ADENOID ENLARGEMENT
By
Dr. Kaminee Kumar Tripura

Embryology
• The formation of the adenoids begins in the 3rd month
of fetal development. This starts with glandular
primordia in the posterior nasopharynx becoming
associated with infiltrating lymphocytes.
• In the 5th month sagittal folds are formed which are
the beginnings of pharyngeal crypts. The surface is
covered with pseudostratified ciliated epithelium.
• By the 7th month of development the adenoids are
fully formed.

Anatomy
• The lymphoid tissue of the nasopharynx and oropharynx
is composed of the adenoids, the tubal tonsils, the
lateral bands, the palatine tonsils, and the lingual tonsils.
• There are also lymphoid collections in the posterior
pharyngeal wall and in the laryngeal ventricles.
• These structures form a ring of tissue named
Waldeyer’s ring after the German anatomist who
described them.

Blood Supply
Tonsils
• Ascending and descending
palatine arteries
• Tonsillar artery
• 1% aberrant ICA just deep to
superior constrictor
Adenoids
• Ascending pharyngeal,
sphenopalatine arteries

•Venous drainage is through the
pharyngeal plexus and the pterygoid
plexus flowing ultimately into the facial and
internal jugular veins.
•Innervation is derived from the
glossopharyngeal and vagus nerves.
•Efferent lymphatics drain to the
retropharyngeal nodes and the upper
deep cervical nodes.

Histology
Tonsils
• Specialized squamous
• Extrafollicular
• Mantle zone
• Germinal center
Adenoids
• Ciliated pseudostratified columnar
• Stratified squamous
• Transitional

Function and Immunology
• The tonsils and adenoids are part of the secondary
immune system.
• Without afferent lymphatics the lymphoid nodules in
these structures are exposed to antigen only in the
crypts of the palatine tonsils and the folds of the
adenoids where it is transported through the epithelial
layer.
• These are involved in the production of mostly
secretory IgA, which is transported to the surface
providing local immune protection.

Common Diseases of the Tonsils and
Adenoids
1. Acute adenoiditis/tonsillitis
2. Recurrent/chronic
adenoiditis/tonsillitis
3. Obstructive hyperplasia
4. Malignancy

The adenoids or pharyngeal tonsil
• It is a single mass of pyramidal tissue with
its base on the posterior nasopharyngeal
wall and it’s apex pointed toward the nasal
septum.
• The surface is invaginated in a series of
folds.
• The epithelium is pseudostratified ciliated
epithelium and is infiltrated by the lymphoid
follicles.

CLINICAL FEATURES
• Acute adenoiditis symptoms include
• purulent rhinorrhea,
• nasal obstruction,
• fever, and
• sometimes otitis media due to their proximity to the Eustachian tubes
• the patient may also present with:
• swallowing difficulties
• speech anomalies (hyponasal speech)
• sleep-disordered breathing
• This can be difficult to differentiate from an acute upper
respiratory infection but tends to have a longer and more
severe course.

•Recurrent acute adenoiditis is 4 or more
episodes of acute adenoiditis in a 6- month
period with intervening periods of wellness.
•Chronic adenoiditis symptoms include
•persistent rhinorrhea,
•postnasal drip,
•malodorous breath, and
•associated otitis media or extra esophageal
reflux lasting at least 3 months.

•Obstructive adenoid hyperplasia
includes symptoms of chronic nasal
obstruction, rhinorrhea, snoring, mouth
breathing, and a hyponasal voice.
•Obstructive sleep apnea in children is
clinically marked by loud snoring, apneic
episodes while sleeping, daytime
somnolence, behavioral problems, and
enuresis

Adenoid facies or “long face
syndrome”.
• It is the long, open-mouthed, face of
children with adenoid hypertrophy.
• The mouth is always open because
upper airway congestion has made
patients obligatory mouth breathers.
• The most common presenting symptoms
are chronic mouth breathing and
snoring.
• The most dangerous symptom is sleep
apnea

•The characteristic
facial appearance
consists of:
•Underdeveloped
thin nostrils
•Short upper lip
•Prominent upper
teeth
•Crowded teeth
•Narrow upper
alveolus

• High-arched palate
• Hypoplastic maxilla
• Eustachian blockage
causing glue ear-
deafness
• The deafness and
inattentiveness
interferes with the
learning
• Child grows with
lowered intelligence
and understanding

Diagnosis
•Endoscopy
•Posterior rhinoscopy
•Otoscopy
•Radiological examination can also help
•CT scan

Posterior Rhinoscopy
•Posterior rhinoscopy is done to look for
lesions in the post nasal space - for
example, adenoids, tumors of the
nasopharynx, etc.

Posterior Rhinoscopy
Mirror
Uses
:
• Examination of the post nasal
space by a procedure called
posterior rhinoscopy, an out-
patient procedure.
• The mirror is warmed and introduced
into the oral cavity while the tongue is
depressed with a tongue depressor.
• The mirror is turned upwards in
order to examine the post nasal
space.
• The shaft of the instrument is bent to
achieve a bayonet shape, a feature
that helps differentiate it from the
indirect laryngoscopy mirror.
• The mirror is available in 5 sizes.

Nasopharygoscopy
• Nasopharyngoscopy is a
procedure which enables the
doctor to examine the internal
surfaces of the nose and throat
(nasopharynx).
• Nasopharyngoscopy provides a
direct view of every part of the
upper respiratory tract from the
nasal passages down the throat to
the larynx

Nasopharygoscope

Lateral neck radiograph
• The main imaging study to evaluate the adenoid is a lateral neck
radiograph, as in the images below.

CT Scan
• CT scan is not normally used to evaluate the
adenoids. However, when a CT scan is performed to
evaluate the sinuses, the choana and nasopharynx
are occasionally imaged, providing information on the
size of the adenoids
• If the adenoids look abnormal or if a mass is present
in the nasopharynx in an older child or in an adult, an
imaging study (eg, CT scan, MRI) is obtained to rule
out a lesion other than an adenoid

MANAGEMENT
•Management options include
•wait until they involute
•surgical removal (ADENOIDECTOMY)
•Non surgical management include-
intranasal corticosteroids

Medical Management
• No good evidence supports any curative medical
therapy for chronic infection of the adenoids.
• Systemic antibiotics have been used long-term (ie, 6
wk) for lymphoid tissue infection, but eradication of the
bacteria failed.
• In fact, with the current trend of resistant bacteria, the
use of prophylactic or long-term antibiotics has been
decreased to prevent the formation of resistant bacteria.

• Some studies indicate a benefit with using topical nasal
steroids in children with adenoid hypertrophy.
• Studies indicate that while using the medication, the
adenoid may shrink slightly (ie, up to 10%), which
may help relieve some nasal obstruction.
• However, once the topical nasal steroid is
discontinued, the adenoid can again hypertrophy and
continue to cause symptoms.
• In a child with nasal obstructive symptoms with or
without presumed allergic rhinitis, a trial of topical
nasal steroid spray and saline spray may be
considered for effective control of symptoms.

Adenoidectomy-Indications
• Four or more episodes of recurrent purulent rhinorrhea
in prior 12 months in a child <12. One episode
documented by intranasal examination or diagnostic
imaging.
• Persisting symptoms of adenoiditis
• after 2 courses of antibiotic therapy.
• Sleep disturbance with nasal airway obstruction
persisting for at least 3 months.
• Hyponasal or nasal speech

•Otitis media with effusion >3 months or
second set of tubes
•Dental malocclusion or orofacial growth
disturbance documented by orthodontist.
•Cardiopulmonary complications including cor
pulmonale, pulmonary hypertension, right
ventricular hypertrophy associated with upper
airway obstruction.
•Otitis media with effusion over age 4.

Contraindications
• A submucous cleft palate which may lead to velopharyngeal
insufficiency after surgery. If the adenoid obstruction is severe
enough, then only superior half adenoidectomy is performed.
• Avoid surgery in patients with hemoglobin less than 10.
• Perform surgery at least 2 weeks after the last attack of
acute tonsillitis.
• Wait at least 6 weeks after polio vaccination.
• Avoid surgery in patients with uncontrolled systemic
diseases (ie. leukemia).

Jennings's Mouth Gag

St. Claire Thomson
Adenoid Curette
• The adenoid curette is
used in adenoidectomy
operations.
• The instrument has a strong
handle, a shaft and a curette
at the tip. The curette itself is
a curved, square window that
allows for the tissue to
engage in it.

How the adenoid curette is used
• For the adenoidectomy operation, the patient lies supine
in the neutral position.
• The mouth is held open with a mouth gag.
• The curette is held at the handle like a dagger.
• The curette is then introduced into the oral cavity, all the
way above and behind the soft palate.
• The adenoid tissue is caught in the curette and removed
with a smooth, shaving movement.
• Adenoidectomy was earlier performed as a blind
procedure. A nasal endoscope can now be used to
visualize the procedure.

Position for Adenoidectomy

Adenoidectomy Specimen

Complications
• The incidence of mortality from adenotonsillar
surgery ranges from 1 in 16,000 to 1 in 35,000
cases.
• Anesthetic complications and hemorrhage
cause the majority of deaths.
• The prevalence of hemorrhage ranges from 0.1% to
8.1%.
• It is divided into primary bleeding, in the first 24 hours,
and secondary bleeding, around 7-10 days post
operatively.

Other risks include:
• Vomiting
• Dehydration
• Airway obstruction due to edema
• Pulmonary edema
• Fever, velopharyngeal insufficiency
• Dental injury
• Burns
• Nasopharyngeal stenosis