10.14639/0392-100X-N1832
Introduction. Nasal endoscopy is likely to be the method of choice to evaluate nasal obstruction and adenoid hypertrophy (AH) in children given its excellent diagnostic accuracy and low risk for the patient. The aim of this study was to update the previous classification of AH to guide physicians in choosing the best therapeutic option. Materials and methods. This is a retrospective observational study including 7621 children (3565 females; mean age 5.92; range: 3-14 years) that were managed for adenoid hypertrophy at our institution between 2003 and 2018. All patients were initially treated with medical therapy and then with surgery if not adequately controlled. We performed a specific analysis based on the presence or absence of comorbidities. Results. In 1845 (24.21%) patients, adenoid obstruction was classified as Grade I when the fiberoptic endoscopy showed adenoid tissue occupying &lt; 25% of choanal space. In 2829 of 7621 (37.12%) patients, the adenoid tissue was scored as Grade II since it was confined to the upper half of nasopharynx, with sufficiently pervious choana and visualisation of tube ostium. In 1611 of 7621 (21.14%) cases, adenoid vegetation occupied about 75% of the nasopharynx with partial involvement of tube ostium and considerable obstruction of choanal openings, and was classified as Grade III. Finally, 1336 of 7621 (17.53%) patients were scored as Grade IV due to complete obstruction with adenoid tissue reaching the lower choanal border without allowing the visualization of the tube ostium. Based on resolution of symptoms in Grade III obstruction after medical therapy (that was mostly seen in patients without comorbidities), we divided patients in two subclasses: Grade IIIA was not associated with comorbidities, while Grade IIIB was correlated with important comorbidities. Conclusions. These results can be useful to guide medical or surgical therapeutic intervention. In patients with class IIIB, surgical treatment offered adequate control not only of nasal symptoms but also of associated comorbidities.
text/xml
1827-675X
1832
en
Matteo Gelardi
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
nasal endoscopy
Update of endoscopic classification system of adenoid hypertrophy based on clinical experience on 7621 children
Text.Serial.Journal
https://www.actaitalica.it/
42
Rhinology
2022-04-08
2021-09-27
2022-07-26
2022-07-26
257-264
1
Matteo Gelardi
2022/04/08
10.14639/0392-100X-N1832
257
Unit of Otolaryngology, University of Foggia, Foggia, Italy
1827-675X
nasal endoscopy
en
264
Update of endoscopic classification system of adenoid hypertrophy based on clinical experience on 7621 children
https://www.actaitalica.it/article/download/1832/755
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:257-264; doi: 10.14639/0392-100X-N1832




Rhinology


Update of endoscopic classification system
of adenoid hypertrophy based on clinical experience
on 7621 children
Aggiornamento del sistema di classificazione endoscopica dell’ipertrofia adenoidea
basato sulla nostra esperienza clinica su 7621 bambini
Michele Cassano1, Eugenio De Corso2, Valeria Fiore1, Rossana Giancaspro1, Antonio Moffa1,3, Manuele Casale3,
Eleonora Maria Consiglia Trecca1, Dario Antonio Mele2, Pasquale Cassano1, Matteo Gelardi1
1
 Unit of Otolaryngology, University of Foggia, Foggia, Italy; 2 Otorhinolaryngology and Head-Neck Surgery Unit, “A. Gemelli” Hospital
Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy; 3 Unit of Integrated Therapies in Otolaryngology, Campus
Bio-Medico University, Rome, Italy


SUMMARY
Introduction. Nasal endoscopy is likely to be the method of choice to evaluate nasal ob-
struction and adenoid hypertrophy (AH) in children given its excellent diagnostic accuracy
and low risk for the patient. The aim of this study was to update the previous classification
of AH to guide physicians in choosing the best therapeutic option.
Materials and methods. This is a retrospective observational study including 7621 chil-
dren (3565 females; mean age 5.92; range: 3-14 years) who were managed for adenoid
hypertrophy at our institution between 2003 and 2018. All patients were initially treated
with medical therapy and then with surgery if not adequately controlled. We performed a
specific analysis based on the presence or absence of comorbidities.
Results. In 1845 (24.21%) patients, adenoid obstruction was classified as Grade I when
the fiberoptic endoscopy showed adenoid tissue occupying < 25% of choanal space. In
2829 of 7621 (37.12%) patients, the adenoid tissue was scored as Grade II since it was
confined to the upper half of nasopharynx, with sufficiently pervious choana and visu-
                                                                                                     Received: September 27, 2021
alisation of tube ostium. In 1611 of 7621 (21.14%) cases, adenoid vegetation occupied
                                                                                                     Accepted: December 29, 2021
about 75% of the nasopharynx with partial involvement of tube ostium and considerable
                                                                                                     Published online: April 8, 2022
obstruction of choanal openings, and was classified as Grade III. Finally, 1336 of 7621
(17.53%) patients were scored as Grade IV due to complete obstruction with adenoid
                                                                                                     Correspondence
tissue reaching the lower choanal border without allowing the visualisation of the tube
                                                                                                     Antonio Moffa
ostium. Based on resolution of symptoms in Grade III obstruction after medical therapy               Unit of Otolaryngology, University of Foggia, via
(that was mostly seen in patients without comorbidities), we divided patients in two sub-            L. Pinto 1, 71122 Foggia, Italy
classes: Grade IIIA was not associated with comorbidities, while Grade IIIB was corre-               E-mail: a.moffa@unicampus.it
lated with important comorbidities.
Conclusions. These results can be useful to guide medical or surgical therapeutic interven-
                                                                                                       How to cite this article: Cassano M, De Corso
tion. In patients with class IIIB AH, surgical treatment offered adequate control not only of
                                                                                                       E, Fiore V, et al. Update of endoscopic classi-
nasal symptoms but also of associated comorbidities.                                                   fication system of adenoid hypertrophy based
KEY WORDS: adenoid hypertrophy, classification, nasal endoscopy                                        on clinical experience on 7621 children. Acta
                                                                                                       Otorhinolaryngol Ital 2022;42:257-264. https://
                                                                                                       doi.org/10.14639/0392-100X-N1832
RIASSUNTO
Introduzione. L’endoscopia nasale è probabilmente il metodo di scelta per valutare l’o-              © Società Italiana di Otorinolaringoiatria
struzione nasale e l’ipertrofia adenoidea (IA) nei bambini, poiché ha un’eccellente ac-              e Chirurgia Cervico-Facciale
curatezza diagnostica e un basso rischio per il paziente. Lo scopo di questo studio è di
aggiornare la precedente classificazione di IA per guidare i medici a scegliere la migliore                         OPEN ACCESS
opzione terapeutica.                                                                                 This is an open access article distributed in accordance with
Materiali e metodi. Questo è uno studio osservazionale retrospettivo che include 7621                the CC-BY-NC-ND (Creative Commons Attribution-Non-
bambini (3565 femmine; età media 5,92; range: 3-14 anni) che sono stati seguiti per l’iper-          Commercial-NoDerivatives 4.0 International) license. The
                                                                                                     article can be used by giving appropriate credit and mentio-
trofia adenoidea presso il nostro istituto tra il 2003 e il 2018. Tutti i pazienti sono stati ini-   ning the license, but only for non-commercial purposes and
zialmente trattati con terapia medica e successivamente con terapia chirurgica, se non ade-          only in the original version. For further information: https://
guatamente controllati. Un’analisi specifica è stata condotta sulla base delle comorbidità.          creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                             257
M. Cassano et al.




Risultati. In 1845 pazienti (24,21%) l’immagine dell’endoscopia a fibre ottiche evidenziava uno scarso tessuto adenoideo occupante < 25%
delle aperture coanale: ostruzione adenoidea di Grado I. In 2829/7621 (37,12%) il tessuto adenoideo era confinato alla metà superiore del ri-
nofaringe, con coana sufficientemente pervia e visualizzazione dell’ostio tubarico: Grado II. In 1611/7621 (21,14%), la vegetazione adenoidea
occupava circa il 75% del rinofaringe, con parziale coinvolgimento dell’ostio tubarico e notevole ostruzione delle aperture coanali: Grado III.
In 1336/7621 (17,53%) l’ostruzione era quasi completa e il tessuto adenoideo raggiungeva il bordo inferiore della coana senza consentire la
visualizzazione dell’ostio tubarico: Grado IV. Sulla base della risoluzione dei sintomi nell’ostruzione di Grado III dopo terapia medica (che è
stata evidenziata principalmente nei pazienti senza comorbidità), abbiamo diviso i pazienti in due sottoclassi: il Grado IIIA non era associato
a comorbidità, mentre il Grado IIIB era correlato a comorbidità importanti.
Conclusioni. I nostri risultati possono essere utili per indicare un intervento terapeutico medico o chirurgico. Essi dimostrano che nei pazienti
di Grado IIIB, il trattamento chirurgico offre un buon controllo non solo dei sintomi nasali, ma anche delle principali comorbidità.
PAROLE CHIAVE: ipertrofia adenoidea, classificazione, endoscopia nasale



Introduction                                                              Materials and methods
Early detection of nasal obstruction and adenoid hypertro-                Study population and study design
phy (AH) is fundamental to avoid important complications                  This is a retrospective observational study including 7621
(recurrent otitis, sleep apnoea syndrome and lower airway                 children (3565 females; mean age 5.92; range: 3-14 years)
diseases) and to prevent alterations of craniofacial devel-               who were managed for AH at the Department of Otolar-
opment in growing children. A wide range of alternative                   yngology at the University Hospital of Foggia between
diagnostic methods have been proposed for diagnosis with                  2003 and 2018. We enrolled patients younger than 14 years
variable sensitivity and specificity over the last few years 1.           with a confirmed diagnosis of adenoid hypertrophy with
These are both clinical exams, such as structured examina-                or without comorbidities, and out of therapy since at least
tions with nasal obstruction index (NOI) 2,3, and imaging                 6 months. Exclusion criteria were previous surgery, nasal
techniques (i.e. videofluoroscopy, multirow detector com-                 obstruction due to anatomic malformations (i.e. choanal
puted tomography-CT 1,4, and lateral cephalogram 5). Nasal                atresia or diaphragm, septal deviations etc.) and chronic
endoscopy is likely to be the method of choice to evaluate                rhinosinusitis with nasal polyps. Finally, we excluded pa-
the nasopharynx in children given its excellent diagnostic                tients who did not complete at least 18 months of follow-
accuracy and low risk for the patient 6,7. Flexible fiberoptic            up.
endoscopy examination is a safe, accurate and well toler-
ated procedure that does not require anaesthesia and allows               Diagnostic protocol at our institution in clinical practice
direct visualisation of the nasal cavities and nasopharynx                for patients with AH
with high sensitivity and specificity 8, as confirmed by au-              In our clinical practice, fiberoptic endoscopy exam is gen-
thors who demonstrated a high correlation between fiber-                  erally performed if AH is suspected. Endoscopy is routine-
optic endoscopy examination and intraoperative nasopha-                   ly performed in children with a paediatric 2.7 mm fibre-
ryngoscopy performed during adenoidectomy 9. Only a few                   endoscope (11101 – SK1 - Karl Storz® – Germany). The
authors underlined some disadvantages such as the lack of                 aim of this examination is to confirm the chronic presence
objective measurements that often cause low inter-observer                of purulent secretion and to establish the grade of AH. We
agreement 10.                                                             classified obstruction into four degrees according to the en-
Currently there are several methods to grade AH in the                    doscopic classification system that we proposed in 2003.
literature 11,12. The method that we previously proposed 6                During the investigation, fiberoptic endoscopy images of
is used by most clinicians worldwide because it is easily                 the choanal openings are divided into four segments from
accessible and applicable by any observer 13,14 and can                   the upper choanal border to the nasal floor. GRADE I is
be very useful to guide physicians in choosing the best                   scored when fiberoptic endoscopy imaging revealed ad-
therapeutic option.                                                       enoid tissue occupying only the upper segment of the na-
The aim of this study was to analyse the impact on clinical               sopharyngeal cavity (≤ 25%) with almost completely free
management of the endoscopic grading system for adenoid                   choanal openings. GRADE II is scored if the adenoid tissue
hypertrophy that we proposed in 2003. For this reason, we                 is confined to the upper half (≤ 50%) of the nasopharyngeal
retrospectively reviewed all cases of children affected by                cavity with sufficiently pervious choana and perfect visual-
AH and classified by our endoscopic grading system at our                 isation of the tube ostium. GRADE III obstruction is given
institution, analysing outcomes of medical and surgical                   if adenoid tissue occupies about 75% of the nasopharynx
treatment. Furthermore, we performed specific analyses                    with partial involvement of the tube ostium and consider-
based on the presence or absence of comorbidities.                        able obstruction of choanal openings. In GRADE IV cases,



258
                                                                                                                   Endoscopic classification of adenoid hypertrophy




the adenoid tissue reaches the lower choanal border with-                                  Results
out allowing visualisation of the tube ostium (> 75%).
Moreover, children with AH usually undergo otoscopic                                       Results of diagnostic work up and analysis of comorbidities
and audiological evaluation. Patients with allergic symp-                                  Fiberoptic endoscopy showed in 1845 patients (24.21%)
toms undergo a Prick test and/or radioallergosorbent test                                  aged 3-14 years a Grade I score of rhino-pharynx obstruc-
(RAST). Since 2006, in our institution, patients reporting                                 tion. In 2829 patients (37.12%) aged 2-14 years, the ad-
sleep disorders (i.e. snoring, sleep apnoea etc.) are gener-                               enoid tissue appeared to be confined to the upper half of the
ally examined with full-night polysomnography in order                                     nasopharyngeal cavity and was scored as Grade II. In 1611
to exclude OSAS. We classify patients according to their                                   patients (21.14%) aged 2-13 years, a Grade III obstruction
Apnoea-Hypopnoea Index (AHI) as mild (AHI: 1-4), mod-                                      was diagnosed. Finally, in 1336 patients (17.53%) aged 1-7
erate (AHI: 5-10) and severe (AHI: > 10).                                                  years, the obstruction was almost complete and was classi-
                                                                                           fied as Grade IV.
Management of AH in our routine                                                            Parents referred a frequent presence of mucous and/or pu-
practice                                                                                   rulent nasal secretion in 2675 (35.1%) cases. Allergic rhi-
If AH is confirmed, we routinely propose a first approach                                  nitis (AR) was diagnosed by Prick-test and/or RAST in 692
with medical treatment and a re-evaluation after 3 months.                                 (9.1%) children (range: 5-14 years). A turbinate hypertro-
Outcomes of medical treatment are considered as resolved                                   phy was seen together with the AH in all patients affected
(complete resolution of symptoms), improved (incomplete                                    by allergies. A history of AOM was observed in 296 (3.9%)
resolution of symptoms), unchanged (any modification                                       patients, while OME was diagnosed in 671 (8.8%). An
on symptoms), or worsened (worsening of symptoms).                                         history of recurrent tonsillitis was reported in 302 (3.9%)
Surgery is taken into consideration in case of failure after                               patients. Recurrent episodes of lower airway disease (i.e.
3 months of medical treatment, and especially in the pres-                                 tracheitis, bronchitis, pneumonitis) were observed in 216
ence of comorbidities.                                                                     subjects (2.8%). A history of sleep disorders was observed
                                                                                           in 2762 (36.2%) cases. Full-night polysomnography was
Clinical data collection and outcomes                                                      performed in 1721 (22.6%) patients and revealed obstruc-
The data were directly extracted from our clinical system                                  tive sleep apnoea (OSA) in 562 (7.4%) cases which was
and from medical records of outpatients. We specifically                                   distributed as follows: mild in 72 (0.9%) children, moder-
assessed clinical data, and in particular we analysed out-                                 ate in 247 (3.2%) and severe in 243 (3.2%).
comes of medical treatment and surgery. We finally ana-                                    We summarised the associated pathologies according to the
lysed data according to the presence/absence of associ-                                    four different classes of AH in Table I.
ated pathologies that may have a physiopathological link
with AH such as recurrent acute otitis media (AOM), oti-                                   Medical treatment outcomes
tis media with effusion (OME), recurrent upper respirato-                                  All patients were initially treated with medical therapy.
ry tract infections (URTI - i.e. tonsillitis, sinusitis), lower                            The treatment consisted of nasal irrigations with isotonic
airway diseases (i.e. tracheitis, bronchitis, pneumonitis)                                 saline solution twice a day for three months and corticos-
and sleep disorders.                                                                       teroid nasal spray (mometasone furoate: 2 sprays in each


Table I. Comorbidities according to the 4 different grades of AH.
 Grade                     Recurrent nasal        Recurrent       OME                Recurrent    Referred sleep    Recurrent lower        Allergic       OSAS
                              secretions           tonsilitis                          AOM         disturbance      airway diseases        rhinitis
 Grade I                                 72                  41           43             21              85                11             30 (1.6%)          13
 (1845 pts – 24.21%)                   (3.9%)             (2.2%)        (2.3%)         (1.1%)         (4.6%)             (0.6%)                           (0.7%)
 Grade II                                218                 54           75             51             275                20             94 (3.3%)          32
 (2829 pts – 37.12%)                   (7.7%)             (1.9%)        (2.6%)         (1.8%)         (9.7%)             (0.7%)                           (1.1%)
 Grade III                               962                 89           208            84             983                75            207 (12.8%)        199
 (1611 pts – 21.14%)                 (59.7%)              (5.5%)       (12.9%)         (5.2%)          (61%)             (4.6%)                          (12.3%)
 Grade IV                               1336                107           324            127           1332                101           340 (25.4%)        300
 (1336 pts – 17.53%)                  (100%)               (8%)        (24.2%)         (9.5%)        (99.7%)             (7.5%)                          (22.4%)
 Total (7621)                           2588                291           650            283           2675                207           671 (8.8%)         544
                                     (33.9%)              (3.8%)        (8.5%)         (3.7%)        (35.1%)             (2.7%)                           (7.1%)
OME: otitis media with effusion; AOM: acute otitis media; OSAS: Obstructive Sleep Apnea.




                                                                                                                                                             259
M. Cassano et al.




nostril once daily for 30 days). Moreover, an antihistamine
medication (levocetirizine: 0.5 drop/kg body weight) was
used for a minimum of one month. After 3 months of fol-
low-up, an adequate control of the pathology (reduction of
nasal secretions and reduction or maintaining of the same
AH degree, resolution of ear and/or lower airways disease)
was reached in 5690 (74.6%) patients. Analysing the results
for each group based on grade of AH we observed the fol-
lowing: 100% of Grade I patients reached adequate control
(1845/1845); 99.8% of Grade II patients (2823/2829), 54.7%
of Grade III patients (881/1611) and 0.9% of Grade IV pa-
tients (12/1336). None of the patients affected by Grade I of
AH requested surgery after medical treatment. In 5 children
                                                                        Figure 2. Flow-chart of diagnostic and therapeutic management of AH.
suffering from Grade II AH, an increase to Grade III oc-
curred, and in these cases surgery (adenotonsillectomy) was
necessary due to the presence of severe OSA. In 881 patients            According to this indication and to the large number of as-
(54.7%) belonging to the Grade III group, medical treatment             sociated pathologies that were not resolved with medical
was effective in controlling nasal obstruction and related pa-          therapy, we divided Grade III obstruction in two subclasses,
thologies and complications. Table II shows the results of
                                                                        A and B. In Grade IIIA, the volume of adenoid was not corre-
medical therapy on symptoms and associated pathologies
                                                                        lated with other ENT pathologies and surgical treatment was
that may have physiopathological link with AH. Resolution
                                                                        not necessary, while in Grade IIIB the volume of the adenoid
of symptoms in Grade III obstruction was mostly seen in
                                                                        was correlated with associated pathologies that have a very
patients without associated pathologies (Fig. 1).
                                                                        likely physiopathological link with IA and the otolaryngolo-
                                                                        gist deemed surgical treatment necessary (Fig. 2).
Outcomes of surgical treatment
                                                                        Results after 12 months of postoperative follow-up are re-
In 730/1611 patients (45.3%) with Grade III obstruction,
                                                                        ported in Table III along with data concerning nasal obstruc-
surgical intervention was considered necessary. Thirty-nine
                                                                        tion, nasal secretions and associated complications, such as
patients refused the operation and, therefore, surgery was
                                                                        lower airway diseases, otitis and referred sleep disorders.
performed in 691 children. Out of this group, 374 under-
                                                                        Surgery was indicated in 1324/1336 (99.1%) patients of the
went adenoidectomy alone, 259 adenoidectomy and ton-
                                                                        Grade IV group who did not improve after medical therapy;
sillectomy, 30 adenoidectomy and tympanocentesis, 22
                                                                        of these, 10 patients refused the operation. Surgery was,
adenoidectomy and ear tube insertion, and 6 adenotonsil-
                                                                        therefore, performed in 1314 children (738 adenoidectomy
lectomy and ear tube insertion.
                                                                        alone, 520 adenotonsillectomy, 13 adenotonsillectomy and
                                                                        ear tube insertion, 27 adenoidectomy and ear tube inser-
                                                                        tion, 3 adenotonsillectomy and tympanocentesis, 13 ad-
                                                                        enotonsillectomy and ear tube insertion).
                                                                        Results after 12 months of postoperative follow-up are re-
                                                                        ported in Figure 3.

                                                                        Discussion
                                                                        Diagnosis of nasal obstruction in children is often chal-
                                                                        lenging because of the limited cooperation of paediatric pa-
                                                                        tients and the frequent overestimation of symptoms by their
                                                                        parents. In clinical practice there are numerous ways to de-
                                                                        termine adenoid size including mirror posterior rhinoscopy,
                                                                        endoscopic examination, lateral X-ray, magnetic resonance
                                                                        imaging (MRI), rhinomanometry and acoustic rhinometry.
Figure 1. Results of medical therapy on symptoms and comorbidities in   Childrens’ cooperation limits the use of mirror examina-
Grade III patients.                                                     tion and can create some difficulties in the execution of



260
                                                                                       Endoscopic classification of adenoid hypertrophy




                                                                 examiner agreement compared to objective criteria. For all
                                                                 these reasons, subjective measurement is strongly recom-
                                                                 mended above all in a clinical setting, where ease of com-
                                                                 munication among professionals and prompt diagnosis are
                                                                 demanded 22. One of the most valid subjective classification
                                                                 systems of AH is the Parikh method, which evaluates the
                                                                 relationship between the adenoids and surrounding struc-
                                                                 tures. According to this classification, patients meet the cri-
                                                                 teria for Grade I when the adenoids are not in contact with
                                                                 adjacent structures; Grade II when adenoids are in contact
                                                                 with torus tubarius; Grade III if adenoids are in contact
                                                                 with the vomer and Grade IV when adenoids reach the soft
                                                                 palate 11. Wang also graded adenoids from 1 to 3 based on
Figure 3. Results of surgery on comorbidities.                   the distance between the vomer and adenoid tissue during
                                                                 nasal endoscopy, observing a good correlation between ad-
                                                                 enoid size and upper respiratory symptoms, such as nasal
rhinomanometry and acoustic rhinometry 15. Lateral ra-
                                                                 obstruction, snoring and tympanometric alterations 23.
diologic evaluation of the nasopharynx has been used for
                                                                 In our previous study 6, we classified obstructions due to
many years to evaluate adenoid size 16. Lateral cephalo-         AH into four groups in relation to the entity of hypertro-
grams have good sensitivity (61-75%), but also more vari-        phy and to structure involvement. This classification, wide-
able specificity (41-95%) due to the wide range of inter-        ly used in clinical practice 13,14,24, can be very useful for
observer variability. This exam has the advantage of being       therapeutic guidance. Our grading demonstrated a better
non-invasive and quickly accessible in a clinical setting.       correlation with symptoms compared to the Parikh clas-
The limits of this technique are the risk of paediatric expo-    sification, especially with regards to AOM and the results
sure to radiation 17 and the indirect correlation between the    of tympanometry 19. This discrepancy can be explained
level of obstruction seen by X-ray and nasal symptoms 6.         by the involvement of the Eustachian tube; in Grade II of
Additionally, the films are static and give a two-dimension-     the Parikh classification, involvement is given by the con-
al representation of a three-dimensional space and do not        tact with torus tubarius, while in our classification there is
take into account that respiration, swallowing and mouth         direct involvement of the Eustachian tube ostium only in
breathing which may cause soft palate elevation during the       Grade III.
examination and, therefore, a reduction of nasopharyngeal        Our case histories indicated that the increase of disorders
cavity size 15,18.                                               due to the obstruction of the nasopharyngeal cavity (i.e.
Nasal endoscopy is definitely a more dynamic, safe, quick        mucous-purulent rhinitis, sinusitis, otitis) was directly pro-
and well tolerated examination that also demonstrated good       portional to the grade of obstruction and affected all chil-
correlation between nasal obstructive symptoms and tym-          dren with the most severe forms of obstruction. In fact,
panogram type 19. Therefore, in children presenting with         patients who presented with ear diseases (i.e. AOM and
nasal obstruction, nasal endoscopy is the best initial choice    OME) were predominantly classified as Grade III and IV,
not only to evaluate adenoid size but also to exclude other      demonstrating the involvement of Eustachian tube. Moreo-
rarer causes of chronic nasal obstruction (i.e., turbinate hy-   ver, our results showed that OSA mostly occurred in cases
pertrophy due to AR, rhinosinusitis, nasal polyposis, septal     with total or subtotal obstruction; however, the presence
deviations, nasal tumours, choanal atresia etc.) 20. Several     of this condition even in lower grades of our classification
methods for assessment of adenoid size by nasal endoscopy        confirmed the important role of tonsil hypertrophy as a
have been introduced and are widely used.                        pathogenetic factor.
Thanks to the development of software and hardware in            Allergy also seems to be related to the degree of the ob-
image processing, objective methods have been proposed           struction. In fact, allergy occurred in subjects with a higher
such as the “adenoid/choanal (A/C) area ratio” for a two-        degree obstruction (Tab. I). These findings seem to agree
dimensional objective measure of AH 21. In many cases            with Huang’s report, which suggested that allergy was a
both subjective and objective methods failed to perform in-      risk factor for the development of AH 25.
tra- or inter-examiners reproducibility tests and reliability    Due to the large percentage of associated pathologies
analysis. However, a comparison between various methods          likely linked to AH in Grade III obstructions that are not
revealed that subjective methods have higher rates of inter-     resolved by medical therapy (Fig. 1), we decided to modify



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M. Cassano et al.




Table II. Results of medical therapy in Grade III obstruction.
                         Nasal obstruction             Nasal secretions            Lower airway             Otitis            Referred sleep
                                                                                     disease                                   disturbance
 Patients (1611)                 1611                       962                          2                   114                  982
 Unchanged                    654 (40.6%)                 693 (72%)                  2 (100%)             59 (51.8%)            599 (61%)
 Resolved                      161 (10%)                 217 (22,6%)                     /                12 (10.5%)           101 (10.3%)
 Improved                     720 (44.7%)                 52 (5,4%)                      /                29 (25.4%)           174 (17.7%)
 Worsened                      76 (4.7%)                      /                          /                14 (12.7%)            108 (11%)



our previous classification and to divide class III in two                         only nasal obstruction but also the associated pathologies
subclasses, both associated with an occupation of 51-75%                           pathophysiologically linked to AH in most cases as seen
of the nasopharyngeal space. Patients in subclass IIIA did                         in Table III. This sub-classification may be useful to iden-
not have associated ENT pathologies, while patients in sub-                        tify a more aggressive phenotype of patients belonging to
class IIIB presented with the same degree of obstruction                           Grade III in which surgery may be more likely indicated
but with associated pathologies very likely linked to AH                           to resolve associated pathologies that may have a physi-
(Fig. 2).                                                                          opathological link to AH.
The aforementioned findings can be useful to indicate                              According to the results of our study, a clinical approach
medical or surgical therapeutic intervention. As stated in                         should be adopted in cases of Grade III obstruction without
our previous study 6, in Grade I and II obstructions there is                      comorbidities. Therefore, a patient should be sent to surgi-
no reason to indicate surgery, since the choanal openings                          cal therapy only after there is no resolution of associated
are pervious and, therefore, the airflow is normal. When                           comorbidities or no improvement of obstructive symptoms
nasal obstruction also occurs in subjects belonging to the                         after 3 months of medical therapy. Conversely, adenoid-
first and second categories, other nasal and nasopharyngeal                        ectomy should be performed without delay in patients af-
pathologies (i.e. malformations, allergy, inflammation, or                         fected by Grade III associated with comorbidities and in
neoplasm) should be suspected and ascertained.                                     Grade IV (Fig. 2). In fact, in such cases nasopharyngeal
According to our experience, in Grade IIIA three months                            obstruction can lead to complications when associated with
of therapy with intranasal corticosteroids should be recom-                        comorbidities and poor results are reached with medical
mended before considering surgery; in fact, according to                           therapy (Fig. 1). Finally, subjects with persistent symptoms
literature data, with intranasal corticosteroids we obtained                       after adenoidectomy should be further studied through al-
good results in improving clinical symptoms and reducing                           lergic assessment in case of residual nasal obstruction and/
the necessity of surgical treatment 26,27. On the other hand,                      or Eustachian tube function tests if episodes of recurrent
we observed that patients with Grade III and concomitant                           otitis persist with the aim of indicating other treatments.
comorbidities were not adequately controlled by a medical                          Another topic to be considered is the possible coexistence
approach and in this case surgery was very often recom-                            of AR in children with AH. Therefore, it is mandatory to
mended to achieve control of the disease and comorbidi-                            inspect the nasopharynx of an allergic patient with obstruc-
ties. For this reason, we propose to update our previous                           tion, but on the other side it is important to diagnose the
classification by adding the new subclass requesting a sur-                        presence of AR in children with nasal symptoms and AH
gical indication (IIIB) to guide the therapeutic decision.                         to define adequate targeted therapy and avoid unnecessary
In fact, in patients with Grade IIIB, surgery resolved not                         adenoidectomies 28. For these reasons, we propose to insert


Table III. Results of surgical therapy in Grade III of adenoid hypertrophy (AH).
                                Nasal obstruction              Nasal secretions       Lower airway         Otitis           Referred sleep
                                                                                        disease                              disturbance
 Patients (691)                      691                           668                      2                73                 610
 Unchanged                             /                         2 (0.3%)                   /                 /               7 (1.1%)
 Improved                         178 (25.8%)                   92 (13.8%)                  /            22 (30.6%)          180 (29.6%)
 Resolved                         513 (74.2%)                   574 (85.9%)             2 (100%)         51 (69.4%)          423 (69.3%)
 Worsened                              /                             /                      /                 /                   /




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patients with Grade III AH and AR in subclass IIIA be-          Conflict of interest statement
cause in many cases targeted medical therapy may improve        The authors declare no conflict of interest.
the patient’s symptoms; in such cases, surgical therapy is
unnecessary. This issue could explain the percentage of         Funding
patients (25.8%) who obtained only partial improvement          This research did not receive any specific grant from fund-
of nasal obstruction after adenoidectomy (Tab. III). In fact,   ing agencies in the public, commercial, or not-for-profit
Prick-test and/or RAST were performed only in 20.9% pa-         sectors.
tients with symptoms and signs of AR. A larger percentage
of allergic patients were probably present in our sample,       Authors’ contributions
and undiagnosed cases of AR could have not benefit from         MC and PC conceived of the presented idea; RG and VF
surgery.                                                        developed the theory and performed the computations; DM
Interestingly, our results showed that patients with almost     and EDC verified the analytical methods; MC and MG en-
similar degrees of AH can have different outcomes after         couraged to investigate and supervised the findings of this
adenoidectomy, even in cases of otologic diseases. In fact,     work; all authors discussed the results and contributed to
ear pathologies showed the highest percentage of incom-         the final manuscript.
plete resolution (30.6%). These findings can be explained
by considering the Eustachian tube function that in many        Ethical consideration
children may be ineffective because of the immaturity of        This study was approved by the Institutional Review Board
its physiologic opening or, especially in allergic patients,    (IRB) (5/2019) of Unit Of Otolaryngology, University of
because of chronic oedema involving tubal walls 29. There-      Foggia.
fore, in these patients the pathogenesis of otologic diseases   The research was conducted ethically, with all study pro-
is related not only to AH. Nontheless, the large percent-       cedures being performed in accordance with the require-
ages of cases that resolved (69.4%) justified our therapeutic   ments of the World Medical Association’s Declaration of
choice in these patients.                                       Helsinki.
Good results were obtained in OSA patients mainly be-           Informed consent for consultation of clinical data was ob-
cause tonsillectomy was associated to adenoidectomy in          tained from parents at the time of original data collection.
these cases. Our data agreed with studies in the literature     The data were anonymously collected and analysed.
considering nasal obstruction as a secondary causal factor
of OSA, in comparison with pharyngeal obstruction due to        References
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