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Origi na l A r tic le

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

Associate 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
1

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

Abstract
Introduction: Adenoid hypertrophy is a common disease in childhood causing nasal symptoms. Encouraging results were
reported by the use of intranasal steroids with or without montelukast. Here, we evaluated the effectiveness of intranasal
Fluticasone spray coupled with oral montelukast in the treatment of adenoid hypertrophy.
Aims and Objectives: The aim of our study was to assess the efficacy of intranasal steroid spray followed by oral montelukast
in children with adenoid hypertrophy. This mode of treatment can be considered as an alternative to adenoidectomy weighing
the risk-benefit ratio in terms of anesthetic and operative complications of adenoidectomy.
Materials and Methods: A total of 30 children in the age group of 4-7 years of both genders who attended the ENT department
with symptoms related to adenoid hypertrophy were included in the study. Based on the history and symptoms, nasopharyngeal
airway was evaluated by lateral neck radiograph, fiberoptic nasal endoscopy and computed tomography nasopharynx.
Management was in the form of intranasal fluticasone spray 50 g twice a day for 4 weeks followed by 50 g daily at night for
another 4 weeks. After 8 weeks of treatment with intranasal steroid spray, patient was put on oral montelukast 4 mg at night
for another 2 months. All children were reviewed at 1-month interval. End result was tabulated based on the post-treatment
symptomatic relief; follow-up neck radiographs and fiberoptic nasal endoscopy.
Results: From our study, 80% of the children had relief of their symptoms in 4 months of treatment with intranasal steroid spray
followed by oral montelukast, thus alleviating the need for surgery.
Conclusion: This study proves the effectiveness of a combination of intranasal steroid spray and oral montelukast in the
treatment of adenoid hypertrophy in children thus providing an effective alternative to surgical treatment.
Keywords: Adenoid hypertrophy, Fluticasonepropionate, Montelukast

INTRODUCTION
Adenoid is a lymphoid tissue located in the roof and
posterior wall of the nasopharynx. Normally being
a resistance center against respiratory infections, it
may itself become a source of recurrent and chronic
infection. Adenoid hypertrophy is a common childhood
disease and cause symptoms such a mouth breathing,
nasal obstruction, hyponasal speech, snoring as well as
obstructive sleep apnea and otitis media with effusion
(OME).1 Adenoid hypertrophy was graded as Grade 1
only top segment of choana is obstructed (<25%),
Grade 2 upper half of choana is obstructed (<50%),

Grade 3 reaching up to Eustachian tube orifice partially


obstructing it (<75%), Grade 4-choana is almost
completely obstructed.2
Treatment for adenoid hypertrophy in children is
determined according to the degree of airway obstruction
and related morbidity. If surgical treatment is indicated, the
individual risk-benefit profile of patients should be assessed
in terms of anesthetic and operative complications.
Although there are only few alternative options to surgical
treatment, these can be considered helpful in lesser grades
of adenoid hypertrophy especially in children whose
parents are reluctant for surgery.

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

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

nasal speech, and apnea were graded as follows: 0 - None,


1 - sometimes, 2 - often, 3 - day long and night long. Night
cough was scored as 0 - none, 1 - mild, 2 - moderate,
3 - severe.4 Tonsil size of the patient was recorded, and
tympanometry test was also performed. Parents were taught
the proper way of nasal spray administration.

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.

Patients were reviewed after 1 week, 3 weeks and 8 weeks


during the fluticasone spray therapy and then at monthly
intervals for 2 months during montelukast treatment.

Aims and Objectives

The aim of the study was to evaluate the efficacy of


intranasal steroid-fluticasone 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 fiberoptic nasal endoscopic examination.
Adenoid hypertrophy was graded as Grade 1 only top
segment of choana is obstructed (<25%), Grade 2 upper
half of choana is obstructed (<50%), Grade 3 reaching
up to Eustachean tube orifice partially obstructing it
(<75%), Grade 4 choana is almost completely obstructed.2
Patients who had perennial or vasomotor rhinitis, who had
undergone the adenoidectomy previously, those who had a
history of chronic nasal bleeding, immunodeficiency and
history of hypersensitivity, positive allergy to fluticasone,
tonsillarhypertrophy, history of OME, anatomic defects
in the nose, craniofacial abnormalities such as cleft palate
and cleft lip, Downs syndrome, neurologic diseases and
cardiovascular diseases were excluded from the study.
Symptom scale was scored before and after treatment. In the
study, nasal airway obstruction, mouth breathing, snoring,

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OBSERVATIONS AND RESULTS


At the beginning of treatment and at the end of 8 weeks
treatment with Fluticasone, symptoms of nasal airway
obstruction were assessed. Significant improvement was
observed in terms of nasal airway obstruction, mouth
breathing, speech abnormalities, snoring, apnea and night
cough at the end of 8 weeks. Further radiologic and
endoscopic evaluation was done at the end of the total
4 months treatment. The average value was calculated
separately for each symptom both before and after
treatment. At the end of 4 months treatment, average total
symptoms dropped from 11 to 3 (Chart 1).
After 8 weeks of fluticasone spray therapy, out of the
30 patients, 18 patients showed almost complete relief
of their symptoms (60%). They were then put on oral
montelukast for another 2 months with follow-up every
month. At the end of 4 months, all the 18 children
were totally free of their symptoms and correlated with
radiologic and endoscopic findings. Six patients who
had a recurrence of symptoms on and off after tapering
of fluticasone spray were put on oral montelukast for
2 months. At the end of completion of treatment, they
were clinically and radiologically cured (20%).
A 6 of the 30 patients (20%) had no relief even after the
8 weeks therapy with Fluticasone spray and were advised
3
2.5
2
1.5
1

Before treatment
After treatment

0.5
0

Chart 1: Grading of symptoms before and after treatment

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

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-inflammatory effect of steroids help to reduce
the adenoidal and nasopharyngeal inflammation, 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 inflammation and play an important role in allergic

airway disease by stimulating bronchoconstriction, mucus


production, mucosal edema and inflammation, airway
infiltration 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 fiberoptic 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 fiberoptic nasal endoscopy also could be done

Outcome

3
Complete recovery

3
24

Surgery
No surgery

Chart 2: Outcome of treatment

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Figure 1: X-ray (soft tissue nasopharynx)

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

pre and post-treatment without much difficulty in 90%


patients.

REFERENCES
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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.

2.

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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.

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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, Conflict of Interest: None declared.

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