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  R  EVISTA  B RASILEIRADE  O TORRINOLARINGOLOGIA  71 (1) P  ART  1 J  ANUARY  /F EBRUARY   2005 / e-mail: Comparison between radiologicaland nasopharyngolaryngoscopicassessment of adenoid tissuevolume in mouth breathingchildren Summary  Edmir Américo Lourenço 1  Karen de CarvalhoLopes 2  Álvaro Pontes Jr. 3  Marcelo Henrique deOliveira 4  Adriana Umemura 5  Ana Laura Vargas 6 1  Joint Professor, Ph.D., Professor responsible for the Discipline of Otorhinolaryngology, Medical School, Jundiaí. 2  Resident Physician, Discipline of Otorhinolaryngology, Medical School, Jundiaí. 3  Resident Physician, Discipline of Otorhinolaryngology, Medical School, Jundiaí.. 4  Resident Physician, Discipline of Otorhinolaryngology, Medical School, Jundiaí.. 5  Resident Physician, Discipline of Otorhinolaryngology, Medical School, Jundiaí.. 6  Resident Physician, Discipline of Otorhinolaryngology, Medical School, Jundiaí. Affiliation: Medical School, Jundiaí/SP Address correspondence to: Marcelo Henrique de Oliveira – Rua Zuferey 155 bloco 05 ap. 104 Vila Arens 13202-420 Jundiaí SP. - Tel (55 11) 4816-4451 Article submited on September 03, 2004. Article accepted on January 20, 2005. T he pharyngeal tonsil (adenoid) constitutes the upperportion of the Waldeyer’s ring and is located at the top of the nasopharynx, next to the auditory tube and choana. Itplays an important role in recurrent otitis of the middle earand many times its enlargement is responsible for upperairway obstruction. Tonsillectomy is often the treatment of choice for tonsillar diseases. So far, it is the most frequentand one of the oldest surgical procedures performed inchildren and young adults. The criteria for tonsillectomy, itseffect on patient’s immunological integrity and the surgicalrisks are widely controversial. Image study using paranasalsinuses x-ray is a very simple, easy and comfortable methodto evaluate the sizes of adenoids and the grade of upperairway obstruction. Cohen et al. supported that paranasalsinuses x-ray is the best way to determine pharyngeal tonsilhypertrophy. On the other hand, nasopharyngolaryngoscopy can provide more accurate data on the nasopharynx, as itcan dynamically reveal its structures and the obstructionstatus of the upper airway. This study compared the gradeof adenoid hypertrophy, as well as upper airway obstruction,using the above-mentioned approaches in children rangingfrom 3 to 10 years old. The study came to the conclusionthat nasopharyngolaryngoscopy is a much more accuratediagnostic procedure than radiological evaluation of thenasopharynx. Key words: adenoid tissue, mouth breathing, radiology of nasopharynx, nasopharyngolaryngoscopy   Rev Bras Otorrinolaringol.V.71, n.1, 23-8, jan./feb. 2005  ORIGINAL ARTICLE  ARTIGO ORIGINAL  R  EVISTA  B RASILEIRADE  O TORRINOLARINGOLOGIA  71 (1) P  ART  1 J  ANUARY  /F EBRUARY   2005 / e-mail: INTRODUCTION The pharyngeal tonsil, also called adenoid, is theupper extension of the lymphatic Waldeyer’s Ring and islocated on the upper posterior wall of the nasopharynx 1 . Itis found adjacently to the choanae and the auditory tubeostium. Adenoid hypertrophy plays an important role inrecurrent otitis as well as in secreting otitis of the middleear. Many times, this structure is associated withenlargement of palatine tonsil, which leads to obstructionof upper airways and may host chronic recurrent pharyngealinfections 2 . Adenoidectomy and/or tonsillectomy are surgicalapproaches frequently adopted in Otolaryngology, and areamong the oldest surgeries to which human beings havebeen submitted in the past years. Recently, emphasis overcareful selection of prospects for these procedures emergedfrom a consensus on the immunological role played by palatine and pharyngeal tonsils, as well as the potentialcomplications of these types of surgery  3 .Lateral x-ray of facial sinuses, including soft tissuesfor paranasal sinuses visualization, is an accessibleprocedure for the physician and relatively comfortablefor the child 4 , consisting of a simple way to determineadenoids’ size, shape and position 3 . Cohen et al. agreethat this is an appropriate modality to evaluate children with suspected adenoidal hypertrophy  5 . On the otherhand, flexible nasofibroscopy is an endoscopic methodthat allows direct visualization of the nasopharynx,including the auditory tube and fossa of Rosenmuller,action of the velopharyngeal sphincter and, consequently,functional evaluation of this region 6 . Some authorsemphasize that, for a comprehensive sight of nasopharynx, flexible nasofibroscopy must be followedby an x-ray, providing reliable data on the relationshipbetween content and continent 7 .This study aims at evaluating and comparing the gra-de of adenoidal hypertrophy through simple radiologicalevaluation of the paranasal sinuses profile and endoscopy assessment by flexible nasofibroscopy in mouth breathingchildren. M TERI L ND METHOD Twenty (20) mouth breathing children, agesranging from 3 to 10 years, were randomly selected atthe Ambulatory of Otolaryngology of Medical School, Jundiaí, Hospital das Clínicas of Franco da Rocha, SaoPaulo – SP (DIR-IV) in the period of March and June2004.Children’s parents or caregivers signed a Term of Consent to whom explanations about the study were given.Furthermore, a questionnaire was filled out with informationabout symptoms, such as presence of snoring, nocturnaldrooling, noisy sleep, mouth breathing, nocturnal sialorrhea,daytime sleepiness, nose itching, sneezing, hyalinerhinorrhea, and nasal obstruction. Following, anotolaryngological examination was performed to evaluatehypertrophy and coloration of nasal conchae, presence andaspect of rhinorrhea and grading of palatine tonsilhypertrophy.Only children who were not under medication orinflammatory/infectious process of the airways were selectedfor the study. A simple x-ray of the paranasal sinuses profile wasperformed to which the patient was asked to inhale, instanding position and with the mouth shut; these instructions were given both to the x-ray professional and the child’sparent/caregiver. Immediately after that, the child wassubmitted to flexible nasofibroscopy. For that, localanesthesia was applied on nasal fossas with 10% lidocaineand oximetazoline with vasoconstrictor, locally. Duringexamination, as soon as full visualization of the choana wasreached, the patient was asked for deep nostril inhaling, asto obtain a reliable image regarding the true obstruction of choanal opening. Assessment of methodology criteria included:1)Interpretation of x-ray paranasal sinuses profile was basedon Cohen & Konak 8  method in which the soft palatethickness (one centimeter below the hard palate or half-centimeter in children younger than 3 years) and the aircolumn width between the palate and the highest pointof convexity of the adenoid are compared. It is consideredsmall when the column is not narrower than the palate’sthickness; medium, when air column is narrower, but widerthan half of the palate’s thickness; large, when the aircolumn is narrower that half of palate’s thickness (Figures1 and 2). Figure 1.  Plain x-ray paranasal sinuses profile.  R  EVISTA  B RASILEIRADE  O TORRINOLARINGOLOGIA  71 (1) P  ART  1 J  ANUARY  /F EBRUARY   2005 / e-mail: 2)All nasofibroscopic procedures were initially  videotaped (VHS), among which the best choanalimages were selected and printed by VideoprinterSony® (Figure 3). After manually outlining thechoanal and adenoid limits, these photos werescanned by Corel Scan 7.0 software, posteriorly processed by Corel Photo Paint 7.0 in bitmap files(Figure 4) and analyzed by Corel Trace 7.0 as vectorfigures (Figure 5). Through this software, it waspossible to assess, with decimal accuracy, the areaoccupied by the choanal adenoid.For better understanding, it was considered smalladenoid when it occupied less than half of choana;medium adenoid, around 50 and 70% of the choana; andlarge adenoid, when occupying over 75% of full choanalarea. Interpretations of both evaluations wereindependent and not correlated with the history dataand clinical findings. RESULTS Figure 2. Scheme illustrating Cohen & Konak method, which compa-res the soft palate thickness (one centimeter below the hard palate orhalf centimeter in children younger 3 years old) presenting the aircolumn between this spot in the palate and the highest convexity spotof adenoid (blue line). In the present example, it is a large adenoid. Figure 5.  Sample of image analyzed by Corel Trace 7.0 as a vectorfigure. Figure 4.  Sample of a scanned image by Corel Scan 7.0, furtherprocessed by Corel Photo Paint 7.0 in bitmap file. Figure 3.  Sample of a selected image printed by Videoprinter Sony®. Table 1.  Individual scoring of adenoid size through x-ray andnasofibroscopy; % - percentage of choanal obstruction. Radiological assessmentNasofibroscopy assessment(Cohen & Konak Method)X-RayClassificationPhoto%Classification1Medium169Medium2Medium282Large3Large380Large4Small487Large5Small567Medium6Medium683Large7Small773Medium8Small875Medium9Small986Large10Small1087Large11Large1187Large12Large1287Large13Medium1380Large14Large1482Large15Large1583Large16Small1656Medium17Medium1787Large18Medium1876Large19Large1978Large20Large2085Large  R  EVISTA  B RASILEIRADE  O TORRINOLARINGOLOGIA  71 (1) P  ART  1 J  ANUARY  /F EBRUARY   2005 / e-mail: Table 2.  Scoring by adenoid size: 1 = small, 2 = medium, 3 =large. X-RayRadiologicalPhotoNasofibroscopyEvaluationEvaluation121222233333414351526263717281829193101103113113123123132133143143153153161162172173182183193193203203Mean2.00Medium2.75 DISCUSSION The first adenoidectomy was probably performed inthe second half of the 19 th  Century. For a long time, due toinexistence of clear criteria for indication of surgery, thisprocedure fell into disbelief among physicians and publicopinion. Recently, accurate indications and clear rules foradenoidectomy have proved to be less controversial 2 . Theliterature reports a concern regarding the best way todiagnose and treat children with suspected adenoidhypertrophy, a very frequent condition observed inOtorhinolaryngology. Clinical evaluation of adenoid size in young children is very difficult. History reported by parentsof nasal obstruction, mouth breathing, nocturnal drooling andspeech disorders ground the relation with adenoidenlargement, not visible at direct inspection through anteri-or rhinoscopy and oroscopy; regarding posterior rhinoscopy,besides the technical difficulty in approaching youngchildren, its real value is controversial 9 . Objective measuresof adenoid hypertrophy are useful to provide informationthat may help deciding the need of surgery and subsequentoutcomes’ evaluation.Today, there is not much consensus over the best way of checking the size and position of adenoid tissue inpreoperative evaluation. Mignon formerly observed theshadow of adenoidal tissue in 1898. Later, it was verified thatthis tissue narrowed the nasopharynx and, after that, many authors investigated different aspects of adenoid andnasopharynx x-rays in an attempt to minimize chances of misinterpretation 10 . There are reports of different radiographicmethods for evaluation of nasopharynx, while theinterpretation of presence or absence of adenoid hypertrophy is not a consensus among authors. According to Wormald etal. who conducted a comparative study among methods,Cohen & Konak developed the best approach providing thehighest positive predictive value 11 . According to these authors,their method takes into account the relation betweennasopharynx and adenoid sizes, besides being a simpleapproach, once it does not require measures and calculations. Graph 1.  Correspondence of number of patients with radiologicallysmall adenoids (n=7) at nasofibroscopy. Graph 2. Correspondence of number of patients with radiologicallymedium adenoids (n=6) at nasofibroscopy. Graph 3. Correspondence of number of patients with radiologicallylarge adenoids (n=7) at nasofibroscopy.
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