Adenoids ANATOMY AND PHYSIOLOGY The nasopharyngeal tonsil, comminaly called "adenoids", is situated at the junction of the roof and posterior wall of the nasopharynx. It is composed of vertical ridges of lymphoid tissue separated by deep clefts . Covering epithelium is of three types: ciliated pseudostratified columnar, stratified squamous and transitional. Unlike palatine tonsils, adenoids have no crypts and no capsule. Adenoid tissue is present at birth, shows physiological enlargement up to the age of 6 years, and then tends to atrophy at puberty and almost completely disappears by the age of 20. Blood supply. Adenoids receive their blood supply from: 1.Ascending palatine branch of facial. 2.Ascending pharyngeal branch of external carotid. 3.Pharyngeal branch of the third part of maxillary artery. 4.Ascending cervical branch of inferior thyroid artery of thyrocervical trunk. Lymphatics from the adenoid drain into upper jugular nodes directly or indirectly via retropharyngeal and parapharyngeal nodes. Nerve supply is through CN IX and X. They carry sensation. Referred pain to ear due to adenoiditis is also mediated through them. AETIOLOGY Adenoids are subject to physiological enlargement in childhood. Certain children have a tendency to generalized lymphoid hyperplasia in which adenoids also take part. Recurrent attacks of rhinitis, sinusitis or chronic may cause chronic adenoid and hyperplasia. Allergy of the upper respiratory tract may also contribute to the enlargement of adenoids.

CLINICAL FEATURES

Symptoms and signs depend not merely on the absolute size of the adenoid mass but are relative to the available space in the nasopharynx. Enlarged and infected adenoids may cause nasal, aural or general symptoms

1.NASAL SYMPTOMS (A)Nasal obstruction is the commonest symptom. This leads to mouth breathing. Nasal obstruction also interferes with feeding or suckling in a child. As respiration and feeding cannot take place simultaneously, a child with adenoid enlargement fails to thrive. (B)Nasal discharge. It is partly due to choanal obstruction, as the normal nasal secretions cannot drain into nasopharynx and partly due to associated chronic rhinitis. The child often has a wet bubbly nose. (c)Sinusitis. Chronic maxillary sinusitis is commonly associated with adenoids. It is due to persistence of nasal discharge and infection. Reverse is also true that a primary maxillary sinusitis may lead to infected and enlarged adenoids. (d)Epistaxis. When adenoids are acutely inflamed, epistaxis can occur with nose blowing. (e)Voice change. Voice is toneless and loses nasal quality due to nasal obstruction. 2. AURAL SYMPTOMS (a) Tubal obstruction. Adenoid mass blocks the eustachian tube leading to retracted tympanic membrane and conductive hearing loss. (b) Recurrent attacks of acute otitis media may occur due to spread of infection via the eustachian tube. (c)Chronic suppurative otitis media may fail to resolve in the presence of infected adenoids. (d) Serous otitis media. Adenoids form an important cause of serous otitis media in children. Adenoid causes intermittent eustachian tube obstruction with fluctuating hearing loss. Impedance audiometry helps to identify the condition.

3. GENERAL SYMPTOMS

(a) Adenoid facies. Chronic nasal obstruction and mouth breathing lead to characteristic facial appearance called adenoid facies. The child has an elongated face with dull expression, open mouth, prominent and crowded upper teeth and hitched up upper lip. Nose gives a pinched- in appearance due to disuse atrophy of ala nasi Hard palate in these cases is highly arched as the moulding action of the tongue on palate is lost. (b) Pulmonary hypertension. Long-standing nasal obstrution due to adenoid hypertrophy can cause pulmonary hypertension and cor pulmonale. (c)Mentally dull, i.e. lack of concentration

DIAGNOSIS Examination of postnasal space is possible in some young children and an adenoid mass can be seen with a mirror. A rigid or a flexible nasopharyngoscope is also useful to see details of the nasopharynx in a cooperative child. Soft tissue lateral radiograph of nasopharynx will reveal the size of adenoids and also the extent to which nasopharyngeal air space has been compromised . Detailed nasal examination should always be conducted to exclude other causes of nasal obstruction TREATMENT When symptoms are not marked,, decongestant nasal drops and antihistaminics for any co- existent nasal allergy can cure the condition without resort to .When symptoms are marked, adenoidectomy is done. ACUTE NASOPHARYNGITIS AETIOLOGY Acute infection of the nasopharynx may be an isolated infection confined to this part only or be a part of the gen¬eralized upper airway infection. It may be caused by viruse- (, influenza, parainfluenza, rhino or adenovi¬rus) or bacteria (especially , pneumococcus or Haemophilus injluenzae). CLINICAL FEATURES Dryness and burning of the throat above the soft palate is usually the first symptom as is commonly noted in com¬mon cold. This is followed by pain and discomfort local¬ized to the back#of nose with some difficulty on swallowing. In severe , there is pyrexia and enlarged cervi¬cal lymph nodes. Examination of nasopharynx reveals congested and swollen mucosa often covered with whitish exudate. TREATMENT Mild cases clear up spontaneously. Some may be required for relief of pain and discomfort. In severe cases with general symptoms, systemic or chemotherapy may be necessary. In children, there is associated adenoid¬itis which causes nasal obstruction and requires nasal decon¬gestant drops

CHRONIC NASOPHARYNGITIS AETIOLOGY It is often associated with chronic infections of nose, paranasal sinuses and pharynx. It is commonly seen in heavy smokers, drinkers and those exposed to dust and fumes. CLINICAL FEATURES Postnasal discharge and crusting with irritation at the back of nose is the most common complaint. Patient has a constant desire to clear the throat by hawking or inspiratory snorting (forcibly drawing nasal secretions back into the throat). Examination of nasopharynx reveals congested mucosa and mucopus or dry crusts. In children, adenoids are often enlarged and infected (chronic adenoiditis). TREATMENT Chronic infections of the nose, paranasal sinuses and oro¬pharynx should be attended to. Excessive smoking and drinking should be corrected. Preventive measures should be taken to avoid dust and fumes. Alkaline nasal douche helps to remove crusts and mucopus. Steam inhalations are soothing.

THORNWALDT'S DISEASE (PHARYNGEAL BURSITIS) It is infection of the pharyngeal bursa which is a median recess representing attachment of notochord to endoderm of the primitive pharynx. Pharyngeal bursa is located in the midline of posterior wall of the nasopharynx in the adenoid mass. CLINICAL FEATURES 1.Persistent postnasal discharge with crusting in the nasopharynx. 2.Nasal obstruction due to swelling in the nasopharynx. . 3.Obstruction to eustachian tube and serous otitis media. . 4.Dull type of occipital headache. 5.Recurrent sore throat. 6.Low-grade . Examination would reveal a cystic and fluctuant swelling in the posterior wall of nasopharynx. It may also show crusts in the nasopharynx due to dried up discharge. TREATMENT are given to treat infection and marsupializa¬tion of the cystic swelling and adequate removal of its lining membrane.