Adenoidectomy versus mometasone furoate nasal spray in treatment of nasal obstruction in children due to adenoid hypertrophy: a comparative study

INTRODUCTION

One of the common causes for nasal obstruction in children is adenoid hypertrophy.¹ It is common indication for surgical removal in these patients due to multiple morbidities. They are in smallest size at birth and start growing in size after immunologic development (at age 1-2- years).² Adenoids are exposed to multiple antigens in the respiratory air and they produce antibody against these antigens. This describes their enlargement after exposure to antigen especially in allergic patients.²

Hypertrophy of the adenoids can lead to repeated infections such as otitis media, sinusitis, mastoiditis, recurrent tonsillitis. Nasal obstructions lead to mouth breathing, snoring, nasal speech, halitosis, obstructive sleep apnea and olfactory disorders.^3-5

In severe symptoms adenoidectomy is recommended, however there are limitations for surgery like cleft palate.⁶ As infections could be a stimulant of adenoid enlargement, medical management of adenoid hypertrophy is presently directed towards harbored infections. The role of oral steroid in alleviating the symptoms due to adenoid hypertrophy is controversial. Systemic steroids produce temporary decrease in size but significant adverse effects. The safety of nasal steroid spray has been well reported.^8-10 No significant effects were seen on adrenocortical function in children’s 6-12 years with allergic rhinitis.⁸ Also intranasal administration of 200 mcg mometasonefuroate aqueous nasal spray once daily for 14 days was found to be safe and well tolerated in children 3-12 years of age.⁹ The aim of the study was to access the short term and long term effects of MF nasal spray in treating adenoid hypertrophy and to compare it with adenoidectomy..

METHODS

This study was conducted in department of ENT, AJ institute of medical sciences, Mangalore between august 2017 to October 2018. 60 children aged between 3-11 years came to ENT department with predominant symptoms of nasal obstruction and confirmed to have adenoid hypertrophy were considered. A prospective randomized comparative study was done. Children who fit the inclusion and exclusion criteria were divided into 2 groups, group A patients underwent adenoidectomy and group B patients were treated with mometasone nasal spray (100 mcg) for 40 days followed by maintenance dose for 3 months. Initial assessment was done by taking detailed history and physical examination and pretreatment and follow up symptom scores at visit 1(at 40 days) and visit 2 (4 months) were assessed. Diagnostic nasal endoscopy done on pretreatment and follow up visits and adenoid hypertrophy grading was determined (Figure 1). Final readings were analysed to determine the efficacy of mometasone nasal spray as an alternative to surgery.

Inclusion criteria

Inclusion criteria were history of nasal obstruction/ snoring for more than 3 months; adenoid hypertrophy confirmed with endoscopic or x ray findings (Figure 2); Group A inclusion criteria includes:

• • Voluntarily requiring surgery
• • Recurrent adenotonsillitis
• • Complications such as otitis media with effusion
• • Contraindications to nasal spray or for steroids.

Exclusion criteria

Exclusion criteria were presence of symptoms of acute respiratory tract infection within 4 weeks of study; use of nasal or systemic or inhaled corticosteroids or antibiotics within 4 weeks prior to study; prior tonsil or adenoid surgery; nasal anatomic anomalies (e.g., nasal septum deviation); sinonasal diseases such as hypertrophy of inferior turbinate and nasal polyposis; craniofacial malformations like cleft lips / cleft palate; history of epistaxis or hypersensitivity to steroids.

Statistical analysis

Data analysis was carried out using statistical package for social science (SPSS, V 10.5) software. In all cases “p” value of less than 0.05 was indicative of statistical significance.

RESULTS

There were 48.3% male and 51.7% female (Table 1) with mean age group of 6.7±1.84 in group A and 6.37±2.10 in group B (Table 2).

SD – standard deviation.

In group A, pre-treatment 9 (30%) had severe nasal obstruction, 12 (40%) had moderate, 8 (26.7%) had mild and 1 (3.3%) had no nasal obstruction. In group B, pre-treatment 7 (23.3%) had severe nasal obstruction, 14 (46.7%) moderate, 7 (23.3%) mild and 2 (6.7%) with no nasal obstruction. During the 40^th day follow up post treatment, a significant difference was found with no nasal obstruction in 93.3% patients who underwent adenoidectomy compared to 63.3% for those treated with MF nasal. The overall decrease severity of nasal obstruction was significant in adenoidectomy versus MF nasal spray (p=0.005). At follow up after 4 months, 93.3% patients in group A had had improvement in clinically as compared to 76.6% in group B were nasal obstruction was relived. The overall decrease was not statistically significant between group A compared to group B (p=0.192) (Table 3).

In group A, there was significant reduction in adenoid hypertrophy grading after adenoidectomy compared to MF nasal spray at 40 days follow up (p=<0.001). 4 month follow up there was statistically significant difference in group A as compared to group B (p=<0.001). Long term MF nasal spray was associated with significant reduction in adenoid hypertrophy but it was not as effective as adenoidectomy (Table 4).

DISCUSSION

Adenoid hypertrophy is one of the most common pathologic condition in paediatric age group. They present with bilateral nasal obstruction, which may be associated with snoring, mouth breathing and obstructive sleep apnea. The treatment for most of children with uncomplicated adenoid hypertrophy is by adenoidectomy but significant risks are present and complications can occur with the surgery are well known. Paulussen et al hypothized that the removal of adenoid lymphatic tissue could have a negative impact on systemic immunologic system.¹⁰

Demain and Goetz described the first successful use of intranasal steroid for adenoid hypertrophy in 1995.¹¹ Since then, other authors have similar encouraging results with different intranasal steroid preparations. The proposed mechanism of action is by direct reduction of adenoid size by lympholytic action of steroid and reduction in adenoidal and nasopharyngeal inflammation by anti-inflammatory effects of steroids.¹¹ Intranasal steroid preparations are also found to be safe in paediatric age group with no systemic side effects.

A study done by Gupta et al on snoring due to adenoids showed a significant improvement in all domains of obstructive sleep apnea due to adenoid hypertrophy.¹² these findings are similar to our study. In another study done by Rezende et al. Mometasone nasal spray had a significant improvement in nasal obstruction as compared to saline nasal spray. Also there was a significant reduction in adenoid area as compared to saline nasal douching which had no effect on the adenoid size.¹³ These findings are similar to our study which showed a decrease in nasal obstruction and decrease in the size of adenoids.

CONCLUSION

Long term topical intranasal mometasone nasal spray can be a good therapeutic option to decrease adenoid hypertrophy and nasal obstruction without the need for surgery. This study provides an effective alternative to surgical treatment in children with adenoid hypertrophy. Intranasal corticosteroids are generally well tolerated in children. In this study no side effects were observed after a total dose of 100 micrograms /day was used for 40 days daily, followed by maintenance therapy. Hence long term use of mometasonenasal spray can be an effective alternative for patients not willing for surgery.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Rutkow IM. Ear, nose, and throat operations in the United States, 1979 to 1984. Arch Otolaryngol-Head Neck Surg. 1986;112(8):873-6.
2. 2. Scadding G. Non-surgical treatment of adenoidal hypertrophy, The role of treating IgE mediated inflammation. Pediatric Allergy Immunol. 2010;21(8):1095-106.
3. 3. Grundfast KM, Wittich DJ Jr. Adenotonsillar hypertrophy and upper airway obstruction in evolutionary perspective. The Latyngoscope. 1982;92(6):650-6.
4. 4. Potsic WP, Wetmore RF. Sleep disorders and airway obstruction in children. Otolaryngologic Clin North Am. 1990;23(4):651-63.
5. 5. Gates GA, Muntz HR, Gaylis B. Adenoidectomy and otitis media. Ann Otol Rhinol Laryngol. 1992;155:24-32.
6. 6. Stuck BA, Windfuhr JP, Genzwurker H, Schroten H, Tenenbaum T, Gotte K. Tonsillectomy in Children. Deutsches Arzteblatt Int. 2008;105(49):852-61.
7. 7. Berlucchi M, Valetti L, Parrinello G, Nicolai P. Long-term follow-up of children undergoing topical intranasal steroid therapy for adenoidal hypertrophy. Int J Pediatric Otorhinolaryngol. 2008;72(8):1171-5.
8. 8. Nayak AS. Ellis MM, Gross GN, Mendelson LM, Sohenkel EJ, Lanier BQ, Simpson B, Mullin ME. Smith JA. The effects of triamcinolone acetomideacqueous nasal spray on the adrenocortical function in children with allergic rhinitis. J Allergy Clinic Immunol. 1988;101:157-62.
9. 9. Brannan MD, Herron JM, Affrime MB. Safety and tolerability of once daily mometasonefuroate aqueous nasal spray in children. Clin Therap. 1997;19(6):1330 -7.
10. 10. Paulussen C, Claes J, Claes G, Jorissen M. Adenoids and tonsils, indications for surgery and immunological consequences of surgery. Acta Otorhinolaryngol Belg. 2000;54:403-8.
11. 11. Demain JG, Goetz DW. Pediatric adenoidal hypertrophy and nasal airway obstruction: reduction with aqueous nasal beclamethasone. Pediatrics. 1995;95:355-64.
12. 12. Gupta V, Gupta M, Matreja PS, Singh S. Efficacy of mometasone nasal spray in children with snoring due to Adenoids. Clin Rhino An int J. 2014;7(1):1-4.
13. 13. Rezende RM, Silveira F, Barbosa AP, Menezes UP, Ferriani VP, Rezende PH, et al. Objective reduction in adenoid tissue after mometasone furoate treatment. Int J Pediatr Otorhinolaryngol. 2012;76(6):829-31.