Delivered by Ingenta to: Boston University Law Library IP: 185.46.84.179 On: Sun, 18 Sep 2016 12:40:43 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm Evaluation and management of pediatric nasal obstruction: A survey of practice patterns Gavriel D. Kohlberg, M.D., 1 Michael G. Stewart, M.D., MPH, 1 Robert F. Ward, M.D., 2 and Max M. April, M.D. 2 ABSTRACT Background: Inferior turbinate (IT) hypertrophy and adenoid hypertrophy are both causes of pediatric nasal obstruction. Objective: The purpose of this survey was to study nasal obstruction evaluation and management among pediatric otolaryngologists with respect to IT and adenoid hypertrophy. Methods: A questionnaire with embedded clinical videos was sent electronically to American Society of Pediatric Otolaryngology members. Results: A total of 435 questionnaires were sent, and 75 were completed. Respondents were presented with scenarios that involved a 7-year-old child with nasal obstruction unresponsive to medical therapy, and the respondents were asked to choose a surgical plan, either IT reduction, adenoidectomy, or combined IT reduction and adenoidectomy. Three questions described the extent of IT and adenoid obstruction in text form, although three questions included a video of the child’s nasal endoscopy. In questions with perceived or stated IT hypertrophy, the respondents chose to perform IT reduction significantly more frequently when the perceived or stated adenoid hypertrophy was less severe (p  0.0001 for video and p = 0.039 for written questions). Conclusion: The decision to perform IT reduction in children is inversely related to the extent of adenoid hypertrophy. Future studies on pediatric IT surgery should include objective descriptions of the IT and adenoid in study subjects. (Am J Rhinol Allergy 30, 274 –278, 2016; doi: 10.2500/ajra.2016.30.4327) N asal obstruction is a major cause of morbidity in children and causes symptomatic nasal congestion, sleep-disordered breath- ing, and craniofacial deformity. 1 Both adenoid hypertrophy and inferior turbinate (IT) hypertrophy can cause nasal obstruction. A recent survey of pediatric otolaryngologists found that 81% of the respon- dents performed IT reduction for nasal obstruction or sleep-disor- dered breathing. 2 This is an astounding degree of acceptance of a procedure that was rarely performed only 2–3 decades ago. Despite the rapid increase in popularity of IT procedures, a recent review of outcomes after IT reduction surgery in children for chronic nasal obstruction found that there was little evidence to support IT reduc- tion in children. 3 In addition, there is not an accepted reliable method for evaluating IT hypertrophy, which could be a contributor to the inconsistent approach to the management of IT hypertrophy. The adenoid is recognized as a major contributor to nasal obstruction and sleep-disordered breathing, and the extent of adenoid hypertrophy has been evaluated by fiberoptic nasal endoscopy in multiple studies, typically by a comparison with the size of the choanal arch. The size of the adenoid seems to correlate with the severity of nasal obstruction, as noted by Wormald and Prescott, 4 who compared an obstructive symp- tomatology score with endoscopic assessment of the percentage of ade- noid obstruction and found a correlation coefficient of  = 0.77. There are several other studies that evaluated the extent of adenoid size when using fiberoptic endoscopy, mostly to assess the response to treatment with nasal steroid sprays. 5–9 Parikh et al. 10 proposed and validated a grading system for endoscopic evaluation of adenoid hypertrophy based on the anatomic relationships between the adenoid tissue and the vomer, soft palate and the torus tubarius. In patients with symptoms and with both IT hypertrophy and adenoid hypertrophy, there is currently little known about the out- comes of adenoidectomy versus IT reduction versus both IT reduction and adenoidectomy. Studies on children with sleep-disordered breathing showed a larger reduction in the apnea-hypopnea index in children who undergo IT reduction and adenotonsillectomy com- pared with those who undergo adenotonsillectomy alone. 11,12 We hypothesized that the decision to perform IT surgery with or without concomitant adenoidectomy is based on the clinician’s perception of IT hypertrophy, along with the extent of adenoid hypertrophy. Our goal in this study was to evaluate and compare how pediatric otolar- yngologists evaluate and treat IT hypertrophy based on the perceived presence of IT hypertrophy and adenoid hypertrophy. METHODS Approval was obtained from Weill Cornell Medical College Insti- tutional Review Board. Informed consent was obtained from the parents of the pediatric subjects to publish videos of nasal endosco- pies on YouTube (San Mateo, CA) so that the videos could be em- bedded in the survey. In January 2014, 435 questionnaires were sent electronically to members of the American Society of Pediatric Oto- laryngology. The survey (SurveyMonkey, Palo Alto, CA) consisted of 13 questions about the evaluation and management of pediatric nasal obstruction related to IT and adenoid hypertrophy (Fig. 1), and it was reviewed and approved by the American Society of Pediatric Otolar- yngology research committee. Most questions had specific multiple- choice answer options, but there were a few with an option for open-ended comment. Three survey questions each included an em- bedded video of a pediatric nasal endoscopy. These videos were obtained from office flexible nasal endoscopies performed by a pedi- atric otolaryngologist (M.M.A.). Statistical analysis was performed by using the statistical programming language R, version 2.15.2 (Vienna, Austria). The Pearson  2 test was used for comparisons of discrete variables, with a level of significance set at p  0.05. RESULTS Demographics Seventy-five of 435 members (17.2%) surveyed responded, and 68 respondents (91%) had completed a pediatric otolaryngology fellow- ship. Thirty-nine percent had been in practice for 20 years, 32% From the 1 Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College, New York, New York, and 2 Department of Otolaryngology, New York University School of Medicine, New York, New York Abstract was presented abstract at the American Society of Pediatric Otolaryngology Spring Meeting, Boston, Massachusetts, April 22–26 2015 The authors have no conflicts of interest to declare pertaining to this article No external funding sources reported Supplemental data available at www.IngentaConnect.com Address correspondence to Michael G Stewart, M.D., MPH, Weill Cornell Medical College, 1305 York Ave., 5th Floor, New York, NY 10021 E-mail address: mgs2002@med.cornell.edu Published online May 18, 2016 Copyright © 2016, OceanSide Publications, Inc., U.S.A. 274 July–August 2016, Vol. 30, No. 4 DO NOT COPY