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Adenoid Hypertrophy

Adenoids Hypertrophy

Adenoid hypertrophy is a common childhood condition with unclear etiology and potentially severe consequences. The disease consists of increased adenoid tonsils and represents one of the most frequent surgical indications in this age period.


Presentation

The disease affects males and females to the same extent and is rarely encountered after the age of 15 years because adenoid tissue undergoes a normal process of involution beyond this age [1] [2]. Patients usually present between the ages of 3 and 5 because adenoid growth causes nasopharyngeal airway narrowing [3]. Children from high socioeconomic classes are infrequently affected.

In incipient stages, adenoid hypertrophy is asymptomatic. As the disease progresses, patients manifest with chronic mouth breathing, sleep disturbances, nasal obstruction, rhinorrhea, swallowing difficulties, snoring, cough, epistaxis, and halitosis. Hearing loss develops gradually as a consequence of persistent or recurring middle ear infections. If left untreated for a long period of time, the patient presents with hyponasal voice and a typical facies, characterized by elongated middle facial area and narrow palate [4].

When obstructive sleep apnea develops as a consequence of adenoid hypertrophy, it can cause more severe, long-term morbidity such as failure to thrive, learning difficulties, delayed speech [5], decreased intelligence quotient, and hyperactivity. Possible cardiovascular impairment consists of elevated diastolic blood pressure, left ventricular hypertrophy, and decreased right ventricular ejection fraction [1] [6].

Clinical examination may reveal signs consistent with atopy such as a cough, expiratory wheezing and rhonchi, and prolonged expiratory time.

Snoring
  • The primary outcomes were improvement in symptoms of nasal obstruction, mouth breathing, rhinorrhea, snoring, cough, and total nasal symptoms.[ncbi.nlm.nih.gov]
  • Topical mometasone significantly improved nasal obstruction, snoring, and apnea and also significantly reduced the adenoid tissue area related to the nasopharynx (p 0.0001).[ncbi.nlm.nih.gov]
  • Mouth breathing, nasal obstruction and snoring were found to be more severe in children with high A/C ratio (p 0.001). The A/C ratio provided the two-dimensional information of the nasopharyngeal airway.[ncbi.nlm.nih.gov]
  • In the evaluation of the relationship between symptoms grading and grading in lateral neck radiography, this relationship was significant about snoring.[ncbi.nlm.nih.gov]
  • Nine five consecutive children complaining of one or more of the symptoms of upper airway obstruction (UAO) (presence of snoring, mouth breathing or difficulty in breathing during sleep, obstructive breathing or apnea during sleep) were included in the[ncbi.nlm.nih.gov]
Rhinitis
  • Nasal citology showed that 21% of patients had a non-allergic rhinitis (NAR) subtype, 17.4% NAR overlapping with infectious rhinitis (IR), 29.6% IR, 4.9% allergic rhinitis (AR), 2.5% AR overlapping with IR and the remaining 24.6% a negative cytology.[ncbi.nlm.nih.gov]
  • Of the AR patients with AH, 90 (76.3 %) had moderate-severe rhinitis and 274 (62.6 %) AR patients without AH had moderate-severe rhinitis (p 0.005).[ncbi.nlm.nih.gov]
  • The second group consisted of sixteen children with adenoid hypertrophy and perennial allergic rhinitis.[ncbi.nlm.nih.gov]
  • The probability of adenoid hypertrophy was statistically more significant (logistic regression analysis) only in children from the study group with allergic rhinitis.[ncbi.nlm.nih.gov]
  • However, cigarette smoke exposure at home and presence of allergic rhinitis was significantly more frequent in the group of patients with AH.[ncbi.nlm.nih.gov]
Nasal Congestion
  • AH should be considered and investigated particularly in non-asthmatic children with pronounced nasal congestion and A. alternata sensitivity.[ncbi.nlm.nih.gov]
  • During the second stage of treatment, the nasal congestion scores of the MF/OXY group significantly decreased. The adenoid/choana ratio of the MF/OXY-treated group decreased and the nasal volume increased significantly.[ncbi.nlm.nih.gov]
  • Adenoid hypertrophy (AH) is a common disorder in children, resulting in chronic nasal congestion. This chronic congestion should be evaluated carefully because it can lead to chronic upper airway obstruction.[ncbi.nlm.nih.gov]
  • Severity of Nasal Congestion at Baseline and Week 12 [ Time Frame: Baseline and Week 12 ] Nasal congestion is a symptom of allergic rhinitis.[clinicaltrials.gov]
  • The scores for nasal congestion and snoring in the MF group exhibited a 0.05; Fig. 2 ).[nature.com]
Tonsillar Hypertrophy
  • There was also a significant difference between rates of tonsillar hypertrophy and nasopharynx obstruction in the EN group (p 0.009).[pagepressjournals.org]
  • Due to the multifactorial etiology of the tonsillar hypertrophy, the patient’s comorbidities must also be taken into account.[czytelniamedyczna.pl]
  • Mean AHI was 8.4 11.6 events/hour for children with tonsillar hypertrophy, and 3.1 6.7 events/hour for those without tonsillar hypertrophy.[journals.plos.org]
  • Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood. Pediatr Pulmonol. 2010;45:275–80. [ PubMed ] 31 Rosen CL, Larkin EK, Kirchner HL, et al., authors.[jdsm.org]
Rhinorrhea
  • There was tendency of improvement in rhinorrhea, and cough with mometasone.[ncbi.nlm.nih.gov]
  • Number of Participants Referred to Surgery (Adenoidectomy) Within 12 Weeks of Start of Therapy [ Time Frame: Baseline to 12 weeks ] Secondary Outcome Measures : Severity of Rhinorrhea at Baseline and Week 12 [ Time Frame: Baseline and Week 12 ] Rhinorrhea[clinicaltrials.gov]
  • As the disease progresses, patients manifest with chronic mouth breathing, sleep disturbances, nasal obstruction, rhinorrhea, swallowing difficulties, snoring, cough, epistaxis, and halitosis.[symptoma.com]
  • Additionally, the patient described ipsilateral facial pain and persistent purulent rhinorrhea. Nasal endoscopic examination revealed purulent secretion and a left sided mass which totally obstructed the nasal cavity.[academic.oup.com]
Recurrent Otitis Media
  • Chronic adenoid infection could lead to the obstruction of the nasopharyngeal Eustachian tube orifice and consequent recurrent otitis media. Therefore, a complete examination of an ear, nose, and throat is useful in all patients.[symptoma.com]
  • Numerous studies have shown that adenoidectomy is more effective than conservative treatment in patients with recurrent otitis media, especially exudative otitis media.[czytelniamedyczna.pl]
  • Recurrent otitis media with effusion Craniofacial and occlusive developmental abnormality due to adenoid enlargement Growth retardation BIBLIGRAPHY : Adherent biofilms in adenotonsillar diseases in children.[drdkjha.com]
  • otitis media due to their proximity to the Eustachian tubes Painful swallowing Sleep apnea Most commonly cultured bacteria Haemophilus influenzae Group A beta-hemolytic Streptococcus Staphylococcus aureus Moraxella catarrhalis Streptococcus pneumoniae[learningradiology.com]
  • Chronic sinusitis, recurrent otitis media with effusion, and chronic serous otitis media associated with pediatric adenoidal hypertrophy are common indications for surgical removal of the adenoid [ 6 ].[panafrican-med-journal.com]
Intravenous Administration
  • After intravenous administration of contrast medium most lesions showed a slight enhancement (58.6%). Moderate enhancement was seen in 32.4% and a marked enhancement was identified in 9.0%.[ncbi.nlm.nih.gov]
Mouth Breathing
  • Deformity in the dental arc and facial skeleton by adenoid hypertrophy due to chronic mouth breathing is a well-known process. Most of the related studies have been based on cephalometric analyses.[ncbi.nlm.nih.gov]
  • To test the validity of four different types of lateral cephalometric radiograph (LCR) measurements as a diagnostic test of adenoid hypertrophy in different age groups of mouth-breathing children.[ncbi.nlm.nih.gov]
  • In this study, I had examined 14 adults with nasal obstruction and mouth breathing. Nine patients also reported deafness--unilateral in three of them and bilateral in six.[ncbi.nlm.nih.gov]
  • Mouth breathing, nasal obstruction and snoring were found to be more severe in children with high A/C ratio (p 0.001). The A/C ratio provided the two-dimensional information of the nasopharyngeal airway.[ncbi.nlm.nih.gov]
  • From August 2007 until January 2009, in the otolaryngology ward of a tertiary referral center, 89 patients who had symptoms related to chronic mouth breathing participated in this study.[ncbi.nlm.nih.gov]
Halitosis
  • As the disease progresses, patients manifest with chronic mouth breathing, sleep disturbances, nasal obstruction, rhinorrhea, swallowing difficulties, snoring, cough, epistaxis, and halitosis.[symptoma.com]
  • The adenoids are located at the back of nose and when enlarged, may cause nasal obstruction, recurrent sinusitis, post nasal drip, sleep apnea, chronic runny nose, halitosis and even chronic cough.[childrensnational.org]
  • Halitosis (bad breath) can occur because of infections of the tonsils. Snoring because of obstruction to the airway from the enlarged tonsils.[entcenterutah.com]
  • […] with adenoid hypertrophy. ( 29313145 ) Cakabay T....Kocyigit M. 2018 4 Superficial punctate keratopathy in a pediatric patient was related to adenoid hypertrophy and obstructive sleep apnea syndrome: a case report. ( 29471795 ) Gao Y.Y....Wu Y. 2018 5 Halitosis[malacards.org]

Workup

Adenoid hypertrophy is best diagnosed by means of flexible nasopharyngoscopy. This investigation is indicated when the manifestations presented above are present or when the patient presents with recurrent sinusitis, otitis media, or persistent ear effusions. When obstructive sleep apnea is suspected, a sleep study is called for in order to gather information about its severity. Radiological evaluation, such as the lateral neck X-ray should be avoided unless more severe pathology, such as neoplasia or angiofibroma, is suspected. However, if a radiography is performed, due to the fact that it is still considered a valid and reliable test [7] [8], the physician should assess not the absolute dimensions of the adenoids, but the degree of obstruction they cause. If adenoids are very small or absent, an immune deficiency should be investigated, while severely enlarged masses may suggest lymphatic malignancy.

Adenoid flora occasionally needs to be assessed. It is usually composed of group A beta-hemolytic streptococci, but Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae may also be encountered. Anaerobic bacteria may be found in the core of the adenoids [9]. Other possibly present bacteria include Enterococcus species, Staphylococcus epidermidis, Streptococcus viridans, Escherichia coli, Pseudomonas, Moraxella, Klebsiella, Neisseria, Prevotella, Fusobacterium, Peptostreptococcus, and Bacteroides species [10] [11]. Chronic adenoid infection could lead to the obstruction of the nasopharyngeal Eustachian tube orifice and consequent recurrent otitis media. Therefore, a complete examination of an ear, nose, and throat is useful in all patients.

Biopsy specimens reveal reactive hyperplasia of B-cells and inflammatory infiltrates consisting of polymorphonuclears, plasmocytes, or eosinophils [2] [12].

Treatment

  • The integrative treatment was effective, safe and well tolerated.[ncbi.nlm.nih.gov]
  • During the second stage, the non-responders from stage one were randomly assigned to 4 groups for 8 weeks of treatment that involved receiving the following treatments: MF/OXY, MF/placebo, placebo/OXY, or placebo/placebo.[ncbi.nlm.nih.gov]
  • After 8 weeks of NSD treatment the initial adenoid/choana (A/C) rate had dropped from 87 to 56% and a total decrease of 35.6% was observed. After 8 weeks of NS treatment the A/C rate dropped from 87 to 85% and a total decrease of 2.2% was observed.[ncbi.nlm.nih.gov]
  • The effect of topical mometasone for adenoid hypertrophy treatment is well established. Nevertheless, the influence of atopy on this treatment remains ill defined.[ncbi.nlm.nih.gov]
  • To establish the efficacy of proton pump inhibitors (PPI) in the treatment of adenoid hypertrophy in children. Randomized controlled double-blinded clinical trial.[ncbi.nlm.nih.gov]

Prognosis

  • Prognosis Hypertrophied adenoids are a normal part of growing up and should be respected for their important role in the development of immunity.[healthofchildren.com]
  • Outcome and Prognosis Chronic persistent otitis media Gates et al have the most quoted article concerning the effectiveness of adenoidectomy for preventing the recurrence of chronic (ie, 2 mo) serous otitis media in children aged 4-9 years. [9] In a study[emedicine.medscape.com]

Etiology

  • Adenoid hypertrophy (AH) is a common etiology of chronic upper airway obstruction. Upper respiratory tract obstruction may cause chronic alveolar hypoventilation and pulmonary vasoconstriction.[ncbi.nlm.nih.gov]
  • Adenoid hypertrophy is a common childhood condition with unclear etiology and potentially severe consequences. The disease consists of increased adenoid tonsils and represents one of the most frequent surgical indications in this age period.[symptoma.com]
  • The exact etiology of AH in adults are known but some studies have tried to propose outcomes. Most common cause is persistence of childhood adenoids due to chronic inflammation [3].[medcraveonline.com]
  • ( 25590321 ) Rezende R.M....Valera F.C. 2015 42 Relative etiological importance of adenoid hypertrophy versus sinusitis in children with persistent rhinorrhoea. ( 25621229 ) Maheswaran S....Irodi A. 2015 43 The effect of adenoidectomy operation made on[malacards.org]
  • Due to the multifactorial etiology of the tonsillar hypertrophy, the patient’s comorbidities must also be taken into account.[czytelniamedyczna.pl]

Epidemiology

  • Department of Biostatistics & Clinical Epidemiology Christian Medical College and Hospital Vellore India 2. Dept. of ENT Speech & Hearing Christian Medical College & Hospital Vellore India[link.springer.com]
  • An epidemiologic study of lower limit of prevalence. Chest 107: 963-966. doi: . PubMed: 7705162 . View Article Google Scholar 4.[journals.plos.org]
Sex distribution
Age distribution

Pathophysiology

  • In one previous study in patients with obstructive sleep apnea (OSA), it has been claimed that mean platelet volume (MPV), an indicator of platelet activation is increased and that MPV has an important role in the pathophysiology of cardiovascular diseases[ncbi.nlm.nih.gov]
  • Chronic upper airway obstruction and cardiac dysfunction: anatomy, pathophysiology and anesthetic implications. Paediatric Anaesth. 2004;14:75-83. 2. Sie KC, Perkins JA, Clarke WR. Acute right heart failure due to adenotonsillar hypertrophy.[arquivosdeorl.org.br]

Prevention

  • Further studies are necessary to evaluate their possible therapeutic role in preventing recurrent tonsillitis and treating postoperative patients to help normalize their blood levels of antioxidants.[ncbi.nlm.nih.gov]
  • Early diagnosis and treatment of upper airway obstruction can prevent these serious complications. Echocardiographic examination should be recommended for these patients as a part of preoperative preparation to avoid anesthetic complications.[ncbi.nlm.nih.gov]
  • Sensitivity to mold allergens is an important risk factor for AH in children with AR; therefore, early prevention of exposure to molds may help reduce occurrence of AH.[ncbi.nlm.nih.gov]
  • Adenoidectomy may be recommended when tympanostomy tube surgery () failed to prevent ear infection.[medical-dictionary.thefreedictionary.com]

References

Article

  1. Kang K, Chou C, Weng W, et al. Associations between Adenotonsillar Hypertrophy, age and obesity in children with obstructive sleep apnea. PLoS ONE. 2013;8(10):78666.
  2. Eziyi J, Amusa Y, Nwawolo C. The prevalence of nasal diseases in Nigerian school children. J Med Med Sci. 2014;5(4):71-77.
  3. Acharya K, Bhusal C, Guragain R. Endoscopic grading of adenoid in otitis media with effusion. J Nep Med Assoc. 2010;49(1):47-51.
  4. Urshitz M, Guenther A, Eggebrecht E, et al. Snoring, intermittent hypoxia and academic performance in primary school children. Am J Respir Crit Care Med. 2003;168(4):464-468.
  5. Roberts J, Burchinal M, Jackson S, et al. Otitis media in early childhood in relation to preschool language and school readiness skills among African American children. Pediatrics. 2000;106(4):723-735.
  6. Scadding G. Non-surgical treatment of adenoidal hypertrophy: the role of treating IgE-mediated inflammation. Pediatr Allergy Immunol. 2010;21(8):1095-1106.
  7. Kurien M, Lepcha A, Mathew J, et al. X-Rays in the evaluation of adenoid hypertrophy: It's role in the endoscopic era. Indian J Otolaryngol Head Neck Surg. 2005;57(1):45–47.
  8. Feres M, de Sousa H, Francisco S, et al. Reliability of radiographic parameters in adenoid evaluation. Braz J Otorhinolaryngol. 2012;78(4):80-90.
  9. Okur E, Aral M, Yildirim I, et al. Bacteremia during adenoidectomy. Int J Pediatr Otorhinolaryngol. 2002;66:149–153.
  10. Taylan I, Ozcan I, Mumcuoglu I, et al. Comparison of the surface and core bacteria in tonsillar and adenoid tissue with beta lactamase production. Indian J Otolaryngol Head Neck Surg. 2011;63:223–228.
  11. Al-Mazrou K, Al-Khattaf A. Adherant Biofilms in adenotonsillar diseases in children. Arch Otolaryngol Head Neck Surg. 2008;134:20–23.
  12. Anita S, Zoltán P, Péter C, et al. Microbiological Profile of Adenoid Hypertrophy Correlates to Clinical Diagnosis in Children. BioMed Research International. 2013;2013:1-10.

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Last updated: 2018-06-22 04:56