Effects of guidelines on adeno-tonsillar surgery on the clinical behaviour of otorhinolaryngologists in Italy.

BACKGROUND: Several guidelines on adeno-tonsillar disease have been proposed in recent years and some discrepancies in relation both to clinical manifestations and indications for surgical treatment have emerged. The aim of the study was to verify what influence (adeno)-tonsillectomy guidelines have had on the clinical behaviour of ENT specialists in Italy. Our study is a retrospective and multi-centre case series with chart review. METHODS: The survey involved 14,770 children, aged between the ages of 2 and 11, who had undergone adeno-tonsillar surgery between 2002 and 2008 in fourteen Italian tertiary and secondary referral centres. Anova test was used for the statistical analysis, assuming p < 0.05 as the minimum statistical significance value. RESULTS: The frequency of adeno-tonsillar surgeries did not change significantly (p>0.05) during the study period and following the Italian policy document publication. Overall, adeno-tonsillectomy was the most frequent intervention (64.1%), followed by adenoidectomy (31.1%) and tonsillectomy (4.8%). The indications for surgery did not change significantly for each of the operations (p>0.05), with the exception of adeno-tonsillectomy in case of feverish episodes due to acute recurrent tonsillitis ≥ 5 without nasal obstruction (decreased p= 0.010) , even when the feverish episodes due to acute recurrent tonsillitis were < 5 over the last year. Nasal obstruction was associated with feverish episodes due to acute recurrent tonsillitis in 65.2% of operated cases, while otitis media had been diagnosed in 43.3% of the patients studied. CONCLUSIONS: The recommendations first developed in Italy in a 2003 policy document and then resumed in guidelines in 2008, were not implemented by ENT units involved in the survey. The study highlights the fact that the indications for adeno-tonsillar operations are based on the overall clinical presentation (comorbidity) rather than on a single symptom. Guidelines are necessary to give coherent recommendations based on both the findings obtained through randomized controlled trials and the data collected from observational studies.

Extracapsular Tonsillectomy versus Intracapsular Tonsillotomy in Paediatric Patients with OSAS.

OBJECTIVE: The objective of our study was to compare our experience of intracapsular tonsillotomy performed with the help of a microdebrider usually used for adenoidectomy with results obtained from extracapsular surgery through dissection and from adenoidectomy in cases of people affected with OSAS, linked to adeno-tonsil hypertrophy, observed and treated in the last 5 years. METHODS: 3127 children with adenotonsillar hyperplasia and OSAS-related clinical symptoms (aged between 3 and 12 years) underwent tonsillectomy and/or adenoidectomy. A total of 1069 patients (Group A) underwent intracapsular tonsillotomy, while 2058 patients (Group B) underwent extracapsular tonsillectomy, from January 2014 to June 2018. The parameters considered in order to evaluate the effectiveness of the two different surgery techniques taken into consideration were as follows: the presence of possible postoperative complications, represented mainly by pain and perioperative bleeding; the level of postoperative respiratory obstruction compared with the original obstruction through night pulse oximetry, performed 6 months before and after the surgery; tonsillar hypertrophy relapse in Group A and/or the presence of residues in Group B with clinical evaluation performed 1 month, 6 months, and 1 year after the surgery; and postoperative life quality, evaluated through submitting to parents the same survey proposed before the surgery 1 month, 6 months, and 1 year after the surgery. RESULTS: Regardless of the technique used (extracapsular tonsillectomy or intracapsular tonsillotomy), there was a clear improvement in both the obstructive respiratory symptomatology and quality of life in both patient groups, as highlighted by the pulse oximetry and the OSA-18 survey submitted later. CONCLUSIONS: Intracapsular tonsillotomy surgery has improved in terms of a reduction in postoperative bleeding cases and pain reduction, with an earlier return to patients' usual lifestyle. Lastly, using a microdebrider with the intracapsular technique seems to be particularly effective in removing most of the tonsillar lymphatic tissue, leaving only a thin border of pericapsular lymphoid tissue and preventing lymphoid tissue regrowth during one year of follow-up.

Association between upper airway obstruction and malocclusion in mouth-breathing children.

OBJECTIVES: To evaluate the association between upper airway obstruction and occlusal anomalies in mouth-breathing children. METHODS: 356 mouth-breathing children were evaluated by ENT physicians and specialists in orthodontics. ENT examination included nasal endoscopy to assess the adenoidal hypertrophy, tonsillar grading and presence of nasal septum deviation. Clinical orthodontic examination was performed to record occlusal variables. Univariate and multivariable logistic regression were performed to study the association between registered variables. RESULTS: 221 patients (mean age ± sd = 6.2 ± 2.5 years) met inclusion criteria. 81.4% of children presented malocclusion. A significant association between tonsillar grade 2 and the presence of malocclusion, Class II relation and increased overjet was shown. Tonsillar grade 4 showed a significant association with the presence of malocclusion and increased overjet. Adenoidal hypertrophy and nasal septum deviation did not show any association with occlusal findings. CONCLUSIONS: A high frequency of orthodontic problems was seen in mouth-breathing children. Our results suggested that severe tonsillar hypertrophy may determine presence of malocclusion and increased overjet. On the other hand, the association between mild tonsillar hypertrophy and many occlusal anomalies in mouth-breathers suggest an important role of malocclusion in the onset of oral breathing in children.

Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Prevention.

BACKGROUND: In recent years, new information has been acquired regarding the diagnosis, treatment and prevention of acute otitis media (AOM). The Italian Pediatric Society, therefore, decided to issue an update to the Italian Pediatric Society guidelines published in 2010. METHODS: The search was conducted on Pubmed, and only those studies regarding the pediatric age alone, in English or Italian, published between January 1, 2010 and December 31, 2018, were included. Each study included in the review was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The quality of the systematic reviews was evaluated using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 appraisal tool. The guidelines were formulated using the GRADE methodology by a multidisciplinary panel of experts. RESULTS: The importance of eliminating risk factors (passive smoking, environmental pollution, use of pacifier, obesity, limitation of day-care center attendance) and the promotion of breastfeeding and hygiene practices (nasal lavages) was confirmed. The importance of pneumococcal vaccination in the prevention of AOM was reiterated with regard to the prevention of both the first episode of AOM and recurrences. Grommets can be inserted in selected cases of recurrent AOM that did not respond to all other prevention strategies. Antibiotic prophylaxis is not recommended for the prevention of recurrent AOM, except in certain carefully selected cases. The use of complementary therapies, probiotics, xylitol and vitamin D is not recommended. CONCLUSIONS: The prevention of episodes of AOM requires the elimination of risk factors and pneumococcal and influenza vaccination. The use of other products such as probiotics and vitamin D is not supported by adequate evidence.

Cerumen: A fundamental but neglected problem by pediatricians.

OBJECTIVES: Under physiological conditions, cerumen (Ce) is regularly extruded from the ear canal by a self-cleaning mechanism. Failure of this mechanism leads to excessive accumulation or impaction of Ce. Limited data are available concerning the prevalence of cerumen in healthy and sick infants and children. We assessed the prevalence of Ce in a large population of infants and children and compared the Ce removal attitudes of paediatricians (PEDs) and otorhinolaryngologists (ENTs). METHODS: Children seen in November 2014 for acute respiratory infections, including suspected acute otitis media, or well-being visits, were enrolled. The following data were recorded: presence, laterality, and amount of Ce; presenting complaints and final diagnosis; attempt to remove Ce during the visit; and type of physician. RESULTS: Among 819 children aged 1 month to 12 years, Ce was present in 594 (72.5%), of whom 478 (80.5%) had bilateral Ce, and 261 (43.9%) had Ce in a relevant amount (cerumen obstructing at least 50% of the ear canal). Presence of Ce was more common in younger and in African or Asian children. PEDs were less likely to remove cerumen than ENTs (28.8% vs 91.0%, p < 0.001) irrespective of age, gender, race and reason for visit. Ce was removed by PEDs in less than one-third of sick children with a final diagnosis of acute otitis media (AOM) (31.6%) compared with almost all the children by ENTs (95.6%, p < 0.001). CONCLUSION: Ce is highly prevalent in healthy and sick children but is quite neglected by PEDs. Educational programs to reinforce the importance of Ce removal and to improve the techniques for removal in case of suspected AOM should be implemented and rigorously evaluated in order to avoid incorrect diagnosis and erroneous treatments.

Development of an algorithm for the management of cervical lymphadenopathy in children: consensus of the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Society of Pediatric Infectious Diseases and the Italian Society of Pediatric Otorhinolaryngology.

UNLABELLED: Cervical lymphadenopathy is a common disorder in children due to a wide spectrum of disorders. On the basis of a complete history and physical examination, paediatricians have to select, among the vast majority of children with a benign self-limiting condition, those at risk for other, more complex, diseases requiring laboratory tests, imaging and, finally, tissue sampling. At the same time, they should avoid expensive and invasive examinations when unnecessary. The Italian Society of Preventive and Social Pediatrics, jointly with the Italian Society of Pediatric Infectious Diseases, the Italian Society of Pediatric Otorhinolaryngology, and other Scientific Societies, issued a National Consensus document, based on the most recent literature findings, including an algorithm for the management of cervical lymphadenopathy in children. METHODS: The Consensus Conference method was used, following the Italian National Plan Guidelines. Relevant publications in English were identified through a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception through March 21, 2014. RESULTS: Basing on literature results, an algorithm was developed, including several possible clinical scenarios. Situations requiring a watchful waiting strategy, those requiring an empiric antibiotic therapy, and those necessitating a prompt diagnostic workup, considering the risk for a severe underling disease, have been identified. CONCLUSION: The present algorithm is a practice tool for the management of pediatric cervical lymphadenopathy in the hospital and the ambulatory settings. A multidisciplinary approach is paramount. Further studies are required for its validation in the clinical field.

Resveratrol plus carboxymethyl-ß-glucan in children with recurrent respiratory infections: a preliminary and real-life experience.

BACKGROUND: Recurrent respiratory infections (RRI), such as the presence of at least one of the following criteria: i) >6 RI per year; ii) >1 RI per month involving upper airways from September to April; iii) >3 RI involving lower airways, constitute a social problem for both their pharmaco-economic impact and the burden for the family. However, several treatment have been proposed with controversial results. OBJECTIVE: As resveratrol plus carboxymethyl-ß-glucan is presently available as solution for aerosol, the aim of this study was to evaluate the effects of this compound, compared to saline solution, whether it is able to prevent RRI in children. DESIGN: The study was designed as real-life, randomized. Globally, 82 children (49 males, mean age 8.1 ± 2.6 years) with acute rhinopharyngitis and RRI were enrolled. Resveratrol plus carboxymethyl-ß-glucan or saline isotonic solution was randomly (ratio 1:1) administered immediately after an anti-infective and anti-inflammatory 10-day treatment (tiamphenicol associated with acetylcysteine plus beclomethasone dipropionate) for the acute rhinopharyngitis. Investigated treatments lasted 20 days. Days with respiratory symptoms, fever, medication use, medical visits, and school absences were evaluated. Children were visited 30, 60, and 90 days after starting treatments. RESULTS: The active compound was able to significantly reduce the number of days with nasal obstruction (p < 0.001), rhinorrhea (p < 0.001), sneezing (p < 0.001), cough (p = 0.002), fever (p < 0.001), medication use (p < 0.001), medical visits (p < 0.001), and school absence (p < 0.001). CONCLUSIONS: This preliminary and real-life study could suggest that an aerosolized solution containing resveratrol plus carboxymethyl-ß-glucan might exert preventive effects in children with RRI.

Allergic Rhinitis in Children: A Randomized Clinical Trial Targeted at Symptoms.

Allergic rhinitis (AR) underlies many symptoms and complications which severely affect children's quality of life. This two-arm study aimed at evaluate the efficacy and safety of the medical device Narivent(®) versus topical corticosteroids in the symptomatic management of allergic rhinitis in paediatric patients. A randomized study was conducted. Forty subjects with a diagnosis of allergic rhinitis were randomized to receive one puff of Narivent(®) into each nostril twice daily for 30 days (n = 20) or to receive one puff of topical intranasal corticosteroid into each nostril twice daily for 30 days (n = 20). In both treatment arms, severity of major symptoms related to AR, including nasal congestion, rhinorrhoea, sneezing and nasal itching, was assessed subjectively on a 0-100 mm visual analogue scale. Nasal congestion, rhinorrhoea and sneezing improved significantly after 30 days of treatment with Narivent(®). Similarly, in topical steroids group severity of all subjective symptoms decreased significantly. Narivent(®) appears to be efficacious in treating nasal congestion and other major symptoms in children with AR over a 30-day period, showing comparable results to intranasal corticosteroids therapy but with a better safety profile.

Management of acute pharyngitis in children: summary of the Italian National Institute of Health guidelines.

BACKGROUND: Discrepancies in the management of pharyngitis in children have been reported in Europe and the United States, and recommendations concerning the use of clinical scores, rapid antigen diagnostic tests (RADTs) or throat cultures, and the indications for antibiotic treatment largely differ. OBJECTIVE: This article summarizes the Italian guidelines on the management of pharyngitis in children issued by the National Institute of Health. METHODS: A multidisciplinary panel of experts (the Guidelines Development Group) developed and used a set of key questions to conduct a systematic review of the literature. Relevant publications in English were identified through a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception through April 30, 2011. Final recommendations were scaled according to the Italian National Guidelines Program grading. RESULTS: Eighteen clinical questions were defined, and 44 recommendations were issued. None of the available scoring systems is sufficiently accurate to identify group A ß-hemolytic streptococci (GABHS) pharyngitis in settings with low prevalence for rheumatic disease. RADT should be performed by trained personnel in every child with a history and signs/symptoms suggestive of GABHS pharyngitis. RADT is not recommended in children with a McIsaac score of 0 or 1 with ≥2 signs/symptoms suggestive of viral infection. Backup culture in children with negative RADT result is not recommended. Culture test with antibiotic susceptibility assay should be performed exclusively for epidemiologic purposes. Streptococcal antibody titers are of no value in diagnosing acute pharyngitis. Antibiotic therapy is recommended in microbiologically documented GABHS pharyngitis. Because penicillin V is not available in Italy, amoxicillin (50 mg/kg/d in 2-3 doses orally) for 10 days is the first choice of treatment. In noncompliant cases, benzathine penicillin may be administered. Although not routinely recommended due to the high cost and wide spectrum of activity, a 5-day course with a second-generation cephalosporin may be used in noncompliant cases. Macrolides should be limited to children with demonstrated type I hypersensitivity to penicillin. Ibuprofen or paracetamol is recommended for relief of pain or fever associated with discomfort. Because the carrier state is not associated with increased risk of suppurative complications and risk of GABHS transmission to contacts is minimal, the carrier state should never be investigated and treated. Recommendations for the management of suppurative complications are given. CONCLUSIONS: This guideline provides a comprehensive, evidence based, tool for the diagnosis and therapy of acute pharyngitis in children.

Surgical treatment of acute recurrent throat infections in children.

OBJECTIVE: The purpose of this study was to define the contribute of surgery and watchful waiting in the treatment of feverish episodes and other clinical manifestations related to acute recurrent throat infections in children. METHODS: An observational, retrospective and multi-centric study was carried out on 407 subjects, aged 2-11, with a minimum two-year follow-up. Chi square test and Fisher's test were used for the statistical analysis. RESULTS: Watchful waiting prevented, similarly to surgery, recurrences of feverish episodes, but did not favourably impact on other clinical manifestations (respiratory obstruction, otitis media, group A beta hemolyticus streptococcus positive laboratory findings) as compared to surgery (p<0.001). CONCLUSIONS: The higher effectiveness of surgical treatment, as compared to watchful waiting, was documented in the study patients, considering all the clinical manifestations related to acute recurrent throat infections.

Craniofacial growth in children with nasal septum deviation: a cephalometric comparative study.

OBJECTIVE: Nasal-breathing impairment has been described as a possible determinant of maxillofacial development in children with adenoids/tonsils hypertrophy. However little is known about the possible influence of nasal septum deviation on craniofacial growth in childhood. We conducted a multicenter cephalometric study to compare skeletal and dental features in children with chronic nasal-breathing obstruction secondary to nasal septum deviation and nose-breathing controls. METHODS: Ninety-eight children (59M, 39F; mean age 8.8 years; age range 7-12 years) with obligate mouth-breathing secondary to nasal septum deviation (group 1) and 98 age- and sex-matched nasal-breathing controls (group 2) were evaluated. Nasal-breathing function was assessed in all patients with clinical history, ENT instrumental examination and anterior active rhinomanometry. Cephalometric parameters were recorded in all subjects. RESULTS: Patients of group 1 showed a statistically significant increase of upper anterior facial height (N-palatal plane) and total anterior facial height (N-Me) with regards to group 2. The angular relationships of the sella-nasion, palatal, and occlusal planes to the mandibular plane were greater in group 1 in comparison to controls. The gonial angle (Ar-Go-Me), palatal height and overjet were significantly higher in the mouth-breathing group. A significantly retrognatic position of the maxilla and mandible was recorded in group 1 in comparison to group 2. Most mouth-breathing children showed class II malocclusion, while the majority of control subjects presented normal occlusion. The prevalence of cross-bite was higher in group 1 with respect to controls (p=0.02). CONCLUSION: Children with obligate mouth-breathing due to nasal septum deviations show facial and dental anomalies in comparison to nose-breathing controls. Possible physiologic explanations of our findings are reported.

Acute otitis media: From diagnosis to prevention. Summary of the Italian guideline.

Acute otitis media (AOM) is the most common disease occurring in infants and children and has major medical, social and economic effects. If we consider the Italian pediatric population and the incidence rates in different age ranges it can be calculated that almost one million cases of AOM are diagnosed in Italy every year. Various attempts have been made internationally to clarify the most appropriate ways in which AOM should be managed. In Italy, this has been done at local or regional level but there have so far been no national initiatives. The objective of this guideline is to provide recommendations to pediatricians, general practitioners and otolaryngologists involved in the clinical management of acute otitis media in healthy children aged 2 months to 12 years. After a systematic review and grading of evidences from the literature, the document was drafted by a multidisciplinary panel with identified key clinical questions related to diagnosis, treatment of the acute episode, management of complications and prevention.

Frequency of surgery among children who have adenotonsillar hypertrophy and improve after treatment with nasal beclomethasone.

OBJECTIVE: To describe the long-term outcome of a cohort of children with symptomatic adenotonsillar hypertrophy treated with aqueous nasal beclomethasone. METHODS: The children enrolled completed a 4-week single-blind, saline solution controlled crossover study of aqueous beclomethasone (total: 400 micro g/d). In a 24-week open-label follow-on study, beclomethasone 200 micro g/d was offered to all patients. During a 100-week follow-up, the degree of nasal obstruction and the frequency of adenotonsillectomy were assessed. RESULTS: Fifty-three children of the 60 enrolled completed the study. After the 4-week crossover trial, the severity of nasal obstruction of 24 children (45%) significantly decreased during the use of nasal steroids, but no child improved when saline solution was used. At 24, 52, and 100 weeks, the 24 children who had initially improved showed a significant decrease of the severity of nasal obstruction and of the frequency of adenotonsillectomy (54% vs 83%) compared with the 29 children who had not responded after the initial steroidal therapy. CONCLUSIONS: Evidence from this study suggests that 45% of children with adenoidal hypertrophy improved after 2 weeks of steroidal therapy. Among these children, an additional 24-week treatment at a lower steroid dosage was associated with a significant 52- and 100-week clinical improvement and with reduction of adenotonsillectomy compared with children (55%) who had not responded after the initial 2-week steroidal therapy.