Adenoid Hypertrophy is an obstructive condition related to an increased size of the adenoids. The condition can occur with or without an acute or chronic infection of the adenoids. The adenoids are a collection of lymphoepithelial tissue in the superior aspect of the nasopharynx medial to the Eustachian tube orifices. In conjunction with the faucial and lingual tonsils, the adenoids make up the structure known as Waldeyer’s ring, a collection of mucosal-associated lymphoid tissue situated at the entrance of the upper aerodigestive tract. Blood supply to the adenoids includes the ascending pharyngeal artery, with some contributions from the internal maxillary and facial arteries. The glossopharyngeal and vagus nerves provide sensory innervation to the adenoids. Adenoid size tends to increase during childhood, usually reaching maximal size by age 6 or 7 before regressing by adolescence.[rx]
Causes of Adenoid Hypertrophy
Adenoid hypertrophy can occur because of infectious and non-infectious etiologies. Infectious causes of adenoid hypertrophy include both viral and bacterial pathogens. Viral pathogens associated with adenoid hypertrophy include adenovirus, coronavirus, coxsackievirus, cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus, parainfluenza virus, and rhinovirus.[rx][rx] Many aerobic bacterial species have been implicated in contributing to infectious adenoid hypertrophy including alpha-, beta-, and gamma-hemolytic Streptococcus species, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Chlamydophila pneumoniae, and Mycoplasma pneumoniae.[rx][rx][rx] Fusobacterium, Peptostreptococcus, and Prevotella species have also been identified as anaerobic organisms involved in infectious adenoid hypertrophy.[rx][rx] Multiple non-infectious causes of adenoid hypertrophy have also been suggested including gastroesophageal reflux[rx], allergies, and exposure to cigarette smoke.[rx] In adults, adenoid hypertrophy can also be a sign of a more serious condition such as HIV infection[rx], lymphoma, or sino-nasal malignancy.[rx]
Diagnosis of Adenoid Hypertrophy
History and Physical
Adenoid hypertrophy is an obstructive condition, with its symptomatology depending on the obstructed structure. Nasal obstruction by hypertrophic adenoid tissue can cause the patient to complain of rhinorrhea, difficulty breathing through the nose, chronic cough, post-nasal drip, snoring, and/or sleep-disordered breathing in children. If the nasal obstruction is significant, the patient can suffer from sinusitis as a result and may complain of facial pain or pressure. Obstruction of the Eustachian tube can lead to symptoms consistent with Eustachian tube dysfunction such as muffled hearing, otalgia, crackling or popping sounds in the ear, and/or recurrent middle ear infections.[rx]
On physical exam, the patient with adenoid hypertrophy will often breathe through the mouth, have a hypo nasal character to the voice, and may have the facial characteristics known as adenoid facies which include a high arched hard palate, increased facial height, and retrognathia.[rx][rx] A complete physical exam should aim to rule out other potential causes of nasal obstruction such as nasal foreign bodies, rhinosinusitis, nasal polyposis, and congenital abnormalities such as choanal atresia or pyriform aperture stenosis.
A thorough history and physical exam are often sufficient to diagnosed adenoid hypertrophy. Lateral head and neck radiography have been used for assessment of the adenoids, especially in fussy or non-cooperative children.[rx] Videofluoroscopy has also been described as a method for determining the degree of adenoid hypertrophy. Both of these radiographic methods have shown some reliability in diagnosing adenoid hypertrophy. However, both also come with the risk of potentially unnecessary exposure to radiation.[rx] Direct visualization of the adenoids by fiberoptic nasopharyngoscopy is another option for assessing the adenoids in the clinical setting with good reliability and without unnecessary exposure to radiation.[rx][rx]
Rapid strep testCulturesAllergy testing
If it presents in the context of pharyngitis, the clinician may want to perform a rapid strep test. The purpose of doing so is two-fold. First, this will give a definitive diagnosis of the patient’s condition and help guide antibiotic therapy. Second, the doctor’s office will have a record of positive and negative strep tests which will play an important role when deciding whether an adenoidectomy, plus or minus tonsillectomy, is indicated. It is important to remember that adenoiditis remains a clinical diagnosis, so if the strep test is negative the physician can presume it is due to a different causative organism.
In cases of persistent infection despite antibiotic therapy, the clinician may choose to perform throat cultures to help identify the causative agent and guide therapy as direct cultures of adenoids may be difficult in the office setting.
If the adenoiditis is believed to be the result of seasonal or environmental allergies, allergy skin testing may be useful in directing therapy.
- Lateral neck X-ray
- Computed tomography (CT) of the sinuses
- Sinus X-rays or sinus CTs may be obtained to look for a source of infection in the sinuses if this is suspected clinically. This is rarely required in routine cases. Lateral neck X-rays are an effective way to evaluate specifically for adenoid hypertrophy. In a patient with adenoid hypertrophy who snores a sleep study can be obtained to rule out obstructive sleep apnea.
Treatment of Adenoid Hypertrophy
- Watch and wait – If the clinician believes the cause of adenoiditis is by the common cold or other common viral infection they should refrain from using antibiotics. Typically, uncomplicated upper respiratory viral infections will resolve within five to seven days.[rx]
- Antibiotic treatment – If symptoms continue or clinical presentation is suggestive of bacterial etiology, such as a high fever or purulent discharge from the nose or throat, the first-line management is antibiotics covering the most common pathogens. Amoxicillin is a commonly used first-line agent due to its good coverage and tolerability. Alternatively, cefdinir or cefuroxime may be used, particularly if the patient has not responded to amoxicillin. If the patient has a penicillin allergy, alternatives include clarithromycin or azithromycin. Effective antibiotic treatment should yield an improvement of symptoms in 48-72 hours. Treatment duration should be ten days, as treating for a shorter duration yields significant relapse rates and breeds antibiotic resistance. If the condition fails to improve after a course of amoxicillin or other first-line agents, amoxicillin-clavulanate should be prescribed to eliminate potential beta-lactamase producing organisms.[rx]
- Allergy treatment – If the adenoiditis is believed to be secondary to environmental allergies, the patient can be given a trial of nasal steroid sprays, oral steroids, oral antihistamines, or some combination thereof to see if this produces any relief in symptoms. If this is effective, the patient may benefit from formal allergy testing followed by immune-modulating therapy to provide definitive relief.
- Reflux treatment – If the adenoiditis is believed to be secondary to LPR/GERD, treatment of this condition using lifestyle and diet modification with or without the use of H2 blockers or proton-pump inhibitors may provide sufficient relief of symptoms.[rx]
In acute and chronic infectious adenoid hypertrophy, medical management with antibiotics is the appropriate first step. Amoxicillin can be used for uncomplicated acute adenoiditis, however, a beta-lactamase inhibitor such as clavulanic acid should be included for chronic or recurrent infections. Clindamycin or azithromycin are considered as alternatives in patients with penicillin allergies. Nasal steroids have been suggested as an additional option for medical treatment with some short-term success noted, overall the evidence is mixed as to the efficacy of these medications.[rx][rx][rx]
Adenoidectomy is the surgical treatment option of choice for adenoid hypertrophy. Adenoidectomy is considered for patients with recurrent or persistent obstructive or infectious symptoms related to adenoid hypertrophy.[rx][rx] Adenoidectomy is performed under general anesthesia with the patient in the supine position with the neck extended slightly and the surgeon seated at the head of the operating table. Adequate exposure of the posterior pharynx is achieved by use of a self-retaining oral retractor, such as a Crowe-Davis mouth gag, and the adenoids are visualized using an angled mirror. Many techniques have been described for performing an adenoidectomy. Sharp instruments such as the adenoid curette or adenotome can be used to sharply dissect the adenoid tissue from the posterior pharyngeal wall, followed by packing of the pharynx or use of suction electrocautery for hemostasis. Suction electrocautery, co-ablation, plasma, laser, and microdebrider instruments have all been described in the literature as tools used for the removal of excessive adenoid tissue during adenoidectomy.[rx][rx][rx] Regardless of the tools employed, the goal of adenoidectomy is the surgical reduction of adenoid tissue mass and/or to eliminate bacterial biofilm from the surface of the adenoid tissue.[rx]
If adenoiditis is left untreated, the patient may develop a chronic infection of the adenoids which in some cases can lead to the development of a biofilm. The adenoids may then serve as a nidus of infection for other closely related structures and lead to rhinosinusitis, pharyngitis, tonsillitis, and otitis media.[rx][rx]
Adenoid hypertrophy is responsible for some of the more common complications related to disease of the adenoids. As they enlarge the tissues can create a significant obstacle to the flow of air through the nasopharynx. This enlargement can cause mouth breathing, snoring, and OSA. OSA can be a life-threatening disease if left untreated. Removing the adenoids can increase the flow of air through the nasopharynx, decreasing obstructive episodes, and leading to better CPAP compliance or resolution of the condition altogether.
Enlarged adenoids may also obstruct the opening of the Eustachian tubes in the nasopharynx. Without proper function of the Eustachian tube, negative pressure can build in the middle ear. This negative pressure can lead to the formation of an effusion which can cause conductive hearing loss and speech problems, as well as serve as a nidus for bacterial infections.
Long-standing adenoiditis with subsequent adenoid hypertrophy can lead to the development of what is known as adenoid facies or long-face syndrome. Enlarged adenoids can block the nasopharynx and result in obligate mouth breathing, which can lead to craniofacial abnormalities including a high-arched palate and retrognathic mandible.[rx]