Acute respiratory infections in children from an ENT perspective

Background. Adenoidectomy remains a frequent surgical approach for recurrent upper respiratory tract infections (URTI) in children. We research if only age and collectivity are responsible for recurrences, or other anatomic conditions can account for the history of the patient. Design. Retrospective case series review. Material and method. Questionnaire about respiratory symptoms and correlations observed between the history of the patient and the presence or absence of short soft palate. Results. 102 children could provide enough data to be included in the study. Frequent URTI were observed in 30% of the aff ected children and only 16% of their normal peers. 41% of URTIs each persisted longer than 10 days in short soft palate children vs. 17% in normal patients. Broncho-pulmonary complications were encountered in 44% of children with short palate as opposed to 27% in others. Conclusions. Short velli palatini can disturb normal swallowing process and allow rhinopharyngeal chronic infl ammation. That can lead to persistent recurrent URTIs, more probable chronic obstruction through the adenoids and other diseases in pediatric ENT practice.


CERCETARE ŞTIINºIFICÅ
Acute respiratory infecti ons in children are extremely common. Some studies report up to 9-10 episodes/year in the range of 1-6 years old.
(1) Some conditi ons can be made responsible for this epidemiologic behaviour: season, crowding, colecti viti es, age-associated immunity. The complicati ons arising from their incidence vary: oti ti s, tracheobronchial disease, meningiti s. Implicati ons of acute respiratory infecti ons in children are multi ple: parental stress, overloading of the medical system and abusive/nonjudicious use of anti bioti cs (by medical staff ) with consequent anti microbial resistance. (2) The issues about acute respiratory infecti ons regard their ethiology and the most effi cient/ right way to address their management or preventi on. Parental concern and consequent low producti vity are other aspects of upper respiratory tract infecti ons (URTI) in children.
From an epidemiological point of view, social conditi ons are of utmost concern, because aerial contagion and colecti viti es can not be completely avoided. (3) Poor social environment and low medical addressability are not dependant on medical care and their soluti on lies in the community.
The goal of this paper is to possibly demonstrate/hypothesize other (e.g. anatomical) factors contributi ng to recurrent acute respiratory infecti ons in children, with arguments from the experience of our pediatric ENT department.

MATERIAL AND METHOD
102 children admitt ed into our pediatric ENT department for adenoidectomy, between January 2011 -December 2012, were enrolled in the study. An informed consent was obtained from each parent.
Every parent of the pati ents enrolled was asked to fi ll a questi onnaire, regarding the upper respiratory infecti on history of their children. The addressed issues were: number of episodes of URTI/month, length of URTI (less or more than 10 days), broncho-pulmonary complicati ons associated with URTI and cough as a persistent symptom among other symptoms of the acute respiratory disease. We introduced the last menti oned issue only later in the study, so only 64 pati ents answered the questi on regarding cough.
The children were admited and operated in our department, with adenoidectomy performed, by Beckmann curett e technique, under general anesthesia. Local appearance of the pharynx, uvula and velli palati ni was noted visually by the senior surgeon and recorded into the medical data. The soft palate was appreciated as being short or normal, subjecti vely. Figure 1 shows a typical aspect, with large distance from the velli palati ni to posterior pharyngeal wall and bifi d uvula.
The recorded data were used to assess the incidence of short soft palate in adenoidectomy pati ents. The associati on of specifi c URTI symptoms with this anatomic conditi on were researched.

RESULTS
Data obtained from the questi onnaires are presented in Table 1 and 2.
The incidence of frecquent URTI (more than 1 episode each month) in adenoidectomy children with short soft palate is 29.4% as compared to 16% (χ2 -test = 0,016) in normal peers. The diff erence is stati sti cally signifi cant.
Broncho-pulmonary complicati ons and cough dominate clinical symptoms and disease in 44% of short palate pati ents but in only 18% for the others (χ2= 0,0001). Persistent cough was seen predominantly in chidren having the palatal incompetence, even if not as overt malformati on and other specifi c symptoms.

DISCUSSIONS
Nasal anatomical conditi ons can predispose to parti cular/prolonged courses of infecti ous diseases of the nose. The responsible mechanisms could be: chronic obstructi on that leads to poorer clearance of nasal mucus, eventually promoti ng local bacterial growth. Consequent hypoxia of the nasal mucosa favors further ciliary damage. Local infl ammatory disease of the nasal mucosa from other diseases can also contribute to recurent local bacterial infecti ons.
It has been cited in the literature that one conditi on promoti ng recurrent infecti ons of the upper airways is pharyngo-laryngeal refl ux. (4) It does so by maintaining an infl amatory status of the rhinopharynx, as stated by some authors. Lack of normal conti nence of the natural muscular ring of the rhinopharynx, as seen in our short soft palate pati ents, could be responsible, at least in part, for such conditi on. Being a terti ary referal and a large surgical pediatric ENT center, most of our surgery comprises adenoidectomy as a standard approach for chronic infl ammatory conditi ons and obstructi on of the nose. It is a common approach in pediatric ENT. (5) We found that in many children submmited to this kind of surgery, short palate is a common fi nding, more than its prevalence in normal populati on (6) (33,3% from our adenoidectomy pati ents). Due to the risks that this anatomical conditi on predisposes postoperati vely (velopharyngeal incompetence in selected cases aft er adenoidectomy) (7), we tried to evaluate the incidence of such children ongoing adenoidectomy and compared their rati o to the risk of the same malformati on in the general populati on. The fi gures are stati sti cally signifi cant.
As long as the most common issues that are presented as main reasons to perform adenoidectomy, from a pati ent's history point of view, are frequent URTIs and the diffi culty to manage them, the questi on about the role of short palate in this conditi on can be discussed.
In our study, the number of upper respiratory infecti ons that a child could have before performing adenoidectomy in our department was higher in children presenti ng with a short palate (30% vs 16%). Also, acute respiratory episodes with a longer durati on (more than 10 days) had a higher incidence in these pati ents: 41% vs 17% than in their normal pharyngeal counterparts. That fi gures suggest that an abnormal status of the nasal/ nasopharyngeal mucosa favors long and reccurent relapses of acute respiratory infecti ous disease.
The incidence of pulmonary complicati ons associated with URTI was signifi cantly higher in short palate children (44% vs 18%). Cough, as a main symptom, was also seen in 50% abnormal children vs 27% in normal ones.
Adenoid obstructi on of the posterior nasal passage can promote less clearing of the nasal secreti ons and enhance microbial infl ammati on and proliferati on. Factors that can add more infl ammatory reacti on to the naso-pharyngeal mucosa have additi onal favorable eff ect on nasal persistent infecti ons.
Cough can also be maintained by persistent discharge in the rhinopharynx. Every pathologic conditi on maintaining this situati on can contribute to cough prolongati on beyond normal healing of a simple infecti ous process.
We hypothesize that the presence of a short velli palati ni prediposes to parti al refl ux of food into the rhinopharynx, during degluti ti on. Mechanical and and chemical infl ammati on of rhinopharyngeal mucosa sti mulates local pathogenic microbial fl ora. That is why these children are frequently seeking medical ent care or are submitt ed to adenoidectomy more frequently than others.
Some sorces of error can be questi oned in our study. First of all, there is no defi niti on of short palate in terms of anatomic measurements. (8) It can be demonstrated usually by means of nasal endoscopy on a cooperati ng child, showing a lack of complete closure of the rhinopharynx in certain types of phonati on. Sti ll, in a pati ent with a large obstructi ve adenoid pad, that vellar incompetence can be difficult to prove/show. (9) It is also impossible to predict postoperati vely the distance between the soft palate and the oropharyngeal wall, after adenoidectomy. Instead, an experienced surgeon can be aware of the conditi on and appreciate "on the move" the existence of the conditi on. Usually, sophisti cated images are not currently used for evaluati on of an indicati on for adenoidectomy. Bifi d uvula can be of use when noted clinically, but it is not always possible to detect it, especially in small or uncooperati ve children. Palpati on of the palatal plate can bring someti mes informati on about an occult submucosal palati ne cleft . (10)

CONCLUSION
Although there is no soluti on to this anatomical inherited conditi on, the specialist that observes a short soft palate can predict and warn