AAMJ, Vol.2, N. 2, April, 2004 ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ RELATIONSHIP BETWEEN 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 and nasal endoscopy during surgery.Maxillary sinus aspirations and 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 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 or by harboring pathogenic [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) complaints, including , nasal obstruction, , 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 (, , and nasal ). 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 Table3. From11 the culture-positive maxillary sinus aspirates, the most frequently isolated bacteria were staphylococcus aureus 4 and streptoco- ccus pneumoniae 3. from the 20 culture-positive adenoid specimens, the most frequently isolated, in descending order, were  -hemolytic streptococcus8, neisseria 6, and  - haemolytic streptorcoccus 4.

27 AAMJ, Vol.2, N. 2, April, 2004 ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Table (3) : The culture results of the maxillary sinus aspirate and adenoid tissue specimens.

Patient Sinus Aspirate Adenoid Specimen No. 1- -hemolytic streptococcus. 1 - hemelytic streptococcus 2- Neisseria. 3- Diphtheroid. 1- - hemolytic streptococcus. 2 2- - hemolytic streptococcus. - hemolytic streptococcus 3- Streptococcus pneumoniae 3 No growth Streptococcus pneumoniae 1- Streptococcus pneum. 4 Streptococcus pneumoniae 2- H. influnzae3-Neisseria 5 No growth H 6 No growth  -hemolytic streptococcus. 7 No growth  -hemolytic streptococcus. 1-  -hem-strept. 8 Staphylococcus aureus 2- strept. Epidermidis. 9 No growth H. influenzae 1-  -hem-strept. 10 No growth 2- Diptheroid. 1- Streptococcus pneumoniae 11 Neisseria. 2- Diphtheroid 1- M catarrhalis 12 Pepto streptococcus 2- Neisseria 1-  -hem-strept. 13 No growth 2- -h. strept. 3- S.Pneum. 14 No growth 1- -h. strept. 2- Neisseria. 1- s.aureus 2-  -h. strept. 15 Saureus 3- -h. strept 4- s.pneumoniae. 16 H influenzae 1- H influenzae 2- Neisseria. 17 S aureus S aureus 18 1- S aureus 2- Diph. 1- S aureus 2- Neisseria. 1- S. epidermidis 19 1-S- epidermidis 2- H.influenzae 2- H influenzae. 3- -h.strept. 1- - hem.strept. 20 No growth 2- S. pneumoniae. Maxillary sinus culture sets yielded a single organism in 6 and polymicrobial growth in 5. One isolated micro-organism was the same in both 7 maxilalry sinus and adenoid tissue specimens. Although the same pathogen was

28 Mostafa S. Hammad et al ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ yielded in 7 cases bilaterally, the correlation between cultures obtained from the adenoid tissue with those from the maxillary sinus was not shown statistically. Adenoid size was large in 12 children and medium in 8, Of 11 maxillary sinus culture-positive children, 7 had large adenoid and 7 medium the relationship between adenoid size and maxillary sinus culture results was not found statistically significant (X2 = O.96. P= 1.0). The symptoms of mouth breathing and snoring were improved in all patients four weeks after surgery. Some patients had reduced symptoms of rhinorrhea (25%), cough (20%), postnasal drainage (20%), headache (5%), and nasal obstruction (5%) (Table 4).

Table (4) : The symptoms of the patient on the evaluation 4 weeks after surgery

Symptom Patients (No.) (%) Nasal Obstruction 1/20 5 Rhinorrhea 5/20 25 Cough 4/20 20 Headache 1/20 5 Postnasal drainage 4/20 20 Mouth breathing 0/20 0 Snoring 0/20 0 DISCUSSION

Pediatric chronic rhinosinusitis is a complex disease whose pathogenesis is poorly understood and there is a known association between adenoid hypertrophy and rhinosinusitis.[1] Various investigators have reported incidence of rhinosinusitis in 22% and 69% cases of and adenoid hypertrophy.[1] Adenoidectomy is recommended as a treatment option for refractory chronic rhinosinusitis in children.[9,14] To explain the relationship between adenoids and symptoms of chronic rhinosinusitis, a theory describes the adenoids as a bacterial reservoir that serves as a nidus for chronic infection.[1] This relationship is really unknown. Also, to our knowledge, there are no adequate reports in the literature that compare adenoid microbiology with maxillary sinus microbiology. In the present study, maxillary sinus cultures were compared with adenoid tissue cultures. Whereas all adenoid specimen cultures showed bacterial growth (100%), bacteria were cultured from 11 of 20 maxillary sinus aspirate (55%). Moreover, there was no statistically correlation between

29 AAMJ, Vol.2, N. 2, April, 2004 ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ cultures obtained from the adenoid tissue with those from the maxillary sinus. These findings suggest that the adenoid tissue does not seem to be a bacterial reservoir that serves as nidus for chronic rhinosinusitis. Another theory is based on adenoid hypertrophy causing mechanical obstruction, stasis of nasal secretions, and a cycle of inflammation and infection.[15] According to our results, it seems that the adenoids act as a barrier causing mechanical obstruction rather than a nidus for chronic rhinosinusitis. Adenoid hypertrophy causes mechanical obstruction, but the relationship between adenoid sizes and sinus infection is not defined clearly. The nasopharyngeal space and the size of the adenoids have been evaluated by using different methods of assessment such as determination of the roentgeno- graphic adenoid/nasopharynx ratio, flexible fiberoptic endoscopy, and direct measurments during surgery. [16] We evaluated the size of the adenoids by pre- operative X-Ray nasopharnynx lateral view, by using flexible fiberoptic endoscopy preoperatively, and nasal endoscopy during surgery. Although it is suggested that the presence of adenoid tissue in a small postnasal space rather than adenoid hypertrophy itself is the main cause of symptoms, Cassellbrant[16] states that adenoid hyperplasia, rather than a decreased nasopharyngeal space, is the main cause of nasopharyngeal obstruction in young children.[17] In our study, all children had adenoid hyperplasia and adenoid hypertroply signs. The relationship between adenoid size and maxillary sinus culture results was not found statistically significant. In other words, the children with medium-size adenoids had maxillary sinusitis. These findings suggest that medium adenoids causing partial obstraction may lead to changes in the microenvironment and may foster bacterial growth in chidren with positive maxillary culture. Studies using maxillary sinus lavage have consistently shown the predominant organisms of acute and subacute rhinosinusitis are streptococcus.- , Hemophilus influenzae, and Moraxella catarrhalis.[18,19] Studies of pediatric patients with chronic rhinoshusitis have sometimes shown an increased importance of anaerobic bacteria and staphylococcal species.[8] Muntz and lusk[20] studies the microbiology of tissue taken at the time of surgery for chronic rhinosinusitis. Their rerults showed very different bacteria from those present in acute rhinosinusitis including –hemolytic streptococcus,S. aureus,M catarrhalis, S pneumoniae, and H infleunzae. In our study, the most frequently isolated bacteria were S. aureus and S. pneumoniae. Wald et all[18] were found bacterial growth in 58% of sinus aspirates obtained from children with subacute Sinusitis. One study reported that 20% to 35% of maxillary sinus aspirates were sterile in pediatric rhinosinusitis.[14] Sterile conditions in sinusitis are partially explained from the potential involvement of chronic catarrhal sinusitis or edematous allergic sinusitis, which are reported to have increased in recent years. [21- 23].

30 Mostafa S. Hammad et al ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

In 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 relastionship 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 invertigation is needed to explain the associastion between adenoid hypertrophy and rhinosinusitis. Adenoidectomy helps to resolve the symptoms of chronic rhinosinusitis in the children with both adenoid hypertropry and chronic rhinosinusitis. REFERENCES

1) D. Lee and R. M. Rosenfeld, Adenoid bacteriology and sinonasal symptoms in children. Otolaryngol Head surg 116 (1997), pp.301-307 . 2) S.C. Manning, Pediatric Sinusitis, Otoloryngol clin North Am 26 (1993)., PP. 623 – 638. 3) B. Sener, G. Has Celik, M. Onerci et al., Evaluation of the microbiology of chronic Sinusitis. J Laryngol Otol 110 (1996), PP. 547 – 550 4) H .E. Cook and J. Haber, Bactenology of the maxillary sirus. J. oral Maxillofac surg 45 (1987), PP. 1011 – 1014. 5) R.S. Jiang, C.Y. Hsu and J.W. Jang, Bacteriology of the maxillary and ethmoidal Sinuses in chronic sinusitis J Laryngol Otol 112(1998), PP 845 – 848. 6) D.M. Don, R.F. Yellon, M.L. Casselbrant et al., Efficacy of a stepwise protocol that includes intravenous antibiotic therapy for the managemnt of chronic sinusitis in children and adolescents. Arch Otolaryngol Head Neck surg 127 (2001), PP. 1093-1098 . 7) I. Brook, Aerobic and anaerobic bacterial flora of normal maxillary sinuses. Laryngoscope 91 (1981), PP. 372-376 . 8) I. Brook, Bacteriological features of chronic sinusitis in children JAMA 246 (1981), PP. 967-969 . 9) S.J. Vanderberg and D.G Heatley, Efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children. Arch Otolaryngol Head Neck surg 123 (1997), PP. 675-678 .

31 AAMJ, Vol.2, N. 2, April, 2004 ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ 10) N.S. Jones, current concepts in the management of pediatric rhinosinusitis. J laryngol Otol 113 (1999), PP. 1-9. 11 ) H.H. Ramadan, Adenoidectomy Vs endoscopic sinus surgery for the Treatment of pediotric sinusitis. Arch Otolaryngol head Neck surg 125 (1999), PP. 1208-1211 . 12) S.M. Finegold and E.J. Baron, Editors, Bailey and scott’s diagnostic microbiology, Cv Mosby, St. Louis (1986). 13) D. Paul, Sinus infection and adenotonsillitis in pediatric patients: Laryngoscope 91 (1981), PP. 997-1000 . 14) G. Isaacson, Sinusitis in childhood. Pediatr Clin North Am 43 (1996), PP. 1297-1317 . 15) R.P. Lusk, R.H. Lazar and H.R. Muntz, the diugnosis and treatment of recurrent and chronic sinusitis in children. Pediatr clin North Am 36 (1989), PP. 1411-1421 . 16) M.L. Casselbrant, what is wrong in chronic adenoiditis/ tonsillitis anatomical considerations. Int. J pediatr Otolaryngol 49 (1999), PP.133-135 . 17) J.W. Tankel and A.D. Cheesman, Symptom relief by adenoidectamy and relationship to adenoid and post-nasal airway size. J Oto laryngol 100 (1986), PP. 637-640 . 18) E.R. Wald, C. Byers, N. Guerra et al., Subacute sinusitis in children. J pediatr 115 (1989), PP. 28-32. 19) E.R. wald, J.S. Reilly, M. Casselbrant et al., Treatment of acute maxillary sinusitis in childhood: A comparative study of amoxicillin and cefaclor. J pediatr 104 (1984), PP. 297 – 302. 20) H.R. Muntz and R.P. Lusk, Bacteriology of the ethmoid bullae in children with chronic sinusitis. Arch Otolaryngol Head Neck surg 117 (1991), PP. 179-181 . 21) K. Suzuki, Y. Nishiyama, K. Sugiyama et al., Recent trends in clinical isolates from paranasal sinusitis. Acta Otolaryngol 525 (1996), PP. 51-55. 22) P.A.R clement, C.D. Bluestone, F. Gordts et al., Managment of rhinosiunsitis in children. Int J pediatric Otorhinolaryngol 49 (1999), P.P. 95-100 . 23) P.R. Cook and G.J. Nishioka, Allergic rhinosinusitis in the pediatric population. Otolaryngol clin North Am 29 (1999), PP. 39-56.

32 Mostafa S. Hammad et al ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

الممخص العربي العالقو بين تضخم لحميو خمف االنف والتياب االنف والجيوب االنفيو المزمن لدي االطفال مصطفي سيد حماد- عبدالعزيز محمد حسن الشريف محمد عبد المتعال جمعو-محمد ابراىيم بسيوني من اقسام االنف واالذن والحنجره والبكتريولوجي بطب المنيا وقسم االنف واالذن والحنجره بطب االزهر ------اجريت ىذه الدراسو عمى عشرين طفال مصابين بتضخم لحميو خمف االنف والتياب االنف والجيوب االنفيو المزمن في مستشفي المنيا الجامعىوتم تقسيم حجم المحميو الي متوسط وكبير عن طريق االشعو والمنظار الضوئي الميفي الرخو وتم استئصال المحميو وسحب محتويات الجيب االنفي الوجني في كل الحاالت واجريت مزرعو عمي نسيج المحميو وعمي ما تم سحبو من داخل الجيب االنفي وتمت مقارنو النتائج و كذلك دراسو العالقو بين حجم المحميو ونتائج مزرعو الجيب االنفي واتضح انو ال توجد عالقو احصائيو بين نتائج مزرعو المحميو ومزرعو ما تم سحبو من الجيب االنفي كذلك ال توجد عالقو احصائيو ذات داللو بين حجم المحميو ونتائج مزرعو الجيب االنفي ونستنتج من ذلك ان تضخم المحميو من الممكن ان يكون سببا في انسداد المجرى اليوائى مما يؤدي الي حدوث التياب االنف والجيوب االنفيو المزمن اكثر من كونيا بؤره مسببو لحدوث االلتياب لذلك فان استئصال المحميو يؤدي الي زوال اعراضااللتياب المزمن في االطفال المصابي . كذلك نري انو يجب اجراء المزيد من االبحاث لتفسير العالقو بين تضخم لحميو خمف االنف وحدوث التياب االنف والجيوب االنفيو المزمن لدي االطفال.

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