids measured at adenoidectomy. This observation may be explained by the fact that other factors like: age, nasal septal deviation, upper respiratory tract infection; may all be playing roles in the development of obstructive adenoidal symptoms.
There was significant correlation between age and the degree of nasopharyngeal obstruction by adenoids (r = -0.340; P<0.05). The degree of nasopharyngeal obstruction was most severe in the younger age groups and milder in oldest age group. This is similar to findings in other
53 studies8,27,37. This may be as result of the documented higher growth rate of adenoid in younger age of 2-5 years followed by its subsequent regression in size as the child grows older10,37.
Although the degree of nasopharyngeal obstruction by the adenoid was slightly higher in boys than girls, the difference was not significant.
Similarly other authors reported no significant sex difference in the sizes of adenoids in their different series 8,37,38.
Adenoids in relation to middle ear effusion.
Tympanometry is a generally accepted reliably diagnostic and screening device for middle ear effusion17,39. In a particular series, type B tympanogram was shown to have up to 93% correct diagnostic value for middle ear effusion32. Using type B tympanogram for diagnosis of middle ear effusion in the present study, the prevalence of otitis media with effusion (OME) was 39%.
Although tympanometry is generally accepted as a reliable diagnostic method for otitis media with effusion, clinical diagnosis of
OME has also been shown to compare favourably with results of tympanometry 17,31,39. In comparing simple otoscopic findings with tympanometry results using 785 unselected ears, 85% agreement was found between the two methods 31. In the present study, up to 84.4% and38.9% of the abnormal ears on otoscopy were associated with type B
54 and C tympanograms respectively thus suggesting that abnormal ear drum on otoscopy has relative good agreement with tympanometry result in the diagnosis of OME. This is similar to the findings in Ogisi’s study series which showed that the highest proportions of abnormal ears on otoscopy were associated with types B and C tympanograms (60% and
26% respectively)39. Thus using otoscopy for the diagnosis of OME, the total number abnormal ear drums suggested OME prevalence of 47.6% among the patients. However, otoscopy is not as reliable as tympanometry as it is obvious that not all the abnormal ears drums were associated with abnormal tympanogram since up to 15.6% of abnormal ear drums on otoscopy were associated with normal type A tympanogram in the present study. Similarly, Ogisi found that 4.4% of abnormal ear drums on otoscopy were associated with normal type A tympanogram39.
A study in Otia, Japan found 62.0% prevalence of OME among
171 children aged 0-18 years that were scheduled for adenoidectomy due to adenoidal obstruction 3. In another related study in Bristol 79.0% prevalence of OME among 38 children aged 3-8 years with obstructive adenoidal symptoms scheduled for adenoidectomy and myringotomies 18.
The differences in the prevalence of OME between the present study and these other series may partly be due to varying age ranges in the different study populations and to racial factors. Prevalence of OME reported
55 among Nigerian children (4.9-9.9%) in nursery and primary school communities was shown to be lower compared with the prevalence OME reported among Caucasian children (9-35%) 35,40,41. There has been no conclusively proven explanation for the observed racial differences in the prevalence of OME between Caucasian and Negroid children.
Genetically determined anatomical differences in the skull base as well as genetically determined eustachian tube function have all been suggested 35,40,42,43. An observation was made that children with large adenoid vegetation in Nigerian population very rarely have aural manifestations arising from the enlargement; even when the enlargement is severe enough and sufficiently prolonged to produce grotesque adenoid facies43.
Akinlade et al found 9.9% prevalence of OME among 253
Nigerian children aged 2-7 years studied in nursery and primary schools in Lagos 40. Earlier studies in Nigerian children reported 4.9% and 8% prevalence of OME respectively 35,39. In the first series, 3-11 year old school children were studied and type B tympanogram only was used for diagnosis of OME; while in the second series, 5-6 year old school children were studied but types B and C tympanograms were used for the diagnosis (1.2% using type B alone for the diagnosis).
56
The higher prevalence of OME (39%) in the present study than that of the school population of Nigerian children (4.9%-9.9%) is due to differences in the sample populations studied. This hospital-based study is on children who already have symptoms and signs of adenoid enlargement and is therefore biased in finding more OME. It suggests that adenoid enlargement is a causative factor in the development of
OME in these children. However, the degrees of nasopharyngeal obstruction by adenoids do not appear to influence the development of
OME as no significant correlation was found between the degrees of nasopharyngeal obstruction and the presence of OME in the present study
(r= 0.109; P>0.05). Furthermore, the mean degrees of nasopharyngeal obstruction was not significantly different between the group of patient with OME and those without OME (t =0.519; P>0.05).
The causal relationship between adenoidal enlargement and OME is still a controversial subject18. Dawes demonstrated middle ear effusion in children where adenoids were not enlarged and also in those where adenoids had previously been removed 21. These group of children constituted two thirds of the 270 children with OME in his series.
A similar study demonstrated that the presence of middle ear fluid was not related to the size of adenoid. No significant difference was found between the size of adenoid in children with OME and their
57 matched control (no OME) 44. Okeowo reported a low incidence (4.9%) of OME among 90 Nigerian children aged 3-11 years with adenoid and/or palatine tonsillar enlargement who underwent adenoidectomy and/or tonsillectomy 22. He found no significant difference in the incidence of OME between these patients and his control group.
Okeowo’s finding differs from the finding in the present study because of the difference in the age ranges of both study population. His series did not include younger children and infants (0-2 years) which were included in the present study population. Akinlade et al demonstrated higher prevalence of OME among Nigerian children in the age range between 2-
3 years (14.2%) compared with those above 3 years (5%) in their study series 40.
Other studies found a high prevalence of OME among adenoidal patients scheduled for adenoidectomy in their respective series 3,18. They also found no significant relationship between the volume of adenoid
(measured after adenoidectomy) and OME, or size of adenoid (from radiological measurement) and OME respectively. On the other hand,
Haapainemi found significant association between large adenoids and
OME (P<0.0001), in his series 8.
Wright et al found no significant association between size of adenoid and presence of OME. They however found high significant
58 association existing between OME and laterally enlarging adenoids abutting the torus tubarius (x2 = 39.12; P<0.001), discovered during adenoidectomy in 273 consecutive patients treated for OME 45. Other suggested causative mechanism of OME by adenoid enlargement was by development of chronic negative nasopharyngeal pressure due to frequent sniffing (found in children with adenoid enlargement) which is transmitted to the middle ear via the Eustachian tube 46.
It is therefore conceivable that adenoid enlargement predisposes to development of OME in children. Though the size of the adenoid is not directly related to development of OME, it is conceivable that larger adenoids are more likely to extend laterally and encroach to obstruct the
Eustachian tube in the nasopharynx thus predisposing to OME.
59
CHAPTER VII
CONCLUSION AND RECOMMENDATION
CONCLUSION
Obstructive adenoid enlargement was a common Paediatric
Otolaryngological presentation at the Otolaryngology clinics of UNTH
Enugu with a prevalence of 16.6% among children aged 0-15 years.
The peak age of presentation was in the age range of 0-3years.
There was a significant male preponderance (X2 =4.07; P<0.05), with male to female ratio of 1.9:1. The commonest presenting symptoms were snoring (98.4%), habitual mouth breathing (96.1%) and nasal obstruction
(78.1%).
The prevalence of OME among the patients presenting with obstructive adenoid enlargement at the ENT clinics of UNTH Enugu was
39% using only type B tympanogram for the diagnosis. However, simple otoscopic abnormal appearances of the ear drums (dullness, retraction and red disclouration) were found to be relatively comparable to tympanometry in the diagnosis of OME.
Obstructive adenoid enlargement was a causative factor of the
OME, but this was not related to the degree of nasopharyngeal obstruction by the adenoids in these patients as no significant correlation was found between these two variables (r = 0.109; P> 0.05).
60
RECOMMENDATION
Obstructive adenoid disease should be suspected in children presenting with symptoms of snoring, mouth-breathing and nasal obstruction. Adenoid enlargement should be considered when evaluating patients with otitis media with effusion.
There is a need to further evaluate the correlation, if any, between the degree of lateral extensions of the adenoids in the nasopharynx and the development of middle ear effusion.
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61
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20. Honjo, I; Fujita, A; Kurata, K; Takahashi, H. Significance of adenoidectomy in the treatment of secretory otitis media. In A clinically oriented update. Adv. Otorhinolaryngol. Galioto G.B (ed.) Switzerland, 1992; vol 47: 246 – 250.
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66
APPENDIX 1
DATA COLLECTION FORM FOR THE STUDY: CLINICAL
EVALUATION OF OBSTRUVTIVE ADENOID ENLARGEMENT
IN UNIVERSITY OF NIGERIA TEACHING HOSPITAL, ENUGU DEPARTMENT OF OTOLARYNGOLOGY
SECTION A (Patient’s Personal Record)
Names:……………………………… Hospital number………………….
Date of Birth.…………Age…………..…Sex…………………………….
SECTION B: (Clinical History)
SYMPTOMATOLOGY ASSESSMENT SCORE
Symptoms Present (1) Absent (0)
Nasal obstruction
Snoring
Nasal discharge
Mouth breathing
Obstructive sleep apnoea
Day-time hypersomnolence
Otalgia
Otorrhoea
Hearing impairment
Total (Max. 9)
67
SECTION C (Examination findings)
General clinical examination: Stertorous breathing open mouth posture Adenoid facie No significant finding
Anterior rhinoscopy: Nasal discharge-Right left nil
Post Nasal examination: Enlarged adenoid Normal adenoidal size
Not successful
0ropharynx: palatine tonsillar enlargement-slight Moderate
Gross Normal size
0toscopy (Tympanic membrane): Right Left Normal Dull Hyperaemic Perforation Retraction
Cardiovascular system: Normal heart sounds Accentuated P2
SECTION D (Radiological Report)
Adenoidal measurement
Nasopharyngeal measurement
Adenoidal-Nasopharyngeal (A-N) Ratio:
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SECTION E (Tympanometry)
Right Left Type of Tympanogram
Compliance
Canal Volume
Pressure
Impression
SECTION F (Pure Tone Audiometry)
Right left
Not successful
Normal Audiogram
Conductive Hearing Loss
Sensorineural Hearing Loss
Mixed Hearing Loss
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APPENDIX 11 WRITTEN CONSENT FORM
I am Dr F.T Orji, a Resident Doctor in the department of Otolaryngology of UNTH Enugu. I am carrying out a research on CLINICAL EVALUATION OF OBSTRUVTIVE ADENOID ENLARGEMENT IN UNTH ENUGU.
I will like your child to be included in the study if a diagnosis of obstructive adenoid enlargement is made.
There will be no additional cost on your child due to the study. The treatment to be offered are the same routine treatment for any patient who has above condition whether he/she is included in the study or not.
You are free to accept to be included or refuse inclusion into the study without affecting the management of your child. You are also free to withdraw from the study at any time you so wish.
Name of patient………………………………………………………..
Address………………………….
This is to certify that I willingly accept the inclusion of my child into the above study.
Name………………………………………………………………………
Relationship………………………………………………………………
Signature………………………………..Date……………………………