Abstract
Chronic adenoiditis leading to adenoid hypertrophy is common in children. Many cases would also have co-existing chronic rhinosinusitis (CRS). Infact, long lasting bacterial infection of the adenoids has been hypothesized to be the cause for CRS in these children. A cross-sectional study was conducted in the departments of ENT and Micro-biology at Kasturba Hospital, Manipal, India between 2016 and 2017. 20 subjects who were diagnosed with CRS and adenoid hypertrophy took part in the study. Aerobic, anaerobic and fungal culture sensitivity of adenoid tissue was done along with aerobic and fungal culture sensitivity of nasal swabs from middle meatus. 2 out of 20 adenoid samples showed positive culture for aerobes and 19 adenoid samples grew anaerobic organisms. 7 out of 20 nasal swabs grew some aerobes and 2 were positive for fungal organisms. The correlation of microorganisms between adenoid hypertrophy and CRS was seen only in one patient in which methicillin resistant Staphylococcus aureus was grown. The present study showed mixed flora in the adenoid samples with anaerobic predominance. Aerobes were predominantly grown in nasal swabs from patients with CRS along with fungal colonizers. Though the study does not establish any bacteriological association with the CRS in our cohorts, the significant growth of the anaerobes from the core of the inflamed adenoids has prompted us to suggest the inclusion of the antibiotics against the anaerobes in the medical management of these children, whenever feasible. We think the addition of specific antibiotics to tackle anaerobes helps by hampering the further inflammatory hypertrophy of adenoid tissue.
Keywords: Adenoid, Rhinosinusitis, Adenoiditis, Microbiology
Introduction
Chronic adenoiditis leading to adenoid hypertrophy is common in children. Many of those affected children would also have co-existing chronic rhinosinusitis (CRS) [1]. Long-lasting bacterial infection of the adenoids has been hypothesized to be one of the causes for CRS in these children [2, 3]. There are reports of improved signs and symptoms of CRS after the removal of the hypertrophied adenoids in the same children [4]. Though bacteria isolated from the adenoids have been implicated in the pathogenesis of CRS [2], not many authors have studied the bacteriological profiles of both the CRS and the adenoiditis together. The present study is unique in which the microbiological aspects of the chronic adenoiditis and the CRS has been compared in the same cohort of children, to verify whether these conditions could have any etiopathological and management implications between them. This study also discusses some peculiar bacteriological characteristics of the adenoiditis and which could be therapeutic importance.
Objectives
The primary objective was to study the association between the microbiological profiles of the adenoiditis and the CRS in children diagnosed to have these co-existing conditions. The purpose is to identify the etiopathological similarities between these conditions, if any. The study is expected to partly answer the hypotheses whether or not these conditions predispose to one another, and whether the treatment of one could affect the symptoms of the others.
Materials and Methods
In this cross-sectional study conducted at a tertiary care hospital in the southern part of India, all those children treated in the Department of Otorhinolaryngology and Head and Neck Surgery between September 2016 and February 2017 were considered to be part of this study. The criteria for inclusion into the study was co-existing chronic rhinosinusitis in children who were undergoing adenoidectomy for chronic adenoid inflammation and its sequel. Those children with either of acute sinusitis, acute exacerbation of chronic rhinosinusitis, pre-existing immunosuppressive condition or syndromic association were excluded from the study. After taking the detailed informed written parental consents, the nasal swabs were taken from the study participants under the general anesthesia, during the adenoidectomy procedure. The nasal swabs were collected from middle meatus under endoscopic guidance just before the adenoid resection by cold instruments. The nasal swabs and then the curated adenoid tissue were collected into a sterile container and sent for bacterial as well as fungal culture and sensitivity studies. For anaerobic culture, the adenoid tissues were inoculated directly into Robertson’s cooked meat broth. All the samples were sent immediately to the microbiology laboratory for processing.
The nasal swabs were directly inoculated onto 5% sheep blood agar and chocolate agar for aerobic bacterial growth, whereas the adenoid tissue specimens were grounded and inoculated onto 5% sheep blood agar and Mac-Conkey agar, and then incubated at 35–37 °C. After incubation, the plates were observed up to 7 days for the presence of growth. Gram Staining was done from each colony prototypes, and identification was made by bio-chemical reaction. For Anaerobic culture of the adenoid tissue specimen, the inoculated samples in Robertson’s cooked meat broth bottles were incubated for 48 h and then were cultured on Blood agar, Neomycin blood agar & Phenyl ethyl alcohol, and then the plates were incubated anaerobically in the anaerobic workstation. This method is routinely followed at our institute for isolating anaerobic organisms from the clinical specimen and has shown to yield optimal results [5]. Both the nasal swab and the tissue were inoculated onto Sabouraud’s dextrose agar for fungal culture. The period of incubation in culture conditions varied between the patients and the culture methods ranging from 48 h to 3 weeks. However, for the growth to be considered as negative for any organism, the minimum incubation period considered was 48 h in case of aerobic culture, 5 days for anaerobic culture and 5 days for fungal culture. The organism cultured from these specimens were tabulated, and the correlation between the nasal specimens and the adenoid tissue specimens were calculated.
Results
A total of 20 children were included after exercising the criteria for inclusion and exclusion. The median age of the cohort was 6 and a half years, ranging between 3 and 16 years. Majority of the included children were boys (n = 13) with a ratio of 1.8:1. Most of the nasal swabs yielded either the no growth or growth of the normal commensals in aerobic culture studies, with only two specimens showing the substantial growth of methicillin-resistant Staphylococcus aureus. Fungal culture did not show any fungal growth in most of the nasal swabs except in two samples, one of which grew Aspergillus flavus and the other grew Bipolaris strain. With the adenoid tissue inoculation also, the aerobic culture yielded only two positive growth, one showing beta-hemolytic Streptococcus and the other showing methicillin-resistant S. aureus. However, the anaerobic culture from adenoid tissue grew anaerobic organisms in all the specimens except 1. Fusobacterium (n = 13) was the most commonly isolated anaerobe from adenoid tissue, followed by Veilonella parvula (n = 7) and Prevotella (n = 2). Three of these tissue samples showed growth of more than one anaerobe. The fungal culture from the inoculated adenoid tissue specimens did not grow any organism. The details of the various culture studies from this study sample have been depicted in Table 1. Quite evidently the microbiological profile isolated from the nasal swab was very dissimilar to that of the adenoid tissue. The histopathological examination of the excised adenoid tissue from all the children showed focal squamous metaplasia of the respiratory epithelium with lymphoid hyperplasia, lymphoplasmacytic infiltrates, prominent germinal centers and intervening fibrosis, suggestive of chronic inflammation.
Table 1.
The culture reports of the study cohort
| S no | Age | Sex | Nasal swab | Adenoid tissue | |||
|---|---|---|---|---|---|---|---|
| Areobic culture | Fungal culture | Areobic culture | Anerobic culture | Fungal culture | |||
| 1 | 16 | M | Normal flora | No growth | No growth | PS | No growth |
| 2 | 5 | F | CNS | No growth | No growth | FS | No growth |
| 3 | 6 | M | No growth | No growth | No growth | VP | No growth |
| 4 | 10 | M | CNS | No growth | No growth | VP | No growth |
| 5 | 6 | M | No growth | Aspergillus flavus | No growth | FS | No growth |
| 6 | 13 | F | No growth | No growth | Normal flora | FS, VP | No growth |
| 7 | 9 | M | No growth | No growth | No growth | VP | No growth |
| 8 | 4 | M | Normal flora | No growth | Normal flora | FS, PS | No growth |
| 9 | 15 | M | No growth | No growth | Normal flora | VP | No growth |
| 10 | 4 | F | No growth | No growth | Normal flora | FS | No growth |
| 11 | 7 | M | MSSA (Scanty) | Bipolaris | No growth | VP | No growth |
| 12 | 5 | M | No growth | No growth | Normal flora | FS | No growth |
| 13 | 5 | M | MRSA (Heavy) | No growth | No growth | FS | No growth |
| 14 | 9 | F | No growth | No growth | No growth | FS | No growth |
| 15 | 13 | M | No growth | No growth | No growth | FS | No growth |
| 16 | 12 | F | MRSA (Heavy) | No growth | MRSA (Moderate) | No [5] | No growth |
| 17 | 5 | M | No growth | No growth | No growth | FS | No growth |
| 18 | 3 | F | No growth | No growth | BHS. | FS | No growth |
| 19 | 13 | M | MSSA (Moderate) | No growth | No growth | FS | No growth |
| 20 | 5 | F | MSSA (Scanty) | No growth | Normal flora | FS, VP | No growth |
The age is in years and the numbers in paracentesis denote days of incubation in culture conditions
Sl no serial number of patient, M male, F female, CNS Coagulase negative Staphylococcus sp, MSSA Methicillin Sensitive Staphylococcus aureus, MRSA methicillin resistant Staphylococcus aureus, BHS Beta haemolytic streptococcus sp, FS Fusobacterium sp, VP Veilonella parvula, PS Prevotella sp
Discussion
The reported isolation rate of organisms from the inflamed adenoid is 79.3–90% [6]. We have isolated the organism in 100% of the adenoid samples. However, contrary to the previous studies which have reported presence of numerous aerobic bacteria like streptococci, Haemophilus influenza, S. aureus, group A beta-hemolytic streptococci, and Moraxella catarrhalis in the adenoid tissue [2, 7], we could isolate aerobes only in two samples of adenoid tissue, one strain each of Beta haemolytic streptococcus and Methicillin-Resistant S. aureus. This reason for this difference may be that we have cultured the adenoid tissue taken from the core and not the surface, and the aerobic microorganisms density is significantly higher at the adenoid surface compared to the adenoid core [8]. There exists a discrepancy between bacteriological profiles of surface and core of the adenoids, and the pathogenic bacteria are generally found in the core compared to the commensals in the surface of the adenoid [6]. Under the anaerobic culture conditions, all the adenoid specimens except one grew organisms in our study. Anaerobic bacteria cultured from these samples include Fusobacterium, Veillonella parvula and Prevotella. These organisms along with the Peptostreptococcus are the common anaerobes reported from the adenoid culture in the previous studies also [7–9].
The microbiological profiles of the adenoiditis tissue and the nasal discharge from the middle meatus were dissimilar both in terms of aerobic bacteria as well as fungal growth. The only similarity observed was in one patient in whom the methicillin-resistant S. aureus was isolated both from the nasal discharge and from the adenoid tissue, however, in context to the whole cohort, this association was statistically insignificant. Our results do not support the bacteriological association between the adenoiditis and CRS. A recently published large-scale study, comprising more than 12,000 children followed up for up to 9 years, downplayed the beneficial effect of adenoidectomy on sinusitis [10]. However, this study was based on the data from the insurance database records and did not consider clinical aspects of CRS in its methods.
On the other hand, all those previous studies showing the favorable results of adenoid resection on sinusitis are also retrospective or uncontrolled studies, constituting relatively lower level of evidence [10]. The Cochrane review itself has concluded that the evidence regarding the beneficial effect of adenoidectomy on CRS symptoms to be insufficient and inconclusive [11]. Even if there is any benefit in CRS children after adenoidectomy, it is unlikely to de due to the removal of the reservoir of pathogenic bacteria. This symptomatic benefit could be attributed to the relief of mechanical obstruction otherwise caused by hypertrophied adenoids and to the improved mucociliary characteristics. Adenoidectomy has been shown to improve the nasal mucociliary clearance time and the mucociliary clearance velocity along with subjective relief of nasal obstruction [12].
A similar microbiological study by Elwany et al. reported a fairly good association between the bacteriological profiles cultured from the adenoid core and the middle meatal swabs [13]. Adenoid core culture had a positive predictive value of 91 and a negative predictive value of 84 in predicting the results of the middle meatal culture. However, in this study, the predominant organisms grown from adenoid core culture were aerobic bacteria and some of which are known to be commensals in the nasal cavity questioning their role in the pathogenicity of CRS. Interestingly the yield of anaerobic growth from adenoid tissue was very limited in this study owing to the differences in culture method. In contrast, the anaerobic growth rates from the adenoid core cultures have been reported to be much more in the previous studies [7]. Despite the smaller sample size in our study, significant anaerobic organisms were cultured from the core tissue of chronically inflamed adenoids, which is probably because of the dedicated technique and the culture media used separately for the anaerobic microorganisms [5]. Our results were similar to the previous studies in terms of anaerobic bacterial isolation from adenoid core tissue [7]. Though we were not able to establish any bacteriological association with the CRS in our cohorts, the significant growth of the anaerobes from the core of the inflamed adenoids has prompted us to suggest the inclusion of the antibiotics against the anaerobes in the medical management of these children, whenever feasible. We think the addition of specific antibiotics to tackle anaerobes helps by hampering the further inflammatory hypertrophy of adenoid tissue. In the similar lines, we think that the use of metronidazole solution wash intraoperatively during adenoidectomy might as well prevent the recurrence of hypertrophy of the remnant tissue and thus the reappearance of the symptoms. However, further prospective clinical studies are required to validate the utility of these suggestions.
Conclusions
Though the study does not establish any bacteriological association with the CRS in our cohorts, the significant growth of the anaerobes from the core of the inflamed adenoids has prompted us to suggest the inclusion of the antibiotics against the anaerobes in the medical management of these children, whenever feasible.
Compliance with Ethical Standards
Conflict of interest
All the authors declare that they have no conflict of interest.
Ethical Approval
Approval from institutional ethical committee.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
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Contributor Information
Rohit Singh, Email: rohit.singh.dr@gmail.com.
R. Shilpa, Email: saishilpa999@gmail.com
Chiranjay Mukhopadhyay, Email: chiranjay.m@manipal.edu.
Padmaja A. Shenoy, Email: padmaja.shenoy@manipal.edu
R. Balakrishnan, Email: baluent@gmail.com
K. Devaraja, Email: deardrdr@gmail.com
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