Adenoid enlargement.

1. Adenoid enlargement
sleep apnea syndrome

2. adenoid
Mass of lymphoid tissue in nasopharynx
Normal structure with definite function
Production of antioibodies-(IgA-locally, G, M-systemically)
Maximum size- 3-7 years then regeress
May vary among individuals and even in same child
as they grow
Size of adenoid and nasopharynx- more significant
Enlargement- ? allergy., infection
Causes- obstruction of nose, nasopharyngeal
airway, lateral wall

3. Adenoid facies
open lip posture,
prominent upper teeth,
pinched nose ,
hypoplastic maxilla
Narrow upper alveolus,
crowded teeth high
arched palate
Ear- OME( obstruction,
infection)
Sleep apnoea
Delayed growth

4. management
X-ray nasopharynx( soft tissue)
Neck extended, mouth open
Asess nasopharynx: adenoid ratio
Ear- OME
If symptomatic- Adenoidectomy
( with/without tonsillectomy, VTI)
Complications- bleeding, damage to eustachian tube,
posterior pharyngeal wall mucosa, uvula trauma

5. adenoid

7. Endoscopic view of adenoid

8. Sleep apnoea syndrome( SAS)

9. definitions
Apnoea- cessation of airflow for at least 10 secs from
mouth /nostrils
Apnoea index- no of apnoea/hr of sleep
Hypoapnoea- reduction in tidal volume
Sleep apnoea syndrome( SAS)
>30 episodes of apnoea,
lasting >10 seconds
during 7 hors of normal sleep
Or apnoec index>5
( some say 10)

10. American sleep Association
Mild= 5-20 apnoeas /hr
Moderate= 20-40
Severe= >40
Pathological episodes is associated with hypoxemia and
bradycardia
Apnoea spells
1. obstructive- cessation of airflow in the presence of
continued respiratory effort
2.Central- no flow of air at nose and mouth associated with
cessation of all respiratory effort. Pt may may not snore
3. Mixed- begins as central, followed by forceful respiratory
effort again with no airflow until airway clears

11. Causes of obstructive sleep apnoea
Nose
Nasal Polyp
Deviated Nasal Septum
Rhinitis
Nasal Packing
Larynx
Tumors
Oedema
Shy- Drager syndrome
Pharynx
Nasopharyngeal Tumor
Enlarged adenoids
Enlarged palatal tonsils
Enlarged lingual tonsils
Retropharyngeal mass
Large Tongue- Myxoeema
- Acromegaly
Micrognathia/ retrognathia
Obesity

13. Clinical Features of obstructive sleep apnoea syndrome
Common
Snoring
Excessive daytime sleepiness
Obstructive episodes
Less common
 Morning headache
 Personality change
 Intellectual deterioration
 Poor memory
 Difficulty in concentrating
 Abnormal body movements
 Frequent waking
 Nocturnal choking
 Nocturnal enuresis
 Impotence
 Systemic hypertension
 Pulmonary hypertension
 Right heart failure
 Cardiovascular mortality

14. Sequelae
Daytime somnolence
Pulmonary HTN
Cor-pulmonale
Test- polysomnography

16. treatment
Sx- tyonsillectomy, adenoidectomy
Indication of adenoidectomy- severe nasal obst
Reccurent OME
Sleep apnea
Contraindications
- recent URTI
Bleeding disorder
Cleft palate
Other contraindications for GA

17. Important aspects of the examination
General appearance weight
Height
Blood pressure
Craniofacial morphology
Nasal airway
Tongue size
Soft palate/uvula/tonsils
Nasopharynx- adenoids/ polyp/ cyst/ tumor
Hypophharynnx – Lingual tonsils/ vallecula , epiglottic or
supra – glottic cystic / tumor
Larynx- vocal cord mobility

18. Investigations
The reasons for investigations in this condition are
threefold:
To assess the patient’s general condition
To differentiate between simple snoring and sleep
apnoea
determine the presence, type and severity of any
apneas or hypopnoeas
To assess the site of obstruction

19. Treatment
Treatment choice depends on a number of factors:
Is it simple snoring or obstructive sleep apnoea?
What does the patient want?
The severity of the obstructive sleep apnoea and the
presence of complication, i.e apnoea index/degree of
oxygen desaturation / apnoea associated
cardiaopulmonary pathology
The level of obstruction

20. No treatment
If patient not concerned with snoring
No daytime somnolence
Cardiopulmonary pathology
Medical
Exclude hypotheyrodism/acromegaly
Alcohol advice
Drug review
Weight loss
Nasal medicatin
Nosovent
Drug treatment (e.g. protriptyline)
Positional advice
Mandibular positioning device
Tongue retaining device
Nasal continuous positive airway pressure

21. Surgical management
Anaesthetic consideration
Nasal surgery
Uvulopalatopharyngoplasty
Midline laser glossectomy
Tracheostomy