156 D. WANG AND P. CLEMENT Figure 2D Small adenoid but very swollen torus tubarius that blocked the eustachian tubal orifice almost completely. without benefit. An adenoid hypertrophy again was sus- pected by one physician. Tympanometry suggested that there was bilateral otitis media with effusions. Fiberscopic examination of the nasal cavity and nasopharynx then was performed under local anesthesia. It revealed a small ade- noid tissue but with a markedly swollen torus tubarius that partially blocked the eustachian tubal orifice. On the left side (2-E), mucosal scar tissue was found between the Figure 2E Same patient as D. A formation of mucosal scar tissue was found () at the left side between the Vomer and torus tubarius. vomer and the torus tubarius. There were abundant puru- lent secretions in both nasal cavities. These findings indi- cated that adenoidectomy certainly should be avoided in this patient. The elimination of nasal (probably sinus) in- fection had to be considered first. This eventually could be followed by appropriate choanal corrective surgery on the left side. DISCUSSION Examination of the ears, nose, nasopharynx, hypophar- ynx, and larynx has been dramatically altered by the ad- vent of flexible fiberscopic devices (4). The major advantage of the fiberscopic examination is that it pro- vides direct visualization of normal and pathologic con- ditions. In pediatric patients, of course, the major problem is patient cooperation. In our study, topical anesthesia alone could be used in all children younger than year and older than 6 years and in most of the 4- to 6-year-old children. In most children between 1 and 3 years, a com- bination of premedication and local anesthesia is needed (1). A careful explanation to the child and a skilled endo- scopist, however, are the most important guarantors of a successful pediatric endoscopy. It is well known that adenoidectomy is one of the most commonly performed surgical treatments in children. Adenoid hypertrophy often has been considered to relate to many disorders of the upper respiratory tract. The au- thors have reported that the size of the adenoid tissue cor- relates very well with the complaints of nasal obstruction (1,2), snoring (3), and the type of tympanogram (1). When an adenoid hypertrophy was evidenced by endoscopic ex- amination, nasal obstruction was improved in 77.2% of patients, and snoring was ended in 89% after adenoidec- tomy. On the other hand, postoperative training for nasal breathing by the child’s parents is very important, because hypertrophy of the adenoid can induce habitual mouth breathing. Adenoid hypertrophy is one of the common etiologic factors in pediatric otitis media. The mechanism may in- volve direct closure of the nasopharyngeal orifice of the eustachian tube, resulting in middle ear transudate. The authors reported previously that there is a better correla- tion between the condition of the eustachian tubal orifice found during fiberscopy and the tympanogram of the same side (P < 0.0001) than between the size of the adenoid and the tympanogram (P 0.009) (1). It proves the impor- tance of direct visualization by fiberscopy in the diagno- sis of otitis media in some children. On the other hand, otitis media has many causes. Recently, many studies demonstrated that the adherence ofbacteria, especially the