Abstract
Adenoid hypertrophy is a common presentation in the growing age group. It results in varied symptomatology resulting in nasal obstruction, mouth breathing, snoring, nasal discharge and nasal intonation of voice. Diagnostic nasal endoscopy and plain radiograph are the two most widely done investigative procedures. In our study we have compared the results of these two diagnostic modalities in defining the grade of adenoid hypertrophy and establish the differences in results so that a proper diagnosis is made and appropriate management is initiated.
Keywords: Adenoid hypertrophy, Nasal endoscopy, Radiographs, Nasopharynx, Adenoid facies
Introduction
Adenoids are aggregation of submucosal lymphoid tissue at the junction of roof and posterior wall of nasopharynx. It shows physiological enlargement up to 6 years of age and then regresses gradually during puberty and disappearing completely by 20 years of age, although hypertrophied not rare in adults. Hypertrophied adenoids obstruct the airway in varying degree resulting in nasal obstruction, mouth breathing, snoring, nasal discharge and nasal intonation of voice. Hypertrophied adenoids can also obstruct the Eustachian tube opening causing varied otologic symptoms. If not treated, hypertrophied adenoids results in ‘adenoid facies’ resulting in crowded upper jaw teeth, prominent mouth, hitched up upper lip, high arched palate and a dull expressionless face. Although there are a wide range of diagnostic tools for assessing adenoids like transoral digital examination, transoral mirror examination, videofluoroscopy, nasal resistance and airflow test, lateral view radiograph of the neck and nasal endoscopy are the two most widely used. This study aims at comparing the grades of adenoid hypertrophy found by both these tools and assessing the difference in results, if any.
Materials and Methods
The study was conducted in 50 patients in the age group of 3–14 years who presented with symptoms of hypertrophied adenoids at the Department of ENT and Head and Neck Surgery, Nightingale Hospital, Guwahati. All the children were advised lateral view radiograph of the nasopharynx and nasal endoscopy and their results were compared. Nasal endoscopies were done using 3 mm Karl Storz 0° rigid endoscope under topical anaesthesia using 4% xylocaine with decongestant (topical xylometazoline). Endoscopies were done in sitting position and scope was passed along the floor of the nasal cavities. In compromised cases such as in inferior turbinate hypertrophy, the scopes were introduced in between middle turbinate and septum and the scope was tilted while viewing the adenoids.
In endoscopic assessment the size of the adenoid was determined according to Clemens et al. classification [1] as shown in Table 1.
Table 1.
Clemens et al. classification
| Grade | Description |
|---|---|
| Grade I | Adenoid tissue filling 1/3rd of the vertical portion of the choanae |
| Grade II | Adenoid tissue filling from 1/3rd to 2/3rd of choanae |
| Grade III | Adenoid tissue filling from 2/3rd to nearly complete obstruction of the choanae |
| Grade IV | Complete choanal obstruction |
Radiological assessment and grading of the size of adenoid was done accordingly (Table 2).
Table 2.
Radiological assessment and grading of the size of adenoid
| Grade | Description |
|---|---|
| Grade I | Soft tissue mass obstructing less than 25% of the nasopharyngeal airway |
| Grade II | Soft tissue mass obstructing 25–50% of nasopharyngeal airway |
| Grade III | Soft tissue mass obstructing 50–75% of nasopharyngeal airway |
| Grade IV | Soft tissue mass obstructing more than 75% of nasopharyngeal airway |
Results
In our study, 28 out of 50 were males and the rest were females (Fig. 1). The age distribution of the patients was from 3 to 14 years. The majority of the patients (76%) were in the age group of 6–10 years of age (Fig. 2). 4 patients were detected as Grade I adenoid by both DNE and X-Ray. The number of patients showing Grade II adenoids on nasal endoscopy and X-rays were 10 (20%) and 16 (32%) respectively. The number of patients showing grade III hypertrophied adenoids on nasal endoscopy and plain radiograph were 20 (40%) and 24 (48%) respectively. Hence, X-rays overdiagnosed Grade II and Grade III adenoids. On the other hand, the number of patients showing Grade IV adenoids by DNE and X-rays were 16 (32%) and only 6 (12%). Hence X-rays mostly underdiagnose Grade IV adenoids (Fig. 3).
Fig. 1.
Sex ratio
Fig. 2.
Age distribution
Fig. 3.
Histograms showing the diagnostic mis-match of the two modalities
Discussion
The results revealed that the symptoms due to hypertrophied adenoids are more common in 6–10 years of age. These findings were probably due to rapid growth of lymphoid tissue and relative decrease in post nasal space in addition to high incidence of upper respiratory tract infection (viral or bacterial) due to low immunity during childhood period [2]. Similar results were found in studies by Pruzansky and Fuzioka [3, 4].
In order to compare the results obtained by X-ray with endoscopic findings, we have considered Grade I as mild hypertrophy, Grade II as moderate hypertrophy and Grade III as large sized adenoids. The difference in results in X-rays are mainly due to lack of standardization of X-ray, the 2 dimensional views by X-ray rather than the 3 dimensional views by endoscope and the effects of positional changes and respiratory movement of the patient [5, 6]. X-rays may also misdiagnose adenoid hypertrophy if the enlargement occurs at lateral direction [7]. On the other hand, nasal endoscopies are safe, reliable, easily tolerated and provides a three dimensional view of the nasopharynx.
In our study, percentage of patients showing Grade IV adenoid hypertrophy on nasal endoscopy and plain radiograph was 32 and 12% respectively. Hence, plain radiograph fail to diagnose accurately the large sized adenoids which may lead to inappropriate treatment modality and affect management outcome. The intra-operative findings also co-related with the endoscopic findings.
Conclusion
Even though plain radiograph is non-invasive and reliable tool for assessing adenoids, it sometimes falls short in determining the grade of adenoid hypertrophy. Nasal endoscopy remains the gold standard diagnostic tool for assessing hypertrophied adenoid and hence should be routinely performed in all patients with suspected adenoid hypertrophy so that a proper diagnosis of the grade of hypertrophy is made and appropriate treatment is initiated. However, children should be counselled properly before initiating the procedure. Also unnecessary X-Ray exposure is prevented if nasal endoscopy in done routinely in these cases.
Compliance with Ethical Standards
Conflict of interest
Authors Nayanjyoti Sarma and Gautam Khaund declares that they have no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
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