2. adenoid enlargement

ADENOID ADENOID ENLARGEMENTENLARGEMENT

Fahad zakwanFahad zakwanMD5MD5

EmbryologyEmbryology

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

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

Blood SupplyBlood SupplyTonsilsTonsils• Ascending and descending

palatine arteries

• Tonsillar artery

• 1% aberrant ICA just deep to superior constrictor

AdenoidsAdenoids• Ascending pharyngeal,

sphenopalatine arteries

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

HistologyHistologyTonsilsTonsils• Specialized squamous• Extrafollicular• Mantle zone• Germinal center

AdenoidsAdenoids• Ciliated pseudostratified columnar• Stratified squamous• Transitional

Function and ImmunologyFunction and Immunology

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

Common Diseases of the Tonsils Common Diseases of the Tonsils and Adenoidsand Adenoids

1.1. Acute adenoiditis/tonsillitisAcute adenoiditis/tonsillitis2.2. Recurrent/chronic Recurrent/chronic

adenoiditis/tonsillitisadenoiditis/tonsillitis3.3. Obstructive hyperplasiaObstructive hyperplasia4.4. MalignancyMalignancy

The adenoids or pharyngeal The adenoids or pharyngeal tonsiltonsil

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

•Obstructive adenoid hyperplasia Obstructive adenoid hyperplasia includes symptoms of chronic nasal includes symptoms of chronic nasal obstruction, rhinorrhea, snoring, mouth obstruction, rhinorrhea, snoring, mouth breathing, and a hyponasal voice.breathing, and a hyponasal voice.

•Obstructive sleep apnea Obstructive sleep apnea in children in children is clinically marked by loud snoring, is clinically marked by loud snoring, apneic episodes while sleeping, apneic episodes while sleeping, daytime somnolence, behavioral daytime somnolence, behavioral problems, and enuresisproblems, and enuresis

Adenoid facies or “long face Adenoid facies or “long face syndrome”.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 The characteristic facial appearance facial appearance consists of:consists of:•Underdeveloped Underdeveloped thin nostrilsthin nostrils• Short upper lipShort upper lip• Prominent upper Prominent upper teethteeth•Crowded teethCrowded teeth•Narrow upper Narrow upper alveolusalveolus

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

DiagnosisDiagnosis•EndoscopyEndoscopy•Posterior rhinoscopyPosterior rhinoscopy•OtoscopyOtoscopy•Radiological examination can also Radiological examination can also helphelp•CT scanCT scan

Posterior RhinoscopyPosterior Rhinoscopy

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

Posterior Posterior Rhinoscopy MirrorRhinoscopy Mirror

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

NasopharygoscopyNasopharygoscopy

• 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 ScanCT Scan

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

MANAGEMENTMANAGEMENT

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

Medical ManagementMedical Management

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

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

Adenoidectomy-IndicationsAdenoidectomy-Indications

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

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

ContraindicationsContraindications

• 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 GagJennings's Mouth Gag

St. Claire St. Claire Thomson Thomson Adenoid CuretteAdenoid Curette• The adenoid curette is The adenoid curette is

used in adenoidectomy used in adenoidectomy operations.operations.

• The instrument has a The instrument has a strong handle, a shaft strong handle, a shaft and a curette at the tip. and a curette at the tip. The curette itself is a The curette itself is a curved, square window curved, square window that allows for the tissue that allows for the tissue to engage in it.to engage in it.

How the adenoid curette is usedHow the adenoid curette is used• For the adenoidectomy operation, the patient lies supine in For the adenoidectomy operation, the patient lies supine in

the neutral position. the neutral position. • The mouth is held open with a mouth gag. The mouth is held open with a mouth gag. • The curette is held at the handle like a dagger. The curette is held at the handle like a dagger. • The curette is then introduced into the oral cavity, all the way The curette is then introduced into the oral cavity, all the way

above and behind the soft palate. above and behind the soft palate. • The adenoid tissue is caught in the curette and removed with The adenoid tissue is caught in the curette and removed with

a smooth, shaving movement.a smooth, shaving movement.• Adenoidectomy was earlier performed as a blind procedure. A Adenoidectomy was earlier performed as a blind procedure. A

nasal endoscope can now be used to visualize the procedure.nasal endoscope can now be used to visualize the procedure.

Position for AdenoidectomyPosition for Adenoidectomy

Adenoidectomy SpecimenAdenoidectomy Specimen

ComplicationsComplications

• The incidence of mortality from adenotonsillar The incidence of mortality from adenotonsillar surgery ranges from 1 in 16,000 to 1 in 35,000 surgery ranges from 1 in 16,000 to 1 in 35,000 cases.cases.• Anesthetic complications and Anesthetic complications and hemorrhagehemorrhage cause the majority of deaths.cause the majority of deaths.• The prevalence of hemorrhage ranges from 0.1% The prevalence of hemorrhage ranges from 0.1%

to 8.1%.to 8.1%.• It is divided into primary bleeding, in the first 24 It is divided into primary bleeding, in the first 24

hours, and secondary bleeding, around 7-10 days hours, and secondary bleeding, around 7-10 days post operatively.post operatively.

Other risks include:Other risks include:

• VomitingVomiting• DehydrationDehydration• Airway obstruction due to edemaAirway obstruction due to edema• Pulmonary edemaPulmonary edema• Fever, velopharyngeal insufficiencyFever, velopharyngeal insufficiency• Dental injuryDental injury• BurnsBurns• Nasopharyngeal stenosisNasopharyngeal stenosis