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Home , Adenoid, Adenoid hypertrophy, Nasal septum, Nasal septum deviation

Talal Althobaiti et al, 2020;4(11):1792–1796. International Journal of Medicine in Developing Countries https://doi.org/10.24911/IJMDC.51-1599758714

ORIGINAL ARTICLE hypertrophy in adults: causes and precipitating factors Talal Althobaiti1, Wael Ali Hadaidi2, Ahmad Saeed A. Alghamdi2, Khaled Fahad J. Alghashmari2, Abdulrahman Ali Hadaidi3, Tamer Mohamed Abd-Elrahman4,5*

ABSTRACT Background: (AH) is suspected in case of nasal obstruction. Recurrent acute and allergic episodes are reported as the most common causes of adenoid hypertrophy. The present study aimed to determine the prevalence, symptoms, and possible causes of adenoid hypertrophy in adults. Methodology: A retrospective cross-sectional study was carried out in the Armed Forces Hospitals, Taif region, Saudi Arabia, during the period from February 2016 to February 2020. All the cases of adenoid hypertrophy diagnosed with nasal obstruction as the chief complaint and patients planned for were included in this study. Results: Forty-six adult patients were diagnosed with adenoid hypertrophy: 32 in group A (patient’s complaint with nasal obstruction) and 14 in group B (patients planned for tonsillectomy); 33 were male and 13 were female. The most commonly involved age group was 17-26 years (65%). The most presenting symptoms were nasal obstruction (100%), (86.9%), and post-nasal discharge (71.7%). The commonest predisposing factor for adenoid hypertrophy was allergic (39.1%). Twenty-five cases (54.4%) had associated nasal polyps, while five cases (10.9%) had adenoid hypertrophy along with inferior turbinate hypertrophy. Conclusion: Adenoid hypertrophy in adults has an increasing incidence nowadays because of chronic , allergy, and pollutions. All patients presented with nasal obstruction and other rhinological symptoms, which should be evaluated for adenoid hypertrophy. Keywords: Adenoid hypertrophy, adults, naso-, rhinological conditions, allergy, nasal obstruction.

Introduction

The consist of unencapsulated lymphoid tissue the persistence of adenoid tissues in the non-pediatric age organized in germinal centers in the naso-pharynx, as group [6]. Theobald in 1948 and Heffner in 1987 also a part of inner Waldeyer’s ring. Adenoids, along with reported marked hyperplasia of adenoid tissues in adults palatine , are first-line defense barriers against [7,8]. A study conducted by Rout et al. [9] showed that antigens from the oral cavity and even air-borne diseases the most frequently involved age group in adults is 16- coming through the nose [1,2]. 25 years and adult males are more commonly involved Symptoms of adenoid hypertrophy, which is non- than females, maybe due to more exposure to outdoor physiological enlargement, include obstructive sleep pollutants. , open-mouth , snoring, hyponasal speech and [3,4]. The disease is prevalent in children and its symptoms Correspondence to: Tamer Mohamed Abd-Elrahman appear more rapidly at a younger age due to the *Surgery Department, College of Medicine, Taif University, increased frequency of upper infections Taif, Surgery Department, Benha Teaching Hospital, General and small volume of the naso-pharynx. Adenoids are Organization of Teaching Hospital and Institutes, Egypt. Email: [email protected] physiologically enlarged in size from birth up to the age Full list of author information is available at the end of of 6 years, and after that it gradually regresses in size the article. to disappear completely at nearly 16 years of age, but it Received: 03 October 2020 | Accepted: 11 October 2020 may persist into adult life [5]. Cowan in 1982 described

© IJMDC. https://www.ijmdc.com 1792 Adenoid hypertrophy in adults: causes and precipitating factors

Adenoid hypertrophy can present in many shapes in Results adults; it should be suspected when facing a case of nasal obstruction, especially if presented with purulent Forty-six adult patients diagnosed with adenoid nasal secretions; also, other possible presentations can hypertrophy were included in the study. The demographic be a change in voice or . The symptoms can characteristics of the patients are shown in Tables 1 and 2. vary in severity according to the hypertrophic size of the The results showed that males are more prone to adenoid adenoid and the size of the naso-pharynx; the smaller the hypertrophy than females. And that adult adenoid naso-pharynx, the more severe the symptoms [10]. hypertrophy is an extension of the child period adenoid. In a study conducted by Al-Juboori et al. [11], all patients In the present study, the patients with adenoid hypertrophy complained of snoring, wherein most of the patients presented with different symptoms as shown in Table 3. suffered from nasal discharge and around half of the No case with hearing impairment or impairment of smell patients had headaches and/or in the . Others was encountered. had sneezing, itching, or hearing impairment; also, some The commonest predisposing factors are shown in Table 4 patients reported impairment of their smelling sensation. Recurrent acute infections and allergic episodes are Fourteen cases (30.4%) had adenoid hypertrophy alone reported as the most common causes of adenoid and the majority of the patients were associated with hypertrophy [12]. other rhinological conditions as shown in Table 5. The present research aimed to determine the prevalence Discussion of adenoid hypertrophy in adult patients, to highlight any alarming symptoms owing to the presence of persistent Adenoid hypertrophy is a common presentation in adenoid tissues, and to investigate the possible causes of children. Although adenoidal tissue undergoes regression adenoid hypertrophy in adults. toward the adolescent ages, it may present as the chief cause of nasal obstruction in adults [13]. Subjects and methods Unlike tonsils, which can be seen by looking directly This study was a retrospective cross-sectional study through the mouth, the adenoid is positioned at the carried out in the Department of ENT and Head and backmost part of the and up behind the Surgery, Armed Forces Hospitals, Taif region, soft palate. Since it sits at the backmost part of the Saudi Arabia, for determining the prevalence, symptoms, nasal cavity, its main symptoms affect nasal function. and possible causes of adenoid hypertrophy, during the On the other hand, nasal obstruction in adults is almost period from February 2016 to February 2020. totally attributed to deviated or turbinate hypertrophy, with adenoid hypertrophy being the least The inclusion criteria included male and female patients likely causative factor in the minds of clinicians. aged 17 years old and above and diagnosed with adenoid hypertrophy. Patients aged 16 years and below Less has been published on adult obstructive adenoid and patients with missing recorded information were hypertrophy, possibly due to its underdiagnosis as a excluded from the study. result of it being overshadowed by the accompanying rhino-pharyngological disorder or due to incomplete The medical history of all patients included in the study nasopharyngeal examination [14]. was taken from the medical records; data were then entered into a predesigned, validated proforma that included socio-demographic information, possible symptoms, and expected risk factors of adenoid hypertrophy in adults, along with findings of physical examination conducted Table 1. Gender distribution of adenoid hypertrophy. in each patient. Number (%) Total Gender Patients were divided into two groups: all the cases of (group A = 32) (group B = 14) n (%) adenoid hypertrophy diagnosed during examination of Male 24 (75%) 9 (64.3%) 33 (71.7%) patients with nasal obstruction as the chief complaint (group A) and diagnosis discovered during investigation Female 8 (25%) 5 (35.7%) 13 (28.3%) for patients planned for tonsillectomy (group B). The diagnosis of adenoid hypertrophy in all cases was carried Table 2. Age distribution of adenoid hypertrophy. out by indirect nasopharyngoscopy and/or Number (%) and imaging (direct films and/or computed tomography); Age Total also, biopsy was conducted in some selected cases. (Years) (group A = 32) (group B = 14) n (%) 17-26 21 (65.6%) 7 (50%) 28 (60.9%) Data were analyzed using Statistical Package for Social Sciences (SPSS) version 24.0 software for Windows 27-36 6 (18.8%) 4 (28.6%) 10 (21.8%) (SPSS, Chicago, IL). Categorical variables are presented 37-46 2 (6.3%) 3 (21.4%) 5 (10.9%) as number and percentage. ≥47 3 (9.4%) 0 (0%) 3 (6.5%)

1793 Adenoid hypertrophy in adults: causes and precipitating factors

Table 3. Symptoms of adenoid hypertrophy.

Number (%) Total Symptoms (group A = 32) (group B=14) n (%) Nasal obstruction 32 (100%) 14 (100%) 46 (100%) Post-nasal discharge 25 (78.1%) 8 (57.1%) 33 (71.7%) Rhinorrhea 9 (28.1%) 3 (21.4%) 12 (26.1%) Snoring 28 (87.5%) 12 (85.7%) 40 (86.9%) Headache and/or facial pain 8 (25%) 4 (28.5%) 12 (26.1%) Impairment of smell 0 (%) 0 (%) 0 (0%) Hearing impairment 0 (%) 0 (%) 0 (0%) Itching 17 (53.1%) 7 (50%) 24 (52.2%) Sneezing 15 (46.8%) 5 (35.7%) 20 (43.4%)

Table 4. Predisposing factors for adenoid hypertrophy.

Number (%) Total Factors (group A = 32) (group B = 14) n (%) 12 (37.5%) 6 (42.8%) 18 (39.1%) Chronic , 7 (21.8%) 2 (14.2%) 9 (19.6%) Chronic , rhinitis, 10 (31.2%) 5 (35.7%) 15 (32.6%) Polyps and benign sinonasal tumors 2 (6.25%) 1 (7.1%) 3 (6.5%) Malignant sinonasal tumors 1 (3.1%) 0 (%) 1 (2.2%)

Table 5. Association of adenoid hypertrophy with rhinological conditions.

Number (%) Disease Total n (%) (group A = 32) (group B = 14) Adenoids + ethmoidal nasal polyps 17 (53.1%) 8 (57.1%) 25 (54.4%) Adenoids + deviated nasal septum 2 (6.2%) 0 (%) 2 (4.4%) Adenoids + inferior turbinate hypertrophy 3 (9.3%) 2 (14.2%) 5 (10.9%) Adenoids 10 (31.2%) 4 (28.5%) 14 (30.4%)

In a study among (15,000) adults, adenoid hypertrophy The commonest age group involved was 17-26 years was diagnosed in 2.5% of the cases [15,16]. Rout et al. (60.9%). This was also similar to that seen in the work of [9] showed a high frequency (21%) of adenoids in adults. Khan et al. [17], where a large number of patients were in In the present study, it was found that the predominant the age group of 16-25 years, and in a study by Shetty et gender involved was male (71.7%). These results were al. [18] the commonest age group involved was of 17-20 synonymous with those of Khan et al. [17] and Rout years. These results of a high number of cases in young et al. [9], wherein 63.76% and 70% of the adult cases adult population are probably attributed to continuation were males, respectively. This might be because of of pediatric adenoid hypertrophy in early adulthood. the excessive exposure of males to outdoor allergens. Multiple etiological mechanisms have been proposed to However, Shetty et al. [18], in his study, concluded explain the presence of adenoid hypertrophy in adults, there was no gender difference in incidence of adenoid including the persistence of childhood adenoids due to hypertrophy. chronic inflammation or re-proliferation of regressed In the present study, adenoid hypertrophy was found adenoidal tissue in response to infections or irritants in 46 patients aged between 17 and 60 years, and in a [14,15,18]. study by Kamel and Ishak in Egypt, 35 cases of enlarged In the present study, the commonest predisposing adenoids with ages ranging between 20 and 42 years were factor for adenoid hypertrophy was allergic rhinitis (18 reported. However, Protasevich et al. [19] diagnosed patients, 39.1%), which was consistent with the results of adenoid hypertrophy in 127 patients aged between 15 Loesel [20.21], where two-thirds of the patients studied and 48 years [15]. had allergic rhinitis diagnosed by history and skin test,

1794 Adenoid hypertrophy in adults: causes and precipitating factors

although Cowan [12] suggested that allergic episodes in 25% of the patients. In a study by Hamad et al. [27], also result in adenoidal enlargement. Also, when Al- they found mild deviated nasal septum in 16.6% of the juboori et al. [22] conducted an allergic reaction test cases. for all adenoid cases, they found that 67% of the cases Developmental affecting nasal experienced a positive allergic reaction. physiology and predisposing to chronic sinonasal In this study, the second common cause was descending inflammation and post-nasal drip may also indirectly infections like chronic sinusitis, rhinitis, and otitis media cause low-grade chronic inflammation of the adenoid (32.6%); after that, the ascending infection was from the interfering with their physiological regression [23,28]. tonsils and pharynx (19.6%), which is similar to the results of Rout et al. [9], where the descending infection was Conclusion responsible for 33.3% of the cases of adenoid hypertrophy, whereas the ascending infection was responsible for 20% Adenoid hypertrophy is an important cause of nasal of the cases. Yildirim et al. [23] concluded that adenoid obstruction in adults with an increasing incidence hypertrophy in adults occurred due to chronic infection nowadays because of chronic infection, allergy, and or recurrent infection, or anatomical disturbances that increased pollutions. All the individuals presented with cause chronic inflammation. Therefore, it was concluded nasal obstruction and other rhinological symptoms; that the common causes of adenoid hypertrophy in adult adenoid hypertrophy should always be kept in mind as patients may be due to either allergy or chronic infection. a cause and the patients should be evaluated for adenoid hypertrophy. Other less common symptoms associated with adenoid hypertrophy in this study were nasal polyps, benign List of Abbreviations tumors (three patients, 6.5%), and malignant sinonasal AH Adenoid Hypertrophy tumors (one patient, 2.2%). Rout et al. [9] found that HIV Human Immunodeficiency HIV infection was associated with 3.3% of the cases NPC Nasopharyngeal Carcinoma and non-Hodgkin’s and other sinonasal malignancy was associated with 3.3% of the cases. So, the possibility of Conflict of interest the presence of malignancy when confronting adult cases The authors declare that there is no conflict of interest of adenoid hypertrophy should not be neglected and regarding the publication of this article. should be kept in mind, and nasopharyngeal carcinoma Funding (NPC) is the most important entity to be ruled out in the None. presence of a nasopharyngeal mass in adults. Finkelstein et al. [24] reported the presence of obstructive Consent for publication adenoids in 30% of heavy smokers, while in this study no Informed consent was obtained from all the participants. relationship of smoking with adenoid hypertrophy was Ethical approval found. Hence, unless the possibility of adenoid in adults This research was approved by the research ethics committee is borne in mind, even with the presence of positive of Armed Forces Hospitals, Taif, via letter number 2020-476, finding on nasal examination which can explain the dated 11-8-2020. patient`s symptoms, its diagnosis can be easily missed [25]. Author details 1 2 Nasal obstruction in adults can have various underlying Talal Althobaiti , Wael Ali Hadaidi , Ahmad Saeed A. Alghamdi2, Khaled Fahad J. Alghashmari2, Abdulrahman Ali conditions, such as deviated nasal septum, inferior 3 4,5 turbinate hypertrophy, nasal polyposis, juvenile nasal Hadaidi , Tamer Mohamed Abd-Elrahman angiofibroma, and nasopharyngeal malignancies 1. ENT Department, Prince Mansour Military Hospital, Taif, [1,18,25]. Adenoids in the adults have some special Saudi Arabia clinical features, i.e., they frequently arise in the presence 2. Colleges of Medicine, Taif University, Taif, Saudi Arabia of nasal pathology (turbinate hypertrophy and septal 3. Emergency Department, Prince Sultan Military Hospital, defect) [19,26]. Taif, Saudi Arabia 4. Surgery Department, College of Medicine, Taif University, In the present study, the majority of the adenoid Taif, Saudi Arabia hypertrophy patients were associated with other 5. Surgery Department, Benha Teaching Hospital, General rhinological conditions: 54.4% had associated nasal Organization of Teaching Hospital and Institutes, Egypt polyps, 10.9% had associated inferior turbinate hypertrophy, and 4.4% had associated deviated nasal References septum. Septal deviation occurred in 41.6% of the adults 1. Karodpati N, Shinde V, Deogawkar S, Ghate G. Adenoid with adenoid hypertrophy in the study by Al-juboori et al. hypertrophy in adults - a myth or reality. Webmedcentral [22] and in 25% of the patients in the study by Yildirim et Otorhinolaryngol. 2013;4(3):WMC004079. https://doi. al. [23]. Also, in a study by Rout et al. [9], adult adenoid org/10.9754/journal.wmc.2013.004079 hypertrophy was associated with nasal septum deviation

1795 Adenoid hypertrophy in adults: causes and precipitating factors

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