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Case Report | DOI: https://doi.org/10.31579/2692-9562/051
1 ENT Institution: NHRIMH Kottayam, Under CCRH
2 Xiray Institution: NHRIMH Kottayam, Under CCRH
*Corresponding Author: Vinitha Edavattath Ramanan, ENT Institution: NHRIMH Kottayam, Under CCRH
Citation: Vinitha Edavattath Ramanan, Sreejith M. (2022). Scope of integrating Homeopathy with ‘Watchful Waiting Approach’ in the Treatment of Adenoid Hypertrophy – an Evidence-based Case Report Journal of Clinical Otorhinolaryngology 4(3); DOI: 10.31579/2692-9562/051
Copyright: © 2022 Vinitha Edavattath Ramanan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 23 April 2022 | Accepted: 13 May 2022 | Published: 25 May 2022
Keywords: homeopathy; watchful waiting approach; adenoid hypertrophy
Frequent respiratory tract infections can result in adenoid hypertrophy and secondary eustachian tube dysfunction resulting in Otitis media. Conventionally Adenoidectomy is indicated for recurrent respiratory tract infections, obstructive sleep apnea, and otitis media with effusion. It is the commonest paediatric surgery world-wide. The size of adenoids starts to reduce by eight to ten years of age. A randomized controlled study has concluded that immediate surgery had no benefits over the 'Watchful waiting approach'. There are many published studies in peer-reviewed indexed journals on the efficacy of homeopathic medicinal products in reducing recurrent respiratory tract infections in children.
A seven-year-old female child presented with chronic nasal congestion, snoring, mouth breathing, and increased salivation at night during August 2019. The Adenoid Nasopharynx [A/N] ratio was calculated as 0.71 before starting the treatment. The obstructive symptoms started reducing within two months of initiating homeopathic treatment. The A/N ratio reduced to 0.63 after 2 years. The modified Naranjo Criteria score of +9/11 suggests a positive causal attribute between the medicine prescribed and the treatment outcome. Hence, it is suggested to explore the scope of integrating homeopathy with a watchful waiting approach for the treatment of Adenoid hypertrophy in children.
The Waldeyer’s ring of lymphoid tissue is composed of adenoids, palatine, tubal, and lingual tonsils [1]. Adenoids are in the nasopharynx and are constantly exposed to allergens, bacteria, and viruses. They protect the body from the invading antigens [2]. Frequent infections can result in adenoid hypertrophy and secondary eustachian tube dysfunction resulting in Otitis media [3]. The common symptoms of Adenoid hypertrophy are snoring, mouth breathing, nasal discharge, hyponasal speech, and sleep apnea. Adenoidectomy is indicated for recurrent respiratory tract infections, obstructive sleep apnea, and otitis media with effusion. It is the most common pediatric surgery worldwide [2]. Airway obstruction during sleep with disruption of normal sleep pattern called sleep-disordered breathing is caused mainly by tonsillitis and adenoid hypertrophy [1]. Conventional non-surgical treatment includes intranasal steroids. Adenoids and tonsils produce immunoglobulins and help in defence mechanisms.
Studies in literature have different views regarding the benefits and risks of adenoidectomy in children [2]. The size of adenoids starts to reduce by eight to ten years of age [2]. An open randomized controlled trial on 111 children aged 1-6 years with recurrent respiratory tract infections in eleven general hospitals and two academic centers reported 7.91 episodes of upper respiratory tract infections in the adenoidectomy group and 7.84 in the watchful waiting group. Two children developed complications after adenoidectomy. The study concluded that immediate surgery had no benefits over the 'Watchful waiting approach' [4].
There are many published studies in peer-reviewed indexed journals on the efficacy of homeopathic medicinal products in reducing recurrent respiratory tract infections in children [5,6,7,8]. The present case report highlights the usefulness of homeopathic medicines in reducing recurrent respiratory tract infections and the need to integrate them with the watchful waiting approach for adenoid hypertrophy.
A seven-year-old female child presented with chronic nasal congestion, snoring, mouth breathing, and increased salivation at night during August 2019. She had these symptoms for a year. On examination, the nasal turbinates, posterior cervical lymph nodes, and tonsils were enlarged, and the right tonsil was congested. She used to take conventional medications with relief during the acute episodes. Since the symptoms recurred, her parents decided to take homeopathic treatment from the ENT OPD of the National Homoeopathic Research Institute in Mental Health Kerala.
The presenting features suggested obstructive symptoms due to Adenoid Hypertrophy. A lateral view radiograph of soft tissue Nasopharynx was taken, and the Adenoid/Nasopharynx ratio [A/N] was calculated as 0.71.
Radiography technique of skull lateral view for A/N ratio calculation [9]
The procedure was explained, and consent was obtained from the parents.
Patient preparation
All radio-opaque materials were removed from the area of interest.
Positioning of the Child and cassette
The child was positioned for the lateral view of the skull. To reduce the time of exposure and radiation exposure to the child non-bucky images were taken. The child is standing or sitting with median sagittal plane parallel and inter-orbital lines perpendicular to the cassette. The shoulders were rotated slightly to allow the correct position. The mouth is closed during exposure. The beam was collimated to include the post-nasal air space, nasopharynx, oropharynx, laryngopharynx, and external occipital protuberance.
Centering of the X-ray beam
The X-ray beam is centered at the angle of the jaw.
Technical factors
Ø Exposure
· kVp- 60-65
· mAs-30
Ø FFD- 180 cm
Ø Cassette size – 10x8 Inches
Ø Grid – Absent
The landmarks, the tip of the hard palate, sphenoid basi -occipital synchondrosis, and external occipital protuberance were identified for the A/N ratio calculations.
The adenoids had an enlarged size of 19.43 mm as per the above landmarks. The A/N ratio revealed an obstruction of 71% which accounted for the obstructive symptoms.
Homoeopathic Treatment, Follow-Up, And Outcome
Case taking was done in detail, emphasizing the general symptoms of the child apart from common symptoms due to hypertrophied adenoids. Considering the symptom totality and constitution of the child, homeopathic medicine Phosphorus 200C was administered at an interval of one month for ten months.
The child reported relief from the obstructive symptoms after initiating homeopathic medications. The recurrent respiratory tract infections were also relieved. So the parents discontinued the treatment. There were no respiratory infections or obstructive symptoms for about a year after discontinuing treatment. By the end of 2021, the child again started developing respiratory infections. The obstructive symptoms also reappeared, although in less severity when compared to the previous episodes. The medicine Phosphorus was started and repeated at fixed intervals with relief for the symptoms.
The size of enlarged Adenoids and tonsils reduced after Homeopathic treatment. The obstructive symptoms started reducing within two months. The A/N ratio reduced to 0.63 after 2 years of initiating homeopathic treatment during March 2022. [Table 1, Figure 1]
Recurrent episodes of respiratory tract infections are frequently associated with hypertrophied adenoids in children and increased risk of Asthma in children in school-going children [1]. In 2000, 1.9 million children died from acute respiratory infection worldwide. 70% of them were from Africa and Southeast Asia [2].
Conventionally Adenoidectomy is indicated in children for recurrent respiratory infections, otitis media, obstructive sleep apnea syndrome, adenoid hypertrophy, and orofacial growth disturbance [2,12].
The present case report explores the scope of homeopathy as an alternative to adenoidectomy.
In an observational study of 30 children with Recurrent Upper Respiratory Tract Infections, homeopathic individualized medicines proved effective in reducing the recurrence of infections [5].
In a prospective, multicenter, randomized, open clinical trial on 200 children, complex homeopathic products reduced the rate of Upper Respiratory tract infections and the use of antibiotics [6].
The results of homeopathic treatment for recurrent Upper respiratory tract infections were favorable, with a faster resolution, reduction in antibiotics usage, and possible long-term benefits [7].
A pragmatic randomized controlled parallel-group clinical trial comparing individualized homeopathic care and waiting-list control revealed a clinically relevant effect of individualized homeopathic care in the prevention of Upper respiratory tract infection in children [8].
The above studies indicate the scope of homeopathy in reducing the rate of upper respiratory tract infections in children. In the present case report, there is a clinically meaningful reduction in the rate of respiratory tract infection with a reduction in the size of the hypertrophied adenoids with the homeopathic medicine Phosphorus 200C.
The medicine Phosphorus was proved and introduced into homeopathic medical Literature by Dr. Samuel Hahnemann. Phosphorus is indicated for respiratory tract infections based on the symptom similarity. The 200C potency possesses 1/10200 part of the original drug substance.[13] The modified Naranjo Criteria score of +9/11 suggests a positive causal attribute between the medicine prescribed and the treatment outcome [14]. [Table 2]
The usefulness of homeopathic medicines in reducing recurrent respiratory tract infections in children is already proven clinically and published in peer-reviewed journals. Recurrent respiratory infections are one of the essential criteria for adenoidectomy in children. Hence it is suggested to explore the scope of integrating homeopathy with a watchful waiting approach for the treatment of Adenoid hypertrophy in children
The child had a clinically meaningful reduction in the rate of respiratory tract infections and the obstructive symptoms due to hypertrophied adenoid after homeopathic treatment.
We express our sincere gratitude to Asst. Director NHRIMH Kottayam, Dr. K. C. Muraleedharan, for providing the Institutional support. We thank Prof. Dr. K. Sudheer, MD, FRCR, Consultant Radiologist, for evaluating the x-ray films before and after treatment. We also thank the parents for their consent to publish the treatment result.
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