Discussion
rhinopharyngeal obstruction, rhinorrhea, otitis, adenoid hypertrophy, respiratory complaints, obstruction of the rhinopharynx), obstruction by the adenoid, nasal obstruction, palate, airway infection, adenoid, hypertrophic adenoids, tonsil hypertrophy
HYPERTROPHIC, OTITIS, SLEEP APNEA, ALLERGIC RHINITIS, ADENOID HYPERTROPHY, TONSIL HYPERTROPHY, COMPLICATIONS
Although nasofibroscopy is considered the gold standard exam in the diagnosis of adenoid hypertrophy, most studies use classifications that are not currently used in clinical practice.In the study, all four evaluators demonstrated a good correlation between T1 and T2 times (R > 0.7). However, although it is a good correlation, it is not excellent (R > 0.9). This could be improved if the evaluators were instructed to use anatomical parameters, for example, to determine the degree of obstruction by the adenoid tissue. We purposely refrained from providing such instructions in order to maintain the dynamics of clinical practice in the office.Another observation pertains to the comparison between the Pro Image J software and the evaluators (objective vs. subjective). All showed a good correlation (R > 0.7), but this correlation varied between 0.93 and 0.7. Due to the limited number of examiners (only four), it was not possible to determine the reasons for this variance.Once the method's reliability was confirmed, we assessed the correlation between the percentage of obstruction and the severity of clinical symptoms using the OSA-18 questionnaire. No correlation was observed, meaning that a more obstructed adenoid did not necessarily result in a more compromised quality of life. Evaluating the impact of the adenoid on these symptoms in isolation is challenging due to the multifactorial nature of sleep apnea, where several other factors may be involved. To ensure sample homogeneity and enhance the internal validity of the study, we applied strict inclusion criteria, excluding significant factors that could interfere with the impact of adenoids, such as tonsil hypertrophy and rhinorrhea/upper airway infection. Furthermore, we performed a linear model analysis of covariance to account for additional factors that might have influenced the results, including BMI, allergic rhinitis, current nasal treatment, and hypertrophic turbinates. Among these factors, only BMI exhibited a significant difference, indicating that higher BMI scores were associated with higher OSA-18 scores.On the other hand, the strict inclusion criteria resulted in the exclusion of 14 patients who experienced rhinorrhea during the examination. Additionally, 12 patients were unable to tolerate the procedure, as it is not our service's protocol to use any patient restraint methods. For future studies, we intend to conduct pre-tests to evaluate patients' tolerance to nasal manipulation, ensuring their inclusion.One of the main limitations of this study is the lack of objective examination to compare with the results evaluated by the examiners. However, the Pro Image J software, despite not being an objective method (it depends on a researcher to delimit the structures), is the best comparison parameter we had available since it is based on the gold standard method (nasofibroscopy) and avoids the limitations of imaging exams. Radiography and computed tomography of the cavum can show great variability in the assessment of adenoid size according to the incidence of the examination or whether the palate muscles are contracted at the time of examination, in addition to exposure to radiation and cost.This study has the potential to impact the clinical practice of otorhinolaryngologists and optimize diagnosis, interpretation and, mainly, procedures. The presented results confirm that the classification of adenoid hypertrophy through a percentage estimate is a reliable, reproducible and consistent method, supporting its use in clinical practice. However, the absence of correlation between the intensity of rhinopharyngeal obstruction by the adenoid and the clinical symptoms evaluated by the OSA-18 call an alert for the way of interpreting this exam. The nasofibroscopic evaluation of adenoid hypertrophy is a complementary exam and, therefore, must complement a reasoning based on the clinical history and the physical exam in order to arrive at an adequate conduct. According to the results of this study, it is not possible, for example, to conclude that adenoid hypertrophy above a certain percentage, regardless of clinical symptoms, is indicative of the need for more invasive therapies, such as adenoidectomy. Thus, adenoidectomy should be indicated based on persistent respiratory symptoms refractory to clinical treatment, corroborated by the nasofibroscopic finding of adenoid hypertrophy.Cassano et al. evaluated 7621 children with adenoid hypertrophy and observed that among those with Grade IV (100% obstruction of the rhinopharynx), there was a strong correlation with clinical repercussions such as sleep apnea and recurrent otitis. Among in 881 patients (54.7%) belonging to the Grade III group (>75% obstruction of the rhinopharynx), medical treatment was effective in controlling nasal obstruction and related pathologies and complications; and therefore, did not require surgical intervention. This finding supports the observations of our study and the approach of our team, which recommends more invasive therapeutic alternatives for patients with more severe clinical involvement, rather than relying solely on the presence of hypertrophic adenoids on examination. It is important to note that Cassano et al.'s study included patients with other conditions that can impact sleep quality, such as tonsil hypertrophy and nasal secretions.Finally, we reinforce the importance of anamnesis and physical examination in the evaluation of respiratory complaints in children and we understand that nasofibroscopy is a reliable complementary exam, but that by itself it is not capable of determining the intensity of symptoms or prognosis.