Adenoid And Adenoidectomy

Introduction

The adenoid, part of Waldeyer's ring, is nasopharyngeal lymphoid tissue linked to sinusitis and obstructive sleep apnea (OSA). Santorini, in 1724, named adenoids "Luschka's tonsil," and Wilhelm Meyer, in 1870, termed them "adenoids" as nasopharyngeal vegetation. Adenoids are part of Waldeyer's ring, a collection of protective lymphoid tissue in the upper aerodigestive tract.

The upper aerodigestive tract involves the nose, nasopharynx, oral cavity, and oropharynx. The adenoid is in the nasopharynx, near the eustachian tube, while the tubal tonsils surround this tube. Palatine tonsils are in the oral cavity, and lingual tonsils are at the base of the tongue. Waldeyer's ring defends against antigens and food particles in the upper aerodigestive tract.

Development of Adenoid

Lymphoid tissue can be observed during intrauterine development at around the 4–6-week gestational period, residing within the mucous membrane of the roof and posterior wall of the nasopharynx. The adenoid becomes distinctly identifiable during the third month of gestation.

The adenoid's lymphoid tissue may extend into the fossa of Rosenmüller and the eustachian tube's orifice, sometimes referred to as Gerlach's tonsil or tubal tonsil. The membrane of the adenoid is covered with stratified squamous epithelium. The adenoids receive blood supply through the branches of the facial and maxillary arteries and sometimes from the thyrocervical trunk. The venous drainage goes via the facial veins into the pterygoid plexus of veins and also directly into the internal jugular veins. Lymphatic drainage from this region primarily flows through the retropharyngeal lymph nodes and the upper deep cervical nodes, specifically the posterior triangle of the neck. The nerve supply is through the glossal and the vagus nerve. The adenoid continues to grow throughout childhood and adolescence. After puberty, the adenoid starts to regress, and after a certain age, it can disappear. The adenoid is the largest in relation to the nasopharynx, between 7-10 years of age. Removal of adenoids depends on their pathological manifestations, such as recurrent sinusitis, OSA, recurrent upper tract infections, and middle ear effusion. The clinical symptoms are more common in the young age group due to the relatively small volume of the nasopharynx and the increased frequency of upper respiratory tract infections.

Immune Function of Adenoid

The adenoid is a constituent of Waldeyer's ring and primarily plays a role in humoral immunity. While it is also engaged in Tcell-mediated immunity, its main function is in the generation

of antibodies. The adenoid is involved in the production of B-cells, which subsequently give rise to IgG and IgA plasma cells upon exposure to antigens. Exposure to antigens through the mouth and nose is a crucial component of naturally acquired immunity during early

Childhood. These cells are also responsible for generating immune memory.

Pathological Effects of Adenoids

Adenoid hypertrophy can lead to:

• Otitis media with effusion-due to eustachian tube ventilation blockage.
• Recurrent acute otitis media-due to eustachian tube ventilation blockage.
• Upper airway obstruction and sleep-disordered breathing
• Rhinosinusitis-due to hindrance of sinus drainage, causing secretions to stagnate, predisposing to sinusitis
• Reduced olfactory sensitivity
• Neoplasia
• Adenoid hypertrophy leads to disordered breathing, causing airway collapse in areas like the retronasal, retropharyngeal, and retropalatal regions. This can lead to apnea episodes known as obstructive sleep apnea (OSA). Complications include disturbed sleep, attention deficit hyperactivity disorder, lack of concentration, energy, or being overactive.

Clinical History of Adenoids

For a comprehensive pediatric Ear, Nose, and Throat (ENT) history

• Focus on middle ear issues and nasal blockages. Inquire about sleep disruptions like bedwetting, difficulty sleeping in one position, restlessness, and snoring, which

might signal nasal obstruction.

• Investigate dietary concerns and signs of atopic symptoms, especially with a family history of atopy.
• Detailed medication history, including prescription, over-the-counter, and alternative medications.
• If an adenoidectomy is planned, consider the specific case history:
• History of bleeding tendencies or coagulopathies.
• In children with Down syndrome, assess for potential atlantoaxial instability and cardiac issues.
• Chronic nasal and oral obstruction can pose risks like cor pulmonale.

Clinical Examination of Adenoids

Focus on the ear, nose, and throat to identify indirect indicators of adenoid hypertrophy.

1. Ear examination for serous otitis media

2. Throat examination for pharyngitis.

3. In the nose, assess for sinusitis, stasis due to secretions, or mucoid discharge.

4. Look for an allergic salute in the supra-tip region as confirmation of atopic disease.

While flexible nasal endoscopy isn't suitable for younger children, it can be performed in children aged 8 years and older to grade adenoid enlargement. The grading of adenoids is as under:

Radiological Investigations of Adenoids

In cases where clinical investigation is not feasible, an X-ray of the lateral soft tissue of the nasopharynx can be performed.

Medical Treatment of Adenoids

Topical nasal steroid sprays, like mometasone, reduce adenoid size, improving conditions such as middle ear fluid, nasal obstruction, cough, snoring, and sleep apnea without systemic effects. In atopic individuals, antihistamines can be prescribed.

Surgical Management of Adenoids

Following are the Indications for adenoidectomy

1. Obstructive sleep apnea (OSA)
2. Recurrent adenoidal infection
3. Chronic adenoiditis
4. Bilateral serous otitis media

Adenoidectomy enhances middle ear function. For unresolved bilateral serous otitis media, myringotomy and grommet insertion might be needed. Other indications for adenoidectomy include adenoid facies and maxillo-facial growth. In maxillo-facial growth, appropriate dental treatment, such as rapid maxillary expanders, is required.

Methods of Adenoidectomy

1. Curettage involves blind scraping of adenoid tissue using a St. Clair Thompson adenoid curette followed by nasopharynx packing for hemostasis.
2. Suction diathermy employs heat to debride and coagulate adenoid tissue.
3. Coblation allows cutting and coagulation of the adenoid tissue simultaneously.
4. Debrider-assisted adenoidectomy involves endoscopic guidance for adenoid dissection.

Complications of Adenoidectomy

1. Bleeding
2. Dental Trauma
3. Retained Swab
4. Coroner's Clot or Nasopharyngeal Clot
5. Infection
6. Nasopharyngeal Dysfunction
7. Regrowth of Adenoid
8. Death

Frequently Asked Questions:

Q: What is the medical management for adenoid hypertrophy?

Answer: Topical and nasal steroid sprays and antihistamines are used for adenoid hypertrophy.

Q: What are the complications of Adenoidectomy?

Answer: The complications of Adenoidectomy are Bleeding, dental trauma, retained swab, coroner’s clot, infection, cervical spine issues, velopharyngeal dysfunction, regrowth, and rare deaths

Q: What is an adenoid?

Answer: The adenoid, part of Waldeyer's ring, is nasopharyngeal lymphoid tissue linked to sinusitis and obstructive sleep apnea (OSA) issues.

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