2. adenoid enlargement
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  • 1. ADENOID ENLARGEMENT Fahad zakwan MD5
  • 2. 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.
  • 3. 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.
  • 4. Blood Supply Tonsils • Ascending and descending palatine arteries • Tonsillar artery • 1% aberrant ICA just deep to superior constrictor Adenoids • Ascending pharyngeal, sphenopalatine arteries
  • 5. •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.
  • 6. Histology Tonsils • Specialized squamous • Extrafollicular • Mantle zone • Germinal center Adenoids • Ciliated pseudostratified columnar • Stratified squamous • Transitional
  • 7. 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.
  • 8. Common Diseases of the Tonsils and Adenoids 1. Acute adenoiditis/tonsillitis 2. Recurrent/chronic adenoiditis/tonsillitis 3. Obstructive hyperplasia 4. Malignancy
  • 9. 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.
  • 10. 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.
  • 11. •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.
  • 12. •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
  • 13. 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
  • 14. •The characteristic facial appearance consists of: •Underdeveloped thin nostrils •Short upper lip •Prominent upper teeth •Crowded teeth •Narrow upper alveolus
  • 15. • 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
  • 16. Diagnosis •Endoscopy •Posterior rhinoscopy •Otoscopy •Radiological examination can also help •CT scan
  • 17. Posterior Rhinoscopy •Posterior rhinoscopy is done to look for lesions in the post nasal space - for example, adenoids, tumors of the nasopharynx, etc.
  • 18. 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.
  • 19. 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
  • 20. Nasopharygoscope
  • 21. Lateral neck radiograph • The main imaging study to evaluate the adenoid is a lateral neck radiograph, as in the images below.
  • 22. 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
  • 23. MANAGEMENT •Management options include •wait until they involute •surgical removal (ADENOIDECTOMY) •Non surgical management include- intranasal corticosteroids
  • 24. 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.
  • 25. • 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.
  • 26. 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
  • 27. • 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.
  • 28. 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).
  • 29. Jennings's Mouth Gag
  • 30. 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.
  • 31. 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.
  • 32. Position for Adenoidectomy
  • 33. Adenoidectomy Specimen
  • 34. 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.
  • 35. Other risks include: • Vomiting • Dehydration • Airway obstruction due to edema • Pulmonary edema • Fever, velopharyngeal insufficiency • Dental injury • Burns • Nasopharyngeal stenosis