Pulmonary function studies in adenoid hypertrophy

Internationai Journal of Pediatric Otorhinolaryngology, @ Elsevier/North-Holland Biomedical Press

PULMONARY

FUNCTION

M. MAURIZI, G. PALUDETTI,

2 (1980)

STUDIES IN ADENOID

243-250

243

HYPERTROPHY

T. TODISCO, M. DOTTORINI and V. GRASS1

Istituto di Clinica Otorinolaringoiatrica, 06100 Perugia (Italy)

Universitci di Perugia, Policlinico Monteluce,

and (T.T., M.D. and V.G.) lstituto di Semeiotica 06100 Perugia (Italy)

Medica, Universitci di Perugia,

(Revised version received May 5th, 1980) (Accepted May 7th, 1980)

SUMMARY

Tests of pulmonary function were performed on children with severe adenoid hypertrophy, before and one month after adenoidectomy. Five types of subjects were selected: (1) normal; (2) cases with isolated increase of residual volume (RV); (3) supernormal type with increased RV; (4) obstructive type of ventilatory defect, and (5) restrictive type of ventilatory defect. Following adenoidectomy there is an objective evidence of improved pulmonary function. The data suggest that 65.7% of clinically normal children with adenoid hypertrophy show pulmonary function abnormalities.

INTRODUCTION

There is increasing evidence that upper airway obstruction can induce pulmonary function abnormalities, generally attributed to alterations in the lower airways. Although nasal breathing doubles the total respiratory resistance, we prefer to breathe through our nose [ 21. The highest resistance to airflow can be found at the nostrils, nasopharynx, pharynx and larynx [ 171. Generally, experimental lung function studies have been made in animals breathing through a tracheal cannula: under these conditions the naso-pulmonary physiology cannot be evaluated [ 151. Kratschmer [lo] first reported naso-laryngeal reflexes causing apnea and

244

bradycardia more than 100 years ago. Furthermore, since 1965, when car pulmonale secondary to enlarged adenoids was first recognized, the total number of cases reported up to 1975 was 27. Many of these patients were children with histories of upper respiratory infections, mouth breathing, alveolar hypoventilation, lethargy, cyanosis and car pulmonale due to pulmonary hypertension [ 1,121. Today it is important to realize that in children, nasal obstruction from whatever cause, anatomic or infectious [ 7-91, causes measurable increase of airway resistance and can be considered as a possible cause of chronic obstructive lung disease in adult life. Despite abnormal pulmonary function, most children with nasal obstruction do not present any sign or symptom. They are usually seen because of recurrent upper respiratory infection, or because there is objective evidence of adenoid hypertrophy. To obtain further information in this field we have studied pulmonary function in clinically normal children affected by adenoid hypertrophy before and one month after adenoidectomy, to confirm recent evidence [4,14,16,20] that upper respiratory obstruction may induce pulmonary function abnormalities. In 1978 we reported the preliminary results of our research concerning pulmonary function in adenoid hypertrophy, and we already mentioned an increased pulmonary function following adenoidectomy [20]. MATERIALS

AND METHODS

We examined 35 normal children (4-12 years of age), 9 females and 26 males. They were classified in 3 age-related groups: group 1, 4 to 6 years; group 2,7 to 9 years; and group 3,lO to 14 years (Table I). Physical examination and chest roentgenogram on admission showed normal lungs. The adenoids were severely hypertrophied in all subjects causing a high degree of nasal obstruction. A complete test of pulmonary function was performed on all children before adenoidectomy. The method used was total body plethysmography (PULMOSTAR SMB Fenyves and GUT - constant volume type plethysmograph) as described by Matthys [ 131, and the following determinations made were: inspiratory vital capacity (IVC) in liters; forced expiratory volume in 1 set (FEVI) in liters/set; expiratory reserve volume (ERV) in liters; inspiratory capacity (IC); maximal midexpiratory flow (MMEF,,_,,) in liters/set; thoracic gas volume (TGV); inspiratory and expiratory airway resistance (Raw Insp.) in cm/H,O-liter/set; specific conductance (SGaw = $/TGV); maximal expiratory flow-volume curves (MEF) at peak expiratory flow (PEF) 25%, 50%, 75% vital capacity (VC); and residual volume (RV) in liters. Reference values are those of Todisco et al. [ 191 and Cotes [ 51. Having obtained these variables, adenoidectomy was carried out; the postoperative tests of pulmonary function were performed one month later.

245 TABLE I PHYSICAL

CHARACTERISTICS

OF THE SUBJECTS

Age group (years)

Number of boys

Height range (cm)

Weight range (kg)

Number of girls

Height range (cm)

Weight range (kg)

4- 6 7- 9 10-14

13 11 2

100-130 114-146 124-165

15-23 18-39 23-57

2 4 3

98-129 loo-138 120-164

17-29 20-46 23-58

RESULTS

Fig. 1 is the complete diagram of lung volumes and capacities as measured by body plethysmography in 35 healthy children before adenoidectomy. We could group them in 5 different types: (1) normal lung volumes (12 cases, 34.3%); (2) isolated increase of RV (5 cases, 14.3%); (3) obstructive type of ventilator-y defect (11 cases, 31.4%); (4) increased VC, but increased RV (‘supernormal’) (4 cases, 11.4%); and (5) restrictive type of ventilator-y defect (3 cases, 8.6%). Lung volume and flow-volume curve data (mean + S.D.) % predicted for normal children and for obstructive and restrictive functional groups, before and after adenoidectomy, are shown in Table II. Table III shows mean values f S.D. for expiratory airway resistance and maximal midexpiratory flow in 35 children with severe adenoid hypertrophy. Significant elevation (P < 0.001) of expiratory Raw Insp. was observed in all subjects before adenoidectomy. Almost invariably, one month after the operation Raw Insp. values showed a pronounced decrease. In particular, the

v

I BTPS

"1

RESPIRATORY

RESTING

LEVEL

2

I -

ISOLATED

2

DBSTR”CTl”E VENTILATOR”

IHCREASE OF R”

3

SUPER HDRMAL WlTH IRCREASED

TIPE DEFECT R”

Fig. 1. Lung volume subdivisions in children with adenoid hypertrophy: 4 different groups were detected. For abbreviations see text and V.l.BTPS = volume in liters at body temperature and pressure and saturated with water vapor.

246 TABLE II LUNG VOLUME DICTED

AND

FLOW-VOLUME

CURVE

DATA

(MEAN

+ S.D.)

% PRE-

B = Before adenoidectomy; A = after adenoidectomy. For abbreviations see text. Obstructive = obstructive ventilatory defect; Restrictive = Restrictive ventilatory defect. Percent predicted mean values i: S.D. and the degrees of statistical significance (combined Student’s t-test) of difference are as follows: *** P < 0.001, **P < 0.01; * P < 0.05. Parameter

Functional group Normal

TLC vc RV FEV, PEF 25% FVC 50% FVC 75% FVC

Obstructive

Restrictive B

B

A

B

A

100.4 (20) 97.9 (17.4) 100.1 (10.8) 98.2 (7.9) 98.8 (9.9) 97.9 (18.2) 99.6 (20.1) 100.2 (15.2)

100.2 (18) 100.0 (18.0) 100.1 (11.4) 100.2 (9.3) 97.4 (17.4) 98.3 (17.4) 101.2 (18.4) 101.0 (12.4)

120.6 (7.8) 89.5 (18.8) 115.4 (12.3) 80.7 (6.5) 79.9 (8.8) 80.2 (15.3) (99.4) (18.2) 64.7 (11.2)

105.7 *** (8.4) 97.8 * (20.2) 94.2 ** (13.2)* 97.2 (10.5) 81.2 (9.8) 88.4 (14.4) 99.7 (15.8) 97.4 *** (7.2)

A

78.1 (10.2) 68.6 (9.8) 85.4 (5.9) 94.4 (11.5) 70.6 (4.4) 68.9 (9.8) 59.7 (7.4) 89.9 (8.4)

84.8 (11.7) 79.9 (7.4) 94.3 (4.4) 97.2 (17.5) 100.0

** *** **

***

(5.9) 94.6 *** (4.7) 89.4 *** (4.9) 90.4 (9.9)

TABLE III AIRWAY RESISTANCE AND MAXIMUM-EXPIRATORY FLOW (MEAN -+ S.D.) IN CHILDREN WITH ADENOID HYPERTROPHY, BEFORE AND AFTER ADENOIDECTOMY B = Before adenoidectomy; A = 1 month after adenoidectomy; NV = normal values. The degrees of statistical significance (combined Student’s t-test) of difference are as follows: ***p < 0.001; ** P< o.o1;*p< 0.05

Age

MMEFg+75

(liters/see)

NV

B

A

10.2 9.8 9.4 7.4 6.5 5.7 5.0

1.2 1.2 1.1 1.2 1.5 1.4 1.8

Raw Insp. (cm HaO/liter/sec)

(number of cases)

B

A

4 (5) 5 (5) 6(5) 7 (5) 8 (5) 9(5) lo-14(5)

26 (25) 34 (k7) 18 (58) 17 (+S) 17 (f9) 20(-+10) 10 (-+a)

19(flO) * 21 (-+9) *** 13 (f9) ** 12 (k4) * 8 (-+S) *** 11 (k7) *** 6 (+3) **

(kO.2) (f0.3) (f0.3) (f0.4) (kO.3) (kO.2) (f0.5)

0.6 1.3 1.5 1.3 1.4 1.3 2.0

NV (20.5) (50.6) (20.6) (kO.5) (kO.7) (kO.5) (kO.6)

0.6-0.9 0.7-0.9 0.9-1.2 1.0-1.3 1.1-1.4 1.2-1.5 1.5-1.9

247 _

OaSERVLD

. . . . . REFEREllCE

VALUES VLLUES

PEF 2..

3

**., :i.._ .::: IL

NORMAL GROUP 12 SUBJECTS

.

3

VC(I)

1

2

WI(l)

-vEoRoup 3

OIITRUCTIVE

QROW

20 -Ts

WUECTS

Fig. 2. Maximal expiratory flow-volume curves (MEF) in 35 children with adenoid hypertrophy (mean values) before adenoidectomy: in all cases a considerable difference between reference values and observed values was detected. For abbreviations see text. 4

-

BEFORE

.,I..

AFTER

4

1 3 I PEF

vc

RV (1)

(1)

RESTRICTIVE

GROUP.

3 SUBJECTS

OBSTRUCTIVE

GROUP. 2 0 SUBJECTS

Fig, 3. Flow-volume curves in children with adenoid hypertrophy before and after : a measurable increase of pulmonary function was detected following adenoidectomy. For abbreviations see text.. adenoidectomy

248

... ::: ::: ... ..::: .. ..... ......... ...... ::: ......... ::: ...

...... .., ... ......... ...... ......... ......... ...... ~ ...

1 1 4-6

*oE

-

r

lo - 12

7-9

,

9

YEARS

Fig. 4. Specific conductance (SGaw) before and after adenoidectomy: considerably increased values were detected after intervention. For abbreviations see text.

expected decrease of airway resistance with increasing age becomes clearly apparent only one month after adenoidectomy. Maximal midexpiratory flow was basically normal in all subjects and there were no changes postoperatively. Fig. 2 shows MEF curve values in the selected groups before intervention. The restrictive group shows a marked decrease (30%) of MEF values at higher lung volumes (PEF, 25% and 50% VC). On the contrary, the obstructive type shows a decrease of MEF values at lower volume. One month after adenoidectomy MEF values returned to normal limits (Fig. 3). Specific conductance before and after adenoidectomy shows a marked decrease in all patients classified in age-related groups (Fig. 4). DISCUSSION

Assessment of lung function in infants and young children with adenoid hypertrophy is important for studies of pulmonary effects of prolonged upper airway obstruction leading to chronic obstructive lung disease, chronic bronchitis and asthma [4,14,16]. The clinical value of body plethysmographic methods to assess lung volumes in infants has been demonstrated [ 6,181: the obstructive disorder in lung function is diagnosed on the basis of an increase of residual volume alone or associated with an increase of bronchial flow resistance. Our results in asymptomatic children with severe nasal obstruction confirm that 65.7% of children with chronic nasal obstruction due to severe adenoid hypertrophy show pulmonary function abnormalities. Recent studies have suggested that chronic pulmonary disorders in adolescents and adults have their origin in the first years of life [16]. Furthermore,

249

hypoventilation, pulmonary hypertension, car pulmonale and congestive heart failure secondary to chronic upper airway obstruction in childhood, have already been recognized in the literature [1,3,4,7,11,12,14]. Our studies show that obstructive type of ventilator-y defect (57.1%) is present in children with severe adenoid hypertrophy. This observation suggests that in recurrent upper airway infections mechanical and reflex components may contribute to the pathogenesis of asymptomatic bronchial obstruction in young children with severe adenoid hypertrophy. Among children with a restrictive type of ventilator-y defect (8.6%), a rapid body growth and development was observed some months after adenoidectomy. In these patients the improvement of lung volume after operation suggests that in these patients the obstructive pattern might be attributable to a slowing of chest and lung growth in relation to age. The improvement of pulmonary function one month after adenoidectomy not only confirmed the etiologic importance of nasal obstruction, but also emphasized the clinical value of body plethysmographic measurements of lung function in children with adenoid hypertrophy. Whether or not there is a correlation between upper chronic airway obstruction in children which may contribute to the pathogenesis of unexplained chronic obstructionlestrictive pulmonary disease in adult life is not known. ACKNOWLEDGEMENTS

This work was supported by Consiglio Nazionale delle Ricerche, Roma, and its Program of Preventive Medicine, Subproject Chronic Obstructive Lung Disease, and by Grant C.N.R. CT79.01014.04. Mr. Lucia Bruni performed measurements. REFERENCES 1 Bland, J.W., Edwards, F.K. and Briensfield, D., Pulmonary hypertension and congestive heart failure in children with chronic upper airway obstruction, Amer. J. Cardial., 23 (1969) 830. 2 Butler, J., Caro, C.G., Alcala, R. and Dubois, A.B., Physiological factor affecting airway resistance in normal subjects and in patients with obstructive respiratory disease, J. clin. Invest., 39 (1960) 584. 3 Cayler, G., Johnson, E.E., Lewis, B.E., Kortzeborn, J.D., Jordan, J. and Fricker, G.A., Heart failure due to enlarged tonsils and adenoids, Amer. J. Dis. Child., 118 (1969) 708. 4 Collier, A.M., Pimmel, R.L., Hasselblad, V., Clyde, N.A., Knelson, J.H. and Brook, J.G., Spirometric changes in normal children with upper respiratory infections, Amer. Rev. resp. Dis., 117 (1978) 47 5 Cotes, J.E., Lung Function, 3rd edn., Blackwell Publications, 1975, p. 94. 6 Doershuk, C.F., Downsit, T.D., Matthews, S.L.W. and Lough, M.D., A method for ventilatory measurements in subjects one month-five years of age: normal results and observations in diseases, Pediat. Res., 4 (1970) 165.

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