Open Access

Nasopharyngeal fiberendoscopy in children: a survey of current Italian pediatric otolaryngological practices

  • Sara Torretta1Email author,
  • Paola Marchisio2,
  • Giovanni Succo3,
  • Pasquale Capaccio1 and
  • Lorenzo Pignataro1
Italian Journal of Pediatrics201642:24

https://doi.org/10.1186/s13052-016-0234-y

Received: 14 December 2015

Accepted: 23 February 2016

Published: 1 March 2016

Abstract

Background

Nasopharyngeal fiberendoscopy (NFE) is the gold standard diagnostic procedure for adenoidal disease, but there is no consensus concerning the optimal technical approach. The aim of this study was to investigate the attitudes of Italian otolaryngologists towards diagnostic NFE in children, and the most widely used methods.

Methods

Nine hundred randomly selected members of the two largest Italian otolaryngological scientific societies were e-mailed an anonymous web-based questionnaire containing 29 multiple-choice items regarding their opinions about, and use of NFE in children.

Results

Questionnaires were returned by 764 clinicians (84.9 %). About 75 % declared they used NFE, but 35 % said they preferred alternative diagnostic methods. Most of the respondents considered NFE safe, but more than 80 % judged it to be poorly or only fairly well tolerated. Almost all declared that they generally use flexible, small-diameter instruments, with the patient seated on a chair or a parent’s lap; 65 % use gentle restraining methods. Fewer than 50 % reported using a standardised hypertrophy grading system.

Conclusion

Italian otolaryngologists have a generally positive attitude towards using NFE in children. However, some have reservations, and there was no unanimous agreement concerning how it should be done. Given the medical advantages of NFE, it is essential to clarify the many still controversial aspects of the procedure by means of comparative studies and educational programmes.

Keywords

EndoscopyNasopharynxChildrenAdenoidsOtolaryngology

Background

Nasal obstruction due to recurrent or chronic adenoid-related nasopharyngeal and middle ear infections is frequent in children [1], and often requires an otolaryngological examination in order to assess whether the size of the adenoids and their possible lateral extension are reducing the patency of the ostium of the Eustachian tube, and evaluate the need for surgical treatment.

This can be done by means of nasopharyngeal fiberendoscopy (NFE), a mirror examination with posterior rhinoscopy, a lateral neck roentgenogram, or a standardised clinical questionnaire [24]. However, NFE is the gold standard for assessing the volume and surface of the adenoids in children with suspected adenoidal disease [57] because it is minimally invasive and repeatable, does not expose patients to harmful ionising radiation, and allows direct inspection of the nasopharynx with complete visualisation of the adenoids, thus making it possible to grade hypertrophy and investigate possible choanal or ostial obstruction [5]. It is also a useful means of dynamically evaluating the entire nasal district, including the ostiomeatal complex and sphenoethmoidal recess, and investigating velopharyngeal closure during speech. This makes it possible to identify or exclude any concomitant nasal or rhinosinusal processes, including allergic rhinitis, nasal polyposis, chronic rhinosinusitis, choanal atresia or velar insufficiency, and allows precise surgical stratification in the case that medical treatment fails.

NFE should therefore be considered a first-level procedure in every otolaryngological facility that has pediatric patients [8]. However, some clinicians are still reluctant because it is not always easy to carry out in the case of younger children and, furthermore, there is no consensus concerning how it should be performed (particularly in relation to the type of instruments to be used) or the most appropriate technical approach to children of different ages or with different diseases. Consequently, it is not clear how, or how extensively NFE is used in everyday practice, particularly in the case of younger children.

The main aim of this study was to evaluate the attitudes of Italian otolaryngologists towards using NFE to diagnose adenoidal diseases in children, and verify the methods actually used in routine clinical practice.

Methods

Study design

This cross-sectional survey of the pediatric use of NFE by a representative sample of otolaryngologists belonging to the Italian Society of Otolaryngology and Head and Neck Surgery (SIOeChCF) and the Italian Society of Pediatric Otolaryngology (SIOP) was carried out between September 2012 and May 2013. The study was approved by our local ethics committee of University of Milan.

Study population

An anonymous questionnaire asking about opinions and practices relating to the pediatric use of NFE was sent to 900 Italian otolaryngologists whose e-mail addresses were selected by means of a computer-based randomisation list.

Questionnaire design and administration

The web-based questionnaire, which was anonymous but coded in order to be able to identify non-responders and ensure the elimination of multiple responses, was conceived by the first author (ST) and drawn up in collaboration with the co-authors before being pilot tested on a sample of 20 otolaryngologists in Milan, Italy. It required about 10 min to complete and guided the respondents through multiple-choice items divided into two main sections: one concerning their personal and demographic data (including gender, and the years of birth, graduation and specialisation); the other consisted of 29 items concerning their attitudes towards using diagnostic NFE in children, and the methods they use in routine clinical practice.

Statistical analysis

The data were descriptively analysed to assess the prevalence and distribution of all the variables. The continuous variables were expressed as mean values and standard deviations (SDs), and the categorical variables as absolute numbers and percentages. The categorical variables were dichotomously analysed at multiple levels. The Kruskal-Wallis equality-of-populations rank test and Fisher’s exact test were used to determine whether attitudes toward NFE and the way it was carried out were related to the demographic data. After adjusting for the main confounders, univariate and multivariate logistic regression models were used to compute odds ratios (ORs) and standard errors (SEs) and 95 % confidence intervals (95 % CIs) in order to measure the strength of the associations. Statistical significance was set at p = 0.05. The data were analysed using STATA 10.0 software (StataCorp, College Station, TX).

Results

Questionnaires were returned by 764 of the 900 otolaryngologists (84.9 %), most of whom were males (589; 77.1 %), aged >50 years (395; 51.7 %), worked in northern Italy (455; 59.5 %), and practised in a hospital setting (397; 52.0 %) (Table 1).
Table 1

Demographic characteristics of the otolaryngologists returning completed questionnaires

Demographic characteristics

No. of respondents

Percent

Total number

 

764

 

Males

 

589

77.1

Age, years

   
 

≥50

395

51.7

 

36–50

322

42.1

 

≤35

47

6.2

No. of otolaryngologists working in Northern Italy

455

59.5

Work setting

   
 

Hospital

397

52.0

 

University

70

9.2

 

Private practice

297

38.8

No. of years since graduation

  
 

≥31

159

20.8

 

20–30

314

41.1

 

11–19

164

21.5

 

≤10

127

16.6

No. of years since specialising in otolaryngology

  
 

≥31

67

8.7

 

20–30

302

39.5

 

11–19

189

24.8

 

≤10

206

27.0

Table 2 shows their attitudes towards NFE. About 75 % of the respondents declared that they used NFE, but 35 % said they still preferred alternative diagnostic procedures to investigate adenoidal disease. About 65 % chose a clinical evaluation (history of recurrent nasopharyngeal and/or middle ear infection and/or sleep disordered breathing, perceived nasal obstruction, speech hyponasality, and the proportion of oral breathing) as the elective alternative method. More than half said they used NFE only in children aged 3–8 years, and nearly 60 % declared that they were able to complete the examination in more than 95 % of children. NFE was considered safe by most of the respondents as 94 % declared the occurrence of untoward effects (mainly nasal bleeding) in fewer than 5 % of cases; however, more than 80 % judged that it was poorly (about 52 %) or only fairly well tolerated (about 32 %). The majority had a positive opinion concerning the usefulness of NFE, and as many as 68 % defined it “a generally well-tolerated, minimally invasive examination that can be used in most children; very useful in clinical practice”.
Table 2

Otolaryngologists’ attitudes towards nasopharyngeal fiberendoscopy (NFE) in children

Parameter

Possible answers

No. of respondents

Percent

Used to using NFE

 

576

75.4

Used to using alternative diagnostic tests

   
 

Clinical evaluation

175/269

65.0

 

Standardised questionnaires

51/269

19.0

 

Posterior rhinoscopy

34/269

12.7

 

Nasopharyngeal X-ray

9/269

3.3

Age of patients in whom NFE is considered feasible

   
 

All pre-school years

104

13.5

 

>3 years

235

30.8

 

3–8 years

425

55.7

Indications for NFE

   
 

Nasal obstruction

33

4.3

 

Adenoidal facies

15

2.0

 

Recurrent or chronic middle ear disease

62

8.1

 

Rhinosinusitis

26

3.4

 

All of the above

628

82.2

Indications for in-patient NFE

   
 

Children with a genetic syndrome

42

5.5

 

Uncooperative children

65

8.5

 

Children aged <18 months in whom severe disease is highly suspected

84

11.0

 

All of the above

283

37.0

 

Children with genetic syndrome or aged <18 months in whom severe disease is highly suspected

290

38.0

Percentage of children in whom NFE is not considered feasible

   
 

≤5 %

448

58.6

 

6–24 %

249

32.6

 

25–50 %

46

6.0

 

49–74 %

11

1.5

 

≥75 %

10

1.3

Percentage of children experiencing untoward effects

   
 

≤5 %

718

94.0

 

6–25 %

44

5.8

 

26–50 %

2

<1

Untoward effects

   
 

Nasal bleeding

579

75.8

 

Traumatic lesions

64

8.4

 

Syncope

90

11.8

 

Desaturation

21

2.7

 

Other

10

1.3

Tolerability

   
 

None

79

10.3

 

Poor

401

52.5

 

Fair

241

31.6

 

Good

37

4.9

 

Excellent

7

<1

Final evaluation of NFE

   
 

A generally well-tolerated, minimally invasive examination that can be used in most children; very useful in clinical practice

518

67.8

 

A not always well-tolerated, minimally invasive examination that should only be used in the case of strong diagnostic suspicion; moderately useful in clinical practice

238

31.1

 

A poorly tolerated invasive examination that should only be used in selected cases; not very useful in clinical practice

8

1.1

Table 3 shows the methods of use. Almost all of the clinicians generally use flexible, small- diameter instruments, with the patient seated on a chair or a parent’s lap. About 65 % said they use gentle restraint (the method preferred by about 82 % is to have the patient sitting on a parent’s lap “with legs held between the thighs of the parent, who holds the child’s wrists over the abdomen with one hand and the child’s head against his or her chest with the other”). About one-third said that they did not use any topical drug before performing NFE, whereas 30 % said they used local vasoconstrictors.
Table 3

Otolaryngologists’ methods of carrying out nasopharyngeal fiberendoscopy (NFE) in children

Parameter

Possible answers

No. of otolaryngologists

Percent

Recommended type of endoscope

   
 

Flexible

720

94.3

 

Rigid

44

5.7

Recommended endoscope diameter

   
 

About 2 mm

312

40.9

 

About 3 mm

369

48.3

 

About 4 mm

83

10.8

Recommended sterilisation

   
 

Disposable sheaths

574

75.2

 

Disposable towels

140

18.3

 

Antiseptic solutions

50

6.5

Use of endoscope connected to a video recorder/monitor set

   
 

Yes

588

76.9

 

No

176

23.1

Method of removing nasal secretions before NFE

   
 

None

184

24.1

 

Urging child to blow his/her nose

211

27.6

 

Helping child to blow his/her nose

117

15.3

 

Nasal saline irrigation

44

5.7

 

Aspiration

208

27.3

Recommended position for NFE

   
 

Seated (alone or on parent’s lap)

714

93.5

 

Lying on back

50

6.5

Need for restraint

   
 

Never

221

28.9

 

Only younger children

495

64.8

 

Always

48

6.3

Recommended method of restraint

   
 

Holding head gently

67/543

12.4

 

Sitting on a parent’s lapa

443/543

81.6

 

Lying on back wrapped in a sheet

33/543

6.0

Restrainers

   
 

Only parents

202/543

37.3

 

Health workers, if parents unable to cooperate

341/543

62.7

Local pre-medication

   
 

None

244

32.0

 

Vasoconstrictors

231

30.2

 

Anesthetic

169

22.1

 

Lubricating ointment

120

15.7

Frequency of bilateral NFE

   
 

Never

20

2.7

 

Sometimes

403

52.7

 

Always

341

44.6

First anatomical landmark assessed

   
 

Adenoids and nasopharynx

562

73.7

 

Ostiomeatal complex

200

26.3

Frequency of evaluation of anatomical structures other than adenoids during NFE

   
 

Never

10

1.3

 

Sometimes

348

45.5

 

Always

406

53.2

How adenoidal hypertrophy is graded

   
 

Percentage of choanal obstruction

252

33.0

 

Percentage of choanal obstruction and patency of Eustachian tube orifice

417

54.5

 

Adenoidal hypertrophy: yes/no

7

1.0

 

Choanal obstruction: yes/no

88

11.5

Standardised classification for grading adenoidal hypertrophy

   
 

None

400

52.4

 

Cassano’s classification [5]

275

36.0

 

Parikh’s classification [9]

65

8.5

 

Other

24

3.1

awith legs held between the thighs of the parent, who holds the child’s wrists over the abdomen with one hand and the child’s head against his or her chest with the other

More than half declared that they graded adenoidal hypertrophy on the basis of the percentage of adenoid-induced choanal obstruction and the patency of the Eustachian tube, and fewer than 50 % that they used a standardised grading system (mainly Cassano’s [5], which was chosen by 36 % of the respondents).

Table 4 shows the significant associations between the otolaryngologists’ attitude towards the pediatric use of NFE and their demographic data. The use of NFE in clinical practice was apparently influenced by gender, age, and geographical working area because the most frequent users were male clinicians aged <50 years working in northern Italy. However, logistic multivariate analysis showed that only gender adjusted for geographical working area remained significantly associated with the routine use of NFE (OR = 2.4, SE = 0.6, 95 % CI = 1.5-3.7; p < 0.001 for males).
Table 4

Otolaryngologists’ attitudes towards nasopharyngeal fiberendoscopy (NFE) in children by demographic variables (only statistically significant relationships)

Parameters

Demographic variables

P-value

Used to performing NFE

    
 

Gender

% of males

% of females

0.004

  

77.7

66.2

 
 

Age

% aged ≥50 years

% aged <50 years

0.002

  

70.6

80.3

 
 

Geographical working area

% in northern Italy

% working in southern Italy

0.050

  

78.0

71.8

 

Used to performing alternative diagnostic tests

    
 

Gender

% of males

% of females

0.013

  

33.5

44.8

 
 

Age

% aged ≥50 years

% aged <50 years

<0.001

  

45.1

28.6

 
 

Years since specialisation

% specialised for ≥20 years

% specialised for <20 years

0.043

  

41.2

33.7

 

Used to performing NFE regardless of patient’s age

    
 

Geographical working area

% working in northern Italy

% working in Southern Italy

0.043

  

56.2

48.2

 
 

Work setting

% in hospital

% in university or private practice

0.002

  

58.5

44.5

 

Unable to perform NFE in >5 % of patients

    
 

Gender

% of males

% of females

0.003

  

44.6

30.9

 
 

Age

% aged ≥50 years

% aged <50 years

0.001

  

47.7

35.2

 
Table 5 shows the significant associations between NFE methods and the demographic data. The choice of rigid endoscopes was only influenced by geographical working area as it was more frequent among the clinicians working in southern Italy (8.9 % vs 3.4 %; p = 0.003). Grading adenoidal hypertrophy on the basis of the standardised classifications was influenced by both geographical working area and the working setting: it was more frequent among clinicians working in southern Italy (54.6 % vs 42.8 %; p = 0.002) and those working in hospitals (51.7 % vs 42.1 %; p = 0.050), although logistic multivariate analysis only confirmed the significance of geographical working area adjusted for working setting (OR = 1.7, SE = 0.3; 95 % CI = 1.1–2.5; p = 0.006 for clinicians working in southern Italy).
Table 5

Methods of carrying out nasopharyngeal fiberendoscopy (NFE) in children by demographic variables (only statistically significant relationships)

Parameter

Demographic variables

  

P-value

Used to using rigid endoscopes

Geographical working area

% working in northern Italy

% working in southern Italy

0.003

  

3.4

8.9

 

Used to using endoscopes connected to a video recorder/monitor set

Gender

% of males

% of females

0.009

  

78.5

68.0

 
 

Age

% aged ≥50 years

% aged <50 years

0.029

  

80.4

73.5

 
 

Years since graduation

% graduated ≥30 years ago

% graduated <30 years ago

0.035

  

80.0

73.2

 

Used to using NFE bilaterally

Geographical working area

% working in northern Italy

% working in southern Italy

0.012

  

40.1

49.8

 

Used to using standardised classification to grade adenoidal hypertrophy

Geographical working area

% working in northern Italy

% working in southern Italy

0.002

  

42.8

54.6

 
 

Work setting

% in hospital

% in university or private practice

0.050

  

51.7

42.1

 

Used to grading adenoidal hypertrophy according to Cassano’s classification [5]

Gender

% of males

% of females

0.047

  

25.2

39.3

 
 

Age

% aged ≥50 years

% aged <50 years

<0.001

  

17.5

35.4

 
 

Years since graduation

% graduated ≥30 years ago

% graduated <30 years ago

0.001

  

19.5

35.5

 
 

Years since specialisation

% specialised for ≥20 years

% specialised for <20 years

0.024

  

20.3

31.6

 
 

Geographical working area

% working in northern Italy

% working in southern Italy

0.001

  

34.3

18.1

 

None of the other demographic variables was statistically associated with attitudes towards NFE or the way in which it was carried out.

Discussion

This is the first study specifically designed to evaluate Italian otolaryngologists’ attitudes towards using NFE to diagnose children, and the way in which do so in routine clinical practice. The randomised selection of the participants and the very small number who failed to respond makes it unlikely that the only respondents were otolarygologists who used NFE. Consequently, it is reasonable to believe that the study population was truly representative of otolaryngologists working in Italy and the members of the two most important Italian otolaryngological associations. The high response rate may have been partially due to the fact that the questionnaire was presented during our most important national congresses.

Despite some differences related to age, gender and geography, the data indicate that the majority of the respondents use NFE in their pediatric clinical practice and have a generally positive attitude towards it because nearly 70 % defined it as “a generally well-tolerated, minimally invasive examination that can be used in most children; very useful in clinical practice”. As NFE has only recently been considered the preferred means of diagnosing adenoidal hypertrophy in children [57], it is not surprising that younger otolaryngologists use it more frequently than those aged >50 years.

It is worth noting that more than one-third of the respondents (mainly females aged >50 years) declared that they used alternative means of diagnosing adenoidal disease, including a clinical evaluation (65 %), standardised questionnaires (19 %), posterior rhinoscopy (about 13 %), and nasopharyngeal radiography (about 3 %). This is not surprising because, until recently, the many proposed methods of assessing adenoid size were not very accurate. In particular, the most widely used clinical scores aimed of predicting the severity of nasal obstruction [9, 10] is the nasal obstruction index (NOI), which is based on the proportion of oral breathing and speech hyponasality [10]. This was proposed by Paradise as a reliable and reasonably valid means of detecting the presence and degree of adenoidal hypertrophy in 1998 [10], but we have shown that it alone is less accurate than NFE in predicting the rate of adenoidal obstruction in children with perceived obstructed nasal breathing or recurrent/chronic middle ear disease, and should therefore be abandoned [7, 11].

About 3 % of the responders said they used nasopharyngeal radiography as an alternative means of diagnosis, but it must be pointed out that its accuracy in assessing adenoidal hypertrophy (sensitivity 70 % and specificity 52 %) is much less than that of NFE [12]. Furthermore, it has been found that radiological measurements such as adenoidal thickness (the distance along a perpendicular line from the basiocciput to the adenoid convexity) and the adenoid-nasopharyngeal ratio (the ratio between adenoid thickness and the distance between the basiocciput and the posterior edge of the hard palate) do not correlate with obstructive symptom scores [8, 13].

However, some clinicians still advocate the use of radiological assessments in children with suspected adenoidal disease [2, 4, 14], especially in order to bridge the diagnostic gap in younger children who do not/cannot cooperate during an NFE examination [4]. Our findings indicate that there is some reluctance among Italian otolaryngologists to use NFE in small children, and most of them said that they only use it in older patients; only about 13 % (mainly ENT specialists working in hospitals in northern Italy) said they use NFE regardless of age. Furthermore, nearly one-third of the respondents (males aged >50 years) stated that they cannot complete an NFE examination in up to 25 % of patients. However, our experience [15] and that of others [3] indicates that NFE is feasible and tolerable in almost all children when it is carried out by a skilled otolaryngologist using a small-calibre flexible endoscope, and if every effort is made to find the best approach on the basis of the child’s age.

NFE is generally considered safe: almost all of the respondents said that fewer than 5 % of the procedures were associated with untoward side effects, mainly minor events such as nasal bleeding or traumatic lesions, and less frequently major events such as syncope (about 12 %) or desaturation (about 3 %). Thirty-eight percent excluded the possibility of using outpatient NFE in “children with a genetic syndrome” or “children aged <18 months in whom severe disease is highly suspected”. To the best of our knowledge, no specific guidelines have yet been published but, on the basis of our experience [15] and that of Pagella [3], we consider that NFE can generally be used in an outpatient setting even in young non-syndromic children.

In terms of the way in which is NFE is carried out, the responses to most of the items varied widely. The only items indicating almost unanimous agreement concerned the recommended type of endoscope (flexible), the position of the patient during NFE (sitting alone or on a parent’s lap), and restraint (with the parent blocking the movement of the child sitting on his/her lap). Various means of carrying out NFE examinations have been proposed [3, 4, 1619], but our own experience confirms that the methods indicated by the answers of our respondents are effective and well-tolerated by almost all children [15]. Some authors [1821] advocate the use of a rigid nasal endoscope, but this may be less well tolerated as it is associated with a failure rate of up to 12 % of children undergoing endoscopy in a supine position even after the administration of topical nasal anesthetics and decongestants [18, 19].

Only 32 % of our respondents said that they do not administer any topical drugs before an NFE examination, whereas the others pre-medicate the nasal cavities with local vasoconstrictors (30 %), an anesthetic (22 %), or lubricating ointment (about 16 %). We have previously reported that NFE can be successfully carried out in most patients without the aid of any of these [15] and, given that the use of topical decongestants has been proscribed by the Italian Medicines Agency in children aged <12 years [22], we suggest they should they not be used.

There was also considerable heterogeneity in the way that adenoidal hypertrophy is graded: just over half of the respondents base the grading on the percentage of choanal obstruction and the possible impaired patency of the Eustachian tube orifice, whereas about one-third only use the former. Only about 48 % said they used a standardised classification (mainly that of Cassano [5]), most of whom work in hospitals in southern Italy. This suggests the need for educational programmes supported by national otolaryngological societies aimed at promoting the use of standardised systems of scoring adenoidal hypertrophy in order to make medical reports comparable.

Conclusions

The findings of this study seem to indicate that Italian otolaryngologists use NFE, and are quite confident about its effectiveness and safety in routine pediatric practice. However, there is some reluctance to using it in younger children, and no unanimous agreement about how it should be carried out. This lack of a standardised approach may account for failures in some patients, and encourage resort to alternative means of diagnosis that should actually be abandoned.

Given the medical advantages of NFE, it is essential to clarify the many still controversial aspects of the procedure by means of comparative studies and educational programmes supported by national health authorities.

Declarations

Acknowledgements

This study was supported by the Italian Society of Otolaryngology and Head and Neck Surgery (SIOeChCF), and the Italian Society of Pediatric Otolaryngology (SIOP).

Financial support disclosure

This study was not supported by funding from any extramural sources.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Otolaryngology Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico
(2)
Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico
(3)
Academic Oncologic Department, Otolaryngology Service, University of Turin, San Luigi Gonzaga Hospital

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© Torretta et al. 2016

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