Adenoid Hypertrophy


Article Author:
Zachary Geiger


Article Editor:
Nagendra Gupta


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
8/21/2019 9:33:54 PM

Introduction

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, also known as the pharyngeal tonsils, are a collection of lymphoepithelial tissue in the superior aspect of the nasopharynx medial to the Eustachian tube orifices. In conjunction with the palatine tonsils, lingual tonsils, and tubal 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.[1]

Etiology

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, human bocavirus parainfluenza virus, and rhinovirus.[2][3] 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.[4][5][2] FusobacteriumPeptostreptococcus, and Prevotella species have also been identified as anaerobic organisms involved in causing infectious adenoid hypertrophy.[6][7] Multiple non-infectious causes of adenoid hypertrophy have also been suggested including gastroesophageal reflux[8], allergies, and exposure to cigarette smoke.[9] In adults, adenoid hypertrophy can also be a sign of a more serious condition such as HIV infection[10], lymphoma, or sino-nasal malignancy.[11]

Epidemiology

Adenoid hypertrophy is more common in children than in adults; the adenoids naturally atrophy and regress during adolescence.[1] A recent meta-analysis showed the prevalence of adenoid hypertrophy among a randomized representative sample of children and adolescents was 34.46%.[12]

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 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.[13]

On physical exam, the patient with adenoid hypertrophy will often breathe through the mouth, have a hypo nasal character to their voice, and may have the facial characteristics known as adenoid facies which include a high arched hard palate, increased facial height, and retrognathia.[14][15] 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.

Evaluation

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.[16] 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.[17] 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.[18][19]

Treatment / Management

In acute and chronic infectious adenoid hypertrophy, medical management with antibiotics is an 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.[20][21][22]

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.[23][24]  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.[25][26][27] 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.[28]

Differential Diagnosis

Symptoms of adenoid hypertrophy are primarily related to nasal obstruction and Eustachian tube dysfunction. Thus the differential diagnosis should include other causes for these non-specific symptoms, such as:

  • Choanal atresia
  • Pyriform aperture stenosis
  • Allergic rhinitis
  • Acute or chronic sinusitis
  • Nasal polyposis
  • Intranasal encephalocele
  • Nasal dermoid
  • Nasopharyngeal neoplasm
  • Acute otitis media
  • Chronic serous otitis media
  • Cholesteatoma

Prognosis

Adenoid hypertrophy is generally a self-limiting condition which resolves as the adenoids atrophy and regress by adolescence.[1] However, given the potentially serious complications and impact on patient quality of life, surgical management of adenoid hypertrophy is employed for many patients annually. Illustrating this fact, in 2006 there were approximately 506,778 adenotonsillectomies and 129,540 adenoidectomies performed in the United States.[29]

Complications

Complications of adenoid hypertrophy are often seen as complications of persistent middle ear effusion and/or sleep disordered breathing which can occur as a result of untreated adenoid hypertrophy. Children with adenoid hypertrophy are at risk for developing speech, language, and/or learning difficulties as a result of conductive hearing loss which can occur with persistent middle ear effusion.[30][31] Adenoid hypertrophy also places patients at risk for sleep-disordered breathing and sleep apnea which in children can lead to behavioral problems, bedwetting, pulmonary hypertension and psychiatric disorders such as depression and ADHD.[32]

Consultations

Referral for evaluation by an otolaryngologist should be considered in any child with symptoms suggestive of sleep-disordered breathing, persistent middle ear effusion, and/or recurrent throat infections despite adequate treatment with antibiotics.

Deterrence and Patient Education

Educating patients, physicians, and allied health professionals is a key component of providing the best evidence-based care possible to achieve improved patient outcomes.

Pearls and Other Issues

  • Adenoid hypertrophy is common in children and is often infectious in origin
  • A thorough history and physical exam are often sufficient to make the diagnosis of adenoid hypertrophy
  • Flexible nasopharyngoscopy is a safe and reliable alternative to imaging for assessment of adenoid hypertrophy
  • Persistent or new-onset adenoid hypertrophy is unusual in adults and may represent a more serious underlying condition such as HIV infection or malignancy, and warrants further investigation

Enhancing Healthcare Team Outcomes

Interdisciplinary team-based clinics have shown promise in improving health outcomes. Pediatric interdisciplinary aerodigestive clinics are a common example of this model of patient care. In this setting, nurse educators assist in educating the patient and family. Multiple medical specialists work with the nursing staff in coordinating care. The pharmacist provides guidance in antibiotic selection and monitoring for side effects. In a recent longitudinal case series of patients with persistent symptoms after evaluation and treatment by a single specialist, 73% of patients showed significant improvement in their presenting symptoms after treatment at an interdisciplinary aerodigestive clinic.[33] (Level V)

While each medical professional certainly has his or her role to play in providing excellent patient care, it is important to consider the collective benefit of a more collaborative team-based approach to providing comprehensive medical care.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Adenoid Hypertrophy - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is not associated with enlarged adenoids?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following structures are also known as the adenoids?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 7-year-old male presents to the clinic with his mother. The patient's mother states that the child has been very ill-behaved lately, and he has recently started to wet the bed. She also states that she often hears the patient snoring, and she will occasionally hear him "gasping for air" while he is sleeping. Which of the following is most likely to reveal the underlying cause responsible for the patient's mother's observations?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 6-year-old male presents to the clinic for evaluation of snoring for the past year. The patient's father states that he often hears the patient snoring loudly with occasional gasps while sleeping. He states that his son is a "mouth breather" who always seems to have a "stuffy nose." On physical exam, the patient is noted to have a high-arched palate, and his tonsils are 2+ without erythema or exudates. Which of the following is the best treatment option for this patient's condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following can cause the adenoids to enlarge?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A six-year-old male patient is evaluated for possible adenoid hypertrophy. He is a chronic mouth breather and has a hyponasal voice. The patient is most likely too young to tolerate an exam with a flexible nasolaryngoscope in the office. How else might the clinician evaluate the child for adenoid hypertrophy?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Adenoid Hypertrophy - References

References

Goeringer GC,Vidić B, The embryogenesis and anatomy of Waldeyer's ring. Otolaryngologic clinics of North America. 1987 May     [PubMed]
Brook I,Shah K, Bacteriology of adenoids and tonsils in children with recurrent adenotonsillitis. The Annals of otology, rhinology, and laryngology. 2001 Sep     [PubMed]
Swidsinski A,Göktas O,Bessler C,Loening-Baucke V,Hale LP,Andree H,Weizenegger M,Hölzl M,Scherer H,Lochs H, Spatial organisation of microbiota in quiescent adenoiditis and tonsillitis. Journal of clinical pathology. 2007 Mar     [PubMed]
Tarasiuk A,Simon T,Tal A,Reuveni H, Adenotonsillectomy in children with obstructive sleep apnea syndrome reduces health care utilization. Pediatrics. 2004 Feb     [PubMed]
Holm K,Bank S,Nielsen H,Kristensen LH,Prag J,Jensen A, The role of Fusobacterium necrophorum in pharyngotonsillitis - A review. Anaerobe. 2016 Dec     [PubMed]
Brook I, The role of anaerobic bacteria in tonsillitis. International journal of pediatric otorhinolaryngology. 2005 Jan     [PubMed]
Ren J,Zhao Y,Ren X, [An association between adenoid hypertrophy and exstra-gastroesophageal reflux disease]. Lin chuang er bi yan hou tou jing wai ke za zhi = Journal of clinical otorhinolaryngology, head, and neck surgery. 2015 Aug     [PubMed]
Evcimik MF,Dogru M,Cirik AA,Nepesov MI, Adenoid hypertrophy in children with allergic disease and influential factors. International journal of pediatric otorhinolaryngology. 2015 May     [PubMed]
Proenca-Modena JL,Paula FE,Buzatto GP,Carenzi LR,Saturno TH,Prates MC,Silva ML,Delcaro LS,Valera FC,Tamashiro E,Anselmo-Lima WT,Arruda E, Hypertrophic adenoid is a major infection site of human bocavirus 1. Journal of clinical microbiology. 2014 Aug     [PubMed]
Rout MR,Mohanty D,Vijaylaxmi Y,Bobba K,Metta C, Adenoid Hypertrophy in Adults: A case Series. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India. 2013 Jul     [PubMed]
France AJ,Kean DM,Douglas RH,Chiswick OM,St Clair D,Best JJ,Goodwin GM,Brettle RP, Adenoidal hypertrophy in HIV-infected patients. Lancet (London, England). 1988 Nov 5     [PubMed]
Pereira L,Monyror J,Almeida FT,Almeida FR,Guerra E,Flores-Mir C,Pachêco-Pereira C, Prevalence of adenoid hypertrophy: A systematic review and meta-analysis. Sleep medicine reviews. 2018 Apr     [PubMed]
Feres MF,Hermann JS,Cappellette M Jr,Pignatari SS, Lateral X-ray view of the skull for the diagnosis of adenoid hypertrophy: a systematic review. International journal of pediatric otorhinolaryngology. 2011 Jan     [PubMed]
Ysunza A,Pamplona MC,Ortega JM,Prado H, Video fluoroscopy for evaluating adenoid hypertrophy in children. International journal of pediatric otorhinolaryngology. 2008 Aug     [PubMed]
Lertsburapa K,Schroeder JW Jr,Sullivan C, Assessment of adenoid size: A comparison of lateral radiographic measurements, radiologist assessment, and nasal endoscopy. International journal of pediatric otorhinolaryngology. 2010 Nov     [PubMed]
Parikh SR,Coronel M,Lee JJ,Brown SM, Validation of a new grading system for endoscopic examination of adenoid hypertrophy. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2006 Nov     [PubMed]
Buzatto GP,Tamashiro E,Proenca-Modena JL,Saturno TH,Prates MC,Gagliardi TB,Carenzi LR,Massuda ET,Hyppolito MA,Valera FC,Arruda E,Anselmo-Lima WT, The pathogens profile in children with otitis media with effusion and adenoid hypertrophy. PloS one. 2017     [PubMed]
Peltomäki T, The effect of mode of breathing on craniofacial growth--revisited. European journal of orthodontics. 2007 Oct     [PubMed]
Harari D,Redlich M,Miri S,Hamud T,Gross M, The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. The Laryngoscope. 2010 Oct     [PubMed]
Chohan A,Lal A,Chohan K,Chakravarti A,Gomber S, Systematic review and meta-analysis of randomized controlled trials on the role of mometasone in adenoid hypertrophy in children. International journal of pediatric otorhinolaryngology. 2015 Oct     [PubMed]
Demirhan H,Aksoy F,Ozturan O,Yildirim YS,Veyseller B, Medical treatment of adenoid hypertrophy with     [PubMed]
Kuhle S,Urschitz MS, Anti-inflammatory medications for obstructive sleep apnea in children. The Cochrane database of systematic reviews. 2011 Jan 19     [PubMed]
Rosenfeld RM,Shin JJ,Schwartz SR,Coggins R,Gagnon L,Hackell JM,Hoelting D,Hunter LL,Kummer AW,Payne SC,Poe DS,Veling M,Vila PM,Walsh SA,Corrigan MD, Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2016 Feb     [PubMed]
Baugh RF,Archer SM,Mitchell RB,Rosenfeld RM,Amin R,Burns JJ,Darrow DH,Giordano T,Litman RS,Li KK,Mannix ME,Schwartz RH,Setzen G,Wald ER,Wall E,Sandberg G,Patel MM, Clinical practice guideline: tonsillectomy in children. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2011 Jan     [PubMed]
Sjogren PP,Thomas AJ,Hunter BN,Butterfield J,Gale C,Meier JD, Comparison of pediatric adenoidectomy techniques. The Laryngoscope. 2018 Mar     [PubMed]
Ida JB,Worley NK,Amedee RG, Gold laser adenoidectomy: long-term safety and efficacy results. International journal of pediatric otorhinolaryngology. 2009 Jun     [PubMed]
Kuo CY,Lin YY,Chen HC,Shih CP,Wang CH, Video Nasoendoscopic-Assisted Transoral Adenoidectomy with the PEAK PlasmaBlade: A Preliminary Report of a Case Series. BioMed research international. 2017     [PubMed]
Drago L,De Vecchi E,Torretta S,Mattina R,Marchisio P,Pignataro L, Biofilm formation by bacteria isolated from upper respiratory tract before and after adenotonsillectomy. APMIS : acta pathologica, microbiologica, et immunologica Scandinavica. 2012 May     [PubMed]
Huang YS,Guilleminault C, Pediatric Obstructive Sleep Apnea: Where Do We Stand? Advances in oto-rhino-laryngology. 2017     [PubMed]
Lehmann MD,Charron K,Kummer A,Keith RW, The effects of chronic middle ear effusion on speech and language development -- a descriptive study. International journal of pediatric otorhinolaryngology. 1979 Sep     [PubMed]
Rosenfeld RM,Schwartz SR,Pynnonen MA,Tunkel DE,Hussey HM,Fichera JS,Grimes AM,Hackell JM,Harrison MF,Haskell H,Haynes DS,Kim TW,Lafreniere DC,LeBlanc K,Mackey WL,Netterville JL,Pipan ME,Raol NP,Schellhase KG, Clinical practice guideline: Tympanostomy tubes in children. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2013 Jul     [PubMed]
Rotsides JM,Krakovsky GM,Pillai DK,Sehgal S,Collins ME,Noelke CE,Bauman NM, Is a Multidisciplinary Aerodigestive Clinic More Effective at Treating Recalcitrant Aerodigestive Complaints Than a Single Specialist? The Annals of otology, rhinology, and laryngology. 2017 Jul     [PubMed]
Bhattacharyya N,Lin HW, Changes and consistencies in the epidemiology of pediatric adenotonsillar surgery, 1996-2006. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2010 Nov     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Child Health PN. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Child Health PN, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Child Health PN, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Child Health PN. When it is time for the Nurse-Child Health PN board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Child Health PN.