1 Adenoids

The adenoids are a mass of lymphoid tissue found at the junction of the roof and posterior wall of the nasopharynx. They are a normal structure and part of Waldeyer’s ring which includes the palatine and lingual tonsils. Their function includes the production of antibodies and activated white blood cells in response to perceived infectious or other inflammatory threats. The size of the adenoids varies, but in general, they attain their maximum size between the ages of 2 and 7 years, as part of the widespread process of lymphoid hyperplasia that occurs in this age group, and then usually regress in size to become almost negligible by the age of 13 years.

1.1 Pathology

Inflammation, most commonly due to acute viral and bacterial infections, and also allergy and other inflammatory conditions, results in hyperplasia with enlargement and multiplication of the lymphoid follicles. Most of the pathological effects attributed to the adenoids are due to this increase in size. The symptoms caused by hypertrophy result from the obstruction of the nasopharynx and eustachian tube orifices. Persistent bacterial colonisation and biofilms are also contributory factors.

1.2 Clinical Features

1. Nasal obstruction leads to mouth breathing, snoring and hyponasal speech. Infants may have difficulty in feeding because they must stop sucking intermittently to take a breath. Nasal discharge, often mucopurulent, and post-nasal drip may develop because of secondary chronic rhinitis and sinusitis. Besides snoring, some children may suffer from episodes of sleep apnoea. The child with the characteristic adenoid facies appearance (an open lip posture, prominent upper incisors, a short upper lip, a thin nose, and a hypoplastic maxilla with a high-arched palate) is rarely seen nowadays because parents and GPs are better informed about the management of obstructive symptoms.

2. Eustachian tube obstruction may result in otalgia and deafness due to recurrent bouts of acute otitis media and otitis media with effusion (glue ear).

When there is mild-to-moderate obstruction, the clinical features of adenoid hypertrophy are not always clear-cut. Adenoidal hyperplasia may be incorrectly diagnosed when allergy and rhinitis may be the cause. In most children, examination of the nasopharynx with a paediatric nasopharyngoscope will identify large adenoids.

1.3 Investigations

A rarely required investigation is a lateral soft tissue radiograph. This will give a measure of the absolute size of the adenoids and an assessment of their proportion in relation to the size of the airway.

The most reliable means of assessing the size of the adenoids is examination under general anaesthetic at the time of the surgical procedure. If enlarged adenoids are identified then, with appropriate consent, they can be removed.

1.4 Indications for Adenoidectomy

Adenoidectomy is only indicated if troublesome symptoms can be attributed to abnormal adenoid hypertrophy. The indications for adenoidectomy are as follows:

• Nasal obstruction—especially if associated with significant and persistent mucopurulent rhinorrhoea, suggesting chronic nasal cavity infection.

• Otitis media with effusion (glue ear).

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