Adenoiditis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2] Synonyms and keywords: Inflamed adenoids; Adenoid inflamed; Tonsilitis; Adenotonstilis

Overview

Adenoid is a lymphoid tissue that form Waldeyer ring which is situated adjacent to the choanae and the pharyngeal ostium of the eustachian tubes in the posterior wall of nasopharynx. This lymphoid tissue is involved in immunoglobin production and maturation of lymphatic cells and defense against pathogens. The adenoid usually undergoes a degree of atrophy and involution from the age of 8-10 years so it is rarely found in adults.

Adenoiditis is the inflammation of adenoid tissue. Adenoid infection is mostly due to viral infections. Some bacterial pathogens include H. influenzae, group A β-hemolytic streptococcus, and S. aureus can cause the disease as well. Adenoids can cause recurrent sinusitis and chronic persistent or recurrent otitis if remain untreated and develop to chronic adenoiditis.

Medications (antibiotics or steroids) or surgical approach may be required for the management of adenoiditis, depending on the causative agent.

Historical perspective

Adenoid was though to be a part of tonsils and responsible for the symptoms of nasal congestion and obstruction. As a result adenotonsilectomy was performed for at least 2000 years. In the early beginning of 19th century, adenoid and tonsil tissue were known as remnants of an unknown infectious disease, and so they were removed with adenotonsilectomy. Willhelm Meyer of Copenhagen, Denmark in 1800 firstly describe adenoiditis due to adenoid vegetations responsible for nasal symptoms and impaired hearing. He probably was the first one who performed an adenoidectomy separately.

Pathophysiology

Adenoids are involved in the production of mostly secretory IgA, which is transported to the surface providing local immune protection. Studies suggest that a reduction in IgA will happen postoperative of adenoidectomy.

Oral cavity normal flora bacteria are found in adenoid flora as well, which include:

• Alpha-hemolytic streptococci
• Enterococci
• Corynebacterium species
• Coagulase-negative staphylococci
• Neisseria species
• Haemophilus species
• Micrococcus species
• Stomatococcus species

Adenoiditis can happen as a result of infection and harbor pathogenic bacterial activity, which may lead to the development of disease of the ears, nose, and sinuses. Adenoiditis can progress to chronic disease if remain untreated for a long term.

Causes

Adenoiditis is mainly due to viral infection but bacterial infections can cause the disease as well:

Viral Causes

• Epstein-barr virus (EBV)
• Human adenovirus
• Enterovirus
• Rhinovirus
• Respiratory syncytial virus
• Mononucleosis
• Cytomegalovirus (CMV)
• Toxoplasmosis
• Herpes virus

Bacterial Causes

• Haemophilus influenzae
• Group A β-hemolytic streptococcus
• Staphylococcus aureus

• Moraxella catarrhalis
• Streptococcus pneumoniae

Other causes

• Sensitivity to mold allergens

Epidemiology and Demographics

Adenoiditis occurs mostly in children. As a result of close location adenoiditis is often associated with acute tonsillitis. Adenoid tissue go through atrophy process after 10 so adeoiditis is rarely seen after 15. Adenoiditis can be seen in adults too. However due to improvement in diagnosis, it is usually treated or removed during childhood.

Natural History, Complications and Prognosis

The symptoms of adenoiditis usually develop in the first decade of life, and start with symptoms such as recurrent upper respiratory tract infections, sleep apnea, and nasal airway obstruction. Without treatment, the patient will develop symptoms of sinusitis and otitis media, which may eventually lead to hearing loss.

Complications

Chronic adenoiditis is contributed to other head and neck diseases. These diseases are as a result of bacterial overload in adenoids and include:

• Recurrent sinusitis
• Chronic persistent otitis media
• Recurrent otitis media
• Conductive hearing loss
• Pneumonia

History and Symptoms

History

Obtaining the history is one of the most important aspect of making a diagnosis of adenoiditis. It provides insight into diagnosis. Complete history will help determine the correct therapy. Adenoiditis patients are mostly young children who are not able to give a good history by themselves, therefore the patient interview may be difficult. In these cases history from the care givers or the family members may need to be obtained. Specific histories about the symptoms (duration, onset, progression), and associated symptoms have to be obtained. Specific areas of focus when obtaining the history, are outlined below:

• Onset, duration and progression of symptoms
• Associated symptoms (fever, headache, ear pain)
• Recurrent episodes of upper respiratory tract infection
• Poor feeding
• Attention deficit problems
• Impairment of smell

Symptoms

The symptoms of adenoiditis can last for 10 or more days. Acute adenoiditis is usually presented with nasal symptoms:

• Nasal airway obstruction
• Snoring
• sleep apnea
• Oral breathing

• Sore or dry throat from breathing through the mouth

Other symptoms that mainly observed during chronic inflammation are usually correlated to adenoiditis complications and include:

• Purulent rhinorrhea
• Nasal obstruction
• Fever
• Ear pain
• Headache
• Sore throat

Diagnostic criteria

Adenoiditis diagnosis can be confirmed if during flexible or rigid nasopharyngoscopy inflamed adenoid tissue is seen. Flexible or rigid nasopharyngoscopy can provide a direct visualization of nasopharynx and Waldeyer ring so the inflamed adenoid tissue can be seen too.

Other ways that can help beside history and symptoms to be close to diagnosis include:

• Throat examinations using swabs to obtain samples of bacteria and other organisms and culture them
• Blood tests to determine the presence of organisms in blood (especially in ill patients with acute disease)
• Lateral neck graphy to determine the size of adenoids

Differential Diagnosis:

• Tonsilitis
• Adenoid disorders
• Tonsil disorders
• Throat infection
• Chronic tonsilitis

Medical Therapy

• Antibiotic therapy:
  • There are no proven evidence of medical therapy effectiveness in recurrent or chronic adenoiditis cases.
  • Systemic oral antibiotics can be used if the suspected organism is a bacteria and should be prescribed for a long-term (ie, 6 wk) for lymphoid tissue infection.
  • The most appropriate antibiotics are amoxicillin - clavulanic acid or a cephalosporin.
  • Although antibiotic therapy can treat acute adenoiditis, it usually fail to eradicate the bacteria in chronic or recurrent adenoiditis.
  • Nowadays with the current trend of resistant bacteria, the use of prophylactic or long-term antibiotics has been decreased.
• Topical therapy:
  • Topical nasal steroids in children can be used to treat adenoid hypertrophy.
  • Topical nasal steroids can lead to adenoid shrinkage slightly (ie, up to 10%), which may help relieve some nasal obstruction symptoms. However, it is not a permanent therapy and all symptoms may raise again after discontinuation of topical nasal steroid.
  • A combination trial of topical nasal steroid spray and saline spray may be considered for effective control of symptoms in children.
• In cases of viral adenoiditis, treatment with analgesics or antipyretics is often sufficient.

Surgical Therapy

In case of adenoid hypertrophy, adenoidectomy may be performed to remove the adenoid. Adenoidectomy has been shown to be effective independent of the size of the adenoids.

Related Chapters

• Tonsilitis

References

adenoids can contribute to recurrent sinusitis and chronic persistent or recurrent ear disease because they can harbor a chronic infection.adenoids can contribute to recurrent sinusitis and chronic persistent or recurrent ear disease because they can harbor a chronic infection.