Overview
Definition:
Adenoid hypertrophy refers to the enlargement of the adenoid tonsil, a lymphoid tissue located in the nasopharynx
This enlargement can obstruct the nasal airway, leading to symptoms of nasal obstruction and contributing to sleep-disordered breathing (SDB) in children.
Epidemiology:
Adenoid hypertrophy is a common condition in children, with peak prevalence observed between the ages of 3 and 7 years
It is a leading cause of chronic nasal obstruction and SDB in this age group
Recurrence is possible, especially in children with a history of recurrent upper respiratory infections.
Clinical Significance:
Untreated adenoid hypertrophy can significantly impact a child's quality of life, affecting sleep, breathing, oral feeding, speech development, and even facial growth
Its association with SDB raises concerns about potential long-term consequences on cardiovascular health and neurocognitive development, making timely diagnosis and management crucial for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Chronic nasal obstruction, often worse at night
Mouth breathing, leading to a characteristic "adenoid facies" with an open mouth, elongated face, and dental malocclusion
Snoring
Episodes of apnea or pauses in breathing during sleep
Restless sleep
Daytime fatigue or somnolence
Recurrent sinopulmonary infections
Nasal discharge (rhinorrhea)
Difficulty feeding in infants.
Signs:
Visible mouth breathing
Nasal airflow limitation on examination
Postnasal drip
Cobblestoning of the posterior pharyngeal wall
Enlarged tonsils (though not always proportional to adenoid size)
Signs of otitis media with effusion (OME)
Characteristic facial features (adenoid facies) if chronic
In severe cases, paradoxical chest wall retractions during inspiration may be noted during sleep.
Diagnostic Criteria:
There are no universally established diagnostic criteria for adenoid hypertrophy itself, as it is a histological finding and an anatomical consequence
Diagnosis is primarily clinical, supported by imaging
Sleep-disordered breathing is often diagnosed using polysomnography (PSG) to assess the severity and type of respiratory disturbance.
Diagnostic Approach
History Taking:
Detailed history of nasal breathing difficulties, mouth breathing, snoring, witnessed apneas, sleep disturbances, and daytime symptoms
Inquire about frequency and severity of sinopulmonary infections
Assess feeding patterns in infants
Family history of sleep disorders or obstructive sleep apnea
Red flags include cyanosis, significant desaturations during sleep, failure to thrive, and severe daytime somnolence.
Physical Examination:
Thorough ear, nose, and throat (ENT) examination
Assess nasal airflow by occluding one nostril at a time
Visualize the posterior pharynx for postnasal drip and adenoid tissue if visible
Palpate the neck for lymphadenopathy
Assess for adenoid facies and dental malocclusion
Evaluate tonsillar size
Assess tympanic membranes for OME.
Investigations:
Lateral neck X-ray: commonly used to visualize the adenoid pad and assess the degree of airway obstruction
measurement of adenoid-nasopharyngeal ratio
Flexible nasopharyngoscopy: provides direct visualization of the adenoid size and airway patency
considered the gold standard by some
Polysomnography (PSG): essential for diagnosing and quantifying the severity of sleep-disordered breathing, including obstructive sleep apnea (OSA).
Laboratory tests are generally not indicated unless ruling out other conditions or investigating recurrent infections.
Differential Diagnosis:
Other causes of nasal obstruction in children include allergic rhinitis, chronic sinusitis, nasal polyps, foreign body in the nose, choanal atresia (congenital), and nasal tumors (rare)
Differential diagnoses for SDB include primary snoring, central sleep apnea, and other conditions affecting upper airway function.
Management
Initial Management:
Management depends on the severity of symptoms and the impact on the child's quality of life
For mild symptoms without significant SDB, conservative management may be considered
For moderate to severe obstruction or confirmed SDB, surgical intervention is often recommended.
Medical Management:
Primarily for associated conditions like allergic rhinitis or chronic sinusitis
Nasal corticosteroids (e.g., fluticasone, mometasone) can reduce inflammation and improve nasal airflow
Antihistamines may be used if allergic rhinitis is present
Antibiotics are indicated for acute bacterial sinusitis but not for hypertrophy itself
Montelukast has shown some benefit in reducing adenoid size in certain studies but is not a first-line therapy.
Surgical Management:
Adenoidectomy is the surgical removal of the adenoid tissue
It is indicated for significant nasal obstruction, recurrent sinopulmonary infections attributed to adenoid hypertrophy, and obstructive sleep apnea due to adenoid enlargement
It can be performed alone or in conjunction with tonsillectomy
Techniques include curettage, electrocautery, coblation, and microdebrider-assisted adenoidectomy.
Supportive Care:
For children with SDB, appropriate positioning during sleep (e.g., elevating the head of the bed) may offer some relief
Close monitoring for signs of respiratory distress, especially postoperatively, is crucial
Nutritional support is important for children with feeding difficulties related to nasal obstruction.
Complications
Early Complications:
Bleeding (hematemesis, epistaxis) is the most common early complication, usually minor but can be severe
Pain, fever, nausea, vomiting, and dehydration
Nasal regurgitation of food if palate injury occurs
Injury to surrounding structures (e.g., Eustachian tube, pharyngeal wall).
Late Complications:
Regrowth of adenoid tissue leading to recurrence of symptoms
Velopharyngeal insufficiency (VPI), resulting in hypernasal speech, is rare but more common in children with underlying palatal abnormalities or those undergoing simultaneous tonsillectomy
Chronic nasal congestion or sinusitis if underlying allergies or anatomical issues persist
Persistent SDB if residual obstruction or other contributing factors remain.
Prevention Strategies:
Meticulous surgical technique during adenoidectomy to minimize trauma to surrounding structures
Careful patient selection for surgery
Postoperative care including adequate hydration and pain management
Early recognition and management of bleeding episodes
Identifying and addressing contributing factors like allergies or obesity.
Prognosis
Factors Affecting Prognosis:
Severity of adenoid hypertrophy and associated SDB
Presence of comorbidities (e.g., obesity, syndromic conditions)
Adherence to medical management if indicated
Surgical success rates
Long-term follow-up and management of residual or recurrent issues.
Outcomes:
Adenoidectomy generally provides significant improvement in nasal breathing, snoring, and resolution of SDB in most children
Long-term outcomes are generally good, with a significant reduction in SDB-related symptoms and improved quality of life
However, some children may experience recurrence of symptoms over time.
Follow Up:
Postoperative follow-up is essential to monitor for bleeding, pain, and signs of VPI
Long-term follow-up may be necessary for children with persistent SDB, recurrent infections, or other ongoing concerns
Assessment of breathing, sleep quality, and recurrent sinopulmonary infections should be part of routine pediatric care for children with a history of adenoid hypertrophy.
Key Points
Exam Focus:
Adenoid hypertrophy is a major cause of nasal obstruction and SDB in children
Clinical suspicion should be high in children with mouth breathing, snoring, and restless sleep
Lateral neck X-ray and flexible nasopharyngoscopy are key diagnostic tools for assessing the adenoid
Polysomnography is crucial for diagnosing and grading SDB
Adenoidectomy is the definitive treatment for symptomatic cases.
Clinical Pearls:
Always consider adenoid hypertrophy in children with persistent mouth breathing and snoring
Remember that enlarged tonsils do not always correlate with the degree of adenoid hypertrophy
Even mild adenoid hypertrophy can significantly disrupt sleep architecture
Be aware of the potential for velopharyngeal insufficiency post-adenoidectomy, especially in at-risk children.
Common Mistakes:
Attributing all snoring to simple adenoid hypertrophy without investigating for underlying OSA
Relying solely on lateral neck X-ray without clinical correlation or considering nasopharyngoscopy for definitive assessment
Failing to perform polysomnography in cases of suspected moderate to severe SDB
Delaying surgical intervention when symptoms significantly impact a child's quality of life or development.