Adenoids

Dr. Priyanjal Gautam

PG-3rd Yr. (MS-ENT)

NIMS, Jaipur

• Synonym: Nasopharyngeal tonsil

• Adenoids is the hypertrophied mass of lymphoid tissue situated at the junction of roof & post. wall of nasopharynx.

• The mass of lymphoid tissue is termed as Adenoids only when it is hypertrophied.

• It usually undergoes atrophy by puberty (13-14 yrs)

FEATURES :

• Pink, globular mass

• Vertical ridges on its surface

• No crypts

• Lined by ciliated columnar epithelium

• No capsule

BLOOD SUPPLY :

• Ascending palatine branch of facial artery

• Ascending pharyngeal artery

• Pharyngeal branch of 3rd part of maxillary artery

LYMPHATIC DRAINAGE :

• Upper deep jugular nodes

• Retropharyngeal nodes

• Parapharyngeal nodes

X-Ray Nasopharynx enlarged adenoids

ETIOLOGY :

• Hereditary

• Cold climate

• Specific infection like tuberculosis

• Physiological hypertrophy may be seen between 3-10 yrs

SYMPTOMS :

LOCAL

• B/L nasal obstruction• Snoring• Mouth breathing• Rhinolalia clausa• Frequent rhinorrhoea• Epistaxis• Feeding problems in

children• Conductive deafness due to

ET block• Cervical lymphadenopathy• Otitis media• Adenoids facies• Bronchitis

GENERAL

• Anorexia• Lethargy• Poor physical & mental

development• Bed-wetting• Pigeon chest• Protuberent abdomen

Adenoids Facies

• Sunken eyes• Narrow pinched nostrils• Open mouth• High-arched palate• Crowded teeth• Dull mask-like face• Protruding teeth• Drooling saliva• Everted upper lip• Rhinorrhoea• Loss of nasolabial fold

Aural manifestations in Adenoids

• Otalgia

• Secretory otitis media

• Acute otitis media

• Atelectasis of TM

• ET block

• Chonic otitis media

Diagnosis :

• H/O nasal obstruction, rhinorrhoea

• Pink globular mass with vertical ridges on post. rhinoscopy

• B/L retracted ear drums

• X-ray nasopharynx Lat. View shows soft tissue mass

Differential diagnosis:

• Thornwaldt’s cyst

• High arched palate

Complications:

• Adenoid facies

• Otitis media with effusion

• Recurrent acute otitis media

• Rhinolalia clausa

• Chronic sinusitis

• Sleep apnea syndrome

• Decreased mental/physical development

Treatment :

MEDICAL

• Adequate nutrition

• Antibiotics

• Anti inflammatory analgesics

• Nasal decongestant drops

SURGICAL

• Adenoidectomy

• Myringotomy with grommet insertion

Adenoidectomy

Indications :

1. Adenoid hypertrophy causing snoring, mouth breathing, sleep apnoea syndrome or speech abnormalities, i.e. (rhinolalia clausa).

2. Recurrent rhinosinusitis.

3. Chronic secretory otitis media associated with adenoid hyperplasia.

4. Recurrent ear discharge in benign CSOM associated with adenoiditis/adenoid hyperplasia.

5. Dental malocclusion. Adenoidectomy does not correct dental abnormalities but will prevent its recurrence after orthodontic treatment.

Contraindications :

1. Cleft palate

2. Haemorrhagic diathesis.

3. Acute URTI

Anaesthesia :

• Always general, with oral endotracheal intubation.

Neck is extended by a sand bag under the shoulders and the head is supported on a ring.

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Rose's position

Steps of Operation :

1. Boyle-Davis mouth-gag is inserted. Before actual removal of adenoids, nasopharynx should always be examined by retracting the soft palate with curved end of the tongue depressor and by digital palpation, to confirm the diagnosis, to assess the size of adenoids mass and to push the lateral adenoid masses towards the midline.

2. Proper size of "adenoid curette with guard" is introduced into the nasopharynx till its free edge touches the posterior border of nasal septum and is then pressed backwards to engage the adenoids. At this level, head should be slightly flexed to avoid injury to the odontoid process.

Adenoid curette

With guard Without guard

3. With gentle sweeping movement, adenoids are shaved off . Lateral masses are similarly removed with smaller curettes; small tags of lymphoid tissue left behind are removed with punch forceps.

4. Haemostasis is achieved by packing the area for sometime. Persistent bleeders are electro-coagulated under vision. If bleeding is still not controlled, a postnasal pack is left for 24 hours.

Adenoidectomy.

Endoscopic Adenoidectomy

• These days adenoids can be removed more precisely by using a debrider under endoscopic control

Nasal endoscopic adenoidectomy using curette

Oral endoscopic adenoidectomy using curette

Micro debrider

Micro debrider Micro debrider-tip blade

Microdebrider adenoidectomy

Mirror assisted microdebrider adenoidectomy

Coblation adenoidectomy

• It is also other wise known as cold

abalation. This technique utilises a field of plasma, or ionised sodium molecules, to ablate tissues. The heat generated varies from 40 - 80 degrees centigrade, much lower than that of electro cautery. The major advantage of this procedure is reduced bleeding and reduced post operative pain.

Coblation adenoidectomy

Post-operative Care :

1. Immediate general care

(a) Keep the patient in coma position until fully recovered from anaesthesia.

(b) Keep a watch on bleeding from the nose and mouth.

(c) Keep check on vital signs, e.g. pulse, respiration and blood pressure.

Post-operative Care cont..

2. Diet When patient is fully recovered he/she is to

take liquids, e.g. cold milk or ice cream.

3. Nasal saline drops

Post-operative Care cont..

4. Analgesics : I/V or oral

5. Antibiotics : Orally or I/V for a week.

Patient is usually sent home 24 hours after

operation unless there is some complication. Patient can resume his normal duties within 2 weeks.

Complications :

1. Haemorrhage

2. Injury to eustachian tube opening

3. Injury to pharyngeal musculature and vertebrae

4. Griesel syndrome. Patient complains of neck pain and develops torticollis. Mostly it is due to spasm of paraspinal muscles, but can be due to atlanto-axial dislocation requiring cervical collar and even traction.

5. Nasopharyngeal stenosis

6. Recurrence

Thank You…