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Medical Treatment of Adenotonsillar Hypertrophy- Study of 50 cases

: Objective: To examine the efficacy of combined use of intranasal steroids, antibiotics and monteleukast for improving adenotonsillar hypertrophy. Materials and Methods: This prospective study was done at Bangladesh ENT Hospital, Dhaka from January 2020 to June 2021. 50 children were included with primary symptoms of mouth breathing, snoring and sleep disturbances. X-ray soft tissue nasopharynx lateral view was done before and after treatment for comparison. All were prescribed intranasal fluticasone, phenoxymethyl penicillin and monteleukast for 3 months and followed up after completion of 3 months treatment. Results: The age of the children ranged from 2-12 years with mean age 5.4 years. There were 30 female and 20 male with female male ratio 3:2. 30 patients (60%) got complete relief of primary symptoms, 12patients (24%) got moderate improvement of symptoms and 8(16%) patients got no benefit of medical treatment and referred for surgery. Conclusion: Intranasal steroid along with oral penicillin and monteleukast are effective reducing size of adenotonsillar hypertrophy, relieving symptoms and reducing the need for surgery.


Introduction:
The adenoids are a pyramid-shaped aggregation of lymphoid tissue in the nasopharynx. 1 The palatine tonsils are composed of lymphoid tissue and are situated in the lateral part of the oropharynx. Both the tonsils and adenoid are components of Waldeyer's ring, the ring of lymphoid tissue in the pharynx required in the production of immunoglobulins and development of both B and T cells. 2,3 Adenotonsillar hypertrophy causes mouth breathing, nasal congestion, hyponasal speech, snoring, obstructive sleep apnoea (OSA), chronic sinusitis and recurrent otitis media. 4 In the long term, OSA can lead to complications including growth failure, cardiovascular morbidity, neurocognitive abnormalities, learning and behavioural problems, hyperactivity, and poor attention. 5 Topical nasal steroids affect the anatomical component. They decrease inspiratory upper airway resistance at the nasal, adenoidal or tonsillar levels. Corticosteroids may decrease adenotonsillar hypertrophy via their lympholytic or anti-inflammatory effects. Intranasal corticosteroids reduce cellular proliferation and the production of proinflammatory cytokines in a tonsil and adenoid mixed-cell culture system. 6 Evidence of a pathophysiologic link between AH and allergy suggests a possible role for intranasal corticosteroids (INS) and antiallergic monteleukast in the management of patients with AH. 4 The role of penicillin for tonsillar hypertrophy is doubtful but can prevent recurrent attack of tonsillitis.

Materials and Methods:
This prospective observational study was done at Bangladesh ENT Hospital, Dhaka from January 20 to July 2021 among the children presenting with mouth breathing, snoring at night, sleep apnoea with or without deafness. 50 children were included for this study.

Inclusion criteria
1. Children of 2-12 years old with primary nasal symptoms with or without ear symptom 2. Children of adenotonsillar hypertrophy where surgery is contraindicated like bronchial asthma, cardiac problems.

Exclusion criteria
1. Adenotonsillar hypertrophy with moderate to severe conductive deafness, gross septal deviation.
2. Parents of children who don't rely upon medical treatment or want surgery.
3. Children who are sensitive to penicillin Plain X-ray soft tissue nasopharynx lateral view was routinely done for all patients to see the size of adenoid and another X-ray after completion of 3 months treatment to see the improvement ( Figure: 1 & 2). PTA and impedance were done if the child got ear symptom/deafness. Medical treatment was given in the form of oral phenoxymethyl penicillin 5ml 2 times daily for 3 months, tablet Monteleukast 4 mg at night and Fluticasone nasal spray 1 puff at each nostril once daily for 3 months in children age upto 5 years and tablet phenoxymethyl penicillin 250 mg BID, tablet Montelukast 5-10 mg at night and nasal spray 2 puffs at each nostril once daily in older age group (6-12 years). Improvement was also assessed by taking history from the parents regarding nasal blockage, mouth breathing, snoring, sleep disturbance, dribbling of saliva and hearing improvement.

Results:
Total number of patients in this study population was 50, female 28 and male 22 with female male ratio 3:2approax. (Table I).
Age of the patients ranged from 2-12 years with mean age 5.4 years and 64% of patient's age are between 2-5 years (Table II).

Discussion:
The size of the tonsil varies with age, hereditary qualities and pathological status. At the fifth or sixth year of life, the tonsils quickly increase in size, achieving their most extreme size at puberty. At pubescence, the tonsils measure20-25 mm in vertical distance across and 10-15 mm in transverse diameter. 7 In all children, the adenoid volume increases with age, up to age five or six years, and afterward diminishes step-by-step by age eight or nine years. 8 Adenoidal hypertrophy can be associated with sleep disorders ranging from snoring to OSA, which may produce both evening and daytime sequelae (i.e. discontinuous sleep, sleepwalking, morning headache, trouble concentrating, drowsiness and enuresis). 9,10 Topical nasal steroids affect the anatomical component. They decrease inspiratory upper airway resistance at the nasal, adenoidal or tonsillarlevels. 6 Fluticasone and Nasonex® seem to have less bioavailability than older nasal steroids (e.g.beclomethasone). 11 Mometasone furoate nasal spray has lower bioavailability. It has a broad first-pass metabolism and a moderately higher binding affinity for the glucocorticoid receptor compared with the other intranasal corticosteroids. It does not suppress the hypothalamic-pituitary-adrenalaxis when administered at doses of 100-200 mcg/day, which was clinically relevant. 12 One study done by Modrzyn´ski Met al showed three months of treatment with intranasal corticosteroids and antihistamine significantly reduced adenoidal hypertrophy (measured by endoscopy and acoustic rhinometry) and obstructive airway symptoms. 13 In a study by Jazi et al., 39 adenoidal hypertrophy patients were randomised to receive fluticasone or azithromycin for 6 weeks. Tonsillar size, adenotonsillar hypertrophy level and OSA symptoms (sleep apnoea, hyponasal speech, snoring and mouth breathing) were assessed, via a selfadministered questionnaire, before treatment, and at one week and eight weeks after treatment. Mouth breathing, snoring, hyponasal speech and sleep apnoea improved significantly in both groups (p < 0.05). In both groups, the grade of obstruction was also significantly reduced. 14 In our study we use topical intranasal steroid, oral penicillin and antihistamine and reported that about 60% of our patient got complete relief of nasal symptoms after three months treatment.
Although medical treatment is one of the option but many of the adenotonsillar hypertrophy patients need surgical option that is adenotonsillectomy. The most common reasons for adenotonsillectomy in the paediatric population include history of recurrent tonsil infection, including peritonsillar abscess, and tonsil hypertrophy with associated sleep disordered breathing (SDB) and obstructive sleep apnea (OSA). 15 Adenotonsillectomy operation is not without risk. Lane et al. evaluated 1780 patients who underwent tonsillectomy or adenotonsillectomy. Twenty-one of the patients (1.2 per cent) had a primary bleed and 69 (3.9 per cent) had a secondary bleed. 14 An estimated 2-3 per cent of patients experience haemorrhage and 1 in 40000 patients die from tonsillectomy-related bleeding. 16,17 On the other hand topical corticosteroids are associated with fewer and milder adverse effects than oral corticosteroids. The local side effects of intranasal steroid therapyprimarily dry nose, crusting, bleeding and candidiasis -have been well described in the literature. 18 In this study not a single patient got this type of side effects of topical nasal steroid.