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Effect of Improved Nasal Airflow After Adenoidectomy on Nasal Erectile Tissue

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Effect of Improved Nasal Airflow After Adenoidectomy on Nasal Erectile Tissue ORIGINAL ARTICLE Effect of Improved Nasal Airflow After Adenoidectomy on Nasal Erectile Tissue Carlos Alberto Carvalho Brinckmann, MD; Fla´via Penso Scapin, MD; Luiz Antoˆnio Guerra Bernd, MD, PhD; Jose´ Faibes Lubianca Neto, MD, PhD Objective: To determine the effect of improved naso- the nasal turbinate region was considered (depth, pharyngeal airflow after adenoidectomy on nasal turbi- 2.20-5.40 cm). nate erectile tissue in pediatric patients. Results: The volume of the turbinate region varied from Design: Clinical, prospective, before-and-after study. 6.03 cm3 in the preoperative evaluation to 6.99 cm3 in the postoperative evaluation, representing an increase of Setting: Pediatric Otolaryngology Clinic at Hospital da 16% (PϽ.04). Multiple linear and logistic regressions did Crianc¸a Santo Antoˆnio de Porto Alegre (Complexo Hos- not reveal any factors other than adenoidectomy that could pitalar Santa Casa de Porto Alegre). explain this change. Patients: Twenty-one 5- to 11-year-old children diag- Conclusions: Because the only possible explanation for nosed as having severe nasal obstruction, with an indi- the observed erectile tissue changes was improvement in cation for adenoidectomy. nasal airflow, we can assume that adenoidectomy favor- ably affects the behavior of nasal erectile structures and is Intervention: Adenoidectomy. associated with a decrease in turbinate size. Combined tur- binate reduction and adenoidectomy should not be the rule Main Outcome Measures: Acoustic rhinometry because children may benefit from adenoidectomy alone. data before and 90 days after surgery. To specifically monitor erectile tissue behavior, only the volume of Arch Otolaryngol Head Neck Surg. 2008;134(8):832-836 ONAIRFLOW RHINITIS WAS pendent of afferent input from nasal air- initially described in pa- flow and that nasal airflow acts as a modu- tients who underwent lator rather than as an initiator of the laryngectomy and had cycling phenomenon. enlarged and sometimes Adenoid hyperplasia is one of the ma- Nviolaceous turbinates without any his- jor reasons for surgery in childhood, and tory of nasal disease or other situations that turbinate hypertrophy is a frequent asso- could justify such alterations.1 A possible ciated finding. For this reason, it is essen- triggering factor could be the change from tial that surgeons have a precise under- nasal breathing to tracheostoma breath- standing of the main cause of nasal Author Affiliations: Medical Sciences Graduate Program, ing. Cyclical temperature and humidity obstruction in each patient before a treat- Universidade Federal do Rio variations associated with the absence of ment decision is made. This may prevent Grande do Sul nasal airflow on nasal mucosa would trig- unnecessary surgery, thus reducing post- (Drs Brinckmann and Neto); ger a vasomotor reaction with loss of vas- operative morbidity and the risk of se- School of Medicine (Dr Scapin) cular tone, which would lead to turbi- quelae such as, in the case of turbinate sur- and Departments of nate enlargement. gery, atrophic rhinitis and nasal synechiae. Immunology (Dr Bernd) and The suggestion that the same phenom- We believe that simultaneous turbinate re- Ophthalmology and enon occurs in children with important na- duction with adenoidectomy is not re- Otolaryngology (Dr Neto), sal obstruction due to adenoid hyperpla- quired in children and that they may ben- Fundac¸a˜o Faculdade Federal de sia was first made by Ritter in 1970.2 efit from adenoidectomy alone. Cieˆncias Me´dicas de Porto Alegre; and Pediatric However, the hypothesis could not be con- In the past 2 decades, acoustic rhinom- Otolaryngology Division, firmed at the time because no appropri- etry has been used in studies involving na- Hospital da Crianc¸a Santo ate tests were available. In 1994, after the sal diseases and treatments, especially to Antoˆnio de Porto Alegre advent of acoustic rhinometry, Fisher et analyze nasal congestion in various situ- (Dr Neto), Porto Alegre, Brazil. al3 concluded that the nasal cycle is inde- ations.4-14 Acoustic rhinometry is a fast, (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO. 8), AUG 2008 WWW.ARCHOTO.COM 832 ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 painless, and noninvasive diagnostic method that re- The surgical procedures were performed by otolaryngol- quires little collaboration from the patient.15 The test cal- ogy residents under the supervision of a single investigator culates cross-sectional areas at different points of the na- (J.F.L.N.), who revised all the cases at the end of surgery. All sal cavity, providing area and distance mapping, with the adenoidectomies were performed using a sharp curette and information on the location of sites with increased nar- without cauterization. Because the study objective was to observe the behavior of rowing, called minimum cross-sectional areas. It also pro- 7,8,16,17 erectile tissue after improved nasal airflow, the volume of the vides information on nasal volume. Some stud- region located at a nasal depth of 2.20 to 5.40 cm, defined as 4-6 ies have already used acoustic rhinometry to observe the turbinate region, was determined before vasoconstriction. nasal geometry changes after treatment of nasal obstruc- With children in this age group, the inferior turbinate head is tion. The objective of this study is to assess the effect of located deeper than 2 cm and the adenoid is located deeper than improved nasopharyngeal airflow after adenoidectomy 6.5 cm.6,15,21 To control possible distortions provoked by the on nasal turbinate erectile tissue in pediatric patients. nasal cycle, the volumes for the 2 nasal cavities were added. The paired-samples t test was used to analyze the difference between turbinate region volumes before and after surgery METHODS (⌬ turbinate region volume). Significance was established at PϽ.05. In addition, multiple linear and logistic regression mod- Twenty-one 5- to 11-year-old children were selected from the els were used to test the effect of sex, age, ethnic group, allergic outpatient clinic at the Hospital da Crianc¸a Santo Antoˆnio de Porto rhinitis, and size of adenoids on ⌬ turbinate region volume. Alegre Pediatric Otolaryngology Division between March 10, This project was approved by the research ethics commit- 2003, and December 18, 2006. All the children noted severe na- tee at Complexo Hospitalar Santa Casa de Porto Alegre. All the sal obstruction and had an indication for adenoidectomy. Pa- parents signed an informed consent form before their child tients with nasal obstruction from other causes, such as signifi- entered the study. cant septal deviation, nasal polyps, hypertrophy of palatine tonsils, and craniofacial malformations, were excluded from this study, RESULTS as were patients who received treatment for nasal obstruction 1 month before selection for the study. Patients with allergic rhi- nitis were not excluded, except those in whom the disease was Twenty-one children aged 5 to 11 years (mean [SD] age, not controlled. All the patients underwent a clinical evaluation 8.62 [1.83] years) were included in the study. Eleven with a complete otolaryngology examination, nasopharynx ra- (52%) were girls. Regarding ethnic group (skin color), diography, nasal endoscopy, skin tests for respiratory allergens, 10 children (48%) were white and 11 (52%) were non- and acoustic rhinometry. Radiography and endoscopy were used white. Skin test results were positive for respiratory al- to document the severity of adenoid obstruction and to control lergens in 9 (43%) of the patients. According to the ra- for the presence of associated nasal abnormalities. diographs, the adenoids were large in 16 (76%) of the In the analysis of radiographs, the adenoid to nasopharynx children and moderate in 5 (24%). Small adenoids were ratio was used to classify adenoids as small (ratios of 0.499- 0.624), moderate (0.625-0.731), or large (0.732-0.853).18 Na- not observed. On nasal endoscopy, 17 participants (81%) sal endoscopy analysis was based on the classification devel- had greater than 75% obstruction of the nasopharynx, oped by Wormald and Prescott,19 which defines small adenoids and in 4 participants (19%) the adenoid occupied 50% as occupying less than 50% the nasopharynx, medium ad- to 75% of the nasopharynx. No children had less than enoids as occupying 50% to 75% of the nasopharynx, and large 50% obstruction. The Figure compares turbinate re- adenoids as occupying more than 75% of the nasopharynx. Skin gion volume before and after surgery. An increase of 16% tests for respiratory allergens were performed to control for the in volume was noted (P=.04). This difference was not presence of allergic rhinitis. Acoustic rhinometry was per- explained by any of the study variables (sex, age, ethnic formed before and 90 days after surgery (SRE 2.100 rhinom- background, allergic rhinitis, and size of adenoids) ac- eter; RhinoMetrics A/S, Lynge, Denmark). The examinations cording to the linear and logistic regression models were performed following Standardization Committee on Acous- tic Rhinometry recommendations.20 The patient’s medical his- (Table 1 and Table 2). tory was recorded, and the otolaryngology examination was per- formed in the same room as the acoustic rhinometry, which COMMENT enabled a period of adaptation to the environment. This is an important aspect because nasal mucosal congestion is affected by changes in temperature and air humidity and by physical Nasal patency assessment is known for its complexity. activity (walking to the test location). Not even a combination of clinical history, nasal cavity The tests were performed with the patient sitting down, with examination, and allergic rhinitis investigation is suffi- the head resting on the back of the chair to prevent it from mov- cient to objectively and precisely describe the end point ing. Children with significant adenoid hyperplasia present more analyzed in this study, which aimed to demonstrate the nasal secretion, so all the patients were required to blow their impact of improved nasal airflow on nasal turbinate nose before the test.
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