Introduction
Adenoid hypertrophy contributes to nasal obstruction and obstructive sleep disorders in children and may necessitate adenoidectomy.Reference Joshua, Bahar, Sulkes, Shpitzer and Raveh1, Reference Calvo-Henriquez, Branco, Lechien, Sandoval-Pacheco, Maldonado-Alvarado and Maza-Solano2 Determining the degree of adenoid hypertrophy can help guide surgical decision making, but current objective methods to directly assess adenoid hypertrophy have significant limitations.
One modality to assess adenoid hypertrophy in the clinic is nasal endoscopy, but this is often difficult to perform in some paediatric age groups because of poor tolerance. Lateral neck radiographs are another method for assessing adenoid size and estimating the degree of nasopharyngeal obstruction, although this is not as accurate as nasal endoscopy and involves radiation exposure as well as added cost.Reference Soldatova, Otero, Saul, Barrera and Elden3–Reference Lertsburapa, Schroeder and Sullivan5 Lastly, head and/or neck magnetic resonance imaging or computed tomography can allow estimation of adenoid size, but they are not used for this indication given the possible need for sedation, risk of radiation and high cost. The decision to perform adenoidectomy in many cases is therefore not based on objective assessment of the adenoid but instead on patients’ history and their subjective self-reported and/or parent-reported symptoms.
Another contributor to nasal obstruction in children is inferior turbinate hypertrophy.Reference Cheng, Fang, Su and Huang6 The inferior turbinates are often easily assessed in children using anterior rhinoscopy. There is currently no research on the relationship between inferior turbinate hypertrophy and adenoid hypertrophy. However, if inferior turbinate hypertrophy can predict adenoid hypertrophy, then the far easier to assess inferior turbinate could thus serve as a proxy for adenoid hypertrophy severity and provide an objective indicator to guide surgical decision-making regarding adenoidectomy.
The aim of the present study was to determine if inferior turbinate hypertrophy can predict adenoid size in a sample of paediatric patients with obstructive sleep disorders.
Materials and methods
Electronic medical record data from children receiving care at the tertiary care facility West Virginia University Children’s Hospital were collected between July 2021 and August 2023. The retrospective cohort study was approved by the West Virginia University Institutional Review Board (protocol number 2302721416). The participants included were children 0–18 years of age with a diagnosis of obstructive sleep-disordered breathing or obstructive sleep apnoea (OSA) who underwent drug-induced sleep endoscopy. Children were excluded if they had a history of adenoidectomy or inferior turbinate surgery, craniofacial abnormalities, chromosomal abnormalities, genetic disorders, cerebral palsy, neuromuscular disease or laryngeal mobility disorders.
Data were gathered via a chart review of patients’ demographics, medical comorbidities and drug-induced sleep endoscopy examination findings. Demographic and clinical data included age at the time of drug-induced sleep endoscopy, obesity, chronic adenoiditis and allergic rhinitis. Obesity was defined as age-specific and sex-specific body mass index greater than or equal to the 95th percentile. Chronic adenoiditis was diagnosed based on symptoms of constant nasal obstruction and thick rhinorrhoea for more than three months, supported by physical examination findings of thick mucus in the nasal cavities and/or post-nasal drip.Reference Wang7 Allergic rhinitis was diagnosed clinically based on history and physical examination according to the American Academy of Otolaryngology – Head and Neck Surgery clinical practice guideline.Reference Seidman, Gurgel, Lin, Schwartz, Baroody and Bonner8
Drug-induced sleep endoscopy examination data were used to determine the size of the inferior turbinates and the adenoids. Drug-induced sleep endoscopy was performed in the operating theatre, with spontaneous breathing maintained using a propofol infusion. A 2.5-mm flexible laryngoscope was used to assess the nasal cavities, nasopharynx, oropharynx and larynx. Inferior turbinate and adenoid hypertrophy severity were defined as their grade of obstruction. The drug-induced sleep endoscopy grading system for the level of obstruction used in this study is shown in Table 1. For more information on the drug-induced sleep endoscopy protocol and grading system, and its validity, see Jaffal et al.Reference Jaffal, Coutras, Dewey, McArdle and Cui9
Grading of inferior turbinate and adenoid obstruction
A series of univariate analyses (chi-square and Kruskal–Wallis rank tests) were conducted to investigate whether age, sex, obesity, allergic rhinitis, chronic adenoiditis and grade of inferior turbinates predicted adenoid size. The variables significantly associated with adenoid size in univariate analyses were included in a multivariate ordered logistic regression model. Statistical significance was set at a two-tailed p value less than 0.05. Statistical analyses were performed using Stata 18 (Stata Statistical Software: Release 18; StataCorp LLC, College Station, TX, USA).
Results and analysis
A total of 269 children were included. The sample’s median age was 3.8 years (interquartile range, 2.4–6.1 years), with 90.3 per cent White, 57.2 per cent female and 26 per cent obese. See Table 2 for more demographic details.
Demographic and clinical characteristics
IQR = interquartile range.
In separate univariate analyses, both older age and greater inferior turbinate hypertrophy predicted greater adenoid hypertrophy in their respective models (χ 2 = 29.0, p < 0.01 and χ 2 =24.4, p < 0.01, respectively). Chronic adenoiditis, allergic rhinitis, sex and obesity were not significantly associated with adenoid hypertrophy (p = 0.18, p = 0.50, p = 0.44 and p = 0.32, respectively).
In multivariate ordered logistic regression controlling for age, inferior turbinate hypertrophy remained a significant predictor of adenoid hypertrophy (B = 0.74, p < 0.01) while age was no longer significant (B = 0.06, p = 0.11). Children with more severe inferior turbinate hypertrophy were found to have worse adenoid obstruction, with 67 per cent of children with severe inferior turbinate hypertrophy having severe adenoid obstruction. See Table 3 for a breakdown of adenoid obstruction grades by inferior turbinate obstruction.
Grades of inferior turbinate and adenoid obstruction
Discussion
Adenoid hypertrophy is a major cause of obstructive sleep disorders in children but is difficult to assess in this population. Inferior turbinate hypertrophy can be more easily assessed in children and may thus serve as a useful indicator for adenoid hypertrophy. The present study is the first to show an association between inferior turbinate hypertrophy and adenoid hypertrophy in children with obstructive sleep disorders. Specifically, paediatric patients with more severe inferior turbinate obstruction tended to have more severe adenoid obstruction. These findings held true irrespective of patient age. In clinical settings, when patients present with signs and symptoms suggestive of adenoid hypertrophy, an examination of the inferior turbinates using anterior rhinoscopy may help provide additional insight into the severity of adenoid hypertrophy and the need for further workup and management.
The association between inferior turbinate hypertrophy and adenoid obstruction found in this study could explain the benefit of combining adenoidectomy with inferior turbinate surgery found in the prior literature. Cheng et al. investigated the effect of adenotonsillectomy with and without microdebrider-assisted inferior turbinoplasty on paediatric OSA and found that performing inferior turbinoplasty in addition to adenotonsillectomy resulted in better subjective and objective outcomes.Reference Cheng, Fang, Su and Huang6
The findings of this study should be interpreted within the context of several limitations. These include the retrospective cross-sectional nature of the study design and the patient population being mostly White, thereby affecting generalisability. Additionally, the use of a drug-induced sleep endoscopy grading system where the inferior turbinates are graded based on the side with more severe obstruction may have led to an overestimation of the degree of turbinate hypertrophy. Future studies may seek to utilise a more diverse and larger sample to improve generalisability to other patient populations, and potentially identify mediators and moderators of the relationship between inferior turbinate and adenoid hypertrophy.
• Adenoid hypertrophy contributes to nasal obstruction and obstructive sleep disorders in children
• Current objective methods to directly assess adenoid hypertrophy have significant limitations
• The inferior turbinates are often easily assessed in children using anterior rhinoscopy
• There is currently no research on the relationship between inferior turbinate hypertrophy and adenoid hypertrophy
• This study is the first to show an association between inferior turbinate hypertrophy and adenoid hypertrophy in children with obstructive sleep disorders
• Paediatric patients with more severe inferior turbinate obstruction tended to have more severe adenoid obstruction irrespective of patient age
Conclusion
This study demonstrates that inferior turbinate hypertrophy can predict adenoid hypertrophy in children with obstructive sleep disorders, irrespective of age. Assessing inferior turbinate hypertrophy may help inform the clinician of the severity of adenoid hypertrophy and aid in decisions about the need for further workup for adenoid hypertrophy or the plan for adenoidectomy.
Competing interests
None declared.
