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Tubal Tonsil Hypertrophy a Cause of Recurrent Symptoms After Adenoidectomy

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Tubal Tonsil Hypertrophy a Cause of Recurrent Symptoms After Adenoidectomy ORIGINAL ARTICLE Tubal Tonsil Hypertrophy A Cause of Recurrent Symptoms After Adenoidectomy Kevin S. Emerick, MD; Michael J. Cunningham, MD Objectives: To assess the incidence of symptomatic tubal was 7 years 2 months, at an average time interval of 4 years tonsil hypertrophy (TTH) after adenoidectomy and to 2 months after adenoidectomy. The comparative incidence attempt to differentiate the clinicoradiographic presenta- of recurrent or residual adenoid was 54%. The symptom- tion of TTH from that of recurrent or residual adenoid. atic manifestations of TTH included nasal obstruction, ob- Design: Retrospective case series review. structive sleep disorder, rhinosinusitis, recurrent otitis me- dia,andotitismediawitheffusion.Preoperativeradiographic Setting: Pediatric otolaryngology practice in a tertiary evaluation was not useful in distinguishing TTH from re- care hospital. current or residual adenoid; nasopharyngoscopy appears to Patients: The charts of all patients scheduled to undergo have better diagnostic potential. Thermal ablation with suc- revision adenoidectomy or nasopharyngeal examination tion cautery was therapeutically effective. under anesthesia over a 5-year period in 1 pediatric oto- Conclusions: Tubal tonsil hypertrophy is a significant clini- laryngologist’s practice were reviewed. cal entity as a cause of recurrent symptoms after adenoid- Main Outcome Measure: Presence of TTH in patients ectomy. The study patients demonstrated the entire spec- with recurrent symptoms after previous adenoidectomy. trum of signs and symptoms seen in patients with adenoid hypertrophy. Operative nasopharyngeal examination is Results: Forty-two patients were identified, 24 of whom required to definitively distinguish TTH from recurrent or satisfied the established criteria of recurrent symptoms af- residual adenoid. terpreviousadenoidectomy.Ten(42%)ofthesepatientswere identified as having TTH. The average age at presentation Arch Otolaryngol Head Neck Surg. 2006;132:153-156 DENOIDECTOMY IS ONE OF amination under anesthesia over a 5-year pe- the most common opera- riod within 1 pediatric otolaryngologist’s (M.J.C.) tions performed on chil- practice were retrospectively reviewed. Atten- dren in the United States. tion was specifically directed toward identify- This surgical statistic re- ing patients with tubal tonsil hypertrophy (TTH). The following data were recorded: epidemio- Aflects the importance of the adenoid (pha- logic criteria, clinical presentation, diagnostic ryngeal tonsil) in the pathogenesis of recur- workup (with a particular focus on nasopharyn- rent otitis media, otitis media with effusion, goscopy, radiographic studies, allergy testing, and rhinosinusitis,nasalairwayobstruction,and immunologic screening), operative findings, obstructive sleep disorder syndrome. treatment, and outcome (if available). After successful adenoidectomy, some children again become symptomatic. The RESULTS presence of residual or recurrent adenoid should be determined in such cases. Allergy Forty-two patients were identified, 36 of or immunodeficiency may also need to be whom had charts that were available for re- ruled out. An additional potential pathogen- view. Cases involving nasal or nasopharyn- esis that warrants consideration is hypertro- geal disease unrelated to our subject of in- phyoftheremaininglymphoidtissueofWal- vestigation, such as choanal atresia, juvenile deyer’s ring, specifically the tubal tonsils angiofibroma, or epistaxis, were excluded. (Figure 1). Removal of the tubal tonsils, also Twenty-fourpatientssatisfiedtheestablished knownasthetonsillatubaria,eustachianton- criteria of recurrent symptoms after previ- sils,orGerlachtonsils,isnotconsistentlyper- ous adenoidectomy. Table 1 summarizes formed during adenoidectomy. Their poten- the final diagnoses in the 24 cases. Ten pa- tialimpactmaynotbeappreciateduntilsymp- tients who were identified as having TTH Author Affiliations: toms persist or recur after adenoid removal. were investigated in greater detail. Department of Otolaryngology, Table 2 Massachusetts Eye and Ear shows the age at which the 10 Infirmary, and Department of METHODS patients with TTH underwent their initial Otology and Laryngology, adenoidectomy or adenotonsillectomy, the Harvard Medical School, The charts of all patients scheduled to undergo age at the time of subsequent nasopharyn- Boston, Mass. revision adenoidectomy or nasopharyngeal ex- geal examination under anesthesia, and the (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 132, FEB 2006 WWW.ARCHOTO.COM 153 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Table 2. Age at Initial Adenoid Hypertrophy Presentation and at Time of Subsequent Diagnosis of Tubal Tonsil Hypertrophy Patient Age at 1st Age at 2nd Time No. Presentation, mo Presentation, mo Interval, mo 1324513 2427634 3 9 32 21 4639431 5339158 6217756 7 77 152 85 8152611 9164529 10 60 224 164 Mean 36.8 86.2 50.2 Figure 1. Endoscopic 120° transoral view of nasopharynx demonstrating bilateral tubal tonsil hypertrophy (photograph courtesy of Charles Bower, MD). Table 3. Symptoms at Initial Adenoid Hypertrophy Table 1. Final Diagnosis at the Time Presentation and at Time of Subsequent Diagnosis of Nasopharyngeal Examination Under Anesthesia of Tubal Tonsil Hypertrophy Diagnosis No. of Patients % of All Cases Patient Symptoms at 1st Symptoms at 2nd No. Presentation Presentation Tubal tonsil hypertrophy 10 42 Recurrent/residual adenoid 13 54 1 NO, OSD, RS NO, RS Chronic rhinosinusitis 1 4 2 NO, OSD NO, OSD 3 NO, OSD OME, OSD 4 NO, OSD, OME OSD, OME 5 OSD, RS RS 6 OSD, ROM ROM 7 OME, OSD OSD, NO time interval between procedures. The mean age at initial 8 ROM, OSD ROM presentation was 36.8 months; the mean age at the time of 9 NO, OME NO the second procedure was 86.2 months; and the mean in- 10 OSD NO, OSD terval was 50.2 months. Table 3 Abbreviations: NO, nasal obstruction; OME, otitis media with effusion; lists the symptoms that prompted the first OSD, obstructive sleep disorder, ROM, recurrent otitis media; RS, rhinosinusitis. evaluation and the symptoms that led to the second evalu- ation. There was considerable variation among the ini- tial presenting symptoms, reflecting the expected spec- atic relief was achieved in all but 1 patient, who had im- trum of problems associated with adenoid hypertrophy provement but not resolution of rhinosinusitis symp- or inflammation: obstructive sleep disorder, nasal ob- toms. Postoperative examination of this patient revealed struction, rhinosinusitis, recurrent otitis media, and oti- persistent remnants of tubal tonsil tissue, which were sub- tis media with effusion. The manifestations at the sec- sequently successfully resected with a microdebrider. ond presentation were generally recurrences of the initial Nine of the 24 patients underwent preoperative evalu- symptoms. There was not 1 specific symptom or diag- ations before revision adenoidectomy or nasopharyn- nosis found in all cases. geal examination under anesthesia to rule out allergy or Six of the 10 patients with TTH underwent preopera- immune deficiency. In 1 patient, an immunologic ab- tive flexible fiberoptic examination of the nasopharynx. normality—IgG2 deficiency—was identified, and 2 pa- The findings of 3 examinations suggested TTH, and 3 ex- tients had documented environmental allergies. None of aminations revealed obstructive lymphoid tissue of un- these patients had TTH. clear etiology. Four patients with TTH underwent lat- eral plain radiography before “revision adenoidectomy”; all 4 films were interpreted by the radiologist as being COMMENT consistent with adenoid hypertrophy (Figure 2). One patient underwent computed tomography with identifi- In the pediatric population, hypertrophy of the pharyn- cation of a soft tissue nasopharyngeal mass, which was geal lymphoid tissue (adenoid) may cause nasal obstruc- also “suggestive of adenoid enlargement” according to tion and obstructive sleep disorder and contribute to the the official radiology report; in retrospect, the bilater- pathogenesis of rhinosinusitis, recurrent otitis media, and ally hypertrophied tubal tonsils can be clearly visual- otitis media with effusion. The success of adenoidec- ized (Figure 3). tomy in treating these conditions is well documented. All patients diagnosed as having TTH were treated by Several randomized trials have addressed the con- means of thermal ablation with suction cautery. Symptom- tributory role of the adenoid to recurrent or persistent (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 132, FEB 2006 WWW.ARCHOTO.COM 154 ©2006 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 A B Figure 3. Axial computed tomogram of patient with bilateral tubal tonsil hypertrophy (X). as it is for otitis media, the benefit of adenoidectomy, par- ticularly as a prelude to endoscopic sinus surgery in younger children, is well established. The obstructive potential of the adenoid is readily ac- knowledged, and the immediate results of improved na- sal breathing and relief of obstructive sleep symptoms af- ter adenoidectomy and adenotonsillectomy are well documented.6 The hypertrophy of the pharyngeal and palatine tonsils in such cases is of varied pathogenesis. In the 19th century, the anatomist Wilhelm von Waldeyer described the ring of lymphoid tissue created by the palatine tonsils, pharyngeal tonsil (adenoid), and lingual tonsils. Less prominent but potentially impor- tant components
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