62International Journal of Scientifi c Study | September 2014 | Vol 2 | Issue 6

Intranasal Steroid Spray and Montelukast in the Management of Adenoid Hypertrophy in Children

Asha Annie Abraham1,P Anil Markose2,

K M Thomas Rony1,M Sajeev George3

1Associate Professor, Department of ENT & Head Neck Surgery, MOSC Medical College Hospital, Kolenchery, Kerala, India, 2Assistant Professor, Department of ENT & Head Neck Surgery, MOSC Medical College Hospital, Kolenchery, Kerala, India, 3Professor & Head, Department of ENT & Head Neck Surgery, MOSC Medical College Hospital, Kolenchery, Kerala, India

Corresponding Author: Dr. Asha Annie Abraham, Department of ENT & Head Neck Surgery, MOSC Medical College Hospital, Kolenchery - 682 311, Kerala, India. Phone: +91-9544366187. E-mail: drashasam@hotmail.com

Grade 3 reaching up to Eustachian tube orifi ce partially obstructing it (

Abraham, et al.: Steroid Spray and Montelukast for Adenoid Hypertrophy

63 International Journal of Scientifi c Study | September 2014 | Vol 2 | Issue 6

Evidence of a pathophysiologic link between adenoid hypertrophy and allergy suggest a possible role for intranasal steroid in their management.3 Over the past years, good results have been reported regarding the use of intranasal steroids for chronic nasal obstructive symptoms due to adenoid hypertrophy in children.4

In this study, the effectiveness of Fluticasone propionate nasal spray followed by oral montelukast is assessed and thereby avoiding surgical treatment. Evidence of a pathophysiologic link between adenoid hypertrophy and allergy suggests a possible role for intranasal steroids in the management of adenoid hypertrophy.

Aims and ObjectivesThe aim of the study was to evaluate the effi cacy of intranasal steroid-fl uticasone nasal spray followed by oral montelukast in the treatment of children with adenoid hypertrophy taking into account the association of adenoid hypertrophy with allergy and allergic rhinitis. This also highlights the alternative option to surgery in the lesser grades of adenoid hypertrophy and in patients who are unwilling for surgery.

MATERIALS AND METHODS

The study was approved by the institutional ethics committee, and informed consent was obtained from parents. Inclusion criteria for the study were children in the age group of 4-7 years, of both gender with adenoid hypertrophy presenting with symptoms of nasal airway obstruction, mouth breathing, speech abnormalities, snoring, apneic spells and night cough. A detailed history and clinical examination was undertaken, and nasal airway obstruction was assessed with the help of lateral neck radiograph and fi beroptic nasal endoscopic examination.

Adenoid hypertrophy was graded as Grade 1 only top segment of choana is obstructed (

Abraham, et al.: Steroid Spray and Montelukast for Adenoid Hypertrophy

64International Journal of Scientifi c Study | September 2014 | Vol 2 | Issue 6

adenoidectomy. All these six patients had a Grade 4 obstruction. Of these six patients, three were willing for surgery (10%) and were relieved of their symptoms and was on the follow-up for 4 months. Three of the six patients who refused surgery (10%) were getting symptoms on and off and were treated symptomatically. No steroid therapy was given after 8 weeks.

Of the study population, 24 patients (80%) had complete relief from symptoms with a combination of treatment with intra nasal steroid spray and montelukast whereas six patients (20%) did not show any improvement. They were put on other modalities of treatment including adenoidectomy. All the 20% had a Grade 4 obstruction (Chart 2).

DISCUSSION

The successful use of intra nasal steroid spray in children with adenoid hypertrophy was first introduced by Demain and Goetz.4 Although it is not yet clear by which mechanism the steroids reduce the nasal airway obstruction, there are some plausible theories. Some of these include reduction of adenoid size directly by lympholytic effect, the anti-infl ammatory effect of steroids help to reduce the adenoidal and nasopharyngeal infl ammation, or they reduce the possibility of the adenoid acting as an infection reservoir.5 Studies which prove the fact that adenoid tissue includes many glucocorticoid receptors and messenger RNA strengthen the probable mechanism.6 The importance lies in the proper application of the nasal spray. In our study, after 8 weeks of treatment with intranasal steroid spray, 60% of the patients had complete relief from their symptoms.

Cysteinyl leukotrienes (Cys LT) are endogenous mediators of infl ammation and play an important role in allergic

airway disease by stimulating bronchoconstriction, mucus production, mucosal edema and infl ammation, airway infi ltration by eosinophils and dendritic cell maturation that prepares for future allergic response. Montelukast inhibits these actions by blocking Type 1 Cys LT receptors found on immunocytes, smooth muscles and endothelium of the respiratory mucosa. It was initially marketed to be used as a maintenance therapy for asthma and subsequently was found to be useful in allergic rhinitis.

In our study, after the 8 weeks steroid therapy, children were put on oral montelukast 4 mg for 2 months with follow-up every month. Eighty percentage of the patients in our study had complete relief of their symptoms after the completion of treatment at 4 months. Of the 80%, 20% of the patients who had a recurrence of symptoms after tapering off Fluticasone spray also responded well to oral montelukast and were completely cured.

Lateral neck radiographs and fi beroptic nasal endoscopy proved to be very effective in assessing the nasal airway. Lateral neck radiography was interpreted by the method of Cohen and Konak.7 According to this method, the thickness of the soft palate in its superoanterior part (SP) and the airway column immediately posterior to it were measured, and AC/SP ratio was calculated. The measurement was done about 1 cm below the upper end of the soft palate in children >3 years and 0.5 cm in younger children. A radiological example is demonstrated (Figure 1).

Degree of obstruction was graded as follows: AC/SP >or = 1 - Grade 0 or no obstruction. AC/SP = 0.5-0.99 - Grade 1 or mild obstruction. AC/SP = 0.01-0.49 - Grade 2 or severe obstruction. AC/SP = 0 - Grade 3 or total obstruction.

Since the children in our study were in the age group of 4-7 years, a fi beroptic nasal endoscopy also could be done

24

33

Outcome

Complete recovery

Surgery

No surgery

Chart 2: Outcome of treatment Figure 1: X-ray (soft tissue nasopharynx)

Abraham, et al.: Steroid Spray and Montelukast for Adenoid Hypertrophy

65 International Journal of Scientifi c Study | September 2014 | Vol 2 | Issue 6

pre and post-treatment without much diffi culty in 90% patients.

From our study, 80% of the children had total relief of their symptoms in 4 months of treatment with intranasal steroid spray followed by oral montelukast, thus alleviating the need for a surgical procedure. We did not observe any side effects of treatment in any of these children during the steroid-montelukast therapy.

CONCLUSION

This study proves the effectiveness of intranasal steroid spray used in a proper way and oral montelukast in the treatment of adenoid hypertrophy in children. This provides an effective alternative to surgical treatment especially in children whose parents are reluctant to surgical modality of treatment.

REFERENCES

1. Paradise JL, Bernard BS, Colborn DK, Janosky JE. Assessment of adenoidal obstruction in children: Clinical signs versus roentgenographic fi ndings. Pediatrics 1998;101:979-86.

2. Cassano P, Gelardi M, Cassano M, Fiorella ML, Fiorella R. Adenoid tissue rhinopharyngeal obstruction grading based on fi berendoscopic fi ndings: A novel approach to therapeutic management. Int J Pediatr Otorhinolaryngol 2003;67:1303-9.

3. Scadding G. Non-surgical treatment of adenoidal hypertrophy: The role of treating IgE-mediated infl ammation. Pediatr Allergy Immunol 2010;21:1095-106.

4. Berlucchi M, Salsi D, Valetti L, Parrinello G, Nicolai P. The role of mometasone furoate aqueous nasal spray in the treatment of adenoidal hypertrophy in the pediatric age group: Preliminary results of a prospective, randomized study. Pediatrics 2007;119:e1392-7.

5. Demain JG, Goetz DW. Pediatric adenoidal hypertrophy and nasal airway obstruction: Reduction with aqueous nasal beclomethasone. Pediatrics 1995;95:355-64.

6. Goldbart AD, Veling MC, Goldman JL, Li RC, Brittian KR, Gozal D. Glucocorticoid receptor subunit expression in adenotonsillar tissue of children with obstructive sleep apnea. Pediatr Res 2005;57:232-6.

7. Cohen D, Konak S. The evaluation of radiographs of the nasopharynx. Clin Otolaryngol Allied Sci 1985;10:73-8.

How to cite this article: Abraham AA, Markose PA, Rony KMT, George MS. Intranasal Steroid Spray and Montelukast in the Management of Adenoid Hypertrophy in Children. Int J Sci Stud 2014;2(6):62-65.

Source of Support: Nil, Confl ict of Interest: None declared.

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