Role of Adenoidectomy in Otitis Mediaand Respiratory Function

Petri S. Mattila

Published online: 19 August 2010# Springer Science+Business Media, LLC 2010

Abstract Adenoidectomy is among the most frequentsurgical procedures performed on children. The rationalefor adenoidectomy is to remove a chronically infected orenlarged and obstructing adenoid. Adenoidectomies areperformed on children who have recurrent or chronic otitismedia with effusion, on children with chronic rhinosinusitis,and on children with nasopharyngeal obstruction causingsleep disturbances and continuous mouth breathing. Variousunderlying factors that lead to adenoidectomy are alsoassociated with asthma. Asthma is associated with recurrentrespiratory tract infections predisposing individuals to recur-rent or chronic otitis media and chronic rhinosinusitis.Children with asthma also have an increased risk of sleep-disordered breathing that is treated with adenoidectomy in thepresence of nasopharyngeal obstruction. In nonasthmaticchildren, adenoidectomy does not influence the developmentof IgE-mediated allergy, bronchial hyperreactivity, or exhalednitric oxide concentrations, all of which are surrogate asthmamarkers. Adenoidectomy in selected asthmatic children mayrelieve comorbidities associated with asthma.

Keywords Adenoidectomy . Otitis media . Asthma

Introduction

The rationale for adenoidectomy is to remove the adenoidonly when it is diseased by chronic infection or by

abnormal hyperplasia and is causing nasopharyngealobstruction. However, in clinical practice, the distinctionbetween a healthy adenoid and a chronically diseasedadenoid is often made by clinical symptoms and signsexhibited by the child.

Chronic adenoidal infection is thought to be associatedwith otitis media by transmission of the adenoidal infectionthrough the eustachian tubes into the middle ears [1]. Inaddition, an enlarged adenoid may obstruct the orifices ofeustachian tubes and contribute to the pathogenesis ofchronic otitis media with effusion [2]. Thus, the adenoidhas a critical location in the nasopharynx in close proximityto the eustachian tubes, which serve as the entry ofpathogenic microbes into the middle ear. Removal of anenlarged or chronically infected adenoid by adenoidectomyhas been reported to be effective in the resolution of chronicotitis media with effusion in children older than 4 years ofage [24]. Adenoidectomy also has been reported to beeffective in the treatment of children with recurrent otitismedia who previously received tympanostomy tubes [5].

The above reports have encouraged the use of adenoi-dectomy to prevent otitis media in children younger than4 years of age [6]. This has been tempting, as this is the agerange in which the highest prevalence of acute otitis mediais observed. It has been suspected that the adenoid could bechronically infected even in very young children, predis-posing them to otitis media. Disappointingly, however,randomized studies have failed to prove any efficacy ofadenoidectomy in preventing acute otitis media in childrenyounger than 4 years of age [79] as well as in olderchildren when used as the first surgical treatment [10].Currently, adenoidectomy is not recommended as theprimary treatment for otitis media unless an evidentadenoidal pathology exists, such as an enlarged adenoidcausing nasopharyngeal obstruction [11, 12].

P. S. Mattila (*)Department of Otorhinolaryngology,Helsinki University Central Hospital,Haartmaninkatu 4 E, P. O. Box 220, 00290 Helsinki, Finlande-mail: petri.mattila@hus.fi

Curr Allergy Asthma Rep (2010) 10:419424DOI 10.1007/s11882-010-0138-7

An enlarged adenoid can cause nasopharyngeal obstruc-tion. This results in continuous mouth breathing, sleepdisturbances, and long-term effects on the growth of thefacial skeleton and teeth [13]. Thereby, adenoidectomies arealso performed in cases of nasopharyngeal obstructionwithout any evident history of recurrent or persistent otitismedia [14]. In addition, adenoidectomies are performed onchildren with chronic sinusitis [15], although they are mostfrequently performed to treat chronic otitis media witheffusion (Fig. 1) or nasopharyngeal obstruction associatedwith sleep disturbances.

Natural Function of the Adenoids: Role in Immunityof Young Children?

The nasopharyngeal location of the adenoid allows it toconfront inhaled antigens, suggesting that it may haveevolved to aid in the maturation of immune responses toinhaled antigens. It is composed mainly of lymphatic tissueand covered by an epithelium that forms specialized invag-inated crypts that are thought to convey nasopharyngealantigens inside the adenoid tissue [16]. The characteristicfeature of the adenoid is that it is present at birth and islargest at 710 years of age; thereafter, it gradually decreasesin size and is usually rudimentary in adults [17].

As the adenoid has persisted through human evolution,its function is probably not insignificant. One may presumethat a healthy adenoid is beneficial for the child. Despitethis, children who have undergone adenoidectomy areapparently healthy, and adenoidectomy is not known toyield any severe long-term side effects.

The nasopharynx has a special role in pneumococcalcolonization in children, as it is the primary reservoir ofpneumococci [18]. This is contrary to what is seen inadults, in whom oropharyngeal swabs yield higher carriagerates of pneumococci than nasopharyngeal swabs [19, 20].Currently, there is no explanation as to why the nasopharynxof a child yields more pneumococci than the nasopharynx ofan adult. However, the possibility exists that the nasopharyn-geal adenoid of the child has a role in this, as adenoids arerudimentary in adults.

In a recent study in which children 14 years of age wererandomly allocated to undergo or not to undergo adenoi-dectomy, adenoidectomy was associated with an increasedrate of nasopharyngeal carriage of pneumococci 1 year afterrandomization [21]. The effect on pneumococcal carriagewas less marked on the 2- and 3-year follow-up visits.Adenoidectomy seemed not to influence nasopharyngealcarriage ofHaemophilus influenzae orMoraxella catarrhalis.As the risk of pneumococcal infections (e.g., otitis media,pneumonia, and sepsis) is highest among children youngerthan 5 years of age, the adenoid may have evolved toaugment immune responses to Streptococcus pneumoniae. Inthis respect, the adenoid resembles the spleen, a lymphoidorgan that has a role in immune defenses against pneumo-coccal infections [22].

It should be noted that in the above study, adenoidec-tomy seemed to increase pneumococcal carriage signifi-cantly in children 14 years of age only during the first yearafter adenoidectomy [21]. Thus, adenoidectomy at anearly age may not result in any long-term effects, as theadenoid may promote and boost pneumococcal immunityonly in very young children, who are the most vulnerableto pneumococcal infections [23]. At an older age, othermechanisms may be more important in immunity, and therelative importance of the adenoid may decrease, whichmay be the reason for its natural involution as the childgrows older.

Epidemiologic Surveys on the Association of ChildhoodAsthma and Adenoidectomy

Reports support an epidemiologic association betweenchildhood asthma and adenoidectomy. A cohort study of8,806 children examined at ages 7, 11, and 16 years showedthat adenotonsillar surgery predicted asthma risk [24]. Aquestionnaire study of 483 individuals who were on average

Fig. 1 An adenoid of a 7-year-old child with chronic otitis media witheffusion. The image shows an inferior view through a rigid 70endoscope. Inflammatory exudate is seen on top of the adenoid. Somelymphatic tissue in the mucosa at the orifices of the eustachian tubes isalso present

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18 years old showed that adenoidectomy was performedmore frequently on asthmatic children [25]. In a survey ofhospital discharge records of 1,606 children who hadundergone adenoidectomy, the frequency of asthma diag-nosis was significantly higher compared with 161 controlchildren who had not undergone adenoidectomy [25]. Thissurvey showed that the frequency of asthma diagnosisincreased even before adenoidectomy was actually per-formed. This indicated that adenoidectomy per se may notincrease the risk of asthma but that underlying factorsassociated with the development of early-childhood asthmaalso predispose children to adenoidectomy. Of note is that incontrast to adenoidectomy, childhood tonsillectomy is notassociated with childhood asthma or atopic disease [25].Also, an association between childhood adenotonsillarsurgery and asthma has not been found in all populations[26]. Despite this, underlying factors can contribute to anepidemiologic association between childhood asthma andadenoidectomy.

Sleep-Disordered Breathing in Asthmatic Childrenand Adenoidectomy

Asthma has been identified as a risk factor for childhoodobstructive sleep apnea (OSA), which is more common inoverweight children [27]. Overweight without sleep-disordered breathing is not associated with increased airwayinflammation [28]. Thus, there seems to be an associationamong OSA, airway inflammation, and asthma.

Children with OSA frequently have adenotonsillarhyperplasia, which causes nasopharyngeal obstruction.Therefore, children with OSA frequently undergo adenoidec-tomy. Children with severe OSA who undergo adenotonsil-lectomy show a significant improvement in respiratorydistress and quality of life over a period of several monthsafter surgery. However, OSA does not resolve in all thesechildren, and some may require additional therapy [14]. Ofnote is that in children with obstructed breathing duringsleep, the presence of asthma is associated with an increasedrisk of respiratory complications after adenotonsillectomy[29]. Taken together, the coincidence of OSA, asthma, andadenoidectomy can contribute to the epidemiologic associ-ation between adenoidectomy and asthma.

Respiratory Tract Infections: A Common FeatureAssociated With Asthma and Otitis Media

According to the hygiene hypothesis, exposure to a farmingenvironment early in life [30] and repeated viral infectionsother than lower respiratory tract infections early in life[31] may protect an individual from asthma. This has been

attributed to exposure to endotoxin and other microbialcompounds that may have a beneficial effect [32, 33].

However, certain viral infections early in life have beenassociated with the development of asthma later in life.Severe lower respiratory tract infections caused by respira-tory syncytial virus at a young age have been found to beassociated with the development of asthma [34], as aresymptomatic infections with rhinovirus early in life.Rhinovirus infections are also major causes of asthmaexacerbations, accounting for more than half of all suchattacks, and rhinovirus persistence in the lower respiratorytract may contribute to asthma persistence and severity [35].

Thus, a clear connection exists between childhood asthmaand infections, as respiratory tract infections are associatedwith childhood asthma [3638], and asthma symptoms areexacerbated by respiratory infections [3941]. Althoughmoderate exposure to pathogens or exposure to certain kindsof microbial products during early childhood may protect anindividual from subsequent development of atopic symptomsand asthma [42], evidence indicates that excessive respira-tory tract infections, especially in the lower respiratory tract,early in life are associated with childhood asthma [43]. Asexposure to respiratory tract infections is associated withrecurrent or chronic otitis media with effusion, which is oftentreated with adenoidectomy, the coincidence of respiratorytract infections in both asthma and otitis media maycontribute to the epidemiologic association between adenoi-dectomy and childhood asthma.

Immune Abnormalities in Asthmatic Childrenand Respiratory Infections

The association of excessive respiratory infections andchildhood asthma may imply that excessive exposure tocertain microbes directly predisposes an individual toasthma. On the other hand, some evidence indicates thatchildren who are vulnerable to asthma have an underlyingimmune abnormality that may predispose them to recurrentinfections and asthma. This may suggest that excessiverespiratory infections and asthma occur by coincidence andthat excessive respiratory infections may not have asignificant role in directly causing childhood asthma. Ithas been reported that asymptomatic 1-month-old neonateswho are colonized with respiratory pathogens are atincreased risk of developing childhood asthma [44]. Also,patients with asthma may have impaired innate antiviralresponses that could predispose them to respiratory tractinfections [35]. Thus, respiratory infections may be morefrequent in asthmatic children due to an underlying immuneabnormality predisposing them to asthma and respiratoryinfections. Nevertheless, children who are prone to asthmaare also susceptible to respiratory infections, which can

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contribute to the epidemiologic association between adenoi-dectomy and childhood asthma.

Effect of Adenoidectomy on Respiratory Functionin Nonasthmatic Children

Although asthmatic children often undergo adenoidectomy,it is not known whether adenoidectomy would have anyeffect on lower airway inflammation or on the developmentof asthma. As the adenoid is a prominent lymphoid organ inthe upper respiratory airway that readily confronts particlesinhaled through the nose, the adenoids could be involved inthe control of airway inflammation. Also, as adenoidectomyis among the most common surgical procedures in children,its possible harmful effects on lung function or on thedevelopment of atopy, which have not been assessedpreviously, need to be investigated.

We recently conducted a randomized study on the effectof adenoidectomy [45]. The study children had sufferedfrom recurrent or persistent otitis media, had no history ofinsertion of tympanostomy tubes, had no evident adenoidenlargement causing obstruction of the nasopharynx, were14 years of age at the start of the trial, and did not haveasthma. The children were randomly assigned to undergo ornot to undergo adenoidectomy. All the children receivedtympanostomy tubes. The children had scheduled visits 1,2, and 3 years after the surgery.

Lung function was evaluated at the 3-year follow-upvisit [45]. Exercise-induced bronchoconstriction waschosen as a measure of bronchial hyperreactivity, as it is asign suggesting asthma [46]. This was assessed by apreviously validated protocol of impulse oscillometry[47]. The mean value of baseline respiratory resistance(Rrs) was first measured at the 5-Hz oscillating pressure.The child then took part in an outdoor running exercise testfor 67 min, and Rrs was measured again. Exercise-inducedbronchoconstriction was estimated as the percentage ofmaximum change in Rrs after the exercise test (Rrs). Anincrease greater than 35% in Rrs was defined as anabnormal response. This corresponds to the 95th percentilein healthy, nonatopic children and has been found to

distinguish children with probable asthma from asymptom-atic children [47].

Exhaled nitric oxide fractional concentration was alsomeasured, as it is considered a surrogate for eosinophilicairway inflammation [48], and it is usually increased inyoung children with probable asthma [49]. We previouslydetermined the normal value for exhaled nitric oxidefractional concentration, which depends on the childsheight. It was considered abnormal when it was more thantwo SDs higher than predicted. In addition, the develop-ment of allergy was assessed by skin prick tests againstcommon allergens.

After the 3-year follow-up, adenoidectomy did not seemto promote exercise-induced bronchoconstriction as evalu-ated by oscillometry, bronchial inflammation as measuredby exhaled nitric oxide, or the development of allergy orclinically diagnosed asthma (Table 1). Collectively, ourresults indicated that adenoidectomy does not increase therisk of asthma or the development of allergy to respiratoryallergens [45]. This is conceptually important, as theadenoids are located in the nasopharynx confrontinginhaled antigens and potentially have a role not only inthe development of immunity to microbes but in thedevelopment of tolerance to inhaled particles.

During the annual follow-up visits, acute otitis mediaepisodes were prospectively documented in patient diaries.Information in the diaries was gathered during the scheduledfollow-up visits 1, 2, and 3 years after the randomization.Analysis of otitis media episodes showed that in the studypopulation, adenoidectomy was inefficient in preventing acuteotitis media. However, analysis of the number of otitis mediaepisodes showed that children who had recurrent episodes ofotitis media during the first follow-up year tended to performworse on lung functions tests [45]. This may explain whythe risk of asthma is increased in children with recurrent otitismedia who had undergone adenoidectomy [25].

Adenoidectomy in Asthmatic Children

Our study did not include children with asthma or adenoidhyperplasia. It is not known whether adenoidectomy has

Table 1 Lung function, allergy, and asthma in children 3 years after randomization to undergo or not to undergo adenoidectomy

Adenoidectomy, % (n) No adenoidectomy, % (n) Odds ratio (95% CI) P value

Children with increased Rrs 4 (82) 10 (72) 0.35 (0.091.42) 0.19

Children with increased FENO 21 (67) 11 (57) 2.16 (0.776.06) 0.15

Children with positive RAST 15 (87) 22 (72) 0.61 (0.271.38) 0.30

Children with asthma diagnosis 0 (89) 4 (77) 0.10

Rrs percentage of maximum change in respiratory resistance, FENO exhaled nitric oxide fractional concentration, RAST radioallergosorbent test

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any effect on lung function and airway inflammation inasthmatic children. In some series, adenotonsillar surgeryhas even been reported to result in improvements in asthma[50], but the topic has not been investigated thoroughly, andthe possible influence of adenoidectomy on lung functionand airway inflammation in asthmatic children remainscontroversial. Nevertheless, adenoidectomy in asthmaticchildren with evident adenoid enlargement or chronic adenoidinfection relieves these asthma-associated comorbidities andlikely increases the quality of life of the children.

Conclusions

Underlying disorders associated with asthma and adenoi-dectomy lead to an epidemiologic association betweenadenoidectomy and childhood asthma. Adenoidectomy perse does not seem to predispose individuals to childhoodasthma. In clinical practice, it is not uncommon to encountera child with asthma and a history of respiratory infections.Some such children may benefit from adenoidectomy.Although adenoidectomy has not been shown to influencethe outcome of asthma, in selected asthmatic children, it mayrelieve comorbidities associated with asthma.

Disclosure No potential conflict of interest relevant to this articlewas reported.

References

Papers of particular interest, published recently, have beenhighlighted as: Of importance Of major importance

1. Gates GA: Otitis mediathe pharyngeal connection. JAMA1999, 282:987989.

2. Nguyen LH, Manoukian JJ, Yoskovitch A, Al-Sebeih KH:Adenoidectomy: selection criteria for surgical cases of otitismedia. Laryngoscope 2004, 114:863866.

3. Gates GA, Avery CA, Prihoda TJ, Cooper JC Jr: Effectiveness ofadenoidectomy and tympanostomy tubes in the treatment ofchronic otitis media with effusion. N Engl J Med 1987,317:14441451.

4. Maw R, Bawden R: Spontaneous resolution of severe chronic glueear in children and the effect of adenoidectomy, tonsillectomy, andinsertion of ventilation tubes (grommets). BMJ 1993, 306:756760.

5. Paradise JL, Bluestone CD, Rogers KD, et al.: Efficacy ofadenoidectomy for recurrent otitis media in children previouslytreated with tympanostomy-tube placement. Results of parallelrandomized and nonrandomized trials. JAMA 1990, 263:20662073.

6. Coyte PC, Croxford R, McIsaac W, et al.: The role of adjuvantadenoidectomy and tonsillectomy in the outcome of the insertionof tympanostomy tubes. N Engl J Med 2001, 344:11881195.

7. Mattila PS, Joki-Erkkil VP, Kilpi T, et al.: Prevention of otitismedia by adenoidectomy in children younger than 2 years. ArchOtolaryngol 2003, 129:163168.

8. Koivunen P, Uhari M, Luotonen J, et al.: Adenoidectomy versuschemoprophylaxis and placebo for recurrent acute otitis media inchildren aged under 2 years: randomised controlled trial. BMJ2004, 328:487.

9. Hammaren-Malmi S, Saxen H, Tarkkanen J, Mattila PS:Adenoidectomy does not significantly reduce the incidence ofotitis media in conjunction with the insertion of tympanostomytubes in children who are younger than 4 years: a randomizedtrial. Pediatrics 2005, 116:185189.

10. Paradise JL, Bluestone CD, Colborn DK, et al.: Adenoidectomyand adenotonsillectomy for recurrent acute otitis media: parallelrandomized clinical trials in children not previously treated withtympanostomy tubes. JAMA 1999, 282:945953.

11. American Academy of Family Physicians, American Academy ofOtolaryngologyHead and Neck Surgery, American Academy ofPediatrics Subcommittee on Otitis Media With Effusion: Otitismedia with effusion. Pediatrics 2004, 113:14121429.

12. Bull P, Haggard M, Raglan E, et al.: Surgical Management ofOtitis Media With Effusion in Children. Clinical Guideline 60NICE (National Institute for Health and Clinical Excellence).London: Royal College of Obstetricians and Gynaecologists;2008. This guideline recommends the insertion of tympanostomytubes in children with persistent bilateral otitis media witheffusion documented over a period of 3 months. Adjuvantadenoidectomy is not recommended in the absence of persistentand/or frequent upper respiratory tract symptoms.

13. Mattila PS: Adenoidectomy and tympanostomy tubes in themanagement of otitis media. Curr Allergy Asthma Rep 2006,6:321326.

14. Mitchell RB, Kelly J: Outcome of adenotonsillectomy for severeobstructive sleep apnea in children. Int J Pediatr Otorhinolaryngol2004, 68:13751379.

15. Ramadan HH: Surgical management of chronic sinusitis inchildren. Laryngoscope 2004, 114:21032109.

16. Pajusto M, Tarkkanen J, Mattila PS: Platelet endothelial celladhesion molecule-1 is expressed in adenoidal crypt epithelialcells. Scand J Immunol 2005, 61:8286.

17. Vogler RC, Ii FJ, Pilgram TK: Age-specific size of the normaladenoid pad on magnetic resonance imaging. Clin Otolaryngol2000, 25:392395.

18. Rapola S, Salo E, Kiiski P, et al.: Comparison of four differentsampling methods for detecting pharyngeal carriage of Strepto-coccus pneumoniae and Haemophilus influenzae in children. JClin Microbiol 1997, 35:10771079.

19. Boersma WG, Lowenberg A, Holloway Y, et al.: The role ofantigen detection in pneumococcal carriers: a comparison betweencultures and capsular antigen detection in upper respiratory tractsecretions. Scand J Infect Dis 1993, 25:5156.

20. Regev-Yochay G, Raz M, Dagan R, et al.: Nasopharyngealcarriage of Streptococcus pneumoniae by adults and childrenin community and family settings. Clin Infect Dis 2004,38:632639.

21. Mattila PS, Hammaren-Malmi S, Saxen H, et al.: Adenoidectomyand nasopharyngeal carriage of Streptococcus pneumoniae in youngchildren. Arch Dis Child 2010May 26 (Epub ahead of print). This isthe first randomized study of the effect of adenoidectomy onnasopharyngeal carriage of bacterial pathogens causing otitismedia.

22. Styrt B: Infection associated with asplenia: risks, mechanisms, andprevention. Am J Med 1990, 88:33N-42N.

23. Bogaert D, De Groot R, Hermans PW: Streptococcus pneumoniaecolonisation: the key to pneumococcal disease. Lancet Infect Dis2004, 4:144154.

Curr Allergy Asthma Rep (2010) 10:419424 423

24. Anderson HR, Bland JM, Peckham CS: Risk factors for asthma upto 16 years of age. Evidence from a national cohort study. Chest1987, 91:127S130S.

25. Mattila PS, Hammaren-Malmi S, Tarkkanen J, et al.: Adenoidectomyduring early life and the risk of asthma. Pediatr Allergy Immunol2003, 14:358362.

26. van Hattum ES, Balemans WA, Rovers MM, et al.: Adenoidectomyand/or tonsillectomy in childhood is not associated with atopicdisease later in life. Clin Exp Allergy 2006, 36:4043.

27. Ramagopal M, Scharf SM, Roberts DW, Blaisdell CJ: Obstructivesleep apnea and history of asthma in snoring children. SleepBreath 2008, 12:381392.

28. Verhulst SL, Aerts L, Jacobs S, et al.: Sleep-disordered breathing,obesity, and airway inflammation in children and adolescents.Chest 2008, 134:11691175.

29. Kalra M, Buncher R, Amin RS: Asthma as a risk factor forrespiratory complications after adenotonsillectomy in childrenwith obstructive breathing during sleep. Ann Allergy AsthmaImmunol 2005, 94:549552.

30. Riedler J, Braun-Fahrlander C, Eder W, et al.: Exposure tofarming in early life and development of asthma and allergy: across-sectional survey. Lancet 2001, 358:11291133.

31. Illi S, von Mutius E, Lau S, et al.: Early childhood infectiousdiseases and the development of asthma up to school age: a birthcohort study. BMJ 2001, 322:390395.

32. Braun-Fahrlander C, Riedler J, Herz U, et al.: Environmentalexposure to endotoxin and its relation to asthma in school-agechildren. N Engl J Med 2002, 347:869877.

33. van Strien RT, Engel R, Holst O, et al.: Microbial exposure ofrural school children, as assessed by levels of N-acetyl-muramicacid in mattress dust, and its association with respiratory health. JAllergy Clin Immunol 2004, 113:860867.

34. Stein RT: Long-term airway morbidity following viral LRTI inearly infancy: recurrent wheezing or asthma? Paediatr Respir Rev2009, 10(Suppl 1):2931.

35. Kelly JT, Busse WW: Host immune responses to rhinovirus:mechanisms in asthma. J Allergy Clin Immunol 2008, 122:671682;quiz 683684. This review describes how rhinovirus has emergedas the most frequent pathogen associated with exacerbations andother aspects of asthma and discusses how the epithelial airwayantiviral response to rhinovirus may be defective in asthma.

36. Stein RT, Sherrill D, Morgan WJ, et al.: Respiratory syncytialvirus in early life and risk of wheeze and allergy by age 13 years.Lancet 1999, 354:541545.

37. Papadopoulos NG, Papi A, Psarras S, Johnston SL: Mechanisms ofrhinovirus-induced asthma. Paediatr Respir Rev 2004, 5:255260.

38. Jartti T, Lehtinen P, Vuorinen T, et al.: Respiratory picornavirusesand respiratory syncytial virus as causative agents of acuteexpiratory wheezing in children. Emerg Infect Dis 2004,10:10951101.

39. Heymann PW, Platts-Mills TA, Johnston SL: Role of viralinfections, atopy and antiviral immunity in the etiology ofwheezing exacerbations among children and young adults. PediatrInfect Dis J 2005, 24:S217S222.

40. Mallia P, Johnston SL: How viral infections cause exacerbation ofairway diseases. Chest 2006, 130:12031210.

41. Murray CS, Poletti G, Kebadze T, et al.: Study of modifiable riskfactors for asthma exacerbations: virus infection and allergenexposure increase the risk of asthma hospital admissions inchildren. Thorax 2006, 61:376382.

42. Alfven T, Braun-Fahrlander C, Brunekreef B, et al.: Allergicdiseases and atopic sensitization in children related to farming andanthroposophic lifestylethe PARSIFAL study. Allergy 2006,61:414421.

43. Kusel MM, de Klerk NH, Kebadze T, et al.: Early-life respiratoryviral infections, atopic sensitization, and risk of subsequentdevelopment of persistent asthma. J Allergy Clin Immunol 2007,119:11051110.

44. Bisgaard H, Hermansen MN, Buchvald F, et al.: Childhoodasthma after bacterial colonization of the airway in neonates. NEngl J Med 2007, 357:14871495.

45. Mattila PS, Hammaren-Malmi S, Pelkonen AS, et al.: Effect ofadenoidectomy on respiratory function: a randomised prospectivestudy. Arch Dis Child 2009, 94:366370. This is the firstrandomized study of the effect of adenoidectomy on respiratoryfunction, airway inflammation, and the development of allergy.

46. Godfrey S, Springer C, Noviski N, et al.: Exercise but notmethacholine differentiates asthma from chronic lung disease inchildren. Thorax 1991, 46:488492.

47. Malmberg LP, Mkel MJ, Mattila PS, et al.: Exercise-inducedchanges in respiratory impedance in young wheezy children andnonatopic controls. Pediatr Pulmonol 2008, 43:538544.

48. Payne DN, Adcock IM, Wilson NM, et al.: Relationship betweenexhaled nitric oxide and mucosal eosinophilic inflammation inchildren with difficult asthma, after treatment with oral prednis-olone. Am J Respir Crit Care Med 2001, 164:13761381.

49. Malmberg LP, Pelkonen AS, Haahtela T, Turpeinen M: Exhalednitric oxide rather than lung function distinguishes preschoolchildren with probable asthma. Thorax 2003, 58:494499.

50. Saito H, Asakura K, Hata M, et al.: Does adenotonsillectomyaffect the course of bronchial asthma and nasal allergy? ActaOtolaryngol Suppl 1996, 523:212215.

424 Curr Allergy Asthma Rep (2010) 10:419424

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c.11882_2010_Article_138.pdfRole of Adenoidectomy in Otitis Media and Respiratory FunctionAbstractIntroductionNatural Function of the Adenoids: Role in Immunity of Young Children?Epidemiologic Surveys on the Association of Childhood Asthma and AdenoidectomySleep-Disordered Breathing in Asthmatic Children and AdenoidectomyRespiratory Tract Infections: A Common Feature Associated With Asthma and Otitis MediaImmune Abnormalities in Asthmatic Children and Respiratory InfectionsEffect of Adenoidectomy on Respiratory Function in Nonasthmatic ChildrenAdenoidectomy in Asthmatic ChildrenConclusionsReferencesPapers of particular interest, published recently, have been highlighted as: Of importance Of major importance