Adenoiditis
Definition And Anatomy
- Represents hyperplasia of nasopharyngeal tonsil (Luschka’s tonsil).
- Located at anatomical junction of roof and posterior wall of nasopharynx.
- Constitutes integral component of Waldeyer’s Ring alongside palatine, lingual, and tubal tonsils.
- Present at birth, undergoes physiologic hypertrophy during 3–7 years mirroring peak immunological activity,.
- Regresses spontaneously by puberty,.
Etiology And Pathophysiology
- Driven by recurrent viral (Rhino/Adenovirus) or bacterial (Beta-hemolytic Streptococci, Haemophilus influenzae, Moraxella catarrhalis) infections.
- Exacerbated by chronic allergic rhinitis triggering continuous lymphoid hyperplasia.
- Associated with environmental irritants including passive cigarette smoke.
- Provoked by chronic irritation from gastroesophageal reflux disease.
- Enlargement causes direct mechanical obstruction of nasopharynx and Eustachian tube orifices,.
- Acts as bacterial reservoir maintaining chronic regional inflammation.
Clinical Features
Nasal And Speech Symptoms
| Feature | Clinical Manifestation |
|---|---|
| Nasal Obstruction | Bilateral, persistent blockage requiring continuous mouth breathing, especially during sleep. |
| Discharge | Chronic mucopurulent nasal discharge indicating concurrent adenoiditis. |
| Voice Alteration | Hyponasal speech (Rhinolalia clausa) lacking normal nasal resonance. |
| Sleep Disordered Breathing | Ranges from simple snoring to severe obstructive sleep apnea. |
Otologic And Systemic Symptoms
| System | Specific Findings |
|---|---|
| Otologic | Eustachian tube dysfunction, recurrent acute otitis media, otitis media with effusion (glue ear) causing conductive hearing loss. |
| Sleep Disturbances | Restless sleep, night terrors, enuresis,. |
| Cardiopulmonary | Rare development of pulmonary hypertension (cor pulmonale) secondary to severe chronic obstructive sleep apnea. |
Adenoid Facies
- Characteristic facial appearance resulting from chronic mouth breathing.
- Elongated face with dull expression.
- Open mouth posture with prominent upper incisors (bunny teeth).
- High arched palate with hypoplastic maxilla and pinched nostrils.
Grading (Clemens Classification)
- Based on endoscopic assessment of choanal obstruction.
- Grade I: 0–25% obstruction.
- Grade II: 26–50% obstruction.
- Grade III: 51–75% obstruction.
- Grade IV: 76–100% obstruction.
Diagnostic Evaluation
| Modality | Utility And Findings |
|---|---|
| Diagnostic Nasal Endoscopy | Gold standard investigation directly visualizing adenoid size and choanal patency. |
| X-Ray Nasopharynx (Lateral) | Soft tissue technique utilizing Fujioka’s Method. Ratio of adenoidal depth to nasopharyngeal space >0.8 indicates significant hypertrophy. |
| Tympanometry | Rules out associated otitis media with effusion demonstrating flat Type B curve. |
| Polysomnography | Gold standard sleep study indicated for suspected obstructive sleep apnea. |
Differential Diagnosis
- Choanal atresia (unilateral or bilateral bony/membranous blockage).
- Antrochoanal polyp (solitary mass originating from maxillary sinus).
- Juvenile nasopharyngeal angiofibroma (adolescent males, profuse bleeding).
- Allergic rhinitis (pale turbinates, sneezing).
- Foreign body (unilateral foul-smelling discharge).
Management
Medical Management
- Constitutes first-line therapy for mild-to-moderate symptoms without severe obstructive sleep apnea.
- Intranasal corticosteroids (Fluticasone/Mometasone) administered for 6–12 weeks.
- Reduces adenoid size by decreasing local lymphocyte infiltration.
- Antibiotics (Amoxicillin-Clavulanate) utilized for acute adenoiditis exacerbations.
- Saline nasal washes indicated for clearing mucopurulent secretions.
- Strict control of underlying co-morbidities including allergies and gastroesophageal reflux.
Surgical Management (Adenoidectomy)
- Indications:
- Severe nasal obstruction causing persistent mouth breathing or established adenoid facies.
- Documented obstructive sleep apnea.
- Recurrent rhinosinusitis failing maximal medical therapy,.
- Chronic otitis media with effusion lasting >3 months with associated hearing loss.
- Recurrent acute otitis media,.
- Severe dental malocclusion.
- Surgical Techniques:
- Conventional blind curettage utilizing St. Clair Thomson curette.
- Endoscopic-assisted powered microdebrider shaving for precision removal.
- Coblation utilizing radiofrequency ablation resulting in less bleeding and pain.
Complications Of Surgery
| Complication | Pathological Mechanism |
|---|---|
| Hemorrhage | Primary or reactive bleeding, though less common compared to tonsillectomy. |
| Grisel’s Syndrome | Atlanto-axial subluxation developing secondary to postoperative paraspinous inflammation. |
| Velopharyngeal Insufficiency | Hypernasal speech (Rhinolalia aperta) arising from excessive tissue removal or underlying submucous cleft palate,. |
| Regrowth | Tissue recurrence possible, especially if surgical extirpation performed at very young age. |