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A study on the relationship between adenoid vegetation and rhinosinusitis
Am J otolaryngol 1021~216,1969
A Study on the Relationship Between Adenoid Vegetation and Rhinosinusitis KATSUNORI FUKUDA, MD, SHOJI MATSUNE,
MD, MASATO USHIKAI, MD, YOKO IMAMURA, MD, AND
MASARU OHYAMA, MD
The relationship between adenoidal-nasopharyngeal ratios (AN ratios) and sinusitis were evaluated in 404 children. The AN ratios of children with snoring, mouth breathing, or nasal obstruction (major symptoms of adenoidal enlargement) were significantly higher than those of children without these symptoms. However, the AN ratios of children with sinusitis were almost equal to those of normal children. AM J OTOLARYNGOL10:214-216. 0 1989 by W.B. Saunders Company.
Adenoid vegetation, rhinitis, and sinusitis are commonly encountered conditions in pediatric otolaryngology. The causal relations among these diseases have long been considered due to their appearance on neighboring organs.lV3 Although the importance of enlarged adenoids in rhinitis and sinusitis has been reported,4’5 the precise pathophysiology is still controversial. Rhinitis and sinusitis could be induced by several factors associated with enlarged adenoids, including aerodynamic, bacteriologic, and immunologic effects. In this study, the relation of adenoidal size to the incidence of rhinitis and ReceivedSeptember11,1988, from the Department of Otolaryngology, Kagoshima University School of Medicine, Kagoshima, Japan. Accepted for publication November 27, 1988. Address correspondence and reprint requests to Katsunori Fukuda, MD, Kagoshima University School of Medicine, Usuki-cho 1208-1, Kagoshima 890, Japan. 0 1989 by W.B. Saunders Company. 0196-0709/89/1003-0002$5.00/O
TABLE 1. SYMPTOMS
Comparison
sinusitis was investigated and the pathogenesis of sinusitis was also considered from the viewpoint of aerodynamic changes in the nasal cavities. METHODS
AND MATERIALS
Lateral radiographic analysis of the nasopharynx was performed on 404 children, 2 to 14 years old, comprising 307 cases who were admitted to our outpatient clinic from 1983 to 1987, and 97 cases who were evaluated on the basis of otolaryngologic examinations in kindergarten. Adenoidal-nasopharyngeal ratios (AN ratios) were calculated from lateral radiographs of the nasopharynx according to the method of Fujioka et a1.6 Snoring, mouth breathing, nasal obstruction, and rhinorrhea were noted. Findings of nasal clinical symptoms, secretion, retraction of the ear drum, sinus radiographs, and audiometric and tympanometric values were also analyzed.
of AN Ratio to Clinical
No. OF PATIENTS
Symptoms
AN RATIO (MEAN ? SD]
Snoring I;;
209 195
0.568 0.610 *f 0.111 0.110 1
P < .OOl
139 265
0.620 0.574 *-c 0.108 0.114 1
P < .02
149 255
0.578 0.610 f? 0.111 I
P < .Ol
271 133
0.590 2f 0.114 0.588 0.112
NS
Mouth breathing Is; Nasal obstruction I;; Rhinorrhea
214
FUKUDA ET AL
TABLE 2. NASAL
AN Ratio and Nasal
227 54
Absent Small Large
Quality Absent Watery
123 )
177
227 37 1
264
RESULTS
Lateral nasopharyngeal radiographic analysis was performed on 414 patients, comprising 307 Comparison of AN Ratio With
AVERAGE SCORE FOR FOUR SINUSES s=o O
180 95 86 44
TABLE 4. CLINICALFINDINGS Ear drum Normal Retructed Audioaram Nor&al Hearing loss Tympanogram
TypeA
NO. OF PATIENTS
Type B or C
Comparison
Sinusitis AN RATIO (MEAN ? SD) 0.596 0.598 0.567 0.592
2 2 k +
0.581* 0.115>
0.585* 0.111
0.5932 0.113 0.583f 0.1251
0.591+ 0.114
0.588 4 0.108
Nasal secretions were classified according to volume (absent, small, or large) and quality (watery, or mucopurulent). Radiographic findings for both maxillary and ethmoid sinuses were used to evaluate the severity of the sinusitis. Scores for each grade were assigned as follows7: normal, 0, slight, 1, moderate, 2, and severe, 3. The average score for all four sinuses (maxillary and ethmoid) was used in the statistical evaluations. In cases without Caldwell and Waters views, the extent of the sinus lesions were estimated from lateral radiographs of the nasopharynx. In the evaluation of audiometric findings, hearing levels greater than 20 dB were considered to denote hearing loss. Tympanometric findings were also classified into three conventional types, A, B, and C. The patients’ AN ratios were analyzed in accordance with the clinical symptoms, otorhinoscopic findings, and other evaluations described above. Statistical analyses were performed using Student’s t test.
of Paranasal
0.593 f 0.113 0.594 -t 0.104
140
Mucous and/or purulent
Findings
AN RATIO (MEAN 2 SD)
No. OF PATIENTS
SECRETIONS
Quantity
TABLE 3. Radiographic
Secretions
0.124 0.108 0.090 0.108
admitted to our outpatient clinic and 97 others evaluated on the basis of routine otolaryngologic examinations in kindergarten. Cases consisted of 263 males and 141 females ranging in age from 2 to 14 years, with 4- to 6-year-olds representing 70% of the total. In the distribution of clinical symptoms characteristic of adenoid enlargement, there were 209 cases with snoring, 139 with mouth breathing, and 149 with nasal obstruction. For each of these symptoms, AN ratios were significantly higher among affected children (Table 1). On the other hand, the AN ratios of the 133 children with rhinorrhea (associated with sinusitis) were nearly equal to those of the children without (Table 1). There were no significant differences in AN ratio corresponding with either the quality or quantity of nasal secretions, or with the severity of sinus lesions based on radiographic images (Tables 2 and 3). In relation to otitis media with effusion, the children with retracted ear drums or a hearing disturbance confirmed by audiograms had significantly higher AN ratios compared with healthy children without any findings of otologic pathology. Furthermore, the AN ratios of children with type B or C tympanometric findings were higher than those of the children with type A (Table 4). DISCUSSION
Several correlations of adenoid vegetation to rhinitis and sinusitis have been described in the
of AN Ratio in Clinical
Findings
of Otitis Media
With Effusion
No. OF PATIENTS
AN RATIO [MEAN k SD)
195
0.5832 0.112 0.608* 0.112I Pi.05
51 113
0.580 _’ 0.108
209
0.6232 0.104 PC.02
Volume
10
Number May
3
1989 215
Figure 1. Radiographic findings of Waters view. (A) A 17year-old female with congenital choanal atresia on the right and maxillary sinusitis on the left. (B) A 27Iyear-old male with congenital choanal atresia on the left and maxillary sinusitis on the right.
American Journal of Otolaryngology 216
past; however, the difficulty of assessing such matters accurately was understood. Adenoid vegetation comprises not only simple enlargement of the tissue, but also its infectious condition and immunologic situation. The influence of adenoid vegetation on the middle ear, nasal cavity, and paranasal sinuses located near the adenoids, differs with each case. Special attention was paid to the influence of adenoidal size on rhinitis and sinusitis. It is widely accepted that AN ratios are radiologically indicative of adenoidal size.6*8 Our results demonstrate a highly significant correlation between AN ratios and the incidence of major clinical symptoms caused by adenoid vegetation. On the other hand, the correlation between AN ratios and the clinical evidence of rhinitis and sinusitis was considerably less significant. Rhinitis and sinusitis are caused by several factors, including mass lesions, infection, allergy, and immunopathology. The exact role of these factors related to rhinitis and sinusitis are not well-understood. According to this study, the aerodynamic changes in the nasal and paranasal cavities caused by enlarged adenoids may not be essential to the development of rhinitis and sinusitis. Although the long-term reduction of air flow results in a change in the mucous membrane in the nasal and paransal cavities,g the pathogenesis of rhinitis and sinusitis cannot be attributed solely to this factor. With a view to justifying this assumption, we have observed cases with congenital choanal atresia in which air flow into the nasal and paranasal cavities has been interrupted. Two representative cases are demonstrated radiographitally in Fig 1. Both cases exhibit maxillary si-
nusitis on one side, whereas no pathologic shadows are seen on the obstructed side of choana (Fig 1). We previously studied the effects of aerodynamic changes on sinusitislO using experimentally induced sinusitis in rabbits according to the methods of Maeyama,l’ of which one anterior nasal airway was surgically obstructed for four days to 6 weeks in order to change the air flow in the nasal and paranasal cavities. No exacerbation of sinusitis was observed due to these aerodynamic changes. References 1. Ruben RJ, Weg N: Contraindications to adenoidectomy. Bull NY Acad Med 1975; 51:817-827 2. Grote II. Kuiioers W: Middle ear effusion and sinusitis. J Laryngol &of 1980; 94:177-183 3. Alhady RA, Sharnoubi h4E: Tympanometric findings in patients with adenoid hyperplasia, chronic sinusitis and tonsillitis. J Laryngol Otol 1984; 98:671-676 4. Merch W: The relationship between adenoidal enlargement and maxillary sinusitis. HNO 1974; 22:198-199 5. Stool SE: Disease of the tonsils and adenoids in relation to rhinitis and sinusitis. Ann Otol Rhino1 Laryngol 1975; 84:73-74 (suppl) 6. Fujioka M, Young LW, Girdany BR: Radiographic evaluation of adenoidal size in children. Am J Radio1 1979; 133:401-404 7. Bertrand BMG, Robillard TAJ: Comparative study of standard radiology, sinuscopy and sinusomanometry in the maxillary sinus of the adult. Rhinology 1985; 23:237-246 8. Elwany S: The adenoidal-nasopharyngeal ratio (AN ratio): Its validity in selecting children for adenoidectomy. J Laryngol Otol 1987; 101:569-573 9. Cvetnic V, Batistic B, Sankovic F: Cytological and histological alterations in the nasal mucous membrane during experimental obstruction of nasal openings. _ - Rhinoio, 1987; 2:5-12 10. Fukuda K. Matsune S, Ushikai M. et al: The relationship between adenoid vegetation and sinusitis. Jpn J Tonsil 1988; 27:255-261 11. Maeyama T: A study of experimental sinusitis in rabbits. Auris Nasus Larynx 1981; 8:87-98 I,.
A Study on the Relationship Between Adenoid Vegetation and Rhinosinusitis KATSUNORI FUKUDA, MD, SHOJI MATSUNE,
MD, MASATO USHIKAI, MD, YOKO IMAMURA, MD, AND
MASARU OHYAMA, MD
The relationship between adenoidal-nasopharyngeal ratios (AN ratios) and sinusitis were evaluated in 404 children. The AN ratios of children with snoring, mouth breathing, or nasal obstruction (major symptoms of adenoidal enlargement) were significantly higher than those of children without these symptoms. However, the AN ratios of children with sinusitis were almost equal to those of normal children. AM J OTOLARYNGOL10:214-216. 0 1989 by W.B. Saunders Company.
Adenoid vegetation, rhinitis, and sinusitis are commonly encountered conditions in pediatric otolaryngology. The causal relations among these diseases have long been considered due to their appearance on neighboring organs.lV3 Although the importance of enlarged adenoids in rhinitis and sinusitis has been reported,4’5 the precise pathophysiology is still controversial. Rhinitis and sinusitis could be induced by several factors associated with enlarged adenoids, including aerodynamic, bacteriologic, and immunologic effects. In this study, the relation of adenoidal size to the incidence of rhinitis and ReceivedSeptember11,1988, from the Department of Otolaryngology, Kagoshima University School of Medicine, Kagoshima, Japan. Accepted for publication November 27, 1988. Address correspondence and reprint requests to Katsunori Fukuda, MD, Kagoshima University School of Medicine, Usuki-cho 1208-1, Kagoshima 890, Japan. 0 1989 by W.B. Saunders Company. 0196-0709/89/1003-0002$5.00/O
TABLE 1. SYMPTOMS
Comparison
sinusitis was investigated and the pathogenesis of sinusitis was also considered from the viewpoint of aerodynamic changes in the nasal cavities. METHODS
AND MATERIALS
Lateral radiographic analysis of the nasopharynx was performed on 404 children, 2 to 14 years old, comprising 307 cases who were admitted to our outpatient clinic from 1983 to 1987, and 97 cases who were evaluated on the basis of otolaryngologic examinations in kindergarten. Adenoidal-nasopharyngeal ratios (AN ratios) were calculated from lateral radiographs of the nasopharynx according to the method of Fujioka et a1.6 Snoring, mouth breathing, nasal obstruction, and rhinorrhea were noted. Findings of nasal clinical symptoms, secretion, retraction of the ear drum, sinus radiographs, and audiometric and tympanometric values were also analyzed.
of AN Ratio to Clinical
No. OF PATIENTS
Symptoms
AN RATIO (MEAN ? SD]
Snoring I;;
209 195
0.568 0.610 *f 0.111 0.110 1
P < .OOl
139 265
0.620 0.574 *-c 0.108 0.114 1
P < .02
149 255
0.578 0.610 f? 0.111 I
P < .Ol
271 133
0.590 2f 0.114 0.588 0.112
NS
Mouth breathing Is; Nasal obstruction I;; Rhinorrhea
214
FUKUDA ET AL
TABLE 2. NASAL
AN Ratio and Nasal
227 54
Absent Small Large
Quality Absent Watery
123 )
177
227 37 1
264
RESULTS
Lateral nasopharyngeal radiographic analysis was performed on 414 patients, comprising 307 Comparison of AN Ratio With
AVERAGE SCORE FOR FOUR SINUSES s=o O
180 95 86 44
TABLE 4. CLINICALFINDINGS Ear drum Normal Retructed Audioaram Nor&al Hearing loss Tympanogram
TypeA
NO. OF PATIENTS
Type B or C
Comparison
Sinusitis AN RATIO (MEAN ? SD) 0.596 0.598 0.567 0.592
2 2 k +
0.581* 0.115>
0.585* 0.111
0.5932 0.113 0.583f 0.1251
0.591+ 0.114
0.588 4 0.108
Nasal secretions were classified according to volume (absent, small, or large) and quality (watery, or mucopurulent). Radiographic findings for both maxillary and ethmoid sinuses were used to evaluate the severity of the sinusitis. Scores for each grade were assigned as follows7: normal, 0, slight, 1, moderate, 2, and severe, 3. The average score for all four sinuses (maxillary and ethmoid) was used in the statistical evaluations. In cases without Caldwell and Waters views, the extent of the sinus lesions were estimated from lateral radiographs of the nasopharynx. In the evaluation of audiometric findings, hearing levels greater than 20 dB were considered to denote hearing loss. Tympanometric findings were also classified into three conventional types, A, B, and C. The patients’ AN ratios were analyzed in accordance with the clinical symptoms, otorhinoscopic findings, and other evaluations described above. Statistical analyses were performed using Student’s t test.
of Paranasal
0.593 f 0.113 0.594 -t 0.104
140
Mucous and/or purulent
Findings
AN RATIO (MEAN 2 SD)
No. OF PATIENTS
SECRETIONS
Quantity
TABLE 3. Radiographic
Secretions
0.124 0.108 0.090 0.108
admitted to our outpatient clinic and 97 others evaluated on the basis of routine otolaryngologic examinations in kindergarten. Cases consisted of 263 males and 141 females ranging in age from 2 to 14 years, with 4- to 6-year-olds representing 70% of the total. In the distribution of clinical symptoms characteristic of adenoid enlargement, there were 209 cases with snoring, 139 with mouth breathing, and 149 with nasal obstruction. For each of these symptoms, AN ratios were significantly higher among affected children (Table 1). On the other hand, the AN ratios of the 133 children with rhinorrhea (associated with sinusitis) were nearly equal to those of the children without (Table 1). There were no significant differences in AN ratio corresponding with either the quality or quantity of nasal secretions, or with the severity of sinus lesions based on radiographic images (Tables 2 and 3). In relation to otitis media with effusion, the children with retracted ear drums or a hearing disturbance confirmed by audiograms had significantly higher AN ratios compared with healthy children without any findings of otologic pathology. Furthermore, the AN ratios of children with type B or C tympanometric findings were higher than those of the children with type A (Table 4). DISCUSSION
Several correlations of adenoid vegetation to rhinitis and sinusitis have been described in the
of AN Ratio in Clinical
Findings
of Otitis Media
With Effusion
No. OF PATIENTS
AN RATIO [MEAN k SD)
195
0.5832 0.112 0.608* 0.112I Pi.05
51 113
0.580 _’ 0.108
209
0.6232 0.104 PC.02
Volume
10
Number May
3
1989 215
Figure 1. Radiographic findings of Waters view. (A) A 17year-old female with congenital choanal atresia on the right and maxillary sinusitis on the left. (B) A 27Iyear-old male with congenital choanal atresia on the left and maxillary sinusitis on the right.
American Journal of Otolaryngology 216
past; however, the difficulty of assessing such matters accurately was understood. Adenoid vegetation comprises not only simple enlargement of the tissue, but also its infectious condition and immunologic situation. The influence of adenoid vegetation on the middle ear, nasal cavity, and paranasal sinuses located near the adenoids, differs with each case. Special attention was paid to the influence of adenoidal size on rhinitis and sinusitis. It is widely accepted that AN ratios are radiologically indicative of adenoidal size.6*8 Our results demonstrate a highly significant correlation between AN ratios and the incidence of major clinical symptoms caused by adenoid vegetation. On the other hand, the correlation between AN ratios and the clinical evidence of rhinitis and sinusitis was considerably less significant. Rhinitis and sinusitis are caused by several factors, including mass lesions, infection, allergy, and immunopathology. The exact role of these factors related to rhinitis and sinusitis are not well-understood. According to this study, the aerodynamic changes in the nasal and paranasal cavities caused by enlarged adenoids may not be essential to the development of rhinitis and sinusitis. Although the long-term reduction of air flow results in a change in the mucous membrane in the nasal and paransal cavities,g the pathogenesis of rhinitis and sinusitis cannot be attributed solely to this factor. With a view to justifying this assumption, we have observed cases with congenital choanal atresia in which air flow into the nasal and paranasal cavities has been interrupted. Two representative cases are demonstrated radiographitally in Fig 1. Both cases exhibit maxillary si-
nusitis on one side, whereas no pathologic shadows are seen on the obstructed side of choana (Fig 1). We previously studied the effects of aerodynamic changes on sinusitislO using experimentally induced sinusitis in rabbits according to the methods of Maeyama,l’ of which one anterior nasal airway was surgically obstructed for four days to 6 weeks in order to change the air flow in the nasal and paranasal cavities. No exacerbation of sinusitis was observed due to these aerodynamic changes. References 1. Ruben RJ, Weg N: Contraindications to adenoidectomy. Bull NY Acad Med 1975; 51:817-827 2. Grote II. Kuiioers W: Middle ear effusion and sinusitis. J Laryngol &of 1980; 94:177-183 3. Alhady RA, Sharnoubi h4E: Tympanometric findings in patients with adenoid hyperplasia, chronic sinusitis and tonsillitis. J Laryngol Otol 1984; 98:671-676 4. Merch W: The relationship between adenoidal enlargement and maxillary sinusitis. HNO 1974; 22:198-199 5. Stool SE: Disease of the tonsils and adenoids in relation to rhinitis and sinusitis. Ann Otol Rhino1 Laryngol 1975; 84:73-74 (suppl) 6. Fujioka M, Young LW, Girdany BR: Radiographic evaluation of adenoidal size in children. Am J Radio1 1979; 133:401-404 7. Bertrand BMG, Robillard TAJ: Comparative study of standard radiology, sinuscopy and sinusomanometry in the maxillary sinus of the adult. Rhinology 1985; 23:237-246 8. Elwany S: The adenoidal-nasopharyngeal ratio (AN ratio): Its validity in selecting children for adenoidectomy. J Laryngol Otol 1987; 101:569-573 9. Cvetnic V, Batistic B, Sankovic F: Cytological and histological alterations in the nasal mucous membrane during experimental obstruction of nasal openings. _ - Rhinoio, 1987; 2:5-12 10. Fukuda K. Matsune S, Ushikai M. et al: The relationship between adenoid vegetation and sinusitis. Jpn J Tonsil 1988; 27:255-261 11. Maeyama T: A study of experimental sinusitis in rabbits. Auris Nasus Larynx 1981; 8:87-98 I,.