Adenoid Hypertrophy

Adenoids

Adenoids, also referred to as the nasopharyngeal tonsil, are pyramidal-shaped structures with the apex of the pyramid pointing towards the nasal septum and the base situated at the junction of the roof and posterior wall of the nasopharynx. It is composed of vertical ridges of lymphoid tissue separated by clefts. Histologically, its covering epithelium is of three types: ciliated pseudostratified columnar, stratified squamous and transitional.

Adenoid tissue is present at birth, shows physiological enlargement up to the age of 6 years, and then tends to atrophy at puberty and almost completely disappears by the age of 20.

The adenoids are part of Waldeyer’s ring, as such it plays a role as first line defence against pathogens entering the pharynx.

• Functions of adenoids
  • Development of T cells and B cells
  • On the surface, adenoid tissue has specialized antigen-capture cells (ACC), M cells, which uptake the pathogenic antigens and then alert the underlying B cells.
  • Activation of B cells
  • Aid in the development of immunologic memory throughout childhood
  • Produce T lymphocytes
• Arterial supply
  • Basisphenoid artery
  • Ascending pharyngeal artery
  • Ascending palatine branch of the facial artery
  • Pharyngeal branch of the maxillary artery
  • Tonsillar branch of the facial artery
  • Artery of the pterygoid canal
• Venous drainage
  • The venous drainage of the adenoids is through the pharyngeal plexus which drains into the internal jugular vein.
• Lymphatic drainage
  • Drain into upper jugular nodes directly or indirectly via retropharyngeal and para- pharyngeal nodes.
• Nerve supply
  • The innervation of the adenoids originates from the vagus (X) and the glossopharyngeal nerves (IX).

Adenoid hypertrophy

Adenoid hypertrophy is the enlargement of the adenoids. The condition can occur with or without an acute or chronic infection of the adenoids. Causes can be divided into infectious and non-infectious. Recurrent rhinitis, sinusitis and chronic tonsillitis causes chronic adenoid infection and hyperplasia. Diagnosis is clinical.

Clinical features of adenoid hypertrophy

In adults, adenoid hypertrophy is seen in immunocompromised states such as in HIV/AIDS and organ transplant patients.

• Causes
  • Physiological (generalized lymphoid hyperplasia up to 6 years)
  • URTIs (rhinitis, sinusitis, tonsillitis)
  • Allergies
  • Gastroespohageal reflux disease
  • Passive smoking
• Common infectious pathogens
  • Bacterial – Streptococcus species, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Chlamydophila pneumoniae, Mycoplasma pneumoniae, Fusobacterium, Peptostreptococcus, and Prevotella species.
  • Viral – adenovirus, coronavirus, coxsackievirus, cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus, parainfluenza virus, and rhinovirus.
• Nasal signs and symptoms (due to nasal obstruction)
  • Rhinorrhea
  • Difficulty breathing through the nose (mouth breathing)
  • Chronic cough
  • Post-nasal drip
  • Snoring
  • Sleep-disordered breathing
  • Sinusitis
  • Epistaxis
  • Voice change (Hyponasal)
  In children nasal obstruction can cause failure to thrive as it interferes with feeding. The child is unable to breath and feed at the same time.
• Aural signs and symptoms (due to obstruction of the eustachian tube)
  • Muffled hearing
  • Otalgia
  • Crackling or popping sounds in the ear
  • Recurrent middle ear infections
  • Delayed speech
  • Learning difficulties
• General signs and symptoms
  • Adenoid facies
  • Pulmonary hypertension
  • Aprosexia (inability to maintain concentration)
• Features of adenoid facies
  • Long, elongated narrow face
  • Short upper lip
  • Underdeveloped thin nostrils
  • Malpositioned and prominent upper teeth
  • High-arched palate
• Differentials
  • Choanal atresia
  • Pyriform aperture stenosis
  • Allergic rhinitis
  • Acute or chronic sinusitis
  • Nasal polyposis
  • Intranasal encephalocele
  • Nasal dermoid
  • Nasopharyngeal neoplasm
  • Acute otitis media
  • Chronic serous otitis media
  • Cholesteatoma
  • Nasopharyngeal malignancy
  • Inverting papilloma
  • HIV
• Investigations
  • Posterior rhinoscopy
  • Lateral view X-ray of postnasal space
  • Flexible nasopharyngoscopy: hyperplasia of the adenoids
  • CT paranasal sinuses
  • Polysomnography overnight: to assess the severity of obstructive sleep apnoea
• Treatment
  • Steroid nasal drops/ spray:
    • Spray if > 2 years for 6 months – mometasone, beclometasone once daily
    • Drops if < 2 yrs for 3 months
  • Antibiotics (azithromycin or clindamycin in case of penicillin allergy)
    • Co-amoxiclav 50mg/ kg for 5- 10 days
    • Amoxicillin 90mg/ kg
  • Nasal decongestants: xylometazoline, oxymetazoline, phenylephrine (for not more than 5 days due to rebound congestion)
  • Supportive management: analgesia+ antipyretics (PCM, Ibuprofen), anti-inflammatory drugs (prednisolone syrup)
  • Adenoidectomy (if indicated)

Adenoidectomy

An adenoidectomy is the surgical excision of adenoid tissue.

• Indications for adenoidectomy
  • Failure to thrive
  • Adenoid facies
  • Febrile convulsions
  • Serous acute otitis media
  • Obstructive sleep apnoea
  • Pulmonary hypertension
  • Speech or language delays
  • Chronic rhinosinusitis unresponsive to medical treatment
  • Recurrent or persistent otitis media
  • Craniofacial growth or occlusive abnormalities
• Post-operative care
  • Rest is encouraged the first one to two (1-2) days to a week
  • Most otolaryngologists allow children to have normal diets once they have recovered from the general anesthetic however soft foods and fluids are recommended.
  • Treat pain with acetaminophen.
  • Gargle with ice water for slight bleeds
• Complications of adenoidectomy
  • Bleeding
  • Velopharyngeal insufficiency
  • Torticollis
  • Nasopharyngeal stenosis
  • Mandibular condyle fracture
  • Eustachian tube injury
  • Injury to the tongue, teeth and other surrounding structures
  • Anaesthetic complications