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Contents lists available at ScienceDirect

Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Efficacy of nasal corticosteroid in preventing regrowth

after adenoidectomy
Yavuz Selim Yildirim, Erol Senturk *, Sabri Baki Eren, Remzi Dogan,
Selahattin Tugrul, Orhan Ozturan
Bezmialem Vakif University, Department of Otorhinolaryngology, Fatih, Istanbul, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Objective: One of the most frequent reasons of nasal obstruction and sleep apnea in pediatrics is
Received 19 May 2015 adenoid hypertrophy. Remaining adenoid tissue can reoccur following hypertrophied adenoid
Accepted 3 February 2016 removal and a second operation may be needed. Nasal corticosteroids are utilized in order to reduce
Available online xxx
adenoid hypertrophy and eliminate adenoidectomy operation. The purpose of our study is to assess
the effect of nasal corticosteroid administration after adenoidectomy on adenoid regrowth and
Keywords:
symptom scores.
Adenoidectomy postoperative
Nasal corticosteroids
Material and method: Seventy patients who had adenoidectomy were enrolled in our study.
Persistent nasal symptoms Patients were divided into two groups. Group I (35 patients) received Mometasone furoate
Regrowth adenoid vegetation (40 mcg/day per nostril) intranasal spray for 6 months, starting at postoperative week 3 after wound
healing. As for Group II (35 patients), they received intranasal saline spray. Patients were followed
up for one year. Every patient had flexible nasal endoscopy at postoperative week 3 and one year
after the operation. Choana was scored according to its occlusion level by the adenoid tissue.
Additionally, nasal obstruction symptoms (nasal congestion, dry mouth, snoring, nasal speaking,
apnea and night coughing) were scored.
Results: Remaining adenoid tissue in the nasopharynx was comparable in flexible endoscopic
assessment and no significant difference was seen between postoperative week 3 nasal obstruction
scores. In the flexible endoscopic assessment completed in the twelfth month of the study,
significant reduction was found in Group 1 compared to Group 2 in terms of adenoid size. When
patients in both groups were compared, statistically significant reduction was observed in nasal
obstruction symptom scores at the twelfth month.
Conclusion: This study has demonstrated that the use of steroid nasal spray following adenoidectomy
significantly prevents regrowth and reduces nasal obstruction symptoms in the early period.
ß 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction upper respiratory tract obstruction among children. The most

The adenoid tissue is part of the Waldeyer’s ring and is
located at the nasopharynx. It is the most frequent cause of
* Corresponding author at: Bezmialem Vakif University, Medical Faculty,
Department of Otorhinolaryngology, Fatih, Istanbul, Turkey.
Tel.: +90 537 268 1852; fax: +90 212 533 2326.
E-mail address: erolsent@gmail.com (E. Senturk).
http://dx.doi.org/10.1016/j.anl.2016.02.001
0385-8146/ß 2016 Elsevier Ireland Ltd. All rights reserved.
frequent symptoms of adenoid hyperplasia are snoring, mouth
breathing, nasal discharge, sleep apnea and hyponasal speech
[1]. Hyperplastic adenoid tissue may also be a source of
recurrent infection [2]. Adenoidectomy performed for the
above-mentioned indications is one of the most frequent
surgeries conducted in children along with tonsillectomy [3].
The persistence of nasal obstruction and recurrent infection
symptoms following adenoidectomy was reported in the range
of 19–26% in a study [4]. Adenoidectomy is a surgery that is

Please cite this article in press as: Yildirim YS, et al. Efficacy of nasal corticosteroid in preventing regrowthafter adenoidectomy. Auris Nasus
Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.001
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performed under indirect view. Also, the lymphoid tissue does breathing, snoring, nasal speech, and apnea symptoms were
not have a clear delineation. For these reasons, complete scored as follows: 0 = none, 1 = sometimes, 2 = often, and
resection is difficult and it is often not possible. A certain 3 = all day. Night cough was scored as: 0 = none, 1 = mild,
amount of remaining adenoid tissue can always be visualized 2 = moderate, and 3 = severe [8]. The patients did not use any
when nasal endoscopy is performed in the early period other systemic or local drugs during this treatment.
following adenoidectomy.
There are several studies suggesting the use of intranasal 2.1. Statistical analysis
corticosteroids for children with adenoid vegetation as an
alternative to surgery [5]. However, a limited number of studies The statistical analysis was carried out using the Statistical
have been performed to prevent regrowth after adenoidectomy Package for the Social Sciences version 13.0 software for
[6]. The purpose of this study was to investigate whether related Windows (SPSS Inc., Chicago, IL, USA). For intragroup
symptoms and adenoid hyperplasia regrowth following comparisons, the paired t test was used. Data normality was
adenoidectomy can be prevented by means of nasal cortico- checked using the Kolmogorov–Smirnov tests of normality. For
steroid treatment. comparing the intergroup data, comparison independent t test was
used. The statistical significance level was selected as p < 0.05.
2. Material and method
3. Results
This cross-sectional clinical study was performed with
70 patients who underwent adenoidectomy. The study protocol Thirty-five patients were included in the intranasal steroid
was approved by the Clinical Trials Ethics Committee of group. One patient was excluded from the study because of
Bezmialem Vakif University (050.01.04/556). An informed epistaxis. The age range was 1–11 years (mean: 4.02). In this
consent form was obtained from the parents of the patients. group, 19 patients (55%) were male and the remaining
Every patient had an anterior rhinoscopy, otoscopy and flexible 15 patients were female (45%). Thirty-five patients were
nasopharyngoscopy preoperatively. The patients who had enrolled in the intranasal saline group; however, 4 patients in
septal deviation, allergic rhinitis, chronic epistaxis, immuno- this group were excluded from the study because of lack of
deficiency disorders, intranasal steroid hypersensitivity, and cooperation. The age range in this group was 1–12 years (mean:
genetic and neurological disorders, such as Down syndrome, 5.1). Fourteen of the patients continuing the study were male
were excluded from the study. According to Cassano et al. (45%) and 17 were female (55%).
classification, we recommended surgery to patients who had No significant statistical difference was observed between
grades 3 and 4 adenoid growth [7]. the two groups for age and gender (p > 0.05).
Under general anesthesia, a Crowe-Davis mouth opener was When the patients in the steroid group were compared
applied. After the soft palate was deflected with the rubber among each other, a statistically significant difference was
retractor, the adenoid tissue was checked using a laryngeal identified for all symptoms in postoperative week 3 and one
mirror. Adenoidectomy was performed using various sizes of year after [nasal obstruction (p = 0.019), mouth breathing
Beckmann adenoid curettes by a single surgeon (YSY). The (p = 0.020), snoring (p = 0.048), apnea (p = 0.003), night cough
surgery was completed following hemorrhage control using a (p = 0.001), and nasal speech (p = 0.001)] (Table 1).
large gauze pack. The patients were discharged on the same day. A statistically significant reduction was found in the
After adenoidectomy, the patients were divided into two symptom scores of patients in the saline group measured in
groups blindly. Group I (35 patients) received Mometasone the postoperative week 3 and month 12, apart from apnea
furoate (40 mcg/day per nostril) intranasal spray for 6 months (p = 0.422) [nasal obstruction (p = 0.001), mouth breathing
starting at postoperative week 3 after wound healing. Group II (p = 0.001), snoring (p = 0.001), night cough (p = 0.014), and
(35 patients) received intranasal saline spray only. Both groups nasal speech (p = 0.030)] (Table 2).
underwent anterior rhinoscopy and oropharynx examination Table 1
before the start of treatment in the postoperative week 3 and six The comparison of measured parameters before and after treatment in Group 1.
months after the end of treatment (12 months after operation).
Group 1: Mometasone Before After treatment Statistic
Following administration of Oxymetazoline (0.05%) and furoate treatment (12th month) p
topical Lidocaine (4%), the patient received a flexible fiber- (n = 34) (3rd week)
optical nasopharyngoscopy to inspect any regrowth of adenoid (19 male/15 female)
tissue. The choana apertures were graded from top to bottom (Mean age: 4.02)
(grades 1–4) and identified as: grade 1: only the top segment of Endoscopic assessment 1.58  0.55 1.20  0.41 0.001¥
the choana was obstructed <25%, grade 2: upper half of the Nasal airway obstruction 0.67  0.47 0.38  0.49 0.019¥
choana was obstructed <50%, grade 3: it is adjacent to the Mouth breaathing 0.70  0.45 0.32  0.47 0.020¥
Snoring 0.71  0.46 0.32  0.47 0.048¥
rhinopharynx and the tube is partially obstructed < 75%, grade
Apnea 0.38  0.49 0.14  0.35 0.003¥
4: the choana is almost completely obstructed [7]. Night cough 0.55  0.50 0.14  0.35 0.001¥
Questions about symptoms were asked to the guardian of the Nasal speech 0.50  0.45 0.14  0.35 0.001¥
patients before and after the treatment. Nasal congestion, Paired t test used for comparison.
mouth breathing, snoring, nasal speech, apnea and night cough ¥
Significance level obtained (p < 0.05).
c
were examined by clinical evaluation; nasal obstruction, mouth Insignificance level obtained (p > 0.05).

Please cite this article in press as: Yildirim YS, et al. Efficacy of nasal corticosteroid in preventing regrowthafter adenoidectomy. Auris Nasus
Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.001
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Table 2 children [10]. So adenoid tissue often regrows if surgery is

The comparison of measured parameters before and after treatment in Group 2. performed before these ages.
Group 2: intranasal Before After treatment Statistic It was demonstrated that the medical use of intranasal
saline treatment (12th month) p corticosteroids like Mometasone furoate [8] or Fluticasone
(n = 31) (3rd week) propionate [5] for the treatment of adenoid hypertrophy
(14 male/17 female)
(Mean age: 5.1)
achieved significant improvements in symptoms. The mecha-
nism is not yet clear but it may be due to the lympholytic effect;
Endoscopic assessment 1.54  0.49 2.20  0.88 0.001¥
Nasal airway obstruction 0.61  0.49 1.14  0.60 0.001¥
the anti-inflammatory effect of steroids help to reduce
Mouth breathing 0.55  0.50 1.17  0.62 0.001¥ adenoidal and nasopharyngeal inflammation or they reduce
Snoring 0.52  0.50 1.20  0.59 0.001¥ the possibility of the adenoid acting as an infection reservoir
Apnea 0.38  0.49 0.44  0.50 0.422c [11]. Studies which proved the fact that adenoid tissue includes
Night cough 0.55  0.50 0.88  0.80 0.014¥ many glucocorticoid receptors and messenger RNA strengthens
Nasal speech 0.50  0.45 0.79  0.73 0.030¥
these probable mechanisms [12].
Paired t test used for comparison. In our study, Mometasone furoate nasal spray was used as a
¥
Significance level obtained (p < 0.05).
c steroid. We chose this because in a study conducted by Jung
Insignificance level obtained (p > 0.05).
et al. it was demonstrated that this treatment did not have any
side effects on growth or on hypothalamic–pituitary–adrenal
While no significant postoperative week 3 differences were axis [13]. Furthermore, the systemic absorption of this
found in the comparison between groups with respect to treatment was found to be lower as compared to other nasal
symptom scores, statistically significant differences were sprays. From the perspective of the treatment duration, it was
identified in the steroid group after one year [nasal obstruction seen that various studies continued the treatment for 8–24
(p = 0.001), mouth breathing (p = 0.001), snoring (p = 0.001), weeks. Criscuoli et al. showed in the study they conducted that
apnea (p = 0.014), night cough (p = 0.001), and nasal speech the effects became visible 2 weeks after the start of the
(p = 0.001)]. treatment. Twenty-four patients exhibited improvement after
No significant differences were identified between groups 2 weeks of steroid treatment, and an additional 24 weeks of
after the adenoid size assessment was performed endoscopi- therapy at a lower steroid dose maintained clinical improve-
cally in the postoperative week 3 (p = 0.954). The adenoid ment at 52 and 100 weeks for 45.8% of those patients [14]. We
grade in the steroid group was found significantly lower at the continued the treatment for 6 months following adenoidectomy.
1-year follow-up after surgery (p = 0.001) (Table 3). Intranasal steroids are commonly used before surgical
treatment in patients with less than Grade 4 obstruction
[5]. Demain and Goetz [11] reported a 29% decrease in A/C
4. Discussion
ratio average. Cengel and Akyol [15] used intranasal
Symptoms may persist following adenoidectomy. In the Mometasone furoate monohydrate in their study and reported
study conducted by Joshua et al., symptoms were not resolved a 50% decrease in initial adenoid size. Berlucchi et al. [8]
in 15% of the patients following adenoidectomy. However, it observed a 20% (12.5–32.5) decrease in average choanal
was seen that 81% of these symptoms were secondary to nasal obstruction in the Mometasone group and 0.0% (0.0–0.0) in the
pathologies. Nasopharyngeal obstructive adenoid tissue was placebo group. Sobhy was the first to compare the use of
identified in the remaining 19% of the patients and the rates of steroids and saline nasal spray after adenoidectomy [6]. This
significant adenoid regrowth following adenoidectomy were author identified a significant improvement in the scores for
approximately 3% [4]. Another study conducted found the nasal obstruction, discharge and snoring with the use of
revision adenoidectomy rate to be 1.3% [9]. Proliferation of postoperative nasal corticosteroids. The assessment performed
lymphoreticular tissue is particularly frequent in 4–6-year-old on the lateral nasal X-ray found that it was effective in
preventing adenoid regrowth. Our study also showed similar
results with respect to symptom scores. While there were no
Table 3 postoperative differences between groups in terms of nasal
The comparison of measured parameters between groups after treatment.a obstruction, mouth breathing, snoring, apnea, night cough and
Evaluation parameters Group 1 Group 2 Statistic nasal speech scores, the symptom scores of the steroid group in
(Mometasone (Saline) p month 12 following treatment were significantly better. Sobhy
furoate) reported in his study that he performed the assessment of
Endoscopic assessment 1.20  0.41 2.20  0.88 0.001¥ adenoid size using lateral nasopharyngeal radiography since
Nasal airway obstruction 0.38  0.49 1.14  0.60 0.001¥ pediatric patients were not able to tolerate flexible nasophar-
Mouth breathing 0.32  0.47 1.17  0.62 0.001¥ yngoscopy well. Adenoid nasopharynx ratio (A/N) is the most
Snoring 0.32  0.47 1.20  0.59 0.001¥
frequently used method for the assessment of adenoid size on
Apnea 0.14  0.35 0.44  0.50 0.014¥
Night cough 0.14  0.35 0.88  0.80 0.001¥ the lateral nasopharynx X-ray. The literature review performed
Nasal speech 0.14  0.35 0.79  0.73 0.001¥ by Feres et al. in three studies did not find the A/N ratio to be
a
Independent t test used for comparison. correlated with the adenoid size while two studies found them
¥
Significance level obtained (p < 0.05). to be correlated [16]. While X-ray has advantages such as being
c
Insignificance level obtained (p > 0.05). non-invasive and easily administered, its disadvantages are that

Please cite this article in press as: Yildirim YS, et al. Efficacy of nasal corticosteroid in preventing regrowthafter adenoidectomy. Auris Nasus
Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.02.001
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4 Y.S. Yıldırım et al. / Auris Nasus Larynx xxx (2016) xxx–xxx
it offers a two-dimensional view and is static. Furthermore, the
effect of radiation may not be ignored albeit at low doses.
However, the bigger problem is that the A/N ratio changes on
the lateral nasopharynx X-rays in the phases of respiration and
swallowing. For this reason, it should be purposefully taken at
the end of the inspiration. But it is quite difficult to take X-rays
at this particular time of respiration, especially during pediatric
ages.
The most important advantage of fiber-optical nasal
endoscopy (FNE) is that it is dynamic. Wang et al. found in
their study that FNE was significantly correlated with the
adenoid size and it could be tolerated by a great majority of the
patients [17]. Because of all these reasons, endoscopy is
considered a gold standard for the diagnosis of adenoid
vegetation [11,18,19]. Due to these reasons, we performed
flexible fiber-optical nasopharyngoscopy on all patients. All our
patients tolerated it after the administration of local anesthetics.
For adenoid size grading, the classification by Cassano et al.
was used [7]. No postoperative week 3 differences between
groups were identified based on the grading we performed as
per this classification. However, the assessment performed in
month 12 found the mean adenoid grade in the Mometasone
furoate group to be significantly lower than the saline group.
5. Conclusion
Nasal corticosteroid sprays are often used before surgical
treatment in adenoid vegetation. However, their postoperative
use is not common. Following adenoidectomy, the symptoms
may persist due to nasal problems or there may be adenoid
regrowth. For these reasons, it was demonstrated that the use of
nasal steroid spray was effective in reducing the symptom scores
and adenoid grade following adenoidectomy. Especially for
patients who have persistent symptoms following surgery,
patients should be examined using FNE and steroid spray should
be used to eliminate nasal symptoms and secondary surgery.
Conflict of interest
None of the authors has any conflict of interest, financial or
otherwise.
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