Cochrane review: Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy

Abstract

AbstractBackgroundAdenoidal 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.ObjectivesTo assess the effectiveness of intranasal corticosteroids for improving nasal airway obstruction in children with moderate to severe adenoidal hypertrophy.Search strategyOur search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2008), MEDLINE (1951 to 2008) and EMBASE (1974 to 2008). All searches were initially performed in May 2007 and updated in April 2008.Selection criteriaRandomised controlled trials comparing intranasal corticosteroids with placebo or no intervention or other treatment in children aged 0‐12 years with moderate to severe adenoidal hypertrophy.Data collection and analysisData from the included trials were extracted and trial quality was assessed by two authors independently. Meta‐analysis was not applicable and data were summarised in a narrative format.Main resultsFive randomised trials, including a total of 349 patients, met the inclusion criteria of the review. All trials except one showed 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 micrograms/day) yielded a greater improvement in mean symptom scores than placebo (‐18.5 vs. ‐8.5, P < 0.05) and a larger reduction in mean adenoid/choana ratio than placebo (right, ‐14% vs. +0.4%, p=0.002; left, ‐15% vs. ‐2.0%, p=0.0006) between week 0 and week 4. The second four‐week cross‐over study demonstrated that the nasal obstruction index decreased by at least 50% from baseline in 38% of patients treated with beclomethasone (400 micrograms/day) between week 0 and week 2, whereas none of the patients treated with placebo had such improvement (p<0.01). The third randomized, parallel‐group trial showed that 77.7% of patients treated with mometasone (100 micrograms/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 randomized, parallel‐group trial showed that eight‐weeks of treatment with flunisolide (500 micrograms/day) was associated with a lager reduction in adenoid size than isotonic saline solution (p<0.05). In contrast, one randomised, parallel‐group trial did not find significant improvement in nasal obstruction symptoms and adenoid size after eight weeks of treatment with beclomethasone (200 micrograms/day).Authors' conclusionsLimited 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 of adenoid size. The long‐term effect of intranasal corticosteroids in these patients remains to be defined.Plain Language SummaryTopical steroids for nasal airway obstruction in children with moderate to severe enlarged adenoidsAdenoidal 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 0‐12 years with moderate to severe adenoidal hypertrophy. Limited evidence derived from the five 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. Further large and high quality randomised controlled trials are warranted.