Adenoid Hypertrophy

Although patients with adenoid hypertrophy may not complain of symptoms, they typically have chronic mouth breathing (because of nasopharyngeal obstruction) and a hyponasal voice quality. Other symptoms include, snoring, sleep disturbances, halitosis, recurrent acute otitis media, conductive hearing loss (secondary to recurrent otitis media or persistent middle ear effusions).

Children with significant adenoid hypertrophy can occasionally develop a characteristic, vertically elongated face (adenoid facies) including a high-arched palate, dental crowding, and a short upper lip.

• Flexible nasopharyngoscopy

• Lateral imaging of the neck

The diagnosis of adenoid hypertrophy is suspected in children and adolescents with characteristic symptoms of nasopharyngeal obstruction (eg, mouth breathing, snoring), persistent middle ear effusions, or recurrent acute otitis media or rhinosinusitis.

Similar symptoms and signs of adenoid hypertrophy in a male adolescent may result from a juvenile nasopharyngeal angiofibroma. Children with velopharyngeal insufficiency (eg, due to velocardiofacial syndrome) may have hypernasal speech (ie, sounding as if too much air escapes through the nose) that must be differentiated from the hyponasal speech (ie, as with a congested nose) of adenoid hypertrophy (see Differential Diagnosis).

The standard for office assessment of the nasopharynx is flexible nasopharyngoscopy. Sleep tape recording, often used to document snoring, is not as accurate or specific. Polysomnography (sleep study) may help define the severity of any sleep disturbance or obstructive sleep apnea due to chronic obstruction; the degree of severity of obstructive sleep apnea may be classified on the basis of the apnea-hypopnea index (AHI) as mild, moderate, and severe (1).

Lateral neck radiography is useful in assessing adenoid size, especially when a child cannot tolerate an endoscopic examination. In conjunction with clinical assessment, lateral neck radiography offers high sensitivity and specificity for evaluating the degree of adenoid hypertrophy (2). CT or MRI may be considered in children when the index of suspicion for angiofibroma or cancer is high.

Enlarged Adenoids (Radiograph)

Image

This radiograph shows large adenoids (white star) causing narrowing of the airway (black star).

© Springer Science+Business Media

• Medical management

• Sometimes surgical management (eg, adenoidectomy)

• Treatment of underlying etiology

The treatment of adenoid hypertrophy includes both medical and surgical approaches. The choice of approach depends on the severity of symptoms (ie, degree of hypertrophy), presence of complications, and patient age. Treatment approaches must also take into consideration the associated underlying etiology.

Medical management is primarily with Intranasal glucocorticoids, which have demonstrated efficacy in adenoid hypertrophy (1, 2). The use of intranasal glucocorticoids and antihistamines is associated with a reduction in the need for surgery in selected patients (3). These agents are also beneficial in the treatment of associated underlying allergy (eg, allergic rhinitis), sinusitis, and nasal polyps. Limited evidence suggests that leukotriene antagonists (primarily montelukast) may improve symptoms (eg, mouth breathing, snoring) related to adenoid hypertrophy; relevant boxed warnings must be discussed with patients and caregivers prior to initiating treatment (). These agents are also beneficial in the treatment of associated underlying allergy (eg, allergic rhinitis), sinusitis, and nasal polyps. Limited evidence suggests that leukotriene antagonists (primarily montelukast) may improve symptoms (eg, mouth breathing, snoring) related to adenoid hypertrophy; relevant boxed warnings must be discussed with patients and caregivers prior to initiating treatment (4).

Surgical removal of the adenoids (adenoidectomy) is generally performed when there is obstructive sleep apnea, abnormal dentofacial growth (due to malocclusion), or if there is any suspicion of malignancy (5). Adenoidectomy may be performed with or without tonsillectomy and tympanostomy tube placement. For example, in children with persistent middle ear effusions or frequent otitis media, adenoidectomy is often performed concurrently with tympanostomy tube placement to limit recurrence (6). If children are > 4 years and require tympanostomy tubes, particularly if performed on a repeated basis (eg, for otitis media with effusion), adenoidectomy is often performed concurrent with tube placement (7). Adenotonsillectomy is also recommended for younger children with recurrent tonsillitis or peritonsillar abscesses. Although it requires general anesthesia, adenoidectomy usually can be performed on an outpatient basis with recovery in 48 to 72 hours.

Adenoidectomy is contraindicated in patients with velopharyngeal insufficiency, which can be associated with submucosal cleft palate and bifid uvula because adenoidectomy can precipitate or worsen hypernasal speech.

Adenoidectomy is generally considered a safe surgical procedure with a low risk of postoperative complications (including hemorrhage) and mortality (8).

An underlying bacterial infection (adenoiditis manifested as halitosis) should be treated with antibiotics. If obstructive sleep apnea is evident on polysomnography, medical management or home bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP) devices may be required.