The document discusses the adenoid and adenoidectomy procedure. It covers the anatomy and function of the adenoid, including its role in immunity. It describes pathological effects like otitis media, upper airway obstruction, and rhinosinusitis. The assessment, management, and complications of adenoidectomy are outlined. While adenoidectomy is effective for upper airway obstruction and otitis media with effusion, its efficacy for other issues like recurrent ear infections, sleep apnea, and sinusitis requires more research. Mild adenoid hypertrophy does not always require surgery.

1. The adenoid & adenoidectomy
Nasopharyngeal lymphoid tissue or adenoid forms part of Waldeyer’s ring of lymphoid tissue at the
portal of the upper respiratory tract. In early childhood, this is the first site of immunological contact
for inhaled antigens.
Historically , the adenoid has been associated with upper airway obstruction, as a focus of sepsis &
more recently with the persistence of otitis media with effusion.
Adenoid continue to grow rapidly during infancy & plateaus between 2 & 14 years of age.
Regression of the adenoid occurs rapidly after 15 years of age. The adenoid appear to be at its
largest in the seven-year old age. However, clinical symptoms are more common in a younger age
group, due to the relative small volume of the nasopharynx & the increased frequency of upper
respiratory tract infections.
Function of adenoid
The adenoid produces B cells which gives rise to IgG & IgA. Exposure to antigen through nasal route
is an important part of natural acquired immunity in early childhood.
The adenoid appears to have an important role in the development of an immunological memory in
younger children. The removal of this tissue at a young age may be immunologically undesirable.
In the children aged 4 to10 years, adenotonsillectomy does not appear to cause significant immune
deficiency, although a slight decrease in IgG,IgA & IgM level are found in the post-operative period
four to six weeks after surgery.
Pathological effects of the adenoid
The adenoid may be implicated in upper respiratory tract disease due to partial or complete
obstruction of the nasal choanae or result of sepsis.
Pathological manifestations of adenoid include rhinitis, rhinosinusitis, otitis media, otitis media with
effusion . Adenoiditis (acute or chronic) is a distinct infective entity. The following effects
1)Otitis media with effusion
The benefit of adenoidectomy in the management of otitis media with effusion has traditionally
been ascribed to the relief of anatomical obstruction of the Eustachian tube. While this may be a
contributory factor, it is clear that adenoid size & physical obstruction alone cannot account for the
benefit following adenoidectomy where the adenoid is small.
Adenoid size in children with or without OME is not significantly different. It is likely that recurrent
acute or chronic inflammation of the adenoid & increased bacterial load, particularly of haemophilus
influenza, results in squamous cell metaplasia, reticular epithelium extension, fibrosis of the
interfollicular connective tissue. Reduced mucocillary clearance in children with OME compared to
those without OME. This is likely to contribute to the development of a biofilm infection resulting

2. in OME( biofilm is a bacterial cell enclosed in a self-produced polymeric matrix & adherent to an
inert or living surface).
Adjuvant adenoidectomy in children over the age of three years who are undergoing insertion of VT.
Chronic gastro-oesophageal reflux has also been implicated in the development of OME, as a result
of inflammation of the nasopharynx& the adenoid.
2) Recurrent acute otitis media
Recurrent acute otitis media in children below 2 years due to partial maturational selective IgA
deficiency is a causative factor in these otitis prone children. Low dose antibiotic treatment
( prophylactic) is preferred until maturation of the immune system occurs naturally.
3) Upper air way obstruction & obstructive sleep apnoea
The prevalence of severe sleep disturbance in children due to upper air way obstruction is estimated
to be about 1% with peak incidence between three to six years of age & equal sex distribution.
Airway obstruction due to adenoidal hypertrophy may produced decreased arterial PaO2 & elevated
Pa CO2 levels> decreased level of serum insulin like growth factor-1(IGF-1)> adenoidectomy> return
to normal after adenoidectomy> growth spurt following surgery.
4) Rhinosinusitis
Children with recurrent rhinosinusitis showed that adenoidectomy is effective in abolishing infective
episodes of infection.
5) Olfaction
Olfactory sensitivity is reduced in relation to adenoid size& this improves after adenoidectomy. This
may ,in part, account for the poor appetite reported in children with adenoidal hypertrophy.
6) Neoplasia
Unsuspected neoplasia of the adenoid & tonsil in childhood is rare. Non-Hodgkin’s lymphoma is
reported.
Assessment and management
Clinical history : special attention to symptoms of middle ear disease & nasal obstruction.
Clinical examination : in particular , look for a skin crease in the supra-tip region that may indicate
frequent nose rubbing from symptoms of rhinitis.
Simple anterior rhinoscopy in children cabn be carried out using otoscope with large speculum.
Nasoendoscopy is increasingly used to assess adenoidal status in an out patient setting.
The correlation of adenoid size with lateral soft tissue radiography of the nasopharynx is poor but
plain radiography may be helpful, if the child unable to tolerate nasoendoscopy in the clinic.
Clinical grading of adenoid size

3. Grade Description
Grade I Adenoid tissue filling one-third of the vertical
portion of the choanae
Grade II Adenoid tissue filling from one-third to two-thirds
of the choanae
Grade III From two-third to nearly complete obstruction of
the choanae
Grade IV Complete choanal obstruction
Complications of adenoidectomy
1. Bleeding
2. Dental trauma ;
3. Airway obstruction due to retained swab, nasopharyngeal blood clot may fall onto larynx during
recovery & causing potentially fatal acute airway obstruction ( Coroner’s clot).
4. Infection ;
5. Cervical spine injury( particularly in Down’s syndrome);
6. Velopharyngeal dysfunction ;
7. Regrowth of the adenoid.
Best clinical practice
1. Adenoidal hyperplasia in children is common & self-limiting, mild symptoms of obstruction
are not an indication for surgery.
2. Adenoidectomy is effective in the upper air way obstruction but may not be effective for
recurrent acute otitis media.
3. Adjuvant adenoidectomy may be considered as part of the surgical management of children
over age of three years with otitis media with effusion.
4. Routine preoperative investigation are not indicated prior to adenoidectomy for children
who are acute sleep apnoea(ASA) grade I.
5. Adenoidectomy under vision using single use instrument.

4. Deficiencies in current knowledge & for future research
1. Efficacy of adenoidectomy in the management of obstructive sleep apnoea in children.
2. Eifficacy of adenoidectomy in the management of chronic & recurrent acute sinusitis in
children.
3. The effects of adenoidectomy on the development of childhood immunity.
4. The relationship between adenoidal hypertrophy & childhood rhinitis.
5. The role of adenoid in facilitating in biofilm infection in the upper respiratory tract.