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Adenoid Disorders

by Clarence T. Sasaki, MD

Hypertrophy or inflammation of the adenoids is common among children. Symptoms include nasal obstruction, sleep disturbances, and middle ear effusions with hearing loss. Diagnosis is enhanced by flexible fiberoptic nasopharyngoscopy. Treatment often includes intranasal corticosteroids, antibiotics, and, for significant nasal obstruction or persistent recurrent acute otitis media or middle ear effusion, adenoidectomy.

The adenoids are a rectangular mass of lymphatic tissue in the posterior nasopharynx. They are largest in children age 2 to 6 yr. Enlargement may be physiologic or secondary to viral or bacterial infection, allergy, irritants, and, possibly, gastroesophageal reflux. Other risk factors include ongoing exposure to bacterial or viral infection (eg, to multiple children at a child care center). Severe hypertrophy can obstruct the eustachian tubes (causing otitis media), posterior choanae (causing sinusitis), or both.

Symptoms and Signs

Although patients with adenoid hypertrophy may not complain of symptoms, they usually have chronic mouth breathing, snoring, sleep disturbance, halitosis, recurrent acute otitis media, conductive hearing loss (secondary to recurrent otitis media or persistent middle ear effusions), and a hyponasal voice quality. Chronic adenoiditis can also cause chronic or recurrent nasopharyngitis, rhinosinusitis, epistaxis, halitosis, and cough.

Diagnosis

  • Flexible nasopharyngoscopy

Adenoid hypertrophy is suspected in children and adolescents with characteristic symptoms, persistent middle ear effusions, or recurrent acute otitis media or rhinosinusitis. Similar symptoms and signs in a male adolescent may result from an angiofibroma (see Juvenile Angiofibromas).

Children with velopharyngeal insufficiency (see Velopharyngeal Insufficiency), eg, due to velocardiofacial syndrome, may produce a hypernasal speech that must be differentiated from the hyponasal speech of adenoid hypertrophy.

The standard for office assessment of the nasopharynx is flexible nasopharyngoscopy. Sleep tape recording, often used to document snoring, is not as accurate. A sleep study may help define the severity of any sleep disturbance due to chronic obstruction.

X-ray imaging is contraindicated in children except when there is a high index of suspicion for angiofibroma or cancer.

Treatment

  • Treatment of cause

  • Sometimes adenoidectomy

Underlying allergy is treated with intranasal corticosteroids, and underlying bacterial infection is treated with antibiotics.

In children with persistent middle ear effusions or frequent otitis media, adenoidectomy often limits recurrence. Children > 4 yr who require tympanostomy tubes often undergo adenoidectomy when tubes are placed. Surgery is also recommended for younger children with recurrent epistaxis or significant nasal obstruction (eg, sleep disturbance, voice change). Although it requires general anesthesia, adenoidectomy usually can be done on an outpatient basis with recovery in 48 to 72 h. Adenoidectomy is contraindicated in velopharyngeal insufficiency because it can precipitate or worsen hypernasal speech.

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