Topical steroids for nasal airway obstruction in children with moderately to severely enlarged adenoids

Zhang L, Mendoza-Sassi RA, César JA, Chadha NK

Published Online:

October 6, 2010

Adenoidal hypertrophy is generally considered a common condition of childhood and represents one of the most frequent indications for surgery in children. In less severe cases, non-surgical interventions may be considered, however few medical alternatives are currently available. This review was conducted to assess the effectiveness of intranasal corticosteroids for improving nasal airway obstruction in children aged 0 to 12 years with moderate to severe adenoidal hypertrophy. Evidence derived from five of the six randomised controlled trials included in this review suggests that intranasal steroids may significantly improve symptoms of nasal obstruction in children with adenoidal hypertrophy and that this improvement may be associated with the reduction of adenoid size. One study did not find a significant improvement in nasal obstruction symptoms. Further large and high-quality randomised controlled trials are warranted.

Abstract (click to read)

Background:

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 3, 2008.

Adenoidal hypertrophy is generally considered a common condition of childhood. When obstructive sleep apnoea or cardio-respiratory syndrome occurs, adenoidectomy is generally indicated. In less severe cases, non-surgical interventions may be considered, however few medical alternatives are currently available. Intranasal steroids may be used to reduce nasal airway obstruction.

Objectives:

To assess the efficacy of intranasal corticosteroids for improving nasal airway obstruction in children with moderate to severe adenoidal hypertrophy.

Search strategy:

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; ISI Web of Science; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 4 May 2010.

Selection criteria:

Randomised controlled trials comparing intranasal corticosteroids with placebo, no intervention or other treatment in children aged 0 to 12 years with moderate to severe adenoidal hypertrophy.

Data collection and analysis:

Two authors independently extracted data from the included trials and assessed trial quality. Meta-analysis was not applicable and we summarised data in a narrative format.

Main results:

Six randomised trials involving a total of 394 patients were included. Five of the six trials demonstrated a significant efficacy of intranasal corticosteroids in improving nasal obstruction symptoms and in reducing adenoid size.

The first eight-week cross-over study showed that treatment with beclomethasone (336 mcg/day) yielded a greater improvement in mean symptom scores than placebo (-18.5 versus -8.5, P < 0.05) and a larger reduction in mean adenoid/choana ratio than placebo (right, -14% versus +0.4%, P = 0.002; left, -15% versus -2.0%, P = 0.0006) between week 0 and week 4. The second four-week cross-over study showed that the Nasal Obstruction Index decreased by at least 50% from baseline in 38% of patients treated with beclomethasone (400 mcg/day) between week 0 and week 2, whereas none of the patients treated with placebo had such improvement (P < 0.01). The third parallel-group trial showed that 77.7% of patients treated with mometasone (100 mcg/day) for 40 days demonstrated an improvement in nasal obstruction symptoms and a decrease in adenoid size, such that adenoidectomy could be avoided, whereas no significant improvement was observed in the placebo group. The fourth parallel-group trial showed that eight weeks of treatment with flunisolide (500 mcg/day) was associated with a larger reduction in adenoid size than isotonic saline solution (P < 0.05). The fifth parallel-group trial demonstrated that eight weeks of treatment with fluticasone (400 mcg/day) significantly reduced nasal obstruction symptoms and adenoid size, and adenoidectomy was avoided in 76% of these patients compared with 20% of the patients treated with normal saline (P < 0.05).

In contrast, one parallel-group trial did not find a significant improvement in nasal obstruction symptoms nor adenoid size after eight weeks of treatment with beclomethasone (200 mcg/day).

Authors' conclusions:

Current evidence suggests that intranasal corticosteroids may significantly improve nasal obstruction symptoms in children with moderate to severe adenoidal hypertrophy, and this improvement may be associated with a reduction in adenoid size. The long-term efficacy of intranasal corticosteroids in these patients remains to be defined.

This record should be cited as:

Zhang L, Mendoza-Sassi RA, César JA, Chadha NK. Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006286. DOI: 10.1002/14651858.CD006286.pub2

Assessed as up to date:

May 4, 2010

Find the research

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Primary Review Group:

Ear, Nose and Throat Disorders Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are intranasal corticosteroids for improving nasal airway obstruction in children with moderate to severe adenoidal hypertrophy?

Bottom line:

Limited evidence suggests intranasal corticosteroids may significantly improve nasal obstruction symptoms in children aged 0–12 years with moderate to severe adenoidal hypertrophy, and this improvement may be associated with a reduction of adenoid size. Given the potential clinically relevant benefits and relatively good tolerability of intranasal corticosteroids, these drugs may be indicated as an alternative treatment for children with moderate to severe adenoidal hypertrophy when adenoidectomy is not urgently required or not available.

Caveat:

Numerous methodological flaws could be observed in the included studies and these may weaken the strength of evidence provided in this review.The trials lasted from 8 to 24 weeks.The optimal duration of treatment, minimum adequate dosage, and risk of adverse events, including adrenal suppression and growth retardation, need to be explored in future studies.

Context:

Adenoidal hypertrophy is a common childhood condition, and represents one of the most frequent indications for surgery in children. Commonly, medical management is limited to the treatment of concurrent infections and the complications of adenoidal enlargement.¹ 1. Sclafani AP et al. Pediatrics 1998; 101:675–681.

Cochrane Systematic Review:

Zhang L et al. Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Reviews 2008, Issue 3. Article No. CD006286. DOI:10.1002/14651858.CD006286.pub2. This review contains 5 trials involving 349 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Ear, nose, & throat > Pharynx > Adenoids

Demographic:

Children

Cochrane group topics:

Ear, Nose and Throat Disorders > Non-malignant disease > Pharynx > Adenoids

Child Health > Child Health + Ear, Nose and Throat

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Topical steroids for nasal airway obstruction in children with moderately to severely enlarged adenoids

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