Pathological Effects of Adenoids

Pathological effects of adenoids:
It may be implicated in upper respiratory tract infections due to partial or complete obstruction or as a result of sepsis.Others are rhinosinusitis, rhinitis, otitis media and otitis media with effusion.Adenoiditis is a distinct infective entity.
Otitis media with effusion:
Adenoidectomy in otitis media with effusion is traditionally been ascribed to anatomical obstruction of eustachian tube while this is contributory but cannot account for if adenoid is small in size. Acute or chronic adenoid infection particularly by Haemophilus Influenzae results in squamous cell metaplasia, reticular epithelium extension, fibrosis of interfollicular connective tissue and reduced mucociliary clearance in children with otitis media with effusion compared to those without otitis media with effusion. These changes increase bacterial adherence leading to biofilm infection resulting in middle ear effusion.Biofilm infection may be defined as a structured community of bacterial cells enclosed in a self produced polymeric matrix and adherent to an inert or living surface.
Recurrent acute otitis media:
The trials of the management of recurrent acute otitis media has shown that adenoidectomy not effective in reducing episodes in children below 2 years.It is likely that partial maturational selective IgA deficiency is a causative factor in these otitis prone children. Low dose prophylactic antibiotic treatment is preferred to adenoidectomy in this group to prevent recurrent acute otitis media and its sequelae till maturation of immune system occurs naturally.
Upper airway obstruction and obstructive sleep apnoea:
The prevalence of severe sleep disturbance in children due to upper airway obstruction is estimated at approximately 1%, with peak between 3 to 6 years of age and equal sex incidence.Airway obstruction due to adenoid hypertrophy produce depressed arterial paO2 and paCO2 levels which to normal after adenoidectomy. The respiratory improvement following adenoidectomy also results in a significant increase in serum insulin like growth factor -1 accounting in part for the clinically observed growth spurt following surgery.Studies have shown that adenoidectomy for upper airway obstruction, the radiographic estimate of the adenoid size correlated highly with the improvement in polysomnographic scores following surgery.
Rhinosinusitis:
Chronic sinusitis undergoing adenoidectomy or Adenotonsillectomy improvement was reported in the majority following surgery. Very few required FESS.
Olfaction:
Olfactory sensitivity is reduced in relation to adenoid size and this improves post surgery. This may in part account for the poor appetite reported in children with adenoid hypertrophy.Neoplasia:Unsuspected neoplasia of the adenoid in childhood is rare. Atypical lymphadenopathy and persistent and asymmetric enlargement of the tonsils and adenoid in the absence of infection are suspicious and should prompt early imaging and biopsy.
Etiology:
Common in childrenPhysiologicalUpper respiratory tract infectionsLow socio-economic statusEnvironments like crowding, pollutionCommon cultured bacteria is H.Influenza, group A Beta haemolytic streptococci, staphylococcous aureus, Moraxella catarrhalis, Streptococcus pneumoniae.
Clinical features:
Nasal: Nasal obstructionDischargePostnasal dischargeSleep apnoeaHyponasal speechEpistaxis rarelyAural symptoms:Recurrent otalgia, deafness, ear discharge due to acute otitis media/ secretory otitis media/ chronic suppurative otitis media.
Throat symptoms:Recurrent pharyngitis/ tonsillitis/ mouth breathingGeneral features:Mental dullness, nocturnal enuresis, night terrors
Adenoid facies:Long standing mouth breathing/ nasal block lead to following-Pinched nose/ mouth breathing/ saliva dribbling/ flat nasal arch/ malar hypoplasia/ elongated face/ dull idiotic appearance/ loss of nasolabial fold/ short protruding upper lip/ crowding of teeth/ high arched palate/ deafness-inattentive child.
General features:
Recurrent lower respiratory tract infection, frequent diarrhea, low nutritional status, pigeon chest, protuberant abdomen, enuresis
Treatment:
Control infection with proper antibioticsAntihistamines/ decongestantsSteroid spray to be triedImprove nutritional statusBreathing exercisesAdenoidectomyMyringotomy
References:
1) Zhang AF et al , Department of Otorhinolaryngology and Head Neck, Dalian Municipal Central Hospital, Dilian, China
2) Berlucchi M et al, Department of Paediatric Otorhinolaryngology, Piazzo Spedali Civili, Brescia, Italy
3) Michael Gleeson, Ray Clarke et al, Scott-Brown Otorhinolaryngology and Head Neck Surgery, 7th edition, vol 1
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