Adenoid Enlargement in children

1. azad82d@gmail.com
azad.haleem@uod.ac
Dr.Azad A Haleem AL.Mezori
MRCPCH,DCH, FIBMS
Assistant Professor
University Of Duhok
College of Medicine
Pediatrics Department
Adenoid Enlargement in
children
Scan
For
Contact

2. Key points
• Anatomy
• Embryology
• Function and Immunology
• Common Diseases of the Tonsils and
Adenoids
• Pathophysiology
• Diagnosis
• Management.

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.
• These structures form a ring of
tissue named Waldeyer’s ring after
the German anatomist who
described them.

5. Embryology
• The formation of the adenoids begins in the 3rd
month of fetal development.
• In the 5th month: the pharyngeal crypts will
develop. The surface is covered with
pseudostratified ciliated epithelium.
• By the 7th month of development the adenoids
are fully formed.

6. Function and Immunology
• The tonsils and adenoids are part of the
secondary immune system.
• Lymphoid tissue of Waldeyer ring is
most immunologically active between 4
and 10 yr of age, with a decrease after
puberty.
• These are involved in the production of
mostly secretory IgA, which is
transported to the surface providing
local immune protection.

7. Common Diseases of the Tonsils
and Adenoids
1. Acute adenoiditis/tonsillitis
2. Recurrent/chronic
adenoiditis/tonsillitis
2. Obstructive hyperplasia
3. Malignancy

8. Pathology
• Acute Infection
• Most episodes of acute pharyngotonsillitis are caused by viruses.
• Group A β-hemolytic streptococcus (GABHS) is the most
common cause of bacterial infection in the pharynx .
• Chronic Infection
• The tonsils and adenoids can be chronically infected by multiple
microbes, which can include a high incidence of β-lactamase–
producing organisms.
• Both aerobic species, such as streptococci and Haemophilus
influenzae, and anaerobic species, such as Peptostreptococcus
predominate.

9. • Airway Obstruction:
• Both the tonsils and adenoids are a major cause of
upper airway obstruction in children.
• Airway obstruction in children is typically manifested in
sleep-disordered breathing, including obstructive
sleep apnea, obstructive sleep hypopnea, and upper
airway resistance syndrome which may cause growth
failure.
• Tonsillar Neoplasm
• Rapid enlargement of one tonsil is highly suggestive of
a tonsillar malignancy, typically lymphoma in children.

10. The adenoids or pharyngeal tonsil
enlargement
• The adenoid 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 follicle

11. The adenoids or pharyngeal tonsil
enlargement
- Peak between 2 – 8 years
- Allergy
- Recurrent RTI
- Genetics
- Obstructive adenoid hyperplasia
includes symptoms of chronic nasal
obstruction, rhinorrhea, snoring, mouth
breathing, and a hyponasal voice.

12. The adenoids enlargement may cause:
• Acute adenoiditis
• Recurrent acute adenoiditis
• Chronic adenoiditis
• Obstructive sleep apnea

13. • 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.

14. • 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.

15. • Obstructive sleep apnea in children is
clinically marked by:
• loud snoring, apneic episodes while
sleeping, daytime somnolence,
behavioral problems, and enuresis.

16. Diagnosis
• Clinical as History & clinical examination:
• Radiological examination (PNS)
• Endoscopy
• Rhinoscopy
• CT scan

17. Always think about detalis history
o Clinical classification:
o Nasal obstruction, snoring, and nasal
discharge
o By asking the parents and caregivers :
o Grade 0: never seen,
o Grade 1: seen during URTI,
o Grade 2: frequently seen,
o Grade 3: always occurs.

18. 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.

19. • The characteristic facial appearance
consists of:
• Underdeveloped thin nostrils
• Short upper lip
• Prominent upper teeth
• Crowded teeth
• 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

20. Nasopharyngeal X Ray
 Adenoid tissue enlargement was graded according
to the Adenoidal-nasopharyngeal ratios (ANR).
 The ANR was obtained by dividing the measurement
for adenoid tissue density by the value for
nasopharyngeal space in millimeters as described by
Fujioka.
 It was rated as:
 Grade 1: > 6 mm,
 Grade 2: 4-6 mm, and
 Grade 3: < 3 mm.

21. Lateral neck radiograph
• The main imaging study to evaluate the
adenoid is a lateral neck radiograph, as in the
images below.

23. Complications
• If adenoid hypertrophy left untreated
may cause many serious problems
such as:
• Cognitive and behavioral disorders,
• Systemic and pulmonary hypertension
• Enuresis
• Developmental delay.

24. MANAGEMENT
• Management options include
1. Wait until they involute
2. Non surgical management include- intranasal
corticosteroids
3. surgical removal (ADENOIDECTOMY)

25. Medical Management
• Chronic adenoiditis: No good evidence
supports any curative medical therapy for
chronic infection of the adenoids.
• Systemic antibiotics have been used long-term
(ie, 6 weeks) 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.

26. • The adenoids enlargement:
• 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 , 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.
Medical Management

27. Topical nasal steroids in children
• Mometasone furoate intranasal spray 50 mcg –
100 mcg /day for 6 to 8 weeks for children
more than 2 years.
• Fluticasone propionate nasal spray of 400
microg/day for 8 weeks for children more than
4 years.
• Beclomethasone intranasal spray 50 mcg /day
for 8 weeks for children more than 3 years.

28. Evidences
• Using nasal steroids to treat nasal obstruction caused by
adenoid hypertrophy: Does it work?
• Data Sources: Published studies indexed in the MEDLINE (1951 to
2008), EMBASE (1974 to 2008), and the Cochrane databases
(Issue 3, 2008).
• Conclusion: The available evidence suggests that nasal steroids
may significantly improve nasal obstruction symptoms in children
with adenoid hypertrophy. This improvement appears to be
associated with a reduction of adenoid size. Evidence of long-term
efficacy is limited but suggests that in many children maintenance
therapy is needed if symptom-relief is to persist. Further studies are
required to support the use of nasal steroids as a first-line approach
in these children.

29. Evidences
Using nasal steroids to treat nasal obstruction
caused by adenoid hypertrophy: Does it work?
Data Sources: more than 100 studies improve no side
effect and improvement reaching 77.7% ?
Alexopoulos EI, Kaditis AG, Kalampouka
E, Kostadima E, Angelopoulos NV, Mikraki
V. Nasal corticosteroids for children with
snoring. Pediatr Pulmonol 2004;38:161-7.
-Fujioka M, Young LW, Girdany BR. Radiographic
evaluation of adenoidal size in children: adenoidal-
nasopharyngeal ratio. Am J Roentgenol 1979;133:401-
4.
-Demain JG, Goetz DW. Pediatric adenoidal
hypertrophy and nasal airway obstruction: reduction
with aqueous nasal beclomethasone. Pediatrics
1995;95:355-64.
- Lepcha A, Kurien M, Job A, Jeyaseelan L, Kurien T.
Chronic adenoid hypertrophy in children - is steroid
nasal spray beneficial? Indian J Otolaryngol Head Neck
Surg 2002;54:280- 4.
Kheirandish L, Goldbart AD, Gozal D. Intranasal
steroids and oral leukotriene modifier therapy in
residual sleep-disordered breathing following
tonsillectomy and adenoidectomy in children.
Pediatrics 2006;117:e61-6.
-Jung YG, Kim HY, Min JY, Hun JD, Seung KC.
Role of intranasal topical steroid in pediatric sleep
disordered breathing and influence of allergy,
sinusitis, and obesity on treatment outcome. Clin
and Exp Otorhinolaryngol 2011;4:27-32.
the treament of children with otitis
media with effusion and/or adenoid
hypertrophy. Int J Pediatr
Otorhinolaryngol 2006;70:639-45.

30. Adenoidectomy-Indications
• Four or more episodes of recurrent purulent
rhinorrhea in prior 12 months in a child <12
(documented by intranasal examination or
diagnostic imaging)
• Persisting symptoms of chronic adenoiditis after 2
courses of antibiotic therapy.
• Sleep disturbance with nasal airway
obstruction persisting for at least 3 months.
• Otitis media with effusion >3 months or
second set of tubes (persistent Otitis media
with effusion over age 4 ).

31. • Dental malocclusion or orofacial
growth disturbance documented by
orthodontist.
• Nasal speech
• Cardiopulmonary complications including
cor pulmonale, pulmonary hypertension,
right ventricular hypertrophy associated
with upper airway obstruction.
Adenoidectomy-Indications

32. THANKS FOR YOUR
Attention