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Relationship Between Adenoid Hypertrophy and Chronic Rhinosinusitis in Children

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Relationship Between Adenoid Hypertrophy and Chronic Rhinosinusitis in Children AAMJ, Vol.2, N. 2, April, 2004 ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ RELATIONSHIP BETWEEN ADENOID HYPERTROPHY AND CHRONIC RHINOSINUSITIS IN CHILDREN. Mostafa S. Hammad, * Abdel-Aziz M.H.El-Sherif,** Mohammad A.Gomaa,* Mohammad I.Bassyony,*** *ENT.Department El-Minia University. **ENT. Department Al-Azhar University. ***Bacteriology Department El-Minia University. -------------------------------------------------------------------------------------------- SUMMARY Purpose: The purpose of this study is to investigate the relationship bedween adenoid microbiology, adenoid size, and maxillary sinus microbiology in children with both chronic rhinosinusitis and adenoid Hypertrophy. Study design: The children with both chronic rhinosinusitis and adenoid hypertrophy were admitted to this prospective study in El-Minia university hospital. The study included 20children. The diagnosis of chronic rhinosinusitis was based on clinical and radiographic examinations. Adenoid hypetrophy was classified as medium and large based on X-Ray nasopharynx lateral view, preoperative flexible fiberoptic endoscopy and nasal endoscopy during surgery.Maxillary sinus aspirations and adenoidectomy were performed in all patients. Sinus aspirate and adenoid tissue specimens were cultured. The correlation of culture results was investigated. The relationship between adenoid size and maxillary sinus culture results was analyzed by using chi- square test. Results: Adenoid sizes were medium in 8 (40%). And large in 12 (60%) cases. Bacterial growth found on 9 of 20 (45%) sinus aspirate, and all adenoid specimen cultures showed bacterial growth 20 (100%). There was no statistical correlation between cultures obtained from adenoid tissue with those from the maxillary sinus. The relationship between adenoid size and maxillary sinus culture results was not found statistically significant (X2 = 0.96, P= 1.0). Conclusion: The reason that there was no correlation between cultures obtained from the adenoid tissue with those from the maxillary sinus is that it seems possible that the adenoids act as a barrier causing mechanical obstruction rather than a nidus for chronic sinus infection. However, there is no relationship between adenoid size and maxillary sinus culture positivity. Medium adenoids causing partial obstruction may lead to changes in the microenvironment and may start bacterial growth in children with positive maxillary culture. Further investigation is needed to explain the association between adenoid hypertrophy and rhinosinusitis. Adenoidectomy help to resolve the symptoms of chronic rhinosinusitis in the children with both chronic rhinosinusitis and adenoid hypertrophy. 24 Mostafa S. Hammad et al ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Key Words: Adenoid hypertrophy-Chronic rhinosinusitis- Adenoidectomy. INTRODUCTION Adenoid hypertrophy and sinus infection are common direases seen in the otolaryngological practice, and the symptoms and clinical findings in each of these conditions are similar and there is a known association between adenoid hypertrophy or chronic adenoid infection and rhinosinusitis[1].The adenoids may predispose to sinus infections via mechanical blockage of nasal breathing or by harboring pathogenic bacteria[2]. Although the maxillary sinus microbial- ogy in adults was adequately investigated in many reports, there are few studies in children[3-8]. Furthermore, despite many reports staging a considerable efficacy of adenoidectomy in managing of chronic rhinosinusitis in children, to our knowledge, there is no report in the literature comparing adenoid microbiology and adenoid size with maxillary sinus microbiology[9-11 ]. The purpose of this study was to investigate the relationship between adenoid microbiology, adenoid size, and maxillary sinus microbiology in children with both adenoid hypertrophy and chronic rhinosinusitis. PATIENTS AND METHODS The children with both chronic rhinosinusitis and adenoid hypertrophy were admitted to this prospective study in El-Minia university hospital the study included 20 children, 12 males and 8 females their ages ranged from 4 to 12 years, with a medium age of 6 years. The diagnosis of chronic rhinosinusitis was based on clinical and radiographic examinations. Patients presenting with recurrent (> 4 acute episodes per year) or persistent (> 12 weeks) sinusitis complaints, including rhinorrhea, nasal obstruction, cough, headache, postnasal drainage, were evaluated for chronic rhinosinusitis. Patients with these complaints and mucoperiosteal thickening of more than 5mm or complete opacification in one or both maxillary sinuses on computed tomography scans were diagnosed as chronic rhinosinusitis. All of the patients also had adenoid hypertrophy signs (mouth breathing, snoring, and nasal airway obstruction). Adenoid hypertrophy was classified as medium (partial obstruction of the posterior nares), and large (complete obstruction of the posterior nares) based on the preoperative X-Ray nasopharynx lateral view, preoperative flexible fiberoptic endoscopy, and nasal endoscopy during surgery. None of the patients received antibiotic treatment for at least 2 weeks before the operation. After informed, parental consent was obtained, maxillary sinus aspiration and adenoidectomy were performed in all patients. Maxillary sinus aspiration was performed with the patient under general anaesthesia. A 16- gauge needle was introduced beneath the inferior turbinate through the nasal lateral wall, inside the maxillary sinus; any fluid present in the sinus was aspirated with a syringe. If no fluid obtained, 3 ml of sterile saline 25 AAMJ, Vol.2, N. 2, April, 2004 ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ was instilled into the maxillary antrum and then aspirates back into the syringe. All the aspirated material was transported to the microbiology laboratory. After the aspiration procedure, the adenoids were removed with a curette. Adenoid specimens were placed into aerobic and anaerobic transport medium and sent to the microbiology laboratory. All specimens were inoculated into media supportive for aerobic and anaerobic organisms. The time between specimen collection and inoculation never exceeded 30 minutes. The adenoid tissue was homogenized in a small amount of brain heart infusion broth or sterile physiologic non bacteriostatic saline. An aliquot of the homogenized tissue was then inoculated on a trypticase agar medium that contained 5% sheep blood, a chocolate agar plate, and a MacConkey agar plate. For maxillary sinus aspirate, several drops were incubated under same conditions. For Anaerobes, the materials were plated onto prereduced vitaman K1- enriched Brucella blood agar, anaerobic blood agar plate containing phenylethyl alcohol, and enriched thioglycolate broth. The plates were incubated in anaerobic Jars and examined at 48 and 96 hours. The thioglycolate broth was incubated for 14 days. The organisms were isolated and identified by the standard methods described in the Bailey and Scott’s Diagnostic microbiology [12]. Results of cultures were correlated between maxillary sinus aspirate and adenoid tissues. Positive correlation implied if the same pathogen isolated from both sides. Negative correlation implied if the pathogen isolated from maxillary sinus was not isolated from the adenoid. In the comparison between adenoid size and maxillary sinus culture results, a chi-square test was used. Postoperatively,oral antibiotics were administered empirically; however, based on culture and susceptibility studies, the antibiotic agents were altered accordingly. Iong-term symptoms control and overall improvement were assessed at a visit 4 weeks after surgery. RESULTS The most frequently presenting symptoms were nasal obstruction (100%) mouth breathing (100%), and snoring (100%), followed by cough (80%), rhinorrhea (80%), post-nasal drainage (80%), and headache (60%). 26 Mostafa S. Hammad et al ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Table (1): The presenting symptoms in 20 children on initial evaluation: Symptom Patients (No) (%) Nasal obstruction 20/20 100 Rhinorrhea 16/20 80 Cough 16/20 80 Headache 12/20 60 Postnasal drainage 16/20 80 Mouth breathing 20/20 100 Snoring 20/20 100 Preoperative computed tomography scans showed varying degrees of maxillary, ethmoidal, frontal, and sphenoid sinus mucosal thickening. The sinuses involved were the maxillary (20 cases), sphenoid (16 cases), elhmoid (10 cases), and frontal (8 cases). Pansinusitis was present in 5 instances (Table 2). Adenoid sizes were medium in 8 (40 %) and large in 12 (60%). Table (2): preoperative CT scan Findings in 20 children. Sinusitis Involvement Patients (No.) (%) Maxillary 20 100 Sphenoid 16 80 Ethmoid 10 50 Frontal 8 40 All nasal mucosa cultures obtained after disinfection and before aspiration of the maxillary sinus showed no bacterial growth. Whereas among the maxillary sinus aspirate, bacteria were cultured from 11 of 20 (55%), all adenoid specimen cultures showed bacterial growth (100%). The types of bacterial growth of the maxillary sinus aspirate and adenoid specimens are shown in
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