Adenoids Definition The adenoids are enlarged and hypertrophied nasopharyngeal tonsils, sufficient to produce symptoms It is disease of infancy and childhood. Adenoids are subjected to physiological enlargement in childhood hence nasopharyngeal tonsils are commonly called Adenoids. Nasopharyngeal Tonsil Single pyramidal mass of sub-epithelial lymphoid tissue, present in nasopharynx at the junction of its roof and posterior wall. The pharyngeal tonsil is composed of vertical ridges of lymphoid tissues separated by deep cleft and covered by Pseudostraitified ciliated columinar epithelium. The free surface has 6 folds It has no capsule These lymphoid tissues consits of T and B lymphocytes. It forms roof of waledeyer’s ring. Can't normally see them because they are above and behind the uvula. Arterial Supply Ascending branch of facial artery Ascending pharyngeal branch of external carotid Pharyngeal branch of third part of maxillary artery. Ascending cervical branch of inferior thyroid artery of thyrocervial trunk Development Adenoids begin forming in 3rd month of fetal development Glandular primordia on posterior pharynx are infiltrated by lymphocytes. Covered by pseudostratified ciliated epithelium Fully formed by 7 month Growth They are not visible on X-ray in infants under age of one month. 50% of cases, it is visible at 6 month. At the age of 2 years undergo hypertrophy and hyperplasia. Can become nearly the size of a Table Tennis ball Hypertrophy continues up to puberty (12 years) Then, undergoes atrophy after puberty Finally disappears in adults Why does adenoid physiologically enlarge? Poorly develop at birth. Grows rapidly during childhood. Generalized lymphoid hyperplasia occurs in children Among the first aggregative lymphoid tissues in respiratory tract. Physiology Part of secondary immune system No afferent lymphatics Exposed to inspired antigens passed through the epithelial layer Membrane cells and antigen presenting cells are involved in transport of antigen from the surface to the lymphoid follicle Antigen is presented to T-helper cells T-helper cells induce B cells in germinal center to produce antibody Secretory IgA is primary antibody produced Involved in local immunity Etiology Age : 3 -12 years Season: winter Food: Cold, sour, oily food General lymphoid hyperplasia Infection in tonsils alone or associated with Rhinitis, Sinusitis, Tonsillitis (esp. chronic maxillary sinusitis) Recurrent attacks of rhinitis, sinusitis or tonsillitis may causes chronic adenoid infection Allergy of respiratory tract. Clinical features Symptoms occur most commonly between ages of 3-7 years. Depending on size of adenoid mass and space 3 types Nasal symptoms Aural symptoms General symptoms Nasal symptoms Bilateral Nasal obstruction Mouth breathing interfere

4. Definition
 The adenoids are enlarged and
hypertrophied nasopharyngeal tonsils,
sufficient to produce symptoms
 It is disease of infancy and childhood.
 Adenoids are subjected to
physiological enlargement in
childhood hence nasopharyngeal
tonsils are commonly called Adenoids.

5. Nasopharyngeal Tonsil
 Single pyramidal mass of sub-epithelial
lymphoid tissue, present in nasopharynx at
the junction of its roof and posterior wall.
 The pharyngeal tonsil is composed of vertical
ridges of lymphoid tissues separated by deep
cleft and covered by Pseudostraitified ciliated
columinar epithelium.
 The free surface has 6 folds
 It has no capsule

6. Nasopharyngeal Tonsil……….cont:
 These lymphoid tissues consits
of T and B lymphocytes.
 It forms roof of waledeyer’s
ring.
 Can't normally see them
because they are above and
behind the uvula.

7. 1. Ascending branch of facial artery
2. Ascending pharyngeal branch of external carotid
3. Pharyngeal branch of third part of maxillary artery.
4. Ascending cervical branch of inferior thyroid artery
of thyrocervial trunk
Pharyngeal Plexus
Ptrygoid Plexus
Facial vein
Internal jugular vein

8. Upper jugular lymph node directly or
Indirectly via retropharyngeal lymph node
No afferent lymphatics
Glossopharyngeal
Vagus

9. Nasopharynx

10. Don’t Confuse With Palatine And Nasopharyngeal Tonsils

11. NASOPHARYNGEAL
TONSIL
PALATINE TONSIL
Location Nasopharynx Oropharynx
Number Single Pair
Ring Ring No ring
Crupts No crupts Crupts
Capsule No capsule Capsule
Epithelium Ciliated columinar epithelium Stratified squamous epithelium
Lymph nodes Upper Deep Cervical Lymph
Nodes
Jagulodigastric lymph nodes

12. Development
 Adenoids begin forming in 3rd month of fetal
development
 Glandular primordia on posterior pharynx are
infiltrated by lymphocytes.
 Covered by pseudostratified ciliated epithelium
 Fully formed by 7 month

13. Growth
 They are not visible on X-ray in infants under
age of one month.
 50% of cases, it is visible at 6 month.
 At the age of 2 years undergo hypertrophy and
hyperplasia.
 Can become nearly the size of a Table Tennis
ball
 Hypertrophy continues up to puberty (12
years)
Then, undergoes atrophy after puberty
 Finally disappears in adults

14. Why does adenoid physiologically enlarge?
 Poorly develop at birth.
 Grows rapidly during childhood.
 Generalized lymphoid hyperplasia occurs in
children
 Among the first aggregative lymphoid tissues in
respiratory tract.

15. Physiology
 Part of secondary immune system
 No afferent lymphatics
 Exposed to inspired antigens passed through the epithelial
layer
 Membrane cells and antigen presenting cells are involved
in transport of antigen from the surface to the lymphoid
follicle
 Antigen is presented to T-helper cells
 T-helper cells induce B cells in germinal center to produce
antibody
 Secretory IgA is primary antibody produced
 Involved in local immunity

16. Etiology
 Age : 3 -12 years
 Season: winter
 Food: Cold, sour, oily food
 General lymphoid hyperplasia
 Infection in tonsils alone or associated with
Rhinitis, Sinusitis, Tonsillitis
(esp. chronic maxillary sinusitis)
 Recurrent attacks of rhinitis, sinusitis or tonsillitis
may causes chronic adenoid infection
 Allergy of respiratory tract.

18. Clinical features
 Symptoms occur most commonly between ages of
3-7 years.
 Depending on size of adenoid mass and space
 3 types
1. Nasal symptoms
2. Aural symptoms
3. General symptoms

19. Nasal symptoms
1. Bilateral Nasal obstruction
Mouth breathing
interfere with feeding.
2. Bilateral Nasal discharge
a) choanal obstruction
b) associated chronic rhinitis
3. Noisy breathing with bubble nose
4. Snoring
5. Sinusitis
chronic maxillary sinusitis is commonly <=> adenoid
6. Epistaxis due to acute inflammation
7. Rhinolalia clause or buccal voice
Sounds of M/N/NG  B/D/G respectively
8. Recurrent rhinitis and sinusitis

20. AURAL SYMPTOMS
1. Conductive hearing loss
2. Recurrent acute otitis media  spread of
infection
3. Chronic suppurative or non-suppurative otitis
media
4. Serous otits media
5. Perforation of tympanic membrane
6. Recurrent otalgia  Referred

21. GENERAL SYMPTOMS
1. Adenoid faces
Child has enlarged face with
 Dull expression,
 Open mouth,
 Prominent and crowded upper teeth,
 Hitched up upper lip,
 Highly arched palate,
 Pinched nostrils,
 Hypoplastic maxilla,
 Noisy breathing,
 Dribbling of saliva,

22. GENERAL SYMPTOMS
2. Mental dullness
3. Morning Headache: One of
constant signs of adenoids is
persistent headache
4. Fever, anorrexia, malaise
5. Apathy and aprosexia
6. Noctural enuresis
7. Night terror
8. Pulmonary hypertension and
cor pulmonate

24. Examination
 Posterior Rhinoscopy  difficult
 Digital palpation not pleasant
 Endoscopic examination the best

25. Investigation
1. Plain X-ray of soft
tissues of nasopharynx
in lateral view
2. Digital palpation of
adenoid with index
fingure

26. DIFFERENTIAL DIAGNOSIS
1. Congnital choanal atresia
2. Deflected nasal septum
3. Foreign bodies in nose
4. Nasal polyp
5. Nasal allergy
6. Some condition of oral cavity can cause mouth
breathing

27. Distinguish three degrees of growth
of a pharyngeal tonsil
 I degree - adenoids cover the top part of a vomer;
 II degree - adenoids cover top two thirds of
vomer;
 III degree - adenoids close all or nearly so all
vomer.

28. Treatment
Medical Treatment
1. Nasal decongestant
2. Systemic antihistamine
3. Breathing exercise
Surgical treatment
ADENOIDECTOMY

29. Adenoidectomy
 Adenoidectomy may be indicated alone or combined with
tonsillectomy.
 Adenoids are removed first and nasopharynx packed before
starting tonsillectomy.

30. Indication
1. Hypertrophied adenoids causing significant
symptoms
2. Adenoid associated with rhinosinusitis
3. = = Chronic secreted otitis media
4. = = Recurrent ear discharge in benign CSOM
5. = = Dental malocclusion

31. Contraindication
1. Cleft palate or submucus palate
2. Acute upper respiratory infection
3. Bleeding disorder
4. Other medical problem where surgery or
anesthesia is contraindicated

32. Procedure
 Always done under general anesthesia with oral endotracheal
intubation
 Rose's position
 Hyperextension should always be avoided
 Mouth is opened by inserting Boyle Davis mouth gag
 Before actual removal of adenoids nasopharynx should always
be examined
 i) by retracting soft palate with curved end of tongue depressor
 ii) digital palpation

33. Procedure
Proper size of adenoid curette with guard is introduced into
nasopharynx till its free border touches posterior border of nasal septum
then pressed backward to engage adenoid.
 With gentle sweeping movement, adenoids are shaved off.
 Small tags of lymphoid tissues left behind are removed with punch
forceps
 Haemostatic is achieved by packing nasopharynx for sometimes
 Persistence bleeding are electrocoagulated under vision by diathermy.
If it is visible by retracting the soft palate.
 If the bleeding is still not controlled, post nasal pack is left for 24-48 hr

35. Postoperative care
Immediate
 Pt is kept lateral position until he is fully recovered from
anesthesia
 Keep a watch on bleeding from nose and mouth
 Keep check on vital signs like pulse, respiration, BP,
temp
Diet
 Pt is kept NPO for 6 hr
 Then liquid diet and ice creams are advised
 On 2nd day diet is gradual built from soft to solid
 Plenty of fluids should be encouraged

36. Postoperative care
Oral hygiene
 Maintained by regular mouth wash and gargles 3-4
times a day with some topical antiseptic solution
 A suitable antibiotic can be given orally or ingestion
for a week
 Analgesic like paracetamol can be given for pain half
an hour before meals

37. Complication
1. Hemorrhage
2. Injury to oral cavity
3. Nasopharyngeal stenosis due to Injury to Eustachian
tube
4. Palatal injury
5. Complication of general anesthesia
6. Griesel syndrome (pt complains of neck pain and
develop torticollis due to spasm of paraspinal
muscles)
7. Recurrent
8. Airway obstruction from edema
9. Pulmonary edema