等离子刀扁桃体部分切除术联合腺样体射频消融术治疗儿童鼾症的 短期疗效研究

目的:探讨等离子刀扁桃体部分切除术(Tonsillotomy,TT)联合腺样体射频消融术治疗儿童鼾症的短期临床疗效。方法:选取2015年1月至2016年1月于我院接受扁桃体和腺样体手术的鼾症患儿77例机分为实验组即扁桃体部分切除术组(TT组)和对照组即扁桃体全部切除术(Tonsillectomy,TE)组(TE组)。选用儿童OSA-18生活质量调查表对儿童鼾症患者术前1个月和术后6个月进行调查随访和评估比较两组临床疗效的差异。采用VAS量表计量两组患儿术后1-7天的吞咽疼痛情况。观察两组患儿术后出血、术后扁桃体发炎情况以及扁桃体增生情况。结果:TT组和TE组患儿术后6个月OSA-18量表的总评分及5个维度的总分较术前比较均下降差异均具有统计学意义(P值均等于0.000),但两组术后OSA-18量表的总评分比较差异无统计学意义(P=0.246)。TT组术后第1天至术后第7天的吞咽疼痛VAS评分均较TE组低差异均具有统计学意义(P值均小于0.01)。两组患者术后均无患儿出血、无扁桃体反复发炎以及扁桃体组织增生。结论:等离子刀扁桃体部分切除术联合腺样体射频消融术治疗儿童鼾症短期临床疗效明确术后吞咽疼痛程度轻微、疼痛时间短,短期内无扁桃体增生及反复扁桃体发炎,可作为治疗儿童鼾症的首选术式之一。     

儿童阻塞性睡眠呼吸暂停低通气综合征与肥胖的相关性研究

目的:探讨儿童阻塞性睡眠呼吸暂停/低通气综合征(OSAHS)与肥胖的相关性。方法:收集单纯性肥胖儿童120例和体重正常儿童110例作为研究对象,进行统一的体格检查和专科检查,并进行多导睡眠监测记录阻塞性呼吸暂停指数(OAI)、呼吸暂停/低通气指数(AHI)、中枢性呼吸暂停指数(CAI)、最低血氧饱和度(LSa O2)和睡眠效率。结果:肥胖组OSAHS患病率为58.33%显著高于对照组的31.82%,差异有统计学意义(P0.05);OAI、AHI、CAI均显著高于对照组,而LSa O2、睡眠效率指标显著低于对照组,差异均有统计学意义(均P0.05);多因素回归分析显示,肥胖、扁桃体增生、腺样体增生是导致OSAHS的独立危险因素,差异有统计学意义(均P0.05)。结论:肥胖是儿童OSAHS发病的重要影响因素,特别是合并扁桃体肿大或腺样体肿大的患儿应注意预防OSAHS的发生。     

High rates of detection of respiratory viruses in tonsillar tissues from children with chronic adenotonsillar disease

Chronic tonsillar diseases are an important health problem, leading to large numbers of surgical procedures worldwide. Little is known about pathogenesis of these diseases. In order to investigate the role of respiratory viruses in chronic adenotonsillar diseases, we developed a cross-sectional study to determine the rates of viral detections of common respiratory viruses detected by TaqMan real time PCR (qPCR) in nasopharyngeal secretions, tonsillar tissues and peripheral blood from 121 children with chronic tonsillar diseases, without symptoms of acute respiratory infections. At least one respiratory virus was detected in 97.5% of patients. The viral co-infection rate was 69.5%. The most frequently detected viruses were human adenovirus in 47.1%, human enterovirus in 40.5%, human rhinovirus in 38%, human bocavirus in 29.8%, human metapneumovirus in 17.4% and human respiratory syncytial virus in 15.7%. Results of qPCR varied widely between sample sites: human adenovirus, human bocavirus and human enterovirus were predominantly detected in tissues, while human rhinovirus was more frequently detected in secretions. Rates of virus detection were remarkably high in tonsil tissues: over 85% in adenoids and close to 70% in palatine tonsils. In addition, overall virus detection rates were higher in more hypertrophic than in smaller adenoids (p = 0.05), and in the particular case of human enteroviruses, they were detected more frequently (p = 0.05) in larger palatine tonsils than in smaller ones. While persistence/latency of DNA viruses in tonsillar tissues has been documented, such is not the case of RNA viruses. Respiratory viruses are highly prevalent in adenoids and palatine tonsils of patients with chronic tonsillar diseases, and persistence of these viruses in tonsils may stimulate chronic inflammation and play a role in the pathogenesis of these diseases.     

Levels of immunoglobulins and lysozyme in 10-year-old children from different regions and the condition of the lymphatic apparatus. I. Condition of tonsils in connection with some immunological parameters and different environment

The condition of tonsils was investigated and the levels of serum IgG, IgA, IgM and lysozyme were measured in 305 ten-year-old children from three localities of the Central-Bohemian Region. The tonsils were not enlarged in 30.8% of children, in 26.2% they were enlarged, in 35.5% furrowed and in 7.5% of children tonsillectomy had been carried out. Mean levels of IgA were significantly higher in two localities in children with enlarged tonsils, insignificantly lower in children with furrowed tonsils and lowest in tonsilectomized children. The difference in the distribution of IgM levels were significant between girls with enlarged furrowed tonsils. The levels of lysozyme were not correlated with the finding in the tonsils, but a significant difference was found in the groups with enlarged tonsils between the three locailties under observation and in the groups with furrowed tonsils between two localities. The importance of the findings observed is discussed from the point of view of a possible influence of air pollution in two of the three localities under study.     

Diagnosis of obstructive sleep apnea syndrome]

Symptoms and signs in 12 patients with severe obstructive sleep apnea (OSA) syndrome have been presented. The most common symptoms were snoring , increased motor activity during sleep and excessive daytime somnolence. The factors predisposing to OSA syndrome were obesity and anatomic abnormalities of the upper airway structure. In some cases the signs of OSA syndrome included hypertension, right heart failure, chronic alveolar hypoventilation and polycythemia. Polysomnography showed sleep fragmentation and the prevalence of light sleep stages. Obstructive sleep apneas repeated 73 +/- 23 times per hour of sleep. The mean apnea duration was 19 +/- 8 s. The mean arterial oxygen saturation during apnea was 72 +/- 14%.     

Pharyngeal critical pressure in children with mild sleep-disordered breathing.

There is evidence that narrowing or collapse of the pharynx can contribute to obstructive sleep-disordered breathing (SDB) in adults and children. However, studies in children have focused on those with relatively severe SDB who generally were recruited from sleep clinics. It is unclear whether children with mild SDB who primarily have hypopneas, and not frank apnea, also have more collapsible airways. We estimated airway collapsibility in 10 control subjects (9.4 +/- 0.5 yr old; 1.9 +/- 0.2 hypopneas/h) and 7 children with mild SDB (10.6 +/- 0.5 yr old; 11.5 +/- 0.1 hypopneas/h) during stable, non-rapid eye movement sleep. None of the subjects had clinically significant enlargement of the tonsils or adenoids, nor had any undergone previous tonsillectomy or adenoidectomy. Airway collapsibility was measured by brief (2-breath duration) and sudden reductions in pharyngeal pressure by connecting the breathing mask to a negative pressure source. Negative pressure applications ranging from -1 to -20 cmH(2)O were randomly applied in each subject while respiratory airflow and mask pressure were measured. Flow-pressure curves were constructed for each subject, and the x-intercept gave the pressure at zero flow, the so-called critical pressure of the upper airway (Pcrit). Pcrit was significantly higher in children with SDB than in controls (-10.8 +/- 2.8 vs. -15.7 +/- 1.2 cmH(2)O; P < 0.05). There were no significant differences in the slopes of the pressure-flow relations or in baseline airflow resistance. These data support the concept that intrinsic pharyngeal collapsibility contributes to mild SDB in children.     

Sleep-disordered breathing, pharyngeal size and soft tissue anatomy in children.

We tested the hypothesis that pharyngeal geometry and soft tissue dimensions correlate with the severity of sleep-disordered breathing. Magnetic resonance images of the pharynx were obtained in 18 awake children, 7-12 yr of age, with obstructive apnea-hypopnea index (OAHI) values ranging from 1.81 to 24.2 events/h. Subjects were divided into low-OAHI (n = 9) and high-OAHI (n = 9) groups [2.8 +/- 0.7 and 13.5 +/- 4.9 (SD) P < 0.001]. The OAHI correlated positively with the size of the tonsils (r2 = 0.42, P = 0.024) and soft palate (r2 = 0.33, P = 0.049) and inversely with the volume of the oropharyx (r2 = 0.42, P = 0.038). The narrowest point in the pharyngeal airway was smaller in the high-compared with the low-OAHI group (4.4 +/- 1.2 vs. 6.0 +/- 1.3 mm; P = 0.024), and this point was in the retropalatal airway in all but two subjects. The airway cross-sectional area (CSA)-airway length relation showed that the high-OAHI group had a narrower retropapatal airway than the low-OAHI group, particularly in the retropalatal region where the soft palate, adenoids, and tonsils overlap (P = 0.001). The "retropalatal air space," which we defined as the ratio of the retropalatal airway CSA to the CSA of the soft palate, correlated inversely with the OAHI (r2 = 0.49, P = 0.001). We conclude that 7- to 12-yr-old children with a narrow retropalatal air space have significantly more apneas and hypopneas during sleep compared with children with relatively unobstructed retropalatal airways.     

Nasopharyngeal Tonsils (Adenoids) Contain Extrathymic Corticothymocytes

Adenoidal tissue (also known as nasopharyngeal tonsils) of 58% of humans in the pediatric age group contains immature T-lymphoid cells with the phenotype of thymocytes (TdT+,CD1abc+, cytoplasmic CD3+, coexpressing CD4 and CD8, lacking an Intraepithelial Lymphocyte-associated phenotype). The notable difference in comparison to palatine tonsils is the clustering in groups and sheets, comprising hundreds or thousands of cells (1.7%±0.2 of total T cells). The thymic epithelium is morphologically and phenotypically absent. Adenoids share with tonsils and lymph nodes the presence of immature B cell precursors (TdT+, CD1a-, Pax5+, Surrogate light chain±), however in these latter the presence of TdT+, CD1a+, Pax5- precursors is absent or limited to individual cells. Human adenoids are distinct among the Waldeyer''s ring lymphoid tissue because of the known embryogenic derivation from the third pharyngeal pouch, from which the thymus develops; in addition, they may display phenotypic incomplete features of a vestigial thymus.     

孟鲁斯特钠对儿童OSAHS治疗效果的初步研究

目的：探讨孟鲁斯特钠对儿童阻塞性睡眠呼吸暂停低通气综合征（obslructivesleepapneahypopneasyndrome,OSAHS）治疗疗效。方法：对经电子鼻咽喉镜检查腺样体Ⅲ、Ⅳ级经多导睡眠监测为OSAHS的儿童96例,分成两组：药物治疗组48例,使用孟鲁斯特钠,连续使用1个月以上;未用药物组48例。对其家长进行相关临床表现的问卷调查。结果：两组患儿在年龄、病程、伴有鼻部疾病情况以及临床问卷分值间均无显著性差异（P〉0．05）。3个月后随访情况为,药物治疗组经治疗后在“响鼾”、“不安宁的睡眠或频繁醒觉”、“鼻阻塞而张口呼吸”以及“鼻腔很多鼻涕”4个症状的改善有统计学差异（P〈0．05）。未用药物组随访前、后问卷调查,差异均不具有显著性（P〉0．05）。结论：孟鲁斯特钠对儿童OSAHS治疗有一定疗效,可先行药物治疗。症状仍无明显改善的再考虑选择手术治疗。     

扁桃体部分切除术最新进展

扁桃体切除术是耳鼻咽喉科最常见的手术之一,临床上治疗由于扁桃体肥大所致的儿童睡眠阻塞性呼吸暂停综合征,最常用的手术方式为双侧扁桃体切除术。扁桃体在儿童生长发育过程中具有重要的免疫功能,完全切除扁桃体对儿童的免疫功能具有一定的影响。且扁桃体全部切除术后常见一些并发症如出血及疼痛,这使得许多学者提出了扁桃体部分切除术。扁桃体部分切除术较扁桃体全部切除术相比,手术时间短、术后并发症少,在缓解儿童阻塞症状的同时,保留了一部分扁桃体,对于免疫功能也有一定的保留。本文将从扁桃体部分切除术治疗儿童睡眠呼吸暂停综合征的临床疗效以及术后出血、术后疼痛方面作一综述,为扁桃体部分切除术应用于临床提供合理依据。     

A Population-Based Investigation into the Self-Reported Reasons for Sleep Problems

Typologies of sleep problems have usually relied on identifying underlying causes or symptom clusters. In this study the value of using the patient''s own reasons for sleep disturbance are explored. Using secondary data analysis of a nationally representative psychiatric survey the patterning of the various reasons respondents provided for self-reported sleep problems were examined. Over two thirds (69.3%) of respondents could identify a specific reason for their sleep problem with worry (37.9%) and illness (20.1%) representing the most commonly reported reasons. And while women reported more sleep problems for almost every reason compared with men, the patterning of reasons by age showed marked variability. Sleep problem symptoms such as difficulty getting to sleep or waking early also showed variability by different reasons as did the association with major correlates such as worry, depression, anxiety and poor health. While prevalence surveys of ‘insomnia’ or ‘poor sleep’ often assume the identification of an underlying homogeneous construct there may be grounds for recognising the existence of different sleep problem types particularly in the context of the patient''s perceived reason for the problem.     

Rhabdomyomatous hamartomata of the pharyngeal region with bilateral microtia and aural atresia: A new association?

BACKGROUND: Bilateral microtia with aural atresia is rare. Rhabdomyomatous hamartomata containing salivary tissue, situated bilaterally and symmetrically simulating the palatine (faucial) tonsils, has apparently not been reported. We present the combination of these findings in two unrelated patients. CASES: In the first case, the patient was exposed prenatally to 13-cis-retinoic acid (isotretinoin) and has typical features of this exposure, including bilateral microtia with aural atresia and bilateral 7th nerve palsies. Due to symptoms of obstructive sleep apnea, patient 1 had a "tonsillectomy" and adenoidectomy. Histopathologic studies demonstrated rhabdomyomatous hamartomata containing salivary and striated muscle tissue in place of the palatine tonsils. In the second case, the patient had been prenatally exposed to alcohol, cocaine, and marijuana. He has been noted to have developmental delay and behavioral issues in addition to bilateral microtia with aural atresia. "Tonsillectomy" and adenoidectomy were performed to alleviate chronic upper respiratory infections and snoring. Again, histopathologic studies of the tissue submitted as "tonsil" demonstrated rhabdomyomatous hamartomata containing salivary and muscle tissue. Although an extended banded karyotype and subtelomere panel were normal, a genetic etiology for the second patient's features cannot be excluded. CONCLUSIONS: We hypothesize that the findings of bilateral microtia with aural atresia and rhabdomyomatous hamartomata containing salivary and muscle tissue in the area of the palatine tonsils may represent a newly recognized association, which may have a teratogenic and/or genetic etiology.     

Snoring in children: association with respiratory symptoms and passive smoking.

OBJECTIVE--To investigate the relation between snoring and various respiratory symptoms and passive parental smoking. DESIGN--Data were collected by questionnaire. SETTING--Primary schools in Guardiagrele and Francavilla in the Abruzzi region in central Italy. SUBJECTS--1615 Children aged 6-13 years were categorised according to whether they snored often; occasionally apart from with colds; only with colds; or never. RESULTS--118 Children were habitual snorers and 137 were reported to snore apart from when they had colds. Never snorers (n = 822) were significantly older than children in other categories. Snoring was significantly associated with rhinitis, production of cough and sputum, previous tonsillectomy, and passive parental smoking. Of the habitual snorers, 82 were exposed to passive smoking. The prevalence of habitual snoring increased significantly with the number of cigarettes smoked by parents (from 5.5% in never smoking [corrected] households to 8.8% in heavy smoking households). CONCLUSIONS--Snoring is quite common in children. The dose-effect relation of smoking and snoring shown in this study adds weight to a further adverse effect of parental smoking on children''s health.     

孤独症儿童生存质量、睡眠质量现状调查及睡眠障碍的影响因素分析

摘要 目的：分析孤独症儿童生存质量、睡眠质量现状,探讨其睡眠障碍的影响因素。方法：选择2017年1月至2019年12月期间我院收治的孤独症儿童100例作为研究组,另选同期于我院进行体检的健康儿童100例作为对照组,分别应用生存质量简易量表、社会支持评定量表、儿童睡眠质量调查问卷调查两组生存质量、社会支持情况、睡眠质量。应用单因素及多因素Logistic回归分析孤独症儿童睡眠障碍的影响因素。结果：研究组儿童生存质量简易量表的主观标准评分、客观标准评分及社会支持评定量表的主观支持评分、客观支持评分、对社会支持的利用度评分、总分均显著低于对照组（P＜0.05）。研究组入睡困难、睡眠不安、间断睡眠、夜惊、夜间尿床、打鼾、梦呓、梦游、张口呼吸、夜间磨牙、睡眠出汗发生率均显著高于对照组（P＜0.05）,两组梦魇发生率比较无统计学差异（P>0.05）。研究组患儿中存在睡眠障碍的46例,无睡眠障碍的54例。单因素分析显示,睡眠障碍组父母关系差、家族精神病史、新生儿窒息史、出生体重<2500 g比例显著高于无睡眠障碍组（P＜0.05）。多因素Logistic回归分析显示,父母关系差、有家族精神疾病史、有新生儿期窒息史、出生体重<2500 g是孤独症儿童睡眠障碍的危险因素（P＜0.05）。结论：与健康儿童相比,孤独症儿童生存质量、社会支持情况较差,睡眠障碍发生率也较高,父母关系差、有家族精神疾病史、有新生儿期窒息史、出生体重<2500 g是孤独症儿童睡眠障碍的危险因素。     

Habitual Snoring in school-aged children: environmental and biological predictors

Background

Habitual snoring, a prominent symptom of sleep-disordered breathing, is an important indicator for a number of health problems in children. Compared to adults, large epidemiological studies on childhood habitual snoring and associated predisposing factors are extremely scarce. The present study aimed to assess the prevalence and associated factors of habitual snoring among Chinese school-aged children.

Methods

A random sample of 20,152 children aged 5.08 to 11.99 years old participated in a cross-sectional survey, which was conducted in eight cities of China. Parent-administrated questionnaires were used to collect information on children''s snoring frequency and the possible correlates.

Results

The prevalence of habitual snoring was 12.0% (14.5% for boys vs. 9.5% for girls) in our sampled children. Following factors were associated with an increased risk for habitual snoring: lower family income (adjusted odds ratio [OR] = 1.46), lower father''s education (OR = 1.38 and 1.14 for middle school or under and high school of educational level, respectively), breastfeeding duration < 6 months (OR = 1.17), pregnancy maternal smoking (OR = 1.51), obesity (OR = 1.50), overweight (OR = 1.35), several respiratory problems associated with atopy and infection, such as chronic/allergic rhinitis (OR = 1.94), asthma (OR = 1.43), adenotonsillar hypertrophy (OR = 2.17), and chronic otitis media (OR = 1.31), and family history of habitual snoring (OR = 1.70).

Conclusion

The prevalence of habitual snoring in Chinese children was similar to that observed in other countries. The potential predisposing factors covered socioeconomic characteristics, environmental exposures, chronic health problems, and family susceptibility. Compared to socioeconomic status and family susceptibility, environmental exposures and chronic health problems had greater impact, indicating childhood habitual snoring could be partly prevented by health promotion and environmental intervention.     

Computational fluid dynamics modeling of the upper airway of children with obstructive sleep apnea syndrome in steady flow

Computational fluid dynamic (CFD) analysis was used to model the effect of airway geometry on internal pressure in the upper airway of three children with obstructive sleep apnea syndrome (OSAS), and three controls. Model geometry was reconstructed from magnetic resonance images obtained during quiet tidal breathing, meshed with an unstructured grid, and solved at normative peak resting flow. The unsteady Reynolds-averaged Navier-Stokes equations were solved with steady flow boundary conditions in inspiration and expiration, using a two-equation low-Reynolds number turbulence model. Model results were validated using an in-vitro scale model, unsteady flow simulation, and reported nasal resistance measurements in children. Pharynx pressure drop strongly correlated to airway area restriction. Inspiratory pressure drop was primarily proportional to the square of flow, consistent with pressure losses due to convective acceleration caused by area restriction. On inspiration, in OSAS pressure drop occurred primarily between the choanae and the region where the adenoids overlap the tonsils (overlap region) due to airway narrowing, rather than in the nasal passages; in controls the majority of pressure drop was in the nasal passages. On expiration, in OSAS the majority of pressure drop occurred between the oropharynx (posterior to the tongue) and overlap region, and local minimum pressure in the overlap region was near atmospheric due to pressure recovery in the anterior nasopharynx. The results suggest that pharyngeal airway shape in children with OSAS significantly affects internal pressure distribution compared to nasal resistance. The model may also help explain regional dynamic airway narrowing during expiration.     

Relation between systemic hypertension and sleep hypoxaemia or snoring: analysis in 748 men drawn from general practice.

OBJECTIVE--To establish whether a history of snoring or the degree of overnight hypoxaemia is an important independent predictor of systemic blood pressure. DESIGN--Prospective community based study of blood pressure in relation to overnight oxygen saturation, height, weight, and a questionnaire assessment of snoring, smoking, and alcohol consumption. Analysis was by multiple linear regression techniques and analysis of variance. SETTING--Small town outside Oxford, served by one group general practice of four partners. All measurements were made at home. SUBJECTS--The names of 836 men aged 35-65 were drawn at random from the general practitioners'' age and sex register and the men then asked to participate; 752 (90%) agreed. MAIN OUTCOME MEASURES--Systolic, mean, and diastolic blood pressures and their association with age, obesity, alcohol consumption, cigarette consumption, snoring, and overnight hypoxaemia. RESULTS--Though systemic blood pressure correlated significantly with overnight hypoxaemia, this was due to the cross correlation with age, obesity, and alcohol consumption. No independent predictive effect of overnight hypoxaemia was found. Snoring was correlated with systemic blood pressure but not significantly so and also was not an independent predictor once age, obesity, and alcohol consumption had been allowed for. CONCLUSIONS--It is unlikely that snoring and sleep hypoxaemia from occult sleep apnoea are important causes of diurnal systemic hypertension when compared with age, obesity, and alcohol consumption. The increased prevalence of cardiovascular complications reported in snorers may be due to the confounding variable of obesity or to nocturnal rises in blood pressure that are not reflected in the daytime figures.     

Sleep-related obstructive disordered breathing in cleft palate patients after palatoplasty

Sleep-disordered breathing is frequently associated with children presenting congenital midface defects. Because of structural and functional anomalies in the upper airway, children with cleft palate, especially after surgery, may carry a higher risk of developing sleep-disordered breathing. However, the presence of such sleep-disordered breathing in older cleft palate children has not been emphasized. The aim of this comparative overnight cardiorespiratory sleep study was to evaluate cleft palate patients according to sleep-disordered breathing. A group of 43 cleft palate children (17 girls and 26 boys; mean age, 12.1 +/- 3.8 years) was compared with a control group of 20 randomly selected, noncleft children matched for age, sex, and body mass index. None of the patients suffered from manifest sleep-disordered breathing. Cleft palate patients had a statistically significantly higher respiratory disturbance index and snoring index, but no increased apnea index. The data suggest that cleft palate patients having undergone primary closure of the palate demonstrate microsymptoms of nocturnal upper airway obstruction.     

骨性Ⅲ类错合畸形患者正颌术后呼吸道情况随访调查

目的：通过评估骨性Ⅲ错合畸形患者正颌手术后睡眠时期的呼吸功能情况,研究该类患者正颌手术后存在呼吸道梗阻的可能性。为临床治疗提供依据。方法：分析56例接受正颌手术的骨性Ⅲ类错合畸形患者的术前及术后1周、1月、3月和术后6月的多导睡眠图报告。设计问卷调查表评估手术影响日间嗜睡度的变化。从PSG报告上获得的术前术后有代表性的2项参数睡眠呼吸暂停低通气指数与最低氧饱和度分别进行比较。结果：数据显示术前和术后AHI指数及SpO2无显著性差异（统计学上无差异）。54例病人术后均未出现睡眠呼吸障碍症状。2例病人术后出现睡眠时期打鼾,但术后随访6月后打鼾逐渐消失。结论：骨性Ⅲ类错合畸形患者正颌术后无明显呼吸道梗阻症状。但若患者同时具有超重、短颈、舌体大等其他危险因素及仅行下颌骨后退手术可能导致睡眠呼吸暂停低通气综合症的发生。     

TONSILLECTOMY IN THE ALLERGIC CHILD

Edema is the chief factor in enlargement of tonsils of children with allergic disease.In the absence of infection tonsillectomy and adenoidectomy are contraindicated in the allergic child except when obstruction is present.Infection produces one of two distinct patterns when it influences allergic states, the pattern depending upon the nature of the infectious disease.Chronic infection of the upper respiratory tract in the allergic child produces a pattern simulating that of acute respiratory infection.If, in the presence of infected tonsils and adenoids, management of the allergic state does not produce results, tonsillectomy and adenoidectomy are indicated. Management of the allergic disease must be continued postoperatively.Whether infection is present or absent, allergic disease can be controlled only through competent management of it.