Abstract
Objective
To identify clinical characteristics of pediatric patients that failed nasal steroid therapy for management of chronic nasal obstruction and to evaluate the efficacy of adenoidectomy in this subset of patients.
Design
Retrospective chart review.
Setting
Tertiary care academic center.
Subjects
Analysis was performed on children that underwent adenoidectomy between 2011 and 2015 for chronic nasal obstruction refractory to nasal steroids.
Results
Seventy-four cases were identified. Average age of presentation was 3.6 years. Pre-operatively, 25.7% of patients had known asthma, 16.2% reported respiratory allergies, and 20.3% reported use of systemic antihistamines. The most common pre-operative symptoms included mouth breathing (82.4%), nasal congestion (81.1%), snoring (71.6%), and rhinorrhea (37.8%). Average adenoid size was 68% pre-operatively. Ninety-eight percent of patients experienced improvement or resolution of their symptoms following adenoidectomy.
Conclusions
This study demonstrates average rates of respiratory allergies, but high rates of asthma among patients that fail nasal steroid therapy for chronic nasal obstruction. Adenoidectomy is a highly efficacious intervention in this subset of patients.
1
Introduction
Chronic nasal obstruction, rhinorrhea, mouth breathing and snoring due to adenoid hypertrophy are some of the most frequent chief complaints evaluated by the pediatric otolaryngologist. This constellation of symptoms has been shown impact quality of life, leading to behavioral changes and emotional distress . Current management of symptoms of chronic nasal obstruction includes allergy treatments, nasal steroid sprays, and surgery.
Nasal steroid therapy has been established as a safe and effective treatment for chronic nasal obstruction . Success rates of nasal steroids range from 45% to 77% when compared to a nasal saline placebo . Responders are often able to avoid surgery, such as adenoidectomy . In addition, nasal steroids have been shown to reduce objective adenoid size . Reduction in adenoid-choana ratio has been correlated with improvement in nasal obstructive symptoms . Nasal steroids are a proven first line therapy in patients with nasal obstruction, but options are limited in treatment of children that fail initial medical management.
Adenoidectomy has long been used as a strategy in treatment of chronic nasal symptoms in the pediatric population. However, recommendation of adenoidectomy in this setting has remained based on anecdotal success, as the current scientific literature has yet to demonstrate its effectiveness. A 2009 Cochrane review on the efficacy of adenoidectomy in children with chronic nasal obstruction concluded that current evidence is sparse and further studies are needed .
Adenoidectomy is also often performed in conjunction with tympanostomy tubes in cases of pediatric otitis media with effusion (OME), but the recently published clinical practice guidelines no longer recommend adenoidectomy for OME in every age group . For children < 4 years old, adenoidectomy is only recommended if the child has concurrent symptoms of nasal obstruction. Due to the high prevalence of concurrent pediatric OME and nasal obstruction, the efficacy of adenoidectomy is of interest. Clear indications for adenoidectomy in the setting of chronic nasal obstruction alone can help guide treatment decisions in patients affected by OME and chronic nasal obstruction.
The question of how to manage nasal obstruction refractory to nasal steroids remains unanswered. In this study, we aim to identify the characteristics of children that fail nasal steroid therapy for management of chronic nasal obstruction and to evaluate the efficacy of adenoidectomy in this subset of patient. In addition, the study aims to elucidate differences between children < 4 and ≥ 4 years old, if present.
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