Proposed clinical and radiological grading system in pediatric adenoid hypertrophy

Santosh V Kondekar; Swarada Sunil Phatale; Tanya Manish Arickatt; Anushri Soni

doi:10.4103/jpai.jpai_19_21

ORIGINAL RESEARCH

Year : 2020 | Volume : 9 | Issue : 4 | Page : 146-150

Proposed clinical and radiological grading system in pediatric adenoid hypertrophy

Santosh V Kondekar¹, Swarada Sunil Phatale², Tanya Manish Arickatt¹, Anushri Soni¹
¹ Department of Pediatrics, Topiwala National Medical College and B.Y.L Nair Charitable Hospital, Mumbai, Maharashtra, India
² Department of Anesthesia, Topiwala National Medical College and B.Y.L Nair Charitable Hospital, Mumbai, Maharashtra, India

Date of Submission	07-Jul-2021
Date of Acceptance	18-Sep-2021
Date of Web Publication	22-Dec-2021

Correspondence Address:
Santosh V Kondekar
Department of Pediatrics, Topiwala National Medical College and B.Y.L Nair Charitable Hospital, Mumbai - 400 008, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpai.jpai_19_21

Abstract

Background: Adenoid hypertrophy is an extremely common cause of upper airway obstruction in the pediatric population. Its high prevalence in children and the complications associated with its delayed diagnosis mandate a timely detection for its early and complete management. Aims & Objectives: The purpose of this study was to 1) detect the prevalence of adenoid hypertrophy in the pediatric population, 2) devise a clinical and radiological severity grading and determine the correlation between the two to develop an undemanding diagnostic approach. Materials and Methods: A total of 62 patients visiting the pediatric respiratory clinic were examined for signs and symptoms of adenoid hypertrophy like adenoid faces, mouth breathing, and runny nose. Their radiological reports were assessed for findings like flattening or convexity on the posterior pharyngeal wall and reduction in the width of the nasopharyngeal cavity. Results: A prevalence of 83.87% and 79.03% was seen based on the clinical and radiological findings respectively. A moderate positive correlation was also noted between the clinical and radiological grades, which was statistically significant. Conclusion: The ease of diagnosis associated with the clinical approach opens the possibility of detection of adenoid hypertrophy in large groups of children in resource-constrained areas, and negates the complications associated with other methods of diagnosis like endoscopy and radiography which are deemed more reliable by some clinicians.

Keywords: Adenoid hypertrophy, pediatrics, respiratory

How to cite this article:
Kondekar SV, Phatale SS, Arickatt TM, Soni A. Proposed clinical and radiological grading system in pediatric adenoid hypertrophy. J Pediatr Assoc India 2020;9:146-50

How to cite this URL:
Kondekar SV, Phatale SS, Arickatt TM, Soni A. Proposed clinical and radiological grading system in pediatric adenoid hypertrophy. J Pediatr Assoc India [serial online] 2020 [cited 2023 Jun 3];9:146-50. Available from: http://www.jpai.in//text.asp?2020/9/4/146/333367

Introduction

Adenoid hypertrophy, an obstructive condition related to an increased size of the adenoids can occur with or without an acute or chronic infection of the adenoids. The adenoids, also known as the pharyngeal tonsils, found on the superior aspect of the nasopharynx medial to the Eustachian tube ^{More Details} orifices, are a collection of lymphoepithelial tissue. In conjunction with the palatine, lingual, and tubal tonsils, the adenoids make up the structure known as Waldeyer's ring, a collection of mucosal-associated lymphoid tissue present at the entrance of the upper aerodigestive tract. Adenoids, although not visible until 3–6 months, are present from birth. They can increase in size up to 6 years of age and then involute naturally and regress during adolescence.^[1]

Adenoid hypertrophy can occur because of infectious and noninfectious etiologies. Infectious causes of adenoid hypertrophy can be viral or bacterial.^[2],[3],[4] Multiple noninfectious causes of adenoid hypertrophy have also been suggested including gastroesophageal reflux,^[5] allergies, and exposure to cigarette smoke.^[6]

Nasal obstruction by hypertrophic adenoid tissue can cause the patient to complain of persistent rhinorrhea, difficulty breathing through the nose, chronic cough, postnasal drip, snoring, and/or sleep-disordered breathing in children. Significant nasal obstruction can lead to sinusitis and the patient may complain of facial pain or pressure. Obstruction of the Eustachian tube can lead to the symptoms such as muffled hearing, otalgia, crackling or popping sounds in the ear, and/or recurrent middle ear infections.^[7]

On physical examination, the patient with adenoid hypertrophy will often breathe through the mouth, have a hyponasal character to their voice, and may have the facial characteristics known as adenoid facies which include a high arched hard palate, increased facial height, and retrognathia.^[8],[9]

A thorough history and physical examination are often sufficient to diagnose adenoid hypertrophy. A lateral X-ray of the nasopharynx is often employed in the study of adenoids, especially in children.^[10] Direct visualization of the adenoids by fiber-optic nasopharyngoscopy is another option for assessing the adenoids in the clinical setting with good reliability.^[11],[12]

This study aims to correlate the clinical suspicion of adenoid enlargement with the radiological report. This established association will help aid in easier and earlier diagnosis of adenoid enlargement and grading its severity in patients with such conditions and hence earlier and complete treatment.

Aims and objectives

To study the prevalence of adenoid hypertrophy in the pediatric respiratory clinic
To study the correlation of clinical suspicion and radiological evidence of adenoid enlargement
To establish a severity grading system on clinical examination.

Methodology

Research work commenced after prior approval from the ethics committee. The study design is a cross-sectional, prospective study. No special procedures or investigations are carried out on any patient for this project.

Patients were enrolled from the pediatric respiratory clinic. Consecutive 62 patients within the age group of 1–12 years registered at OPD of our hospital were studied. The patients whose radiological reports are not available were excluded from this study.

Adenoid faces, mouth breathing, and runny nose for duration of more than 15 days are considered positive for clinical suspicion of adenoid enlargement as per the following:

0 – No symptoms suggestive of adenoid hypertrophy
1 – Adenoid faces
2 – Two week persistent mouth breathing
3 – Runny nose for duration of more than 15 days.

Flattening or convexity on the posterior pharyngeal wall, reduction in the width of the nasopharyngeal cavity, or any other criteria mentioned by the radiologist is considered as radiological evidence as per the following:

R0 – No radiological evidence of adenoid enlargement
R1 – Flattening on the (posterior) nasopharyngeal wall
R2 – Reduction in the width of the nasopharyngeal cavity
R3 – Convexity on (posterior) nasopharyngeal wall.

This grading was reviewed by a number of professionals and modified accordingly. The data regarding demography, diagnosis and clinical suspicion, and radiological evidence of adenoid enlargement are noted in the colliquative form. The data are analyzed in Microsoft Excel in the descriptive form. The association between radiological reports and clinical suspicion of adenoid enlargement is studied by using Spearman's rank-order correlation. The results are described as the prevalence of clinical and/or radiological adenoid enlargement in patients showing different respiratory clinical symptoms such as asthma, recurrent or frequent wheezers, occasional wheezers, and regular cough and cold; and their association will be studied.

Results

Out of a total of 62 patients assessed under this study, 43 were male and 19 were female.

In context to the age wise distribution of study participants, 33 children were aged below 6 years of age and 29 children are aged between 6 years and 12 years of age.

The number of patients with different diagnosis is depicted in [Figure 1].

Figure 1: Distribution of patients visiting the paediatric respiratory clinic based on their diagnosis

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Clinical grade

Clinically, adenoid hypertrophy is graded as per the following:

0 – No symptoms suggestive of adenoid hypertrophy
1 – Adenoid faces
2 – Two week persistent mouth breathing
3 – Runny nose for a duration of more than 15 days.

As shown in [Table 1], out of total 62 patients, 52 patients, i.e., 83.87% patients had variable degrees of adenoid hypertrophy.

Table 1: Clinical grading of adenoid hypertrophy in asthmatics and nonasthmatics

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Amongst those, 20 patients out of 24 studied patients of asthma, i.e., 83.33% of patients with asthma had variable degrees of clinically diagnosed adenoid hypertrophy.

Whereas, 32 out of 38 patients with other than asthma diagnosis, i.e., 84.21% of patients had variable degrees of adenoid hypertrophy.

Radiological grade

The radiological evidence is graded as per following:

R0 – No radiological evidence of adenoid enlargement
R1 – Flattening on the posterior nasopharyngeal wall
R2 – Reduction in the width of the nasopharyngeal cavity
R3 – Convexity on posterior nasopharyngeal wall.

As shown in [Table 2], out of total 62 patients studied, 49 patients had radiological evidence of adenoid hypertrophy.

Table 2: Radiological grading of adenoid hypertrophy in asthmatics and nonasthmatics

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Among these, 21 of 24 patients of asthma, i.e., 87.5% of patients had radiological evidence of adenoid hypertrophy.

Whereas, among 38 patients with other than asthma group, 28 patients, i.e., 73.68% of patients show adenoid hypertrophy radiologically.

A Spearman's rank-order correlation was run to determine the relationship between 62 patients' Clinical versus radiological grades, as shown in [Table 3]. There was a moderate, positive correlation between Clinical and radiological grades, which was statistically significant (rs = 0.401, P = 0.001).

Table 3: Correlation part: Radiological grading on X axis versus clinical grading on Y axis

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Discussion

Adenoid hypertrophy is the commonest cause of upper respiratory tract obstruction in the pediatric population. Its prevalence in the general pediatric population is 49.70% making adenoidectomy a very common childhood surgical procedure.^[13]

Despite the high prevalence of AH, its diagnosis still proves to be a dilemma for quite a few clinicians. This is especially the case in resource-constrained settings, like rural India where radiography and endoscopy are not available, and places where a large number of children have to be evaluated quickly, like in schools-by teachers, nurses, and doctors. These reasons invariably lead to the missing of classical features of AH.

In the world of medicine, earlier diagnosis paves a clearer path for management void of complications. In the case of AH, this early diagnosis could mean prevention of chronic cough, snoring, muffled hearing, otalgia, difficulty breathing through the nose, postnasal drip, and even severe conditions like recurrent middle ear effusions leading to conductive hearing loss, sleep-disordered breathing, and pulmonary hypertension. These children are also more likely to develop speech, language, and/or learning difficulties, behavioral problems, and bedwetting.^[7],[14]

The best method for the diagnosis of AH is somewhat a controversial topic. In general, lateral neck X-ray and nasal endoscopy are considered more reliable.^[15],[16] Hence much research has been done on the same bringing forth various grading systems.

Parikh et al. proposed a new subjective grading system for endoscopic examination of adenoid size based on the anatomic relationship between the adenoid tissue and other structures in its proximity.^[12] Cassano et al. also graded AH endoscopically based on the degrees of obstruction.^[17] Another classification was Wang's classification assessing the distance between the vomer and adenoid tissue.^[18] Saedi et al. introduced both radiographical and endoscopic grading systems based on the assessment of adenoid size.^[19]

But in the real world, these gold standard methods are not without enough practical problems of their own.

(1) Endoscopy requires the administration of anesthesia in a young child before the procedure and is invasive in nature. (2) X-ray causes young children to be exposed to radiation to the neck. (3) Lack of access to these facilities in resource-constrained settings. (4) Noncompliance of the patient to undergo such procedures when the complaints are relatively mild.

Thus it is impractical to apply the above-mentioned grading systems to every patient presenting to the respiratory clinic.

This leads to the missing diagnosis of various cases of AH, which later present with more severe complications. Thus, despite the wide range of diagnostic tools available, clinicians still depend on the history and clinical examination of the patient to ascertain a diagnosis. Keeping this in mind, the following grading systems based on the symptoms and signs have also been proposed. However, their validity remains a source of debate for researchers.

Saedi et al. devised a clinical grading of AH based on snoring, nasal obstruction, sleep apnea, otitis media, and recurrent pharyngitis. Another clinical scoring system was created by Sharifkashani, et al. which included difficulty of breathing during sleep, apnea, and snoring.^[20]

In our study, we have tried to devise an even simpler clinical grading based on the presence of adenoid facies, mouth breathing, and runny nose. Simpler and easy-to-understand gradings have the potential to be used more widely, even by nonhealth-care professionals, like teachers and nurses in school settings and grass-root level health workers.

A radiological grading was also devised in accordance with the clinical grading.

In the past, studies comparing the clinical symptoms and lateral soft-tissue neck radiography have shown no correlation between the two.^[21] A poor correlation has been noted between the extent of mouth breathing and the amount of adenoid tissue removed at adenoidectomy.^[22] In a few other studies, a limited correlation has been observed between clinical and X-ray findings.^[23],[24] A possible reason for these unfavorable results can be the choice of symptoms used for grading, or the complete absence of a grading or scoring system while making the diagnosis. In our study, the correlation between clinical and radiological grades was seen to be significant. Many researchers have reported findings similar to ours, with a substantial correlation between clinical and X-ray grades of the degree of AH.^{[25],[26],[27],[28]}

A limitation of this study is its relatively smaller sample size. For this grading to be widely accepted, a much larger sample would be necessary. Numerous studies need to be done to deem this grading reliable.

Conclusion

Despite the high prevalence of adenoid hypertrophy in the pediatric population, ambiguity persists amongst clinicians on its diagnosis. This is especially the case when diagnostic tools like endoscopy and radiography are not available to certain patients. The formulation of a clinical grading system based on the signs, symptoms, and history of the child including findings as simple as adenoid faces, persistent mouth breathing, and runny nose can potentially make the diagnosis a lot simpler and widely applicable. This will not only help clinicians but also other agencies involved in the well-being of a child, like parents, teachers, and school nurses. A complementary radiological grading has also been devised to verify as well as supplement the clinical diagnosis. Larger studies spanning across various regions are needed to validate or reject the proposed grading and know more about the prevalence and presentation of adenoid hypertrophy, especially in patients coming to respiratory clinics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Goeringer GC, Vidić B. The embryogenesis and anatomy of Waldeyer's ring. Otolaryngol Clin North Am 1987;20:207-17.
2.	Tarasiuk A, Simon T, Tal A, Reuveni H. Adenotonsillectomy in children with obstructive sleep apnea syndrome reduces health care utilization. Pediatrics 2004;113:351-6.
3.	Proenca-Modena JL, Paula FE, Buzatto GP, Carenzi LR, Saturno TH, Prates MC, et al. Hypertrophic adenoid is a major infection site of human bocavirus 1. J Clin Microbiol 2014;52:3030-7.
4.	Brook I, Shah K. Bacteriology of adenoids and tonsils in children with recurrent adenotonsillitis. Ann Otol Rhinol Laryngol 2001;110:844-8.
5.	Ren J, Zhao Y, Ren X. An association between adenoid hypertrophy and exstra-gastroesophageal reflux disease. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2015;29:1406-8.
6.	Evcimik MF, Dogru M, Cirik AA, Nepesov MI. Adenoid hypertrophy in children with allergic disease and influential factors. Int J Pediatr Otorhinolaryngol 2015;79:694-7.
7.	Buzatto GP, Tamashiro E, Proenca-Modena JL, Saturno TH, Prates MC, Gagliardi TB, et al. The pathogens profile in children with otitis media with effusion and adenoid hypertrophy. PLoS One 2017;12:e0171049.
8.	Peltomäki T. The effect of mode of breathing on craniofacial growth – Revisited. Eur J Orthod 2007;29:426-9.
9.	Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope 2010;120:2089-93.
10.	Feres MF, Hermann JS, Cappellette M, Pignatari SS. Lateral X-ray view of the skull for the diagnosis of adenoid hypertrophy: A systematic review. Int J Pediatr Otorhinolaryngol 2011;75:1-11.
11.	Lertsburapa K, Schroeder JW Jr., Sullivan C. Assessment of adenoid size: A comparison of lateral radiographic measurements, radiologist assessment, and nasal endoscopy. Int J Pediatr Otorhinolaryngol 2010;74:1281-5.
12.	Parikh SR, Coronel M, Lee JJ, Brown SM. Validation of a new grading system for endoscopic examination of adenoid hypertrophy. Otolaryngol Head Neck Surg 2006;135:684-7.
13.	Pereira L, Monyror J, Almeida FT, Almeida FR, Guerra E, Flores-Mir C, et al. Prevalence of adenoid hypertrophy: A systematic review and meta-analysis. Sleep Med Rev 2018;38:101-12.
14.	Geiger Z, Gupta N. Adenoid Hypertrophy. InStatPearls [Internet] 2020 Aug 10. StatPearls Publishing.
15.	Ysunza A, Pamplona MC, Ortega JM, Prado H. Video fluoroscopy for evaluating adenoid hypertrophy in children. Int J Pediatr Otorhinolaryngol 2008;72:1159-65.
16.	Lourenço EA, Lopes KD, Pontes Á Jr., Oliveira MH, Umemura A, Vargas AL. Comparison between radiological and nasopharyngolaryngoscopic assessment of adenoid tissue volume in mouth breathing children. Rev Bras Otorrinolaringol 2005;71:23-8.
17.	Cassano P, Gelardi M, Cassano M, Fiorella ML, Fiorella R. Adenoid tissue rhinopharyngeal obstruction grading based on fiberendoscopic findings: A novel approach to therapeutic management. Int J Pediatr Otorhinolaryngol 2003;67:1303-9.
18.	Wang DY, Bernheim N, Kaufman L, Clement P. Assessment of adenoid size in children by fibreoptic examination. Clin Otolaryngol Allied Sci 1997;22:172-7.
19.	Saedi B, Sadeghi M, Mojtahed M, Mahboubi H. Diagnostic efficacy of different methods in the assessment of adenoid hypertrophy. Am J Otolaryngol 2011;32:147-51.
20.	Sharifkashani S, Dabirmoghaddam P, Kheirkhah M, Hosseinzadehnik R. A new clinical scoring system for adenoid hypertrophy in children. Iran J Otorhinolaryngol 2015;27:55-61.
21.	Mlynarek A, Tewfik MA, Hagr A, Manoukian JJ, Schloss MD, Tewfik TL, et al. Lateral neck radiography versus direct video rhinoscopy in assessing adenoid size. J Otolaryngol 2004;33:360-5.
22.	Hibbert J, Tweedie MC. The value of signs and symp-toms in the diagnosis of enlarged adenoids. Clin Otolaryngol 1977;2:297-304.
23.	Crepeau J, Patriquin HB, Poliquin JF, Tetreault L. Radiographic evaluation of the symptom-producing adenoid. Otolaryngol Head Neck Surg 1982;90:548-54.
24.	Sørensen H, Solow B, Greve E. Assessment of the nasopharyngeal airway. A rhinomanometric and radiographic study in children with adenoids. Acta Otolaryngol 1980;89:227-32.
25.	Elwany S. The adenoidal-nasopharyngeal ratio (AN ratio). Its validity in selecting children for adenoidectomy. J Laryngol Otol 1987;101:569-73.
26.	Paradise JL, Bernard BS, Colborn DK, Janosky JE. Assessment of adenoidal obstruction in children: Clinical signs versus roentgenographic findings. Pediatrics 1998;101:979-86.
27.	Bitar MA, Rahi A, Khalifeh M, Madanat LM. A suggested clinical score to predict the severity of adenoid obstruction in children. Eur Arch Otorhinolaryngol Head Neck 2006;263:924-8.
28.	Maw AR, Jeans WD, Fernando DC. Inter-observer variability in the clinical and radiological assessment of adenoid size, and the correlation with adenoid volume. Clin Otolaryngol Allied Sci 1981;6:317-22.