The Relationship between Hypertrophy and Maxillary Rhinosinusitis in Children Ehab Taha Yaseen FICMS (ENT)* . Abstract: Back ground: The role of in rhinosinusitis is not completely understood. Current opinion states that the adenoids act as a reservoir for pathogenic and interferes with nasal mucociliary clearance, even without being obstructive. Obstructive adenoids on the other hand may cause stasis of nasal secretions with resultant infection. Objective: To evaluate the effect of adenoid size in pediatric rhino as a cause of mechanical blockage. Patients and Methods: This cross sectional study included (150) Children. The size of adenoid was graded according to endoscopic findings. The grades of maxillary rhinosinusitis were determined by radiological findings of water’s view. The results were analyzed and the X-ray findings of the maxillary sinuses were correlated with the size of adenoid on endoscopic examination. Results: The highest incidence of adenoid hypertrophy was seen in 3-5 years old Children (60%), with male: female ratio as 1.1:1.The frequency of positive water's view maxillary sinus X-ray findings among hypertrophied adenoid patients were (51%), The highest frequency of maxillary sinus X-ray findings was noted in grade III adenoid (46.7%). Conclusions: The adenoid grade determined endoscopically is significantly associated with increasing in positivity of water’s view x-ray findings. Key words: Paediatric rhinosinusitis. Adenoid hypertrophy. Maxillary sinusitis.

Introduction clinic of E.N.T Department of Al-Yarmouk or normal physiologic function of the paranasal Teaching Hospital from January 2009 - January F sinuses, the ostia must be patent, the cilia should 2010.Their ages ranged from 3-12 years. All patients be functioning effectively, and the secretions should with craniofacial abnormalities, other possible be normal.(1) Retention of secretions in the paranasal predisposing factors of rhinosinusitis such as sepal sinuses can be due to one or more of the following: deviation, previous history of sinus surgery or obstruction of the ostia, reduction in the number or and patient below 3 years or above impaired function of the cilia, or overproduction or 12 years old were excluded from the study. change in the viscosity of secretions.(2) According to The size of adenoid was determined according to current understanding of sinus physiology, the Clemens et al classification(4), by which grade I primary sinus abnormality for initiation of adenoid was labeled when the adenoid tissue filling rhinosinusitis is obstruction of the osteomeatal one third of the vertical portion of the choanae, complex by mucosal edema or mechanical grade II when filling from one third to two thirds of obstruction.(1,2) Various local, regional, or systemic the choanae, grade III from two third to nearly factors may lead to an obstruction of the osteomeatal complete obstruction of the choanae and grade IV complex. Local and regional factors include nasal complete choanal obstruction. septal deviation, nasal polyps, and anatomic variants The grade of maxillary rhinosinusitis was such as choanal atresia, edema attributed to viral determined by radiological findings of water's infections, allergic inflammation, and nonallergic view.(5) Grade 0 was defined as no abnormal . findings in the maxillary sinuses bilaterally, grade 1 Other factors that have been attributed to the as mucosal thickening in the maxillary sinuses etiology of pediatric rhinosinusitis include innate bilaterally, grade 2 as mucosal thickening on one and acquired immune deficiencies, gastroesophageal side and total haziness on the other side, and grade 3 reflux, environmental pollution, malnutrition and as total haziness of the maxillary sinuses bilaterally. biochemical abnormalities.(3) Data analysis was carried out by calculating Although many conditions can lead to percentages. Chi squared test was used to analyze obstruction of the natural ostia, viral upper the association between adenoid hypertrophy and infections and allergic inflammation maxillary rhinosinusitis in children. Criterion for are by far the most frequent causes.(2) statistical significance was set at p<0.05.

Hypoxia following sinus obstruction leads to Results ciliary dysfunction and abnormal movement of The mean age of the studied patients was 6 years (6 mucous from the sinus, this helps the bacteria in the ± 2.33). The highest incidence of adenoid upper respiratory tract to multiply and invade the hypertrophy was seen in 3-5 years old Children (1) mucosa of the obstructed sinus. (60%).Gender distribution revealed that 81 patients The aim of the study is to evaluate the effect of (54%) were males and 69 patients (46%) were adenoid size in pediatric rhino sinusitis as a cause of females. The Male: female ratio was 1.1:1. mechanical blockage. The commonest grade of adenoid size was grade III, 50 patients (33.3%) and the lowest grade of adenoid Patients and method: size was grade I, 20 patients (13.3%). As shown in This cross sectional study included (150) table (1) Children were seen and examined in the outpatient

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Table 1: Numbers of patients with adenoid hypertrophy according to adenoid grading Adenoid grade Patients with adenoid hypertrophy (n=150) No. % IV 37 24.6 III 50 33.3 II 43 28.6 I 20 13.3

The commonest grade of maxillary rhinosinusitis (48.6%), while the lowest grade was grade 3, 6 (according to water’s view) was grade 0, 73 patients (4.0%) as shown in table (2).

Table 2: Grading of maxillary rhino sinusitis (based on water’s view) Grading of Maxillary Patients with adenoid hypertrophy (n=150) rhinosinusitis No. % 0 73 48.6 1 60 40.0 2 11 7.3 3 6 4.0

The frequencies of positive findings in water's view 77, while the lowest frequency of water's view among hypertrophied adenoid patients were 77 findings were noted in grade I adenoid, 5 patients patients out of 150 patients (51%). (25%) out of 77 as shown in table 3. The highest frequency of water's view findings were noted in grade III adenoid, 36 patients (72%) out of

Table 3: The distribution of adenoid grade (based on fibrooptic nasopharyngoscope) and findings in the maxillary rhino sinusitis (based on water’s view) Adenoid grade based on Positive waters view maxillary sinus x-ray fibrooptic findings nasopharyngoscope No % IV (n=37) 22 59.5 III (n=50) 36 72.0 II (n=43) 14 32.6 I (n=20) 5 25.0 Total (n=150) 77 51.3 P=0.0001 (Highly significant using chi-squared test at 0.05 level of significance)

Discussion: patients (40%) were females, with male to female The maximum incidence of adenoid hypertrophy was ratio as1.1:1. Differences probably were due to the seen in 3-5 years old Children, 90 patients (60%). The larger sample involved in the current study. mean age of our patients was 6 years (6 ± 2.33). These The commonest grade of adenoid size in the findings are probably due to rapid growth of lymphoid current study was grade III, 50 patients (33.3%) tissue and relative decrease in post nasal space and to the followed by grade IV, 37 patients (24.6%) as shown incidence of upper respiratory tract infection during in table (1). childhood period. (6) The commonest grade of maxillary rhinosinusitis Fujioko etal reported that adenoidal-Nasopharyngeal (according to water’s view) was grade 0, 73 ratio reached its highest value at age 4 years and then (48.6%), while the lowest grade was grade 3, 6 decreased.(7) patients (4.0%) as shown in table (2). Pruzansky in his study reported that large The overall incidence of positive findings in adenoids were most frequently observed in the ages water's view among hypertrophied adenoid patients of 6-8 years. (8) were 77 patients out of 150 patients (51%) as shown A study by A.S. Bercin et al reported that in table (3). adenoids reach a maximum size at the age of 3-7 Paul and Preston reported higher incidence of years, and then start to regress. (9) rhinosinusitis 68% and 69% respectively in children A study by E.S. Kolo and his colleagues revealed with adenoid hypertrophy. (11,12) Differences from that 22 (64.7%) were males and 12 (35.3%) were the results of the current study probably explained females in their study of 34 children with obstructive by the size of the study sample and the weather adenoids.(10) While the results of the current study circumstances which encountered during their revealed that 81 patients (54%) were males and 69 studies.

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According to table (3) which assess the surgical option before endoscopic sinus surgery relationship between water’s view findings & (ESS), especially in younger children with adenoid size, the highest incidence of water’s view obstructive symptoms.(19) findings was noted in grade 3 adenoid size, 36 On the other hand Fukuda et al reported no patients out of 50 (72%). But the frequency of difference in adenoidal-nasopharyngeal ratio (taken reporting positive findings in water' view decreased by lateral X-ray of post nasal space) between in grade IV (59.5%) if compared to grade III (72%), sinusitis and control groups also he reported no these differences may be explained by the larger correlation between sinusitis severity and adenoid sample of patients with grade III adenoid size, hence volume on CT scan. (20) a future study with emphasis on this fact should be considered to evaluate the possible involved reasons. The conclusion is that Maximum age incidence of However, in both grade III and grade IV the adenoid hypertrophy in children was in 3-5 years. frequency of positive findings in water's view were The adenoid gradings determined endoscopically higher than other grades. There was highly is significantly associated with increasing in significant correlation between adenoid grade positivity of water’s view X-ray findings. diagnosed endoscopically and water’s view x-ray Further investigations are needed to explain the findings (P= 0.0001). relation between adenoid as reservoir for pathogenic A probable explanation for that, hypertrophied bacteria and microbiological evaluation of maxillary adenoid obstructing the posterior choanae interfering rhino sinusitis. with the natural drainage of the nasal and hence the sinus secretions resulting in stasis which provide References: good media for bacterial growth and consequently 1. Ott NL, O' Connell EJ, Hoffman AD. Mayo infection of the . Clinic's Proceedings. 1991; (66):1238-47. These findings support the role of adenoids as 2. Wald ER. Sinusitis. Pediatric annals 1998; mechanical obstruction in the causation of sinusitis. 27(12):p. 811-17. Georgalas and his colleagues concluded that 3. Glenis Scadding and Helen Caulfield. Paediatric there is a high association between adenoidal rhinosinusitis. In: Michael Gleeson, George G hypertrophy and rhinosinusitis in their study.(13) Browning, Martin J Burton, Ray Clarke, John Tuncer and his colleagues reported that there is Hibbert, Nicholas S Jones, et al (editors). Scott- no correlation between cultures obtained from the Brown's Otolaryngology, Head and adenoid tissue with those from the maxillary sinus Surgery. Seventh edition. London: Hodder and it seems possible that the adenoids act as a Arnold; 2008. Vol. 1 P. 1079-93. barrier causing mechanical obstruction rather than a 4. Peter J Robb. The adenoid and adenoidectomy. nidus for chronic sinus infection.(14) In: Michael Gleeson, George G Browning, Merck in his study divided the children with Martin J Burton, Ray Clarke, John Hibbert, sinusitis into 3 groups according to size of their Nicholas S Jones, et al (editors). Scott-Brown's adenoid, he observed that 34% of large adenoid Otolaryngology, Head and Neck Surgery. group showed signs of sinusitis on radiograph Seventh edition. London: Hodder Arnold; 2008. examinations as compare to 13% in small adenoid Vol. 1 P. 1097-101. group. (15) 5. Kwany Soo Shine, Seek Hyun Cho, Kyung Van Cauwenberg et al supported the role of Raekim, Kyung Tae, Seung Hwan Lee, Chul adenoid in maxillary rhinosinusitis and their Won Park. Relationship between adenoid explanation based on the fact that the sinuses lies in bacteriology and pediatric rhinosinusitis. Iner. J. closed anatomical contact with the adenoid, it is Pediat. Oto. (2008) 72, 1643-1650. tempting to presume that pathological process in 6. David L. Cowan, John Hibbert. Tonsils and nasopharynx will influence the sinuses. This adenoids. In: David A. Adams, Michael J. influence, however might work in the other direction Cinnamond (editors). Scott-Brown's in which rhino sinusitis might cause adenoiditis or Otolaryngology. Sixth edition. Oxford: adenoid hypertrophy. (16) Butterworth-Heinemann; 1997. Vol. 6. P. Lec and Rosen Feld studied the adenoid role in 6/18/1-16. pathogenesis of rhinosinusitis and they conclude that 7. M. Fujioka, L.W. Young, B.R.Girdany.: the adenoid may cause mechanical obstruction of Radiographic evaluation of adenoid size in nasopharynx resulting in stasis of secretions and children: adenoid as key factor in upper airway infections. (17) infection. Int. J. Ped. Otorhinolaryngo. 32 Ramadan and Tiu reported that adenoid (June) (1995) S71-80. hypertrophy may mimic sinusitis symptoms by 8. S. Pruzansky.: Roentgen Cephalometric studies causing obstruction & stasis of secretions this stasis of Tonsil and adenoid in normal and in turn obstruct sinus ostium and cause sinusitis. (18) pathological states. Ann. Otol. Rhino. Laryngo. Ungkanont and Damrongsak reported that 84(March-April (2 part 2 suppl.19)) (1975) adenoidectomy should be most beneficial as a P.55-62.

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9. A.S. Bercin, A.ural, A. Kutluhan, V. Yurttas.: 15. W. Merck.: Pathogenetic relationship between Relationship between sinusitis and adenoid size adenoid vegetations and maxillary sinusitis in in paediatric age group. Ann. Otol. Rhino. children (1974-June) 22.PP.198-199. Laryngol. 2007; 116 (7):550-553. 16. Van cans wen berge PB, Bellussi, Naw AR., et 10. E.S. Kolo, A.O. Ahmed. M.J. Kazeem, O.G.B. al.: The adenoid as key factors in upper airway Nwaorgu. Plain radiographic evaluation of infection. Int. J. Pediat. Oto Rhin.1995, 32: children with obstructive adenoid. Eur J radiol. S71-S80. 2010 doi: 10.1016/j.ejrad. 2010.09.027. 17. D. Lec, R.M. Rosen Field.: Adenoid 11. D. Paul.: Sinus infection and adenotonsillitis in Bacteriology and Sino nasal symptoms in pediatric patient. Laryngoscope (1981-June) 91 children. Otol. Head and Neck Surgery. 1997; PP. 997-1000. 116:301-7. 12. H.G. Preston.: Maxillary sinusitis in children, its 18. H.H. Ramadan, J. Tiu.: Failures of relation to coryza and adenoidectomy for chronic Rhinosinusitis in adenoidectomy, Va. Med. Mon. (1955-may) 82 children: for whom and when do they fail? PP.229-232. (2007-June) 117 PP.1080-1083. 13. Georgalas C., Thomas K., Owens C., 19. Ungkanont K., Damrongsak S. Effect of Abramovich S., Lack, G. Medical treatment for adenoidectomy in children with complex rhinosinusitis associated with adenoidal problems of rhinosinusitis and associated hypertrophy in children: an evaluation of diseases. Int-J-Pediatr-Otorhinolaryngol. 2004 clinical response and changes on magnetic Apr; 68(4): 447-51. resonance imaging. Ann-Otol-Rhinol-Laryngol. 20. K. Fukuda, S. Matsun, M.Ushika, Y. Imamura, 2005 Aug; 114(8): 638-44. M.Ohyama.: Study on the relationship between 14. Tuncer U., Aydogan B., Soylu L., Simsek M., adenoid vegetation and Rhinosinusitis. Am. J. Akcali ., Kucukcan A. Chronic rhinosinusitis Otol. (1989-May-June) 10 PP. 214-216. and adenoid hypertrophy in children. Am-J- Otolaryngol. 2004 Jan-Feb; 25(1): 5-10. * ENT Division Dept. of Surgery, College of Medicine Al – Mustansiriya University, Baghdad, Iraq

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