Adenoid hypertrophy and otitis media with effusion are prevalent conditions in pediatric otolaryngology. Pathological Adenoid hypertrophy is caused by repeated stimulation from bacteria, viruses and allergies, leading to clinical manifestations, such as nasal congestion, excessive nasal discharge, breathing through the mouth, obstructive sleep apnea, snoring and a characteristic facial appearance known as "adenoid face", Chronic airway obstruction is a significant contributing factor to the development or worsening of middle ear effusion, [1,2]. 

Adenoid hypertrophy is common in children and its symptoms manifest more quickly in younger individuals owing to the higher occurrence of upper respiratory tract infections and the smaller size of the nasopharynx. The adenoids undergo physiological hypertrophy from birth until the age of 6, after which they progressively decrease in size until they fully vanish at the age of 16. However, in certain cases, they may linger into adulthood [3].

Friedman's criteria, (Tonsil grading system), were used to categorize Adenoid hypertrophy, the grading system for tonsils is as follows: grade 0 (patients who have undergone tonsillectomy), grade 1 (tonsils located within the tonsillar fossa), grade 2 (tonsils protruding beyond the tonsillar pillars), grade 3 (tonsils extending beyond the tonsillar pillars but not reaching the midline) and grade 4 (tonsils extending up to the midline) [4,5]. Tonsil hypertrophy was characterized as tonsil grade II or above [6].

Otitis media with effusion refers to the persistent buildup of mucus, serous, or glue-like fluid in the middle ear and sometimes in the mastoid air cell system. The duration required for the presence of the fluid to classify the illness as chronic is often considered to be 12 weeks. [7], Otitis media with effusion is often seen in youngsters due to the accompanying hearing loss and occasionally follows a previous sickness and ear pain resulting from an episode of acute otitis media [8]. While the precise origin of otitis media with effusion remains unknown, it is commonly recognized that Eustachian tube occlusion is a significant contributing factor [9,10].

Inflammation in the nasal passages caused by a viral infection in the upper respiratory tract, allergic rhinitis, enlarged adenoids, or a mass at the back of the nasal cavity may disrupt the normal functioning of the Eustachian tube and lead to the accumulation of fluid in the middle ear. [11].

Multiple studies have been conducted to uncover the cause of otitis media with effusion. The main causes of otitis media with effusion include respiratory tract infections, adenoid hypertrophy, craniofacial abnormalities, mechanical blockage of the nasopharynx and allergy and immunological factors. Possible variables contributing to middle-period effusion include gender, climatic circumstances, environment, humidity, socioeconomic level, length of nursing, living in a crowded household, attending nursery or kindergarten, exposure to passive smoking and gastric reflux [12,13]. 

The presence of adenoid tissue contributes to the development of otitis media with effusion through several mechanisms, including its abnormally large size, interference with nasopharyngeal ventilation, blockage of the Eustachian tube due to mass effect, buildup of secretions, potential for infection, inflammation-induced swelling and release of allergic inflammatory mediators by mast cells in the adenoid tissue [14,15].

Several research has been conducted to evaluate the association between adenoid hypertrophy and middle ear effusion. One of these investigations demonstrates, the occurrence of middle ear effusion was highest in the younger individuals with adenoid hypertrophy grade II and grade III. and the predominant symptoms seen were auditory impairment, snoring and nasal blockage, with Greater grade of adenoid hypertrophy are crucial for the continued presence of middle ear effusion and may lead to the failure of conservative treatment [16], while another study revealed to, Adenoid Hypertrophy can be relevant in the pathogenesis of otitis media with effusion due to its anatomic position [15].

Several previous studies have been undertaken on a subject comparable to ours. However, these studies still need to examine the prevalence of middle ear effusion in pediatric patients in the city of Baqubah. Hence, our research aims to investigate the variables that lead to the occurrence of middle ear effusion in pediatric patients with adenoid hypertrophy in Baqubah City.

Study Populations

The research included eighteen pediatric patients with recently identified adenoid hypertrophy at the ENT clinic of Baqubah Teaching Hospital. The study took place between 22nd March and 1st October 2022, Patients were selected within the age range of 3-12 years; from the total number of patients, the female number was 50 while the male number was 30, at a ratio equal to 1.6:1, The research included pediatric patients who reported clinical symptoms and signs of adenoid hypertrophy, The question was posed to parents and patients in order to gather information on the signs and symptoms, which included nasal obstruction, rhinorrhea, mouth breathing, snoring, obstructive sleep apnea and hearing problems.

Grouping Criteria

The patients included in the study were separated into two groups: one with adenoid hypertrophy and another with adenoid hypertrophy accompanied by middle ear effusion. This division was based on the presence of middle ear effusion. Patients who were diagnosed with middle ear effusion were included in the group of individuals with adenoid hypertrophy and middle ear effusion. Only pediatric patients who did not have middle ear effusion were included in the adenoid hypertrophy group. Pediatric patients who were diagnosed with middle ear effusion were further split into two groups: those with unilateral middle ear effusion and those with bilateral middle ear effusion.

Investigation

The diagnostic procedure for adenoid hypertrophy included the use of nasal endoscopy and lateral soft tissue X-ray of the skull, tonsil grading was employed to measure the extent of adenoid hypertrophy. The grading was determined based on the degree of choanal opening occlusion caused by the adenoid, as follows:

• Grade 0: Refers to people who have had a tonsillectomy

• Grade 1: The tonsils are located inside the tonsillar fossa and cause obstruction of less than 25% of the choanal orifice

• Grade 2: The tonsils protrude beyond the tonsillar pillars: The adenoid gland occupies around 25% to 50% of the choanal orifice

• Grade 3: The tonsils protrude beyond the tonsillar pillars but do not reach the center line

The adenoid fills 50%-75% of the choanal aperture. while the patient is in grade 4, with tonsils that extend up to the midline. The adenoid is blocking 75% to 100% of the choanal orifice., [17], Patients with grade 3 and 4 adenoid enlargement were sent for a hearing evaluation test using tympanometry.

The tympanogram result is classified into three categories: Type A, Type B, or Type C. Results classified as Type A are deemed within the usual range. Both types B and C indicate the occurrence of middle-period effusion [18].

Ethical Approval

The research on ethics received clearance from the Medical Faculty at the University of Diyala, Baqubah and the patient's medical history was gathered with their consent.

Statistical Analysis

The quantitative data were reported using measures such as standard deviation, standard error of the mean and percentage. The χ2 test was used to compare the various variables in the research. The statistical significance was assessed at a significance level of p<0.05 using SPSS, version 21 (SPSS Inc, Chicago, Illinois) [19].

The research comprised 80 patients, consisting of 30 boys and 50 girls, there was a considerable difference between the gender groups in the research. Table 1, Figure 1, the average age of the patients participating was six years, the investigation revealed a significant difference between infected individuals with adenoid hypertrophy and middle ear effusion and patients with adenoid hypertrophy but without middle ear effusion (p<0.05). The findings indicate that out of the 80 pediatric patients with adenoid hypertrophy, 55 were diagnosed with middle ear effusion. In contrast, the remaining 25 pediatric patients only had adenoid hypertrophy without middle ear effusion.

Table 1: Distribution of Genders Among a Total of 80 Patients

*Significant at level (p<0.05), SD = Stander Deviation, SE = Stander Error of Mean

Figure 1: Distribution of Genders Among a Total of 80 Patients

The results of tympanogram categorization showed that out of 80 pediatric patients with adenoid hypertrophy, 25 patients (31.25%) were classed as A and 35 patients (43.75%) were categorized as B. while the last group, consisting of 20 patients, was classified as category C. The difference between the two groups was statistically significant, with a p-value (p<0.05) (Table 2, Figure 2).

Table 2: Grades of Adenoid Hypertrophy Seen in Individuals Diagnosed with Adenoid Hypertrophy. n = 80

*Significant at Level (p<0.05), SD = Stander Deviation, SE = Stander Error of Mean

Figure 2: Patients' Unliteral and Bilateral Middle Ear Effusion Distribution n = 55

The results also showed a significant difference between individuals with unilateral middle ear effusion compared to those with bilateral middle ear effusion (p<0.05), The findings indicate that out of the total number of patients with middle ear effusion, 18 patients exhibited unilateral effusion, accounting for 33% of the cases. The other patients, totaling 37, had bilateral middle ear effusion, representing 67% of the total number of patients with middle ear effusion (Table 3, Figure 3).

Table 3: Patient Distribution with Middle Ear Effusion in Adenoid Hypertrophy n = 80

*Significant at Level (p<0.05), SD = Stander Deviation, SE = Stander Error of Mean

Figure 3: Symptoms in 80 Adenoid Hypertrophy Patients

On the other hand, the findings of the symptoms analysis showed a statistically significant change in the symptoms of adenoid hypertrophy (p<0.05). A study involving 80 patients with adenoid hypertrophy revealed that all 80 patients reported hearing problems. Additionally, 44 patients experienced mouth breathing, 50 patients had nasal obstruction, 52 patients snored, 32 patients complained of sleep disturbance, 24 patients exhibited voice changes, 16 patients reported headaches and eight patients had epistaxis (Table 4, Figure 4).

Table 4: Tympanometric Distribution of Adenoid Hypertrophy Patients, n = 80

*Significant at Level (p<0.05), SD = Stander Deviation, SE = Stander Error of Mean

Figure 4: Tympanometric Distribution of Adenoid Hypertrophy Patients, n = 80

The results demonstrated the categorization of patients based on tonsil grading, patients with grad zero was 4 , three with adenoid hypertrophy and one with adenoid hypertrophy with middle ear effusion , while number of patients with grad one was 6, 3 patients with adenoid hypertrophy and 3 patients with adenoid hypertrophy with middle ear effusion , grad two patients involved 10 patients, 3 patients with adenoid hypertrophy and 7 patients with adenoid hypertrophy with middle ear effusion, while number of patients in grad three was 29 divided to 8 patients with adenoid hypertrophy and 21 patients with adenoid hypertrophy with middle ear effusion , grad 4 patients included 31 patients ,8 patients with adenoid hypertrophy and 23 patients with adenoid hypertrophy with middle ear effusion. Statistically there was a significant difference between groups (p<0.05) (Table 5,6, Figure 5,6).

Table 5: Patients' Unliteral and Bilateral Middle Ear Effusion Distribution. N = 55

*Significant at Level (p<0.05), SD = Stander Deviation, SE = Stander Error of Mean

Figure 5: Grades of Adenoid Hypertrophy Seen in Individuals Diagnosed with Adenoid Hypertrophyn = 80

The findings of our investigation indicate a substantial correlation between adenoid hypertrophy and the gender of the patients, the higher prevalence of adenoid hypertrophy in males may be attributed to the greater frequency of upper respiratory infection episodes experienced by boys compared to girls [20]. Additional study findings corroborate our results, indicating that males are more often affected by adenoid hypertrophy compared to girls [21].

Our study result conduct to the most common grade of adenoid hypertrophy with middle ear effusion in study patients' sample was in grade III and grad IV, this result is compatible with other study that shows, the incidence of middle ear effusion in the adenoid grade IV group was 26.86%, which was significantly higher than that in the grade III group (14.5%), The incidence of middle ear effusion in the adenoid grade IV group was 1.662 times than that in the grade III group. A high adenoid grade is a risk factor for adenoid hypertrophy complicated by middle ear effusion [1].

Table 6: Symptoms in 80 Adenoid Hypertrophy Patients

* Significant at level (p<0.05), SD=stander deviation; SE=stander error of mean

Figure 6: Patient Distribution with Middle Ear Effusion in Adenoid Hypertrophy

On other side, tympanogram result shows 43.75% for patients with adenoid hypertrophy shows type B and 31.25% shows type C, while 25 % show type A, grade A proportion represented patients with grade 0,I and II of adenoid hypertrophy, this result indicated incidence of middle ear effusion is most commonly in patients with adenoid hypertrophy grade III and IV , this conclusion similar to the conclusion of other studies showing , grade 4 adenoid hypertrophy showed a highly significant correlation with type B tympanometry either as unilateral or as bilateral finding [22]. (While others reveled to grade 3 adenoid hypertrophy showed higher number of cases of middle ear effusion [23].

Study result shows incidence of middle ear effusion is more commonly as bilateral comparing with unilateral, several studies revealed to resemble outcomes, as a study shows, 14% of cases presented with unilateral middle ear effusion, while 86% of cases showed a bilateral middle ear effusion [24].

Patients involved in the study shows a different symptom including mouth breathing, nasal obstruction, snoring, sleep disturbance, voice change, headache and epistaxis, because Middle ear effusion is a major cause of hearing loss in children [25]. The majority of patient involved in our study complain from hearing impermeant.

The research provided, however, had several limitations. The sample sizes were constrained due to the small number of patients available for the research from Baqubah city, which has a limited number of people; in addition, the research was confined to a certain number of participants due to the restricted time of investigation, which was between March and October. These factors contributed to the restriction in the number of patient samples studied.

study result conduct to a significant correlation between incidence of middle ear effusion in pediatric patient with adenoid hypertrophy mostly in male and in pediatric patients with grade III and IV of adenoid hypertrophy, with the majority cases was bilateral middle ear effusion and the most common symptom involved was hearing impermeant, according to this relation adenoid hypertrophy and middle ear effusion that exhibit by our study, we advise to, any children with adenoid enlargement should be screened for middle ear effusion and managed accordingly for best outcome to be achieved in the children.

Authors’ Contributions

• Conception and Design: Ali Lafta Salman, Qays Jaafar Khalaf

• Data Collection and Compilation: Ali Lafta Salman

• Data Analysis and Interpretation: Qays Jaafar Khalaf

• Drafting of the Article: Qays Jaafar Khalaf

• Reviewing the Paper Critically for Key Ideas: Ali Lafta Salman, Qays Jaafar Khalaf

• Proficiency in Statistical Analysis: Ali Lafta Salman, Qays Jaafar Khalaf

• Article's Ultimate Endorsement and Guarantor: Ali Lafta Salman

Acknowledgements:

The authors express gratitude for the assistance provided by the management and staff of Baqubah Teaching Hospital/ENT Clinic.

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