• 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
• By the 7th month of development the adenoids are
• 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
• Ascending and descending
• Tonsillar artery
• 1% aberrant ICA just deep to
• Ascending pharyngeal,
•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.
Function and Immunology
• The tonsils and adenoids are part of the secondary
• 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
• 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
1. Acute adenoiditis/tonsillitis
3. Obstructive hyperplasia
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
• The surface is invaginated in a series of
• The epithelium is pseudostratified ciliated
epithelium and is infiltrated by the
• 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
•Recurrent acute adenoiditis is 4 or more
episodes of acute adenoiditis in a 6-
month period with intervening periods of
•Chronic adenoiditis symptoms include
•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
Adenoid facies or “long face
• 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
• The most dangerous symptom is sleep
• High-arched palate
• Hypoplastic maxilla
• Eustachian blockage
causing glue ear-
• The deafness and
interferes with the
• Child grows with
•Radiological examination can also
•Posterior rhinoscopy is
done to look for
lesions in the post
nasal space - for
tumors of the
• Examination of the post nasal
space by a procedure called
posterior rhinoscopy, an out-
• 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
• The shaft of the instrument is bent
to achieve a bayonet shape, a
feature that helps differentiate it
from the indirect laryngoscopy
• The mirror is available in 5 sizes.
• Nasopharyngoscopy is a
procedure which enables the
doctor to examine the internal
surfaces of the nose and throat
• Nasopharyngoscopy provides a
direct view of every part of the
upper respiratory tract from the
nasal passages down the throat
to the larynx
Lateral neck radiograph
• The main imaging study to evaluate the adenoid is a lateral neck
radiograph, as in the images below.
• 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
•Management options include
•wait until they involute
•surgical removal (ADENOIDECTOMY)
•Non surgical management include-
• 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
• 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.
• Four or more episodes of recurrent purulent
rhinorrhea in prior 12 months in a child <12. One
episode documented by intranasal examination or
• 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.
• 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
• Wait at least 6 weeks after polio vaccination.
• Avoid surgery in patients with uncontrolled systemic
diseases (ie. leukemia).
St. Claire Thomson
• The adenoid curette is
used in adenoidectomy
• 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
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.
• The incidence of mortality from adenotonsillar
surgery ranges from 1 in 16,000 to 1 in 35,000
• Anesthetic complications and hemorrhage
cause the majority of deaths.
• The prevalence of hemorrhage ranges from 0.1% to
• It is divided into primary bleeding, in the first 24
hours, and secondary bleeding, around 7-10 days
Other risks include:
• Airway obstruction due to edema
• Pulmonary edema
• Fever, velopharyngeal insufficiency
• Dental injury
• Nasopharyngeal stenosis
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