Enlarged Adenoids

Overview

The adenoids are a cluster of lymphoid tissue found on the nasopharyngeal posterior wall beyond the soft palate. Waldeyer's ring is made up of the adenoids, as well as Gerlach's faucial tonsils, lingual tonsils, and tubal tonsils. In infancy, these tissues work together to become an important aspect of the human immune system.

Antigens enter the oral and nasal passages and come into touch with Waldeyer's ring immune cells. These cells can then establish immunologic memory of the antigens and resist them by making IgA antibodies; this is hypothesized to result in immune system "priming" in infancy.

The adenoids are present at birth and grow throughout childhood, reaching their maximum size by the age of seven. They will decline in size during puberty and may be almost nonexistent by adulthood in the majority of people. As a result, adenoiditis is usually associated with childhood and adolescence. Adenoid hypertrophy occurs when the adenoid tissue becomes inflamed as a result of infection, allergies, or irritation from stomach acid.

Adenoid hypertrophy seldom occurs on its own and is usually part of a larger illness process such as adenotonsillitis, pharyngitis, rhinosinusitis, and so on. Constant irritation can cause adenoid hypertrophy, which is the root cause of many adenoid disease issues. Inflammation of adenoids is classed as either acute or chronic.

Treatment with analgesics or antipyretics is frequently adequate in cases with viral adenoiditis. Antibiotics, such as amoxicillin-clavulanic acid or a cephalosporin, can be used to treat bacterial adenoiditis. Adenoidectomy may be performed to remove the adenoid in cases of adenoid hypertrophy.

What are adenoids?

The pharyngeal tonsils, also known as adenoids, constitute the bulk of lymphatic tissue within Waldeyer's ring. Adenoids are located high in the neck behind the nose and the roof of the mouth and are not visible without the use of specific instruments. A dental mirror and light are typically used by doctors to find the adenoids. Adenoids develop from birth to the first 6 or 7 years of life, then start to diminish by adolescence.

The adenoids receive their blood supply from the ascending pharyngeal artery, maxillary artery, and facial artery. Venous drainage occurs through the pharyngeal veins. Nervous innervation is through the vagus nerve and glossopharyngeal nerve. Adenoid size grading is on a scale of zero to four:

• 0: absent
• 1+: <25% obstruction of the nasopharynx
• 2+: 25-50% obstruction
• 3+: 50-75% obstruction
• 4+: >75% obstruction

How common is adenoids enlargement?

Exact incidence and prevalence statistics for adenoids enlargement alone are difficult to determine since it is generally handled in the context of a larger disease process, such as rhinosinusitis or adenotonsillar illness. Because adenoid tissue atrophies throughout puberty, adenoids hypertrophy is generally a childhood condition. The current evidence does not indicate a gender, racial, geographic, or socioeconomic class preference in this disease, while parental smoking has been found to be positively associated.

Adenoiditis and concurrent adenoid hypertrophy can be challenging to differentiate from bacterial sinusitis in children. Statistics on sinusitis in children, therefore, may give us some idea of the frequency of adenoiditis. Estimates are that children have six to eight viral URIs per year. Five to thirteen percent of these viral URIs result in bacterial superinfection, leading to sinusitis with adenoiditis as a potential component of the illness.

What causes adenoid hypertrophy?

Many agents and infections can induce adenoid tissue inflammation. An acute onset of adenoids inflammation and hypertrophy is frequently preceded by a viral upper respiratory tract infection (URI). Bacterial pathogens can infect and grow in these sensitive tissues.

The most common bacterial pathogens cultured from adenoid specimens are:

• Haemophilus influenza
• Streptococcus pneumoniae
• Streptococcus pyogenes
• Staphylococcus aureus

Chronic adenoiditis is more typically a polymicrobial infection caused by anaerobic bacteria and is usually caused by biofilm formation.

Allergies are thought to contribute to adenoiditis and consequent adenoid enlargement. Allergens breathed via the nose touch the adenoid tissue. The tissues will multiply in order to make IgA and develop a response to allergens.

Chronic stomach acid irritation in the context of gastroesophageal reflux disease (GERD) may also have a role in adenoiditis and adenoid hypertrophy, particularly in newborns and young children.

How Adenoid inflammation and hypertrophy develop?

Acute adenoiditis is frequently caused by a viral upper respiratory tract infection (URI). Bacterial agents multiply and infect the adenoids and surrounding tissue, causing inflammation and increased exudate production. Rhinorrhea, post-nasal drip, nasal obstruction, snoring, fever, and halitosis are some of the symptoms.

Chronic adenoiditis exhibits many of the same symptoms as acute adenoiditis but lasts 90 days and is frequently caused by polymicrobial infections and biofilm development. In chronic adenoiditis, exudates are typically lacking.

Environmental allergens or caustic irritation from stomach acid in the context of GERD are possible causes of adenoiditis and adenoids hypertrophy.

Any type of persistent inflammation can cause lymphoid tissue to proliferate and cause adenoids hypertrophy. This hypertrophy can cause nasal airway blockage and Eustachian tube obstruction, which can lead to further issues such as obstructive sleep apnea (OSA) and otitis media.

Symptoms and signs of Adenoids enlargement

Around puberty, adenoid tissue normally regresses. As a result, the typical adenoids hypertrophy patient is a prepubescent child with a recent history of upper respiratory tract infection (URI). Recurrent acute otitis media, chronic nasal obstruction with mouth-breathing, chronic otitis media, sleep-disordered breathing/obstructive sleep apnea, or GERD may also be present.

Purulent rhinorrhea, post-nasal drip, nasal blockage, snoring, fever, mouth breathing, and halitosis are all physical manifestations. The indirect mirror exam may allow the practitioner to see larger adenoids with exudates, but it is a difficult test to do on children. A flexible nasal and laryngeal endoscopic exam can allow for a better examination of the adenoids, but it requires extensive training and the agreement of the kid and parents to employ.

Long-term adenoiditis with subsequent adenoid enlargement in children can result in the development of adenoid facies, also known as long face syndrome. Enlarged adenoids restrict the nasopharynx, forcing people to breathe via their mouths, which can result in craniofacial anomalies such a high-arched palate and a retrognathic jaw.

How are the causes of Adenoids enlargement evaluated?

Clinical Evaluation:

The clinical diagnosis of acute adenoid enlargement is obtained based on the following findings:

• possible concomitant acute otitis media, Fever, Purulent rhinorrhea, postnasal drip, nasal blockage, throat pain Halitosis
• A laryngeal mirror or nasal endoscope can be used to view the adenoids visually.

Laboratory Testing:

• Rapid strep test:

If it manifests as pharyngitis, the doctor may want to perform a quick strep test. The reason for doing so is twofold. First and foremost, this will provide a definite diagnosis of the patient's disease and will aid in the direction of antibiotic therapy.

Second, the doctor's office will have a record of positive and negative strep tests, which will be crucial in determining if an adenoidectomy, plus or minus tonsillectomy, is necessary. It's crucial to note that adenoiditis is still a clinical diagnosis, so if the strep test comes back negative, the doctor can assume it's caused by a different organism.

• Throat culture:

In situations when infection persists after antibiotic therapy, the doctor may choose to perform throat cultures to assist identify the causative agent and guide therapy, as direct cultures of adenoids may be challenging in the office environment.

• Allergy testing:

If the adenoiditis is thought to be caused by seasonal or environmental allergies, allergy skin testing may help guide treatment.

Radiology Testing:

• Lateral neck X-ray.
• Computed tomography (CT) of the sinuses.

If a cause of infection in the sinuses is suspected clinically, sinus X-rays or CT scans may be acquired. In most circumstances, this is not necessary. Lateral neck X-rays are an efficient approach to screen for adenoid enlargement. A sleep study can be conducted in a patient with adenoid hypertrophy who snores to rule out obstructive sleep apnea.

Treatment of Adenoids enlargement

Clinically, adenoiditis and enlargement of adenoids tissue are frequently recognized as a component of rhinosinusitis or pharyngitis. As a result, when treating adenoiditis, practitioners frequently employ clinical care recommendations for rhinosinusitis and pharyngitis.

Medical Management:

• Observation:

If the practitioner suspects the etiology of the adenoid hypertrophy is a common cold or another common viral infection, antibiotics should be avoided. Uncomplicated upper respiratory virus infections usually clear up in five to seven days.

• Antibiotic Treatment:

If symptoms persist or the clinical picture is indicative of bacterial etiology, such as a high fever or purulent discharge from the nose or throat, antibiotics covering the most prevalent pathogens are used as first-line therapy. Because of its high coverage and tolerability, amoxicillin is a routinely utilized first-line agent. If the patient has not responded to amoxicillin, cefdinir or cefuroxime may be given instead.

If the patient is allergic to penicillin, options include clarithromycin or azithromycin. An effective antibiotic therapy should result in a 48-72-hour improvement in symptoms. Treatment should last 10 days since treatment for less time results in substantial recurrence rates and the development of antibiotic resistance. If the situation does not improve after a treatment of amoxicillin or other first-line antibiotics, a course of amoxicillin-clavulanate should be recommended to eradicate possible beta-lactamase generating organisms.

• Allergy Treatment:

Whether the adenoiditis is thought to be caused by environmental allergens, the patient can be given a trial of nasal steroid sprays, oral steroids, oral antihistamines, or a combination of these medications to see if it relieves symptoms. If this works, the patient may benefit from official allergy testing, followed by immune-modulating medication to offer long-term relief.

• Reflux Treatment:

If the adenoiditis is thought to be related to LPR/GERD, therapy with lifestyle and food changes, with or without H2 blockers or proton-pump inhibitors, may give enough symptom relief.

Surgical Management (Adenoidectomy):

In the lack of symptomatic improvement following amoxicillin-clavulanate therapy, or if the patient has several bouts of adenoiditis requiring antibiotic treatment, the patient should be referred to an otolaryngologist for further assessment and possible surgical intervention. Surgical methods may include adenoidectomy with or without tonsillectomy, myringotomy with tympanostomy tube implantation, or endoscopic sinus surgery, depending on the unique conditions. If the patient satisfies the Paradise criteria for tonsillectomy, most otolaryngologists will also remove the adenoids to eliminate another probable source of recurring infections.

What happens after the Adenoidectomy?

Your child will wake up in the recovery area. In most cases, kids can go home the same day as the procedure. Some may need to stay overnight for observation.

The typical recovery after an adenoidectomy often involves a few days of mild pain and discomfort, which may include sore throat, runny nose, noisy breathing, or bad breath.

In less than a week after surgery, everything should return to normal and the problems caused by the adenoids should be gone. There are no stitches to worry about, and the adenoid area will heal on its own.

Are there any risks from Adenoidectomy?

Your kid will be awakened in the recovery room. In most circumstances, children can return home on the same day as the surgery. Some patients may be required to stay overnight for observation.

A few days of moderate pain and discomfort, such as a sore throat, runny nose, loud breathing, or poor breath, are common following an adenoidectomy.

Everything should go back to normal in less than a week, and the issues created by the adenoids should be gone. There will be no sutures, and the adenoid region will heal on its own.

How can I help my child feel better?

As recommended by your health care professional, give your kid pain medication.

Make lots of drinks available. Most children may eat and drink normally within a few hours following surgery, although soft foods such as pudding, soup, gelatin, or mashed potatoes can be introduced first.

Children should rest for a few days following surgery. They should avoid nasal blowing and any hard play or contact sports for a week following surgery.

If your child's nose is congested, a cool-mist humidifier may assist. To avoid mold formation, clean the humidifier on a daily basis.

When should I call the doctor?

Call the doctor if your child:

• Develops a fever
• Vomits after the first day or after taking medicine
• Has neck pain or neck stiffness that doesn't go away with pain medicine
• Has trouble turning the neck
• Refuses to drink
• Isn't peeing at least once every 8 hours

Get medical care right away if your child:

• Has blood dripping out of the nose or coating the tongue for more than 10 minutes.
• Has bleeding after the first day.
• Vomits blood or something that looks like coffee grounds.

Outcome of Adenoids hypertrophy management

In most cases, the medical treatment offered for adenoiditis is effective. Adenoidectomy, which removes hypertrophic or inflamed adenoid tissue, provides a permanent cure for people with recurring disease.

Complications of prolonged inflammation of adenoids

If adenoiditis is not treated, the patient may develop a persistent infection of the adenoids, which can lead to the formation of a biofilm in some cases. The adenoids may then act as a nidus of infection for other tissues that are closely connected, resulting in rhinosinusitis, pharyngitis, tonsillitis, and otitis media.

Some of the most prevalent consequences associated with adenoidal disease are caused by adenoid hypertrophy. As the tissues swell, they can provide a considerable impediment to the passage of air via the nasopharynx. Mouth breathing, snoring, and OSA can all result from this expansion. If left untreated, OSA can be a fatal illness. Removing the adenoids can improve CPAP compliance or resolve the disease entirely by increasing the passage of air through the nasopharynx and lowering obstructive episodes.

Adenoids that are too big may also restrict the entrance of the Eustachian tubes in the nasopharynx. Negative pressure can build up in the middle ear if the Eustachian tube does not operate properly. This negative pressure can generate an effusion, which can cause conductive hearing loss and speech impairments, as well as serve as a breeding ground for bacterial infections.

Long-term adenoiditis, followed by adenoid enlargement, can result in a condition known as adenoid facies or long-face syndrome. Enlarged adenoids can obstruct the nasopharynx, resulting in obligatory mouth breathing and craniofacial anomalies such as a high-arched palate and retrognathic jaw.

Conclusion

Adenoid hypertrophy is an obstructive disease caused by enlarged adenoids. The syndrome can arise with or without an acute or persistent adenoid infection. The adenoids are a collection of lymphoepithelial tissue located in the superior nasopharynx, medial to the Eustachian tube orifices. The adenoids, along with the faucial and lingual tonsils, form Waldeyer's ring, a cluster of mucosal-associated lymphoid tissue located near the upper aerodigestive tract's entry.

The ascending pharyngeal artery supplies blood to the adenoids, with some help from the internal maxillary and facial arteries. The adenoids are innervated by the glossopharyngeal and vagus nerves. Adenoid size typically increases during childhood, reaching a peak around the age of 6 or 7 before regressing during puberty.

A detailed history and physical examination are frequently adequate to identify adenoid enlargement. Lateral head and neck radiography has been used to evaluate adenoids, particularly in fussy or uncooperative children. A technique for measuring the degree of adenoid hypertrophy has also been reported using videofluoroscopy.

Both of these radiographic approaches have demonstrated some accuracy in identifying adenoid hypertrophy. Both, however, include the danger of potentially unneeded radiation exposure. Direct imaging of the adenoids by fiberoptic nasopharyngoscopy is another alternative for examining the adenoids in the clinical context with high reliability and minimal radiation exposure.

Medical therapy with antibiotics is the proper initial step in acute and chronic infectious adenoid hypertrophy. Amoxicillin can be used for simple acute adenoiditis; however, for chronic or recurring infections, a beta-lactamase inhibitor such as clavulanic acid should be used. In individuals who are allergic to penicillin, clindamycin or azithromycin are being evaluated as alternatives. Although nasal steroids have been offered as an alternative option for medical therapy, with some short-term success observed, the evidence for their usefulness is equivocal.

Adenoidectomy is the preferred surgical treatment option for adenoid enlargement. Patients with recurrent or chronic obstructive or infectious symptoms caused by adenoid hypertrophy may benefit from adenoidectomy. Adenoidectomy is performed under general anesthesia, with the patient supine with his or her neck slightly extended, and the surgeon positioned at the head of the operating table.