Adenoiditis

Definition And Anatomy

• Represents hyperplasia of nasopharyngeal tonsil (Luschka’s tonsil).
• Located at anatomical junction of roof and posterior wall of nasopharynx.
• Constitutes integral component of Waldeyer’s Ring alongside palatine, lingual, and tubal tonsils.
• Present at birth, undergoes physiologic hypertrophy during 3–7 years mirroring peak immunological activity,.
• Regresses spontaneously by puberty,.

Etiology And Pathophysiology

• Driven by recurrent viral (Rhino/Adenovirus) or bacterial (Beta-hemolytic Streptococci, Haemophilus influenzae, Moraxella catarrhalis) infections.
• Exacerbated by chronic allergic rhinitis triggering continuous lymphoid hyperplasia.
• Associated with environmental irritants including passive cigarette smoke.
• Provoked by chronic irritation from gastroesophageal reflux disease.
• Enlargement causes direct mechanical obstruction of nasopharynx and Eustachian tube orifices,.
• Acts as bacterial reservoir maintaining chronic regional inflammation.

Clinical Features

Nasal And Speech Symptoms

Feature	Clinical Manifestation
Nasal Obstruction	Bilateral, persistent blockage requiring continuous mouth breathing, especially during sleep.
Discharge	Chronic mucopurulent nasal discharge indicating concurrent adenoiditis.
Voice Alteration	Hyponasal speech (Rhinolalia clausa) lacking normal nasal resonance.
Sleep Disordered Breathing	Ranges from simple snoring to severe obstructive sleep apnea.

Otologic And Systemic Symptoms

System	Specific Findings
Otologic	Eustachian tube dysfunction, recurrent acute otitis media, otitis media with effusion (glue ear) causing conductive hearing loss.
Sleep Disturbances	Restless sleep, night terrors, enuresis,.
Cardiopulmonary	Rare development of pulmonary hypertension (cor pulmonale) secondary to severe chronic obstructive sleep apnea.

Adenoid Facies

• Characteristic facial appearance resulting from chronic mouth breathing.
• Elongated face with dull expression.
• Open mouth posture with prominent upper incisors (bunny teeth).
• High arched palate with hypoplastic maxilla and pinched nostrils.

Grading (Clemens Classification)

• Based on endoscopic assessment of choanal obstruction.
• Grade I: 0–25% obstruction.
• Grade II: 26–50% obstruction.
• Grade III: 51–75% obstruction.
• Grade IV: 76–100% obstruction.

Diagnostic Evaluation

Modality	Utility And Findings
Diagnostic Nasal Endoscopy	Gold standard investigation directly visualizing adenoid size and choanal patency.
X-Ray Nasopharynx (Lateral)	Soft tissue technique utilizing Fujioka’s Method. Ratio of adenoidal depth to nasopharyngeal space >0.8 indicates significant hypertrophy.
Tympanometry	Rules out associated otitis media with effusion demonstrating flat Type B curve.
Polysomnography	Gold standard sleep study indicated for suspected obstructive sleep apnea.

Differential Diagnosis

• Choanal atresia (unilateral or bilateral bony/membranous blockage).
• Antrochoanal polyp (solitary mass originating from maxillary sinus).
• Juvenile nasopharyngeal angiofibroma (adolescent males, profuse bleeding).
• Allergic rhinitis (pale turbinates, sneezing).
• Foreign body (unilateral foul-smelling discharge).

Management

Medical Management

• Constitutes first-line therapy for mild-to-moderate symptoms without severe obstructive sleep apnea.
• Intranasal corticosteroids (Fluticasone/Mometasone) administered for 6–12 weeks.
• Reduces adenoid size by decreasing local lymphocyte infiltration.
• Antibiotics (Amoxicillin-Clavulanate) utilized for acute adenoiditis exacerbations.
• Saline nasal washes indicated for clearing mucopurulent secretions.
• Strict control of underlying co-morbidities including allergies and gastroesophageal reflux.

Surgical Management (Adenoidectomy)

• Indications:
  • Severe nasal obstruction causing persistent mouth breathing or established adenoid facies.
  • Documented obstructive sleep apnea.
  • Recurrent rhinosinusitis failing maximal medical therapy,.
  • Chronic otitis media with effusion lasting >3 months with associated hearing loss.
  • Recurrent acute otitis media,.
  • Severe dental malocclusion.
• Surgical Techniques:
  • Conventional blind curettage utilizing St. Clair Thomson curette.
  • Endoscopic-assisted powered microdebrider shaving for precision removal.
  • Coblation utilizing radiofrequency ablation resulting in less bleeding and pain.

Complications Of Surgery

Complication	Pathological Mechanism
Hemorrhage	Primary or reactive bleeding, though less common compared to tonsillectomy.
Grisel’s Syndrome	Atlanto-axial subluxation developing secondary to postoperative paraspinous inflammation.
Velopharyngeal Insufficiency	Hypernasal speech (Rhinolalia aperta) arising from excessive tissue removal or underlying submucous cleft palate,.
Regrowth	Tissue recurrence possible, especially if surgical extirpation performed at very young age.