Case Report

Adenoid Hypertrophy

Presentator
dr. Ines Camilla Putri

Moderator :

dr. Hesty Dyah Palupi, Sp.T.H.T.K.L

Otorhinolaryngology Head and Neck Surgery Department

Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Dr. Sardjito Hospital Yogyakarta
2019
INTRODUCTION
The adenoids, also known as the
pharyngeal tonsils, are a collection of
lymphoepithelial tissue in the superior aspect
of the nasopharynx medial to the Eustachian
tube orifices. In conjunction with the palatine
tonsils, lingual tonsils, and tubal tonsils, the
adenoids make up the structure known as
Waldeyer's Ring, a collection of mucosal-
associated lymphoid tissue situated at the
entrance of the upper aerodigestive tract.1
Adenoid hypertrophy is more common
in children than in adults, the adenoids
naturally atrophy and regress during
adolescence. A recent meta-analysis showed
the prevalence of adenoid hypertrophy among
a randomized representative sample of children
and adolescents was 34.46%.2
Adenoid hypertrophy is an obstructive
condition related to an increased size of the
adenoids. The condition can occur with or
without an acute or chronic infection of the
adenoids. 1
Viral pathogens associated with adenoid
hypertrophy include adenovirus, coronavirus,
coxsackievirus, cytomegalovirus (CMV),
Epstein-Barr virus (EBV), herpes simplex
virus, human bocavirus parainfluenza virus,
and rhinovirus.3,4 Many aerobic bacterial
species have been implicated in contributing to
infectious adenoid hypertrophy including
alpha-, beta and gamma hemolytic
Streptococcus species, Haemophilus influenza,
Moraxella catarrhalis, Staphylococcus aureus,
Neisseria gonorrhoeae, Corynebacterium
diphtheriae, Chlamydophila pneumoniae,
and Mycoplasma pneumoniae.5,6
Physical examination often elicits a
history of mouth breathing, hyponasal voice,
and the classic adenoid facies, characterized by
an incompetent lip seal, a narrow upper dental
arch, increased anterior face height, a steep
mandibular plane angle, and a retrognathic
mandible. This development occurs as the
result in the changes in head and tongue
position and muscular balance secondary to the
open mouth breathing that accompanies
nasopharyngeal obstruction.7 Recent studies
confirm that there are changes in facial growth
and development among children with adenoid
hypertrophy. These changes are characterized
by increased total and inferior anterior heights
of the face, as well as more anterior and inferior
position of the hyoid bone.8
In acute and chronic infectious adenoid
hypertrophy, medical management with
antibiotics is an appropriate first step.
Amoxicillin can be used for uncomplicated
acute adenoiditis, however, a beta-lactamase
inhibitor such as clavulanic acid should be
included for chronic or recurrent infections.
Clindamycin or azithromycin are considered
as alternatives in patients with penicillin
allergies. Nasal steroids have been suggested as
an additional option for medical treatment with
some short-term success noted, overall the
evidence is mixed as to the efficacy of these
medications.9,10,11
1
 Adenoidectomy is the surgical treatment
option of choice for adenoid
hypertrophy. Adenoidectomy is considered for
patients with recurrent or persistent obstructive
or infectious symptoms related to adenoid
hypertrophy.12,13
Adenoidectomy is performed under
general anesthesia with the patient in the supine
position with the neck extended slightly and the
surgeon seated at the head of the operating
table. Adequate exposure of the posterior
pharynx is achieved by use of a self-retaining
oral retractor, such as a Crowe-Davis mouth
gag, and the adenoids are visualized using an
angled mirror. Many techniques have been
described for performing an adenoidectomy.
Sharp instruments such as the adenoid curette
or adenotome can be used to sharply dissect the
adenoid tissue from the posterior pharyngeal
wall, followed by packing of the pharynx or use
of suction electrocautery for hemostasis.
Suction electrocautery, co-ablation, plasma,
laser, and microdebrider instruments have all
been described in the literature as tools used for
the removal of excessive adenoid tissue during
adenoidectomy.14,15,16 Regardless of the tools
employed, the goal of adenoidectomy is the
surgical reduction of adenoid tissue mass
and/or to eliminate bacterial biofilm from the
surface of the adenoid tissue.17
CASE REPORT
A 3 years old boy came to ENT clinic
of Dr. Sardjito Hospital with chief complain of
nasal congestion and mouth breathing. Mouth
breathing was started since 3 month ago and
worsened in the last 1 month. His parents also
complaint that the patient sometimes snoring
during sleep and stopped breathing during sleep
± 3 times a week. Complaints of the ears and
nose were denied. The parents told that the
patient often affected by cough and cold.
History of allergy was denied and there was no
history of similar complaint in patient’s family.
The general condition of the patient was
good and the vital signs was normal. The
patient’s heart rate was 124 x/minute,
respiratory rate 22 x/minute, and body
temperature 36,0o C. From the physical
examination of the ear was obtained right and
left auricula within normal limit, from otoscopy
examination obtained right and left tympanic
membrane intact with positive cone of light
reflex. On anterior rhinoscopic examination
there were within normal limit. Posterior
rhinoscopic was difficult to do. On oropharynx
examination there were within normal limit.
Neck examination showed no palbable lump or
lymphnode enlargement. On endoscopic
examination there was an adenoid hypertrophy.
From Xray examination found that
adenoidnasopharyngeal ratio with the Fujioka
index was 0,93.
Based on the history taking, physical
examination, endoscopy, and X-ray, the patient
was diagnosed with adenoid hypertrophy and
underwent an adenoidectomy. The issue of this
case is about the treatment.
2
DISCUSSION
Adenoids, also known as the
pharyngeal tonsils, develop in close
approximation to mucous glands along the
posterior surface of the nasopharynx.1
The basic structure of the adenoids is
characterized by multiple shallow sagittal folds
and plicae covered by respiratory epithelium.
Lymphoid follicles develop around the crypts
and adjacent glandular ducts. Crypts begin to
develop at 3 months of gestation and are fully
developed by the seventh month.
Immunoglobulin populations have been found
present in embryonal adenoid tissue. The
adenoids will often increase in size until the
sixth to seventh year of life at which point they
begin to diminish and subsequently atrophy by
early puberty.1
Adenoid hypertrophy is an obstructive
condition, with its symptomatology depending
on the obstructed structure. Nasal obstruction
by hypertrophic adenoid tissue can cause the
patient to complain of rhinorrhea, difficulty
breathing through the nose, chronic cough,
post-nasal drip, snoring, and/or sleep
disordered breathing in children. If nasal
obstruction is significant, the patient can suffer
from sinusitis as a result and may complain of
facial pain or pressure. Obstruction of the
Eustachian tube can lead to symptoms
consistent with Eustachian tube dysfunction
such as muffled hearing, otalgia, crackling or
popping sounds in the ear, and/or recurrent
middle ear infections.18 The classic adenoid
facies, characterized by an incompetent lip seal,
a narrow upper dental arch, increased anterior
face height,. a steep mandibular plane angle,
and a retrognathic mandible.
This patient came with chief complain
of nasal congestion and mouth breathing.
Mouth breathing was started since 3 months
ago and worsened in the last 1 month. His
parents also complaint that the patient
sometimes snoring during sleep and stopped
breathing during sleep ± 3 times a week. The
parents told that the patient often affected by
cough and cold.
Estimation of the
adenoidnasopharyngeal (A/N) ratio (Fujioka
Index) can be calculated from the distance
between the outermost point of convexity of
adenoid shadow and spheno-basiocciput
divided by the distance between spheno-
basiocciput and posterior end of the hard palate.
From X-ray examination of this patient found
that adenoid-nasopharyngeal ratio with the
Fujioka index was 0,93. From the
Nasoendoskopi we can see there are
hypertrophy adenoid. Therefore it can be
concluded that the patient has an adenoid
hypertrophy.
Physiological adenoid hypertrophy may
occur in children aged 6 - 10 years. This is
usually followed by atrophy at the age of 16
years. Removal of the adenoids during
childhood may be immunologically
undesirable. Adenoid enlargement is quite
uncommon in adults. Since examination of the

3
nasopharynx by indirect posterior rhinoscopy is
rarely adequate, many cases of enlarged
adenoid in adults can be misdiagnosed and
accordingly maltreated.
Management of a child with
adenotonsillar disease depends on the
underlying etiology and can include medical
and surgical approaches. Acute infections need
appropriate antibiotic therapy and symptom
control. However the majority of persistent
adenotonsillar disease is considered a surgical
treatment.1 Recurrent or chronic adenoiditis
due to infection should be treated with an
antimicrobial agent effective against
betalactamase producing microorganisms. In
terms of a durable response from other medical
therapies, including inhaled nasal steroids for
adenoidal hypertrophy, some review has shown
only limited short-term benefit. When enlarged
tonsils and adenoids cause an acute upper
airway obstruction, a nasopharyngeal airway
with intravenous steroids may be the most
effective way to achieve immediate relief.
When bacterial infection is suspected,
antimicrobial therapy is initiated. Rarely is
there an indication for immediate tonsillectomy
and adenoidectomy in the acute setting.1
Absolute indications for tonsillectomy
and adenoidectomy include adenotonsillar
hypertrophy with obstructive sleep apnea,
failure to thrive, or abnormal dentofacial
growth; suspicion of malignant disease; and
(for tonsillectomy) hemorrhagic tonsillitis.
Relative indications for both procedures are
adenotonsillar hypertrophy with upper airway
obstruction, dysphagia, or speech impairment,
and halitosis. Otitis media and recurrent or
chronic rhinosinusitis or adenoiditis are relative
indications for adenoidectomy but not
tonsillectomy. Recurrent or chronic
pharyngotonsillitis, peritonsillar abscess, and
streptococcal carriage are relative indications
for tonsillectomy but not adenoidectomy. This
patient came with complaints of mouth
breathing, snoring, and stopped breathing
during sleep ± 3 times a week. These clinical
manifestations showed that the patient got an
indication for adenoidectomy.19
Adenoidectomy techniques in the past
have employed the use of adenoid curettes or
adenotomes with hemostasis achieved with
packing; topical hemostatic agents; or the use
of suction electrocautery. Concerns and
complications with these techniques centered
on excessive bleeding, difficulty in teaching the
technique to inexperienced surgeons, and the
almost certainty of residual tissue around the
Eustachian tube and posterior choana. Suction
Bovie cautery, Microdebrider and coblation
are currently widely used for removal of
adenoids and have been shown to be effective,
efficient, and associated with better hemostasis.
A known disadvantage of these techniques is
the increased expense as compared to
traditional methods. This patient underwent an
adenoidectomy using adenoid curettes or
adenotomes with hemostasis achieved with
packing.1
4
 Adenoidectomy has its own attendant SUMMARY
risks. Postoperative hemorrhages, It has been reported that a three years
velopharyngeal insufficiency, persistent old boy came with complaints of mouth
Eustachian tube dysfunction from iatrogenic breathing, snoring, and stopped breathing
manipulation, nasopharyngeal stenosis, cspine during sleep ± 3 times a week. From the
subluxation from hyperextension during Anamnesis, physical examination,
surgery are all known risks for children nasoendoscopy, and X-ray, the patient was
undergoing adenoidectomy. Special attention diagnosed with adenoid hypertrophy and
must be given to children with Down syndrome underwent an adenoidectomy.
because of the risk of atlantoaxial subluxation.
The most common complaint in children Reference
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