Can computed tomography score predict outcome of adenoidectomy for chronic rhinosinusitis in children Hassan H. Ramadan, M.D., M.Sc., and Chadi A. Makary, M.D.

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ABSTRACT

Background: Chronic adenoiditis (CA) and chronic rhinosinusitis (CRS) in children are difficult to distinguish based on symptoms alone. A computed tomography (CT) scan is one way to distinguish between the two entities. The purpose of this study was to determine whether CT scores can predict outcome of adenoidectomy. Methods: A retrospective review was performed over a 10-year period. All children who failed medical treatment had a CT scan and an adenoidectomy, which were reviewed. Children who had a CT score of ⱖ5 were included in the CA with concurrent CRS group, whereas those who had a CT score of ⬍5 were included in the CA without CRS group. Results: Two hundred thirty-three children met the aforementioned criteria. Mean age was 5.5 years and mean CT score was 6.4. The CRS group had a success rate of 43%, whereas the CA group had a 65% success rate (p ⫽ 0.0017). Those children who were asthmatic and had CRS had a success rate of 28% compared with 53% for those who had CA (p ⫽ 0.022). Conclusion: Making the diagnosis of CRS in children seems to be critical in determining whether, initially, an adenoidectomy alone is an appropriate treatment, specifically for those who have asthma. (Am J Rhinol Allergy 28, e80 –e82, 2014; doi: 10.2500/ajra.2014.28.4004)

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urgery for children with chronic rhinosinusitis (CRS) refractory to medical management continues to be a subject for discussion. Adenoidectomy is currently the mainstay of treatment for the majority of children with CRS.1,2 It has the advantage of being a simple procedure with low complication rates. Adenoidectomy, however, is effective, on average, in about 50% of cases with a range of 47–56%.1,3,4 It has even been shown to be less effective in children who have asthma with CRS.4 Why it is more effective in certain children but not others seems to be complex and perplexing. We do know that symptoms of CRS in children are very similar to those with chronic adenoiditis (CA).5 Those symptoms include nasal stuffiness, nasal discharge, cough, and headache in older children. Bhattacharyya et al.6 in 2004 noted that a distinction can be made based on the Lund-Mackay computed tomography (CT) score.7 They suggested that a CT score of ⱖ5 represents true CRS. Therefore, for those children with symptoms of CRS that is not responsive to medical treatment with a CT score of ⱖ5, diagnosis of CRS was given, whereas for the remaining children the diagnosis was CA. We hypothesized that children with CA, as evidenced by CT score, would respond better to adenoidectomy than those who have CA and CRS as evidenced by CT scan.

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MATERIALS AND METHODS A retrospective review of prospectively collected data for all children with symptoms of CA and CRS referred to a tertiary pediatric otolaryngology practice over a 10-year period was performed. An Institutional Review Board approval was obtained from West Virginia University. All children who failed maximal medical treatment and had a CT scan of their sinuses as part of their evaluation as reported previously was evaluated.4 All those children who had an adenoidectomy were reviewed. Adenoidectomy was performed usFrom the Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Morgantown West Virginia Presented (poster) at the meeting of the Triological Society, Orlando Florida, April, 12–13, 2013 The authors have no conflicts of interest to declare pertaining to this article Address correspondence to Hassan H. Ramadan, M.D., M.Sc., Department of Otolaryngology–Head and Neck Surgery, West Virginia University, Room 2222 Health Science Center South, P.O. Box 9200, Morgantown, WV 26506-9200 E-mail address: [email protected] Copyright © 2014, OceanSide Publications, Inc., U.S.A.

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ing the suction electrocautery technique. CT scans of the sinuses were graded using the Lund-Mackay system.7 Children who met the following criteria were included in this study: (1) age between 2 and 12 years, (2) children who had a CT scan and had an adenoidectomy performed, and (3) available follow-up at least 12 months postoperatively. Patients with a history of immunodeficiency disorders, ciliary motility disorders, or cystic fibrosis were excluded. None of the patients included had any previous sinus surgery. Using the Bhattacharyya et al. criteria, children who had a CT score of ⱖ5 were included in the CA with CRS group, whereas those with a CT score of ⬍5 were included in the CA without CRS group (Fig. 1). All children between 2 and 12 years of age were initially evaluated. Afterward, the caregiver was asked to give us information about the major symptoms of nasal obstruction or stuffiness, rhinorrhea, cough, and facial pain or headache in the form of a questionnaire (Appendix). The children were followed up after surgery at 3-month intervals. The questionnaire (Institutional Review Board approved) was administered at 6-month intervals after surgery. The questionnaire was used to assess the status of the major symptoms of each child and the degree to which these symptoms had changed since surgery. The questionnaire was administered by a nurse or mailed to the parents/caregivers. The parents/caregivers ranked each preoperative symptom as cured, better, same, or worse. Improvement (cured or better) of symptoms of all children was then evaluated. The questionnaire that was used was subjective because, when the study was initiated, no validated chronic sinusitis instruments were available for use. Any child who needed another procedure or who had a revision procedure was considered as a failure. Those children with ⱖ50% symptoms that were the same or worse were also labeled failures. One hundred twelve (48%) patients had all four symptoms marked on the questionnaire, 84 (36%) had three, and 37 (16%) had two. Those who had three of the four symptoms marked, failure was defined when two or more symptoms were marked as same or worse. For those with four symptoms, 13 patients had two better/cured and two same/worse symptoms. For those with only two symptoms marked, only four (11%) had one better/cured versus same/worse. Univariate statistical analysis was performed using ␹2-test and Fisher’s exact test in the analysis of binary outcomes. For continuous variables, a t-test was performed. Multivariable analyses were performed using a logistic regression model.

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Table 2 Patient characteristics by group (n ⴝ 224) Variable

CA with CRS

CA without CRS

p Value

No. of patients Male sex Age (yr) Allergy Asthma Mean CT score Success

127 (56.7%) 80 (63%) 5 56 (48%) 53 (43%) 9.7 43%

97 (43.3%) 57 (59%) 6.4 45 (51%) 39 (42%) 2.6 65%

0.52 0.75 0.0001 0.68 0.77 0.0001 0.0017

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CA ⫽ Chronic adenoiditis; CRS ⫽ chronic rhinosinusitis; CT ⫽ computed tomography.

Figure 1. Flow diagram showing patient classification. Table 3 Multivariate analysis of variables Table 1 Patient characteristics (n ⴝ 224) Variable

No. (%)

No. of patients Male sex Mean age (yr) Allergy Asthma Mean CT score

233 142 (61) 5.5 104 (49.7) 96 (43) 6.4

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DISCUSSION Adenoidectomy is chosen by most otolaryngologists as a first-line surgical treatment for children who fail medical therapy for symptoms suggestive of CRS. Frequently, it is performed before obtaining a CT scan to document CRS. It is thought to work by eradicating the reservoir for bacteria as well as the biofilm.8 Prior studies have shown an overall success rate of around 50%.1,3,4 There is tremendous nonuniformity in the studies performed. Some documented the presence of CRS by a CT scan whereas others depended solely on the symptoms. We have shown previously that those children who have

p Value

Point Estimate

Allergy Asthma Age (yr) Smoke Gender CT score

1.3256 5.5 0.1845 1.515 1.259 9.6524

0.249 0.019 0.6675 0.218 0.262 0.0019

1.48 2.25 0.972 0.629 1.46 2.995

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Two hundred thirty-three children were reviewed and completed 12 months of follow-up. The age range was 2–12 years with an average age of 5.5 years. One hundred forty-two children (61%) were boys. Ninety-six children (43%) had asthma and 104 children (49.7%) had allergies. The average preoperative CT score was 6.4 (SD, 4.5). One hundred twenty-seven (56.7%) children had a CT score of ⱖ5 and thus were labeled as the CRS group. Ninety-seven (43.3%) children were remaining and were labeled as the CA group. Children with CA were significantly older than those with CRS (6.4 versus 5 years; p ⫽ 0.0001). Minimum time of follow-up was 12 months. Patient characteristics are summarized in Tables 1 and 2. Overall success rate was 51.4%. The CRS group had a success rate of 43% compared with 65% for the CA group (p ⫽ 0.0017). Children who were asthmatic with CRS had a success rate of 28% compared with 53% who had CA alone (p ⫽ 0.022). Those who did not have asthma but had CRS had a 54% success rate compared with 71% for those with CA (p ⫽ 0.051). There was no statistical difference in outcome for those children with or without allergies. A multivariate analysis was performed, which showed CT score (CRS versus CA) and asthma as the only two predictors of outcome. Those with CA had better outcome than those with CA with concurrent CRS, and, specifically, asthmatic children with CRS had a very poor outcome compared with those with CA alone (28%; Table 3).

Wald ␹2

95% Wald Confidence Limits 0.759–2.886 1.142–4.425 0.854–1.106 0.301–1.316 0.754–2.826 1.499–5.984

CT ⫽ computed tomography.

CT ⫽ computed tomography.

RESULTS

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Variable

asthma and a low CT score will have a lower success rate than those without asthma.4 Bhattacharyya recently reported that those children with CRS will have a CT score of ⱖ5.6 We postulate that those who have similar symptoms but with a CT score of ⬍5 will have CA rather than CRS. Using the aforementioned criteria we evaluated both groups of children, those with CRS and those with CA without sinusitis. We found that those children with CA and CRS had a lower success rate than those with CA alone (43% versus 65%; p ⫽ 0.0017). We also showed that asthmatic children with CRS had a very poor response rate to adenoidectomy alone when compared with asthmatic children with CA (28% versus 53%; p ⫽ 0.022). The CA group was noted to have a higher mean age compared with those with CA with sinusitis group. That may be a coincidence rather than the nature of the disease process. On multivariate analysis, however, age did not seem to be a confounding variable. In children, paranasal sinus disease is considered an important risk factor for the development of lower respiratory tract diseases, and rhinosinusitis and asthma seem to be two different expressions of a common pathological process.9 The indication that rhinosinusitis and asthma coexist in patients at a higher frequency than the prevalence of each in the general population provides a strong connection between the upper and lower airways.10,11 Sinonasal disease in asthmatic patients seems to be different from that of the general population and the sequence of disease and parallel inflammatory pathways involved suggest that they may be progressive manifestations of a common disease process.12 Patients with severe asthma frequently have worse sinus disease, and medical treatment of rhinosinusitis results in an improvement of clinical asthma and greater control of respiratory symptoms. It has been our observation that when adenoidectomy alone is performed on asthmatic children with symptoms of CRS, those children usually do not have a good outcome and revision surgery is usually warranted to address their CRS. Based on the aforementioned data, we believe that asthmatic children with symptoms of rhinosinusitis need to be evaluated for documented sinusitis with a CT scan. The best outcome for these children with asthma and CRS is addressing the pathology of the sinuses at the

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time of adenoidectomy. In those with CA per CT score, an adenoidectomy should suffice. We would like to caution the reader that because our questionnaire did not measure baseline symptoms, children with CRS may have been more symptomatic than the CA group. This may explain the lower success rate of the CRS group compared with the CA group. The same analogy can be used for those children with asthma. Thus, our results should be interpreted with that limitation in mind.

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CONCLUSION

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Adenoidectomy was very helpful for children with CA who were nonasthmatic patients. Making the diagnosis of CRS in children with CT scan seems to be critical in determining whether, initially, an adenoidectomy alone is an appropriate treatment specifically for those who have asthma.

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4. 5. 6.

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10.

REFERENCES 1.

2.

Vandenberg SJ, and Heatley DG. Efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg 123:675–678, 1997. Chandran SK, and Higgins TS. Chapter 5: Pediatric rhinosinusitis: Definitions, diagnosis, and management—An overview. Am J Rhinol Allergy 27(suppl 1):S16–S19, 2013.

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Ramadan HH. Adenoidectomy vs endoscopic sinus surgery for the treatment of pediatric sinusitis. Arch Otolaryngol Head Neck Surg 125:1208–1211, 1999. Ramadan HH. Surgical management of chronic sinusitis in children. Laryngoscope 114:2103–2109, 2004. Fokkens WJ, Lund VJ, Mullol J, et al. European position paper on rhinosinusitis and nasal polyps 2012. Rhinol Suppl 23:1–298, 2012. Bhattacharyya N, Jones DT, Hill M, and Shapiro NL. The diagnostic accuracy of computed tomography in pediatric chronic rhinosinusitis. Arch Otolaryngol Head Neck Surg 130:1029–1032, 2004. Lund VJ, and Mackay IS. Staging in rhinosinusitis. Rhinology 31:183– 184, 1993. Lee D, and Rosenfeld RM. Adenoid bacteriology and sinonasal symptoms in children. Otolaryngol Head Neck Surg 116:301–307, 1997. Staikuniene` J, Vaitkus S, Japertiene LM, and Ryskiene S. Association of chronic rhinosinusitis with nasal polyps and asthma: Clinical and radiological features, allergy and inflammation markers. Medicina (Kaunas) 44:257–265, 2008. Meltzer E, Szwarcberg J, and Pill MW. Allergic rhinitis, asthma, and rhinosinusitis: Diseases of the integrated airway. J Manag Care Pharm 10:310–317, 2004. Feng CH, Miller MD, and Simon RA. The united allergic airway: Connections between allergic rhinitis, asthma, and chronic sinusitis. Am J Rhinol Allergy 26:187–190, 2012. Steinke JW. The relationship between rhinosinusitis and asthma sinusitis. Curr Allergy Asthma Rep 6:495–501, 2006.

APPENDIX

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CS Survey for Children

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Please answer the following questions concerning your child’s health and symptoms of sinusitis in the past 6 mo. Participation is voluntary. You do not have to answer every question but doing so would help with our project. Do not put a name on this form. Your child had surgery that consisted of (circle one): A. Removing the adenoids B. Endoscopic sinus surgery (cleaning the sinuses) C. Both 1. Did your child go to day care? Yes No 2. Does anybody at home smoke? Yes No 3. Does your child have any of the following: Allergy Yes No Was he/she tested Asthma Yes No Immune deficiency Yes No 4. After the surgery, your child’s condition regarding the following (if he/she had any) is (circle one): Yellow/green nasal discharge Worse Same Better Cough Worse Same Better Nasal congestion Worse Same Better Headache Worse Same Better 5. Were you satisfied with the results of surgery? Return in the enclosed envelope.

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Yes

No

Cured Cured Cured Cured Yes

No

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Can computed tomography score predict outcome of adenoidectomy for chronic rhinosinusitis in children.

Chronic adenoiditis (CA) and chronic rhinosinusitis (CRS) in children are difficult to distinguish based on symptoms alone. A computed tomography (CT)...
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