Flexible Fiberoptic Endoscopy Research Articles

Performance of videolaryngoscope and flexible fibreoptic endoscope in simulating difficult airways

Performance of videolaryngoscope and flexible fibreoptic endoscope in simulating difficult airways

A Study on 489 Cases of Epistaxis

We investigated the data of 489 patients with epistaxis who visited our hospital between 2009 and 2013. Epistaxis was more frequent in males (298 cases) than in females (191 cases).The mean age was 57.1 years, with the largest number of patients were in their 70s, 60s and 50s, in that order. Epistaxis occurred more often in the winter and spring, with a significantly lower number of patients in the summer and autumn. The most frequent onset time was in the morning from 6 am to 8 am. The sites of bleeding were Kiesselbach’s area (50.7%), followed by unidentifiable site (25.2%), nasal septum (11.5%), inferior meatus and turbinate (7.4%), and middle meatus and turbinate (3.7%). Of all the patients, 42.7% were treated by electrical coagulation with or without a rigid endoscope, 40.5% were managed by observation, and 16.6% by gauze packing. Of the 489 patients, 48 (9.8%) required hospitalization, and re-bleeding occuered in 64 (13.1%) cases. The major underlying disease was hypertension (32.5%), while 25.8% of all cases were receiving anticoagulant therapy.It is most important to identify the bleeding site by flexible fiberoptic and/or rigid endoscopy. Electrical coagulation with a rigid endoscope was a very useful procedure in the treatment of epistaxis, especially that occurring from the posterior part of the nasal cavity.

Brunner Glands

The development of the flexible fiberoptic endoscope and the ability to obtain endoscopic ultrasound–guided fine-needle aspirations of the pancreas has significantly changed the management of patients with pancreatic lesions. Cytopathologists have understood the diagnostic criteria applied to these relatively new specimens and have learned to recognize normal gastrointestinal contaminants that might be encountered in the smears. Well-recognized examples of such contaminants include duodenal and gastric epithelium. To date, however, no one has reported the presence of Brunner gland epithelium as a contaminant in these specimens. We report 2 cases in which normal Brunner gland epithelium was interpreted as lesional tissue in cytology preparations, leading to surgical procedures. By describing the cytomorphologic features of these cells, we hope to create awareness of this finding as a potential pitfall in these samples.

A role for panendoscopy? Second primary tumour in early stage squamous cell carcinoma of the oral tongue.

Panendoscopy is routinely used for the identification of occult second primary tumours in head and neck squamous cell carcinoma. However, its role in low risk subgroups, particularly non-smoking, non-drinking patients and patients presenting with early stage oral cavity lesions, is debatable. The records of 112 patients with T₁ or T₂ oral tongue squamous cell carcinoma were retrospectively reviewed. Demographic, disease characteristics and survival data were collected. Average follow-up duration was 71.7 months (range, 3.6-238.3 months). Thirty-five patients died within this period. Thirteen second primary events were identified in 11 patients, with all but 2 tumours in the oral cavity or oropharynx. There was a single synchronous primary - a lung adenocarcinoma; all other events were metachronous. No non-smoking, non-drinking patients re-presented with a second primary tumour; tobacco and alcohol use are clearly risk factors for development of a second primary tumour. The role of panendoscopy for identifying synchronous primary tumours in patients with early stage oral tongue squamous cell carcinoma should be re-evaluated, particularly in non-smoking, non-drinking patients who are at low risk of second primary development. Close follow up with regular clinical examination including flexible fibre-optic endoscopy may be sufficient in this subgroup.

Importance of laryngologic examination in chronic cough

This study aims to investigate the distribution of etiologic factors related to otorhinolaryngology in chronic cough patients with normal lung examination and spirometric findings, and also highlight the importance of videolaryngostroboscopic (VLS) examination with these patients. Seventy-six patients (31 males, 45 females; mean age 48.0±15.5 years; range 18 to 83 year) who applied to pulmonology outpatient clinic with cough complaint for more than two months were included in the study. After being evaluated by a pulmonologist, patients were referred to otolaryngology outpatient clinic. To detect the underlying cause of cough, patients' detailed histories, and flexible fiberoptic endoscopy and VLS findings were reviewed. Reflux symptom index (RSI) was used for the diagnosis of gastroesophageal reflux. In RSI ≥13 group, posterior commissure edema was detected in 12 patients (42.9%), and posterior commissure hyperemia was detected in four patients (14.3%). These findings were statistically significantly higher than RSI <13 group (p=0.006 and p=0.016, respectively). No significant difference was present between the group of patients with allergic rhinitis and the group of patients without allergic rhinitis in terms of VLS findings. Mucopurulent secretion rate in posterior commissure in patients with acute sinusitis findings was statistically higher than patients without acute sinusitis findings (p<0.001). Chronic cough is a common symptom of many different diseases. Therefore, a multidisciplinary approach is important for diagnosis. Videolaryngostroboscopy is a valuable examination tool in the differential diagnosis of gastroesophageal reflux and acute sinusitis.

Fiberoptic endoscopy: the singular transformative event of our time.

Thousands of manuscripts are published each week, and there continues to be a vast wave of new journals becoming available almost daily for the dissemination of new knowledge. Yet, almost all advances in medicine are incremental. By contrast, revolutionary advances, which change the natural history of disease or alter clinical practice, are quite rare. One such event was the development and widespread adoption of fiberoptic endoscopy, which forever altered the science, and practice of gastroenterology. In this issue of the Journal, Dr. Kaunitz [1] chronicles the timeline of the development of the endoscope from the rigid instruments to the early flexible fiberoptic endoscope, highlighting the major milestones and contributions from legends such as Rudolph Schindler and Basil Hirschowitz and the skills and ingenuity that they possessed. Building upon this historical background, I will review fiberoptic endoscopy in the context of its impact on current clinical practice and societal health. Several common themes throughout this journey are that we had to wait for technology to catch up with our interventional dreams, and the profound effect endoscopy has had not only on our practice but also on other specialties, especially surgery. I will make the case that fiberoptic endoscopy was the singular transformative event of the last century for our specialty. From Inspection to Palpation

A New Coupling Device to Record Fiber‐Optic Laryngoscopies onto a Smartphone: A Pilot Study

Objectives: Evaluate the diagnostic accuracy of flexible fiberoptic examinations of the larynx recorded directly onto smartphones using a novel coupling device. Methods: Prospective, blinded study at a tertiary referral hospital. Inpatients requiring laryngoscopy underwent bedside flexible fiberoptic endoscopy. A smartphone was then attached to the endoscope using a novel coupling device and the same examination was recorded. The laryngologist performing the live examination documented their findings on a standardized scoring sheet. A second laryngologist, blinded to the findings of the first, evaluated the recorded examination using an identical scoring sheet. Results: Eighteen patients were evaluated from July 2013 to January 2014. Evaluation of airway patency was identical (Kappa 1.0, P &lt; .001). Evaluation of vocal cord motion was identical for 14 subjects: 9 normal, 3 paretic, 2 paralytic (Kappa 0.687, P &lt; .001). There was no disagreement on the sidedness of the vocal fold involved (3 left, 1 right, 1 bilateral). There was 1 paretic-paralytic and 2 normal-paretic discrepancies. Subjective evaluation of the mucosa over each subsite showed moderate reliability (Kappa 0.515, P &lt; .001). Conclusions: There is high correlation between laryngeal diagnoses using live flexible fiberoptic laryngoscopy and recordings of those examinations using a coupling device to transfer the recordings on to smart phones. Critical findings such as airway patency and vocal fold motion showed the highest correlation, subjective evaluation of the quality of the mucosa showed more variability.

Progressive Left Nasal Obstruction and Intermittent Epistaxis

A man in his 20s presented to a tertiary rhinology center in southwestern Florida with a 3-month history of progressive left nasal obstruction and intermittent epistaxis. Two years previously, the man had similar presenting symptoms at an outside facility and was treated with surgery to excise a sinonasal mass. He did not have any visual changes, pain, or purulent nasal discharge. He reported no olfactory impairment. He was originally from Bangladesh but had moved to the United States 6 years earlier. In-office flexible fiberoptic nasal endoscopy revealed a soft, friable polypoid mass with a strawberry-like appearance originating from the lateral nasal wall and filling the left nasal cavity (Figure, A). Computed tomography of the sinuses revealed a left nasal cavity mass without bony destruction or paranasal sinus involvement (Figure, B). The patient underwent endoscopic sinus surgery on the left side, where complete surgical excision of the mass was performed along with electrocautery of attachment sites. The mass was found to have multiple attachments surrounding the maxillary sinus ostium and mucosa overlying the lacrimal bone. Pathologic evaluation revealed squamoid-type mucosa with large, thick-walled sporangia with numerous endospores. Also present was an exuberant mixed inflammatory infiltrate consisting of polymorphonuclear leukocytes, plasma cells, and lymphocytes (Figure, B and C). What is your diagnosis? A B

Growth Hormone Therapy and Respiratory Disorders: Long-Term Follow-up in PWS Children

Adenotonsillar tissue hypertrophy and obstructive sleep apnea have been reported during short-term GH treatment in children with Prader-Willi syndrome (PWS). We conducted an observational study to evaluate the effects of long-term GH therapy on sleep-disordered breathing and adenotonsillar hypertrophy in children with PWS. This was a longitudinal observational study. We evaluated 75 children with genetically confirmed PWS, of whom 50 fulfilled the criteria and were admitted to our study. The patients were evaluated before treatment (t0), after 6 weeks (t1), after 6 months (t2), after 12 months (t3), and yearly (t4-t6) thereafter, for up to 4 years of GH therapy. The central apnea index, obstructive apnea hypopnea index (OAHI), respiratory disturbance index, and minimal blood oxygen saturation were evaluated overnight using polysomnography. We evaluated the adenotonsillar size using a flexible fiberoptic endoscope. The percentage of patients with an OAHI of >1 increased from 3 to 22, 36, and 38 at t1, t4, and t6, respectively (χ(2) = 12.2; P < .05). We observed a decrease in the respiratory disturbance index from 1.4 (t0) to 0.8 (t3) (P < .05) and the central apnea index from 1.2 (t0) to 0.1 (t4) (P < .0001). We had to temporarily suspend treatment for 3 patients at t1, t4, and t5 because of severe obstructive sleep apnea. The percentage of patients with severe adenotonsillar hypertrophy was significantly higher at t4 and t5 than at t0. The OAHI directly correlated with the adenoid size (adjusted for age) (P < .01) but not with the tonsil size and IGF-1 levels. Long-term GH treatment in patients with PWS is safe; however, we recommend annual polysomnography and adenotonsillar evaluation.

Disinfection of flexible fibre-optic endoscopes out-of-hours: confidential telephone survey of ENT units in England – 10 years on

To audit out-of-hours flexible endoscope disinfection practice in England and compare the findings with a previously published first audit cycle, with the 2005 ENT UK guidelines as the key intervention. A telephone survey of the 104 ENT units in England was conducted out-of-hours, replicating the first cycle. The on-call clinician answered questions concerning access to flexible endoscopes, training, disinfection procedures and record keeping. Information regarding the clinician's trainee grade and their cross-covering duties was also acquired. Responses were compared to the first cycle results and published guidance. In total, 72 of the 104 units agreed to participate. The on-call clinician cleaned the flexible endoscope in 43 per cent of units. However, adequate training in disinfection only occurred in a minority of units (37 per cent), though this was an improvement from the first cycle (12 per cent). Furthermore, 27 per cent of units used an inadequate method of disinfection out-of-hours. One confounding factor may be the increase in cross-cover out-of-hours, with 68 per cent of respondents covering one or more other specialties. An overall moderate improvement in the safety of out-of-hours endoscopy in the past 10 years cannot obscure the urgent need for universal compliance with national guidelines.

Rhinosinusitis in children.

Rhinosinusitis is the inflammation of the mucous membranes of nose and paranasal sinus(es). 5–13% of upper respiratory tract infections in children complicate into acute rhinosinusitis. Though not life threatening, it profoundly affects child's school performance and sleep pattern. If untreated, it could progress to chronic rhinosinusitis (CRS). The pathogens involved in perpetuation of CRS consist of multidrug-resistant mixed microflora. CRS is challenging to manage and could further extend to cause eye or intracranial complications. In children, CRS diagnosis is often either missed or incomprehensive. Due to this, morbidity and strain on healthcare budget are tremendous. Flexible fiberoptic endoscopy has revolutionized management of CRS. Its utility in children is being increasingly recognized. Optimal management entails specific appropriate antimicrobials as well as treatment of underlying causes. The aim is to normalize sinus anatomy and physiology and regain normal mucociliary function and clearance.

Reliability of subjective, linear, ratio and area cephalometric measurements in assessing adenoid hypertrophy among different age groups.

To test the validity of four different types of lateral cephalometric radiograph (LCR) measurements as a diagnostic test of adenoid hypertrophy in different age groups of mouth-breathing children. Eighty-six mouth-breathing children (male 54.65%, mean age 7.0 ± 2.2 years) were randomly selected from a hospital population. Adenoid obstruction of the nasopharynx was evaluated by subjective, linear, ratio, and area LCR measurements. Each measurement was compared with flexible fiberoptic endoscopy diagnosis. Kendall correlation coefficients for agreement between tests were ≥ 0.67 and kappa scores were substantial (≥ 0.64). Higher correlation coefficients and agreement values were found in older age groups. When the sample was stratified by age, the 3- to 5-year-old age group showed lower correlation coefficients and agreement strength for subjective, linear, and ratio measurements. The sensitivity of LCR varied from 71% (ratio) to 84% (linear). The specificity varied from 83% (linear) to 97% (ratio). The positive predictive value varied from 88% (linear) to 97% (ratio). The negative predictive value varied from 70% (ratio) to 78% (linear). The validity of each measure was different among the age groups. LCR is a valid method for measuring adenoid hypertrophy in children from 6 to 12 years old. The diagnosis of adenoid hypertrophy, based on LCR measurements, in children with primary dentition (3-5 years old) should be made with caution. The combination of linear and ratio LCR measurements is a reliable screening tool to determine the need for an ear, nose, and throat evaluation.

Supraglottoplasty for Occult Laryngomalacia to Improve Obstructive Sleep Apnea Syndrome

To evaluate the polysomnographic outcomes after supraglottoplasty (SGP) performed for obstructive sleep apnea syndrome (OSAS) associated with occult laryngomalacia. Retrospective case series with medical chart review. Tertiary pediatric medical center. Twenty-two patients aged 2 to 17 years met the inclusion criteria of polysomnography-proven OSAS and occult laryngomalacia seen on flexible fiber-optic sleep endoscopy. Infants with congenital laryngomalacia were excluded. Carbon dioxide laser SGP was performed either alone or in conjunction with other operations for OSAS. Preoperative and postoperative nocturnal polysomnographic data were paired and analyzed statistically. Supraglottoplasty for occult laryngomalacia resulted in statistically significant reduction in the apnea-hypopnea index (AHI) (from 15.4 to 5.4) (P <.001). Subgroup analysis of children who underwent either SGP alone or in combination with other interventions showed comparable reductions in AHI. Medical comorbidities were associated with worsened postoperative outcomes, although still significantly improved compared with baseline. Overall, 91% of children had an improvement in AHI, and 64% had only mild or no residual OSAS after SGP. Supraglottoplasty is an effective technique for the treatment of OSAS associated with occult laryngomalacia.

TRANSIENT UNILATERAL VOCAL CORD PARALYSIS DURING ENDOSCOPIC ULTRASOUND

To the Editor, Endoscopic ultrasound (EUS) is generally a safe procedure. However, the longer, rigid tip of the echoendoscopes raises concern about cervical esophageal perforation during intubation.1 Iatrogenic injury of the recurrent laryngeal nerve is the most common cause of vocal cord paralysis.2 We report a case of esophageal perforation and vocal cord paralysis associated with EUS. A 67-year-old man was referred to our hospital because of progressive dysphagia. The endoscopic ultrasound revealed a normal esophagus. The patient developed neck pain and painful swelling after the examination. Physical examination demonstrated that it was not cervical crepitus, and neck radiograph revealed air in the retropharyngeal space. Indirect laryngoscopy showed paralysis of the right vocal cord. The left vocal cord was normal with no ulceration or growth. Assessment and diagnosis of the vocal cord paralysis by otorhinolaryngologists after EUS included interviews and flexible fiberscopy. There were no previous clinical symptoms of neuropathy and no positive history for inherited neuropathies. Computed tomography (CT) scan of the neck and thorax showed perforation of the right pyriform sinus and the presence of a right-sided large laryngocele. Oral intake was withheld and high-dose antibiotics and prednisone (40 mg/day) were administered through the central venous system over 10 days. The patient reported that voice quality and perforation improved suddenly after 10 days of medication. Subsequent laryngoscopy and flexible fiber optic endoscope showed normal movement of the left vocal cords. Control CT scan of the neck and chest obtained 10 days after the first one did not show gas or fluid collection in the right pyriform sinus. Oral intake was restarted on the 10th day and the patient was discharged on the 11th day. EUS have become important tools in evaluation of patients who have various gastrointestinal and non-gastrointestinal disorders, and are being increasingly utilized at many centers.3 EUS is generally a safe procedure. Complications can occur but are rare.2 Vocal cord paralysis may occur for many reasons. The most common cause of esophageal perforation is injury to the esophagus during a medical procedure, such as intubation with inadvertent placement of the tracheal tube in the esophagus, nasogastric tube placement, upper gastrointestinal endoscopy and transesophageal echocardiograph.4 To our knowledge, this is the first reported case of vocal cord paralysis in a patient undergoing EUS. The cause of the complication was damage to the right recurrent laryngeal nerve, which occurred during insertion of the EUS into the esophagus.

Emerging applications for OCT in the head and neck

Objectives: To describe the current and promising new applications of Optical Coherence Tomography (OCT) as a helpful tool when imaging the different sites in the head and neck. We used the OCT Niris system, which is the first commercially available OCT device for applications outside the field of ophthalmology. Methods: OCT images were obtained of normal, benign, premalignant and malignant lesions in different areas of the head and neck. The OCT imaging system has a tissue penetration depth of approximately 1-2mm, a scanning range of 2mm and a spatial depth resolution of approximately 10-20μm. Imaging was performed using a flexible probe in two different settings, the outpatient clinic and the operating room. Results: High-resolution cross-sectional images from the larynx were obtained with the patient awake, without the need for general anesthesia, under direct visualization with a flexible fiberoptic endoscope. The OCT probe was inserted through the nasal cavity and placed in slight contact with the laryngeal tissue. In the ears, cholesteatoma was differentiated from inflamed middle ear mucosa by the different hyperintensity. In the neck, normal as well as different pathologies of the thyroid were identified. Conclusions: This system is non invasive and easy to incorporate into the operating room setting as well as the outpatient clinic. It requires minimal set-up and only one person is required to operate the system. OCT has the distinctive capability to obtain highresolution images, and the microanatomy of different sites can be observed. OCT technology has the potential to offer a quick, efficient and reliable imaging method to help the surgeon not only in the operating room but also in the clinical setting to guide surgical biopsies and aid in clinical decision making of different head and neck pathologies, especially those arising form the larynx.

Indications for oesophagogastroduodenoscopy in Ilorin, Nigeria--a 30 month review.

Oesophagogastroduodenoscopy is one of the most commonly performed endoscopic procedures. Properly performed, it provides valuable information in patients with upper gastrointestinal conditions. Oesophagogastroduodenoscopy is a visual examination of the upper intestinal tract using a lighted, flexible fibreoptic endoscope or videoscope. Oesophagogastroduodenoscopy is generally indicated for evaluating upper abdominal symptoms such as dysphagia or odynophagia, oesophageal reflux symptoms, gastroduodenal or oesophageal ulcer, upper tract stricture or obstruction, gastrointestinal bleeding, persistent vomiting of unknown cause etc. This study is therefore to review the indications for oesophagogastroduodenoscopy in Ilorin, Nigeria. To review the indications for oesophagogastroduodenoscopy in Ilorin, Nigeria. A review of the indications for oesophagogastroduodenoscopy was undertaken to cover a thirty-month period from June 2006 to November 2008. The endoscopy register of the operating theatre was examined over this period. The biodata of the patients who underwent the procedure over this period was reviewed. A total of 206 patients had oesophagogastroduodenoscopy done on them during the period under review. 124 of the patients were males (60.2%) while 82 were females (39.8%). The indications for oesophagogastroduodenoscopy were dyspepsia, 94 patients (45.6%); upper gastrointestinal tract bleed, 54 patients (26.2%); gastric outlet obstruction, 12 patients (5.8%); gastric cancer, 11 patients (5.3%); dysphagia, 9 patients (4.3%); acute exacerbation of peptic ulcer disease, 8 patients (3.8%); gastro-oesophageal reflux disease, 7 patients (3.4%); recurrent vomiting, 3 patients (1.5%); bloody stool, 2 patients (1.0%); epigastric mass, 2 patients (1.0%); 1 patient (0.5%) each on account of excessive salivation, foreign body ingestion, ingestion of corrosive, and recurrent anaemia. The commonest indication for oesophagogastroduodenoscopy in Ilorin is dyspepsia.

Neonatal Vocal Cord Paralysis

Neonatal vocal cord paralysis (VCP) remains an important cause of acute and chronic respiratory compromise in infants. Despite a normal cry, infants who have bilateral VCP may present with marked respiratory distress, and emergency tracheostomy is a lifesaving procedure in the most severe cases. Unilateral VCP usually causes more pronounced abnormalities of the infant's voice, but respiratory symptoms are typically mild. VCP most commonly results from iatrogenic causes due to injury to the left recurrent laryngeal nerve during cardiac surgery. VCP also can result from congenital or neurologic disorders. Vocal cord dysfunction usually improves over time but may take years to resolve. Infants who have VCP are at risk for aspiration, prolonged duration of mechanical ventilation, reactive airway disease, and persistent feeding problems. Serial examination of vocal cord function at regular intervals using flexible fiberoptic endoscopy or direct laryngoscopy is essential to monitor airway patency and document improvement or resolution of paralysis over time. Affected infants also must be followed closely to determine the need for future medical or surgical intervention.

Persistent pediatric obstructive sleep apnea and lingual tonsillectomy

Objective To describe a new method and the indications for lingual tonsillectomy with endoscopy and coblation, and to document its utility for treating children with persistent obstructive sleep apnea after previous tonsillectomy and adenoidectomy. Study Design and Setting Case series with chart review in a tertiary pediatric medical center. Subjects and Methods Twenty-six patients aged 3 to 20 met the inclusion criteria of polysomnography-proven persistent obstructive sleep apnea after tonsillectomy and adenoidectomy, as well as diagnosis of lingual tonsillar hypertrophy made by flexible fiberoptic sleep endoscopy. Endoscopic-assisted coblation lingual tonsillectomies were performed between June 2005 and January 2008. Preoperative and postoperative nocturnal polysomnogram data were paired and analyzed statistically. Results Statistically significant reductions in the respiratory distress index (RDI) were seen when preoperative and postoperative data were compared (mean, 14.7 vs 8.1). There were similar reductions in the number of obstructive apneas and hypopneas. The mean minimum O 2 saturation did not change. Two patients in this series developed adhesions between the epiglottis and tongue base; there appeared to be no consequence for airway or feeding issues. Conclusion Endoscopic-assisted coblation lingual tonsillectomy is an effective technique for the treatment of lingual tonsillar hypertrophy causing persistent obstructive sleep apnea in some children.

Transmural gastric closure and NOTES – How far have we come?

The ability to perform secure closure of transmural gastric defects will represent a significant milestone in the evolution of therapeutic gastrointestinal endoscopy. In 1958, the flexible fiberoptic endoscope was introduced by Larry Curtiss and Basil Hirschowitz as a diagnostic modality. Over the ensuing decades, an interventional focus gradually took shape – initially for more invasive diagnostic techniques, such as biopsies and polypectomies, but later encompassing hemostasis, pancreaticobiliary procedures (i. e., endoscopic retrograde cholangiopancreatography and sphincterotomies), fine needle aspirations under endoscopic ultrasound guidance, and endoscopic mucosal resection and endoscopic submucosal dissection for resection of early-stage cancers. However, this growing interventional focus was mostly confined to the gastrointestinal lumen.

Obstruction of the Eustachian Tube Orifice and Pressure Changes in the Middle Ear: Are They Correlated?

We performed a cross-sectional study to investigate whether the obstruction of the eustachian tube orifice due to adenoid hyperplasia changes the pressures in the middle ear. Fifty consecutive children 2 to 12 years of age with nasal obstruction were examined from May to October 2005. Adenoid size and status of the eustachian tube orifice were assessed with nasal flexible fiberoptic endoscopy. Tympanometry was used to evaluate the middle ear. In children with occlusion of the eustachian tube orifice by adenoid tissue, 87% had abnormal pressure in the middle ear according to tympanograms. When orifices were not occluded, 86% of the tympanograms were normal (p < .001). Obstruction of the eustachian tube orifice by adenoid tissue was associated with tympanograms suggestive of abnormal pressure in the middle ear. Future studies with a larger sample size are necessary to clarify this association.