International Journal of Otorhinolaryngology and Head and Neck Surgery Thimmappa TD et al. Int J Otorhinolaryngol Head Neck Surg. 2019 Mar;5(2):412-415 http://www.ijorl.com pISSN 2454-5929 | eISSN 2454-5937 DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20190771 Original Research Article Adenoid hypertrophy in adults T. D. Thimmappa, K. S. Gangadhara* Department of ENT, SIMS, Shivamogga, Karnataka, India Received: 14 November 2018 Revised: 13 January 2019 Accepted: 17 January 2019 *Correspondence: Dr. K. S. Gangadhara, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: Adenoid is a nasopharyngeal tonsil becomes active between 3 to 7 years of age. Starts involution by adolescence. Few of the occasions, the adenoid persists causing various symptoms including ear, nose, throat and facial deformities. It is also important while addressing the cause for nasal obstruction due to the co-existent adenoid tissue which may fail to diagnose pre-operatively becomes an on-table surprise. Methods: Adult patients above 16 years are subjected to study. Routine clinical examination done followed by diagnostic nasal endoscopy and the size of the adenoid tissue and other associated findings are recorded. Results: 100 patients were included in the study and gradings were done. Conclusions: We conclude the presence of adenoid tissue is due to persistence of a childhood problem, which is supported by presence of associated findings like high arched palate, supernumerary teeth. Keywords: Adult adenoid, Diagnostic nasal endoscopy, Adenoid grading INTRODUCTION alpha haemolytic Peptosterptococci, Enterococci and Morexalla catrrhalis in it. Its enlargement causes nasal, Adenoid by meaning is a gland like organ; it is a ear, sleep disturbances and generalized symptoms, may nasopharyngeal tonsil a lymphoid tissue situated in the retard growth in children. roof of nasopharynx. It develops from mesodermal cell origin at 16 weeks of intra uterine life by sub epithelial Adenoid is graded in to I-IV grades by examiners infiltration of lymphocytes. Santorni described the subjective perception. Grade I-clinically up to 25% nasopharyngeal lymphoid aggregate as Lushka tonsil in obstruction of choanae, Grade II-clinically 25% to 50% 1724, Wilhelm 1870 called this tissue adenoid. block, Grade III-50% to 75% block Grade IV-75% to 100% obstruction. Adenoid along with other lympho reticular tissue of waldeyers lymphatic ring it traps virus bacteria, allergen Relationship with structures such as (a) vomer (b) torus etc, contributes for immunological homeostasis. At the tubaris and (c) soft palate are critical in grading of time of birth it is small in size and becomes active adenoid. Adenoid enlargement not in contact with any of between 3 years to 7 years of age.1 It is clinically felt like the above structure is grade I, in contact with torus is a bag of worms. It starts its involution by adolescence. grade II, contact with torus tubaris and vomer bone grade Histologically it is constituted by respiratory epithelium III and in contact with all above three organs even in rest with cilia, crypts and germinal centre. is grade IV. Adenoid harbors normal bacterial flora such as Grade I-adenoid tissue filling one-third of vertical portion Lactobacillus, Nocardia, anaerobic Peptostreptococci, of the choanae. Grade II-adenoid tissue filling from one- International Journal of Otorhinolaryngology and Head and Neck Surgery | March-April 2019 | Vol 5 | Issue 2 Page 412 Thimmappa TD et al. Int J Otorhinolaryngol Head Neck Surg. 2019 Mar;5(2):412-415 third to two–thirds of the choanae.2 Grade III-from two thirds to nearly complete obstruction of the choanae. Grade IV-complete choanal obstruction. male Various method are employed to remove hypertrophied adenoid few of them are adenoid shaving by curratage, female debridement by a micro debrider, coablator and magnetic resonance generator etc. It has been observed, while routine FESS surgeries in many of the adult patients with presence of adenoid in the Figure 1: Sex distribution in adult patients with nasopharynx. Sometimes we fail to take consent to adenoid. address adenoid problem preoperatively. Thus we felt to assess and study the occurrence of adenoid tissue, in Table 1: Clinical symptoms of adenoid hypertrophy in adults as a prime objective. adults. METHODS Symptoms No. of cases % Nasal obstruction 88 88 It is a low risk, clinical prospective observational study. Headache 26 26 Patients who attend to the department of ENT, Bleeding from nose 04 04 Government McGann teaching Hospital, SIMS Shimoga, Allergic symptoms 11 11 Karnataka, India and referred from other departments Speech complaints 02 02 with symptoms of nasal obstruction, headache, epistaxis, Post nasal drip 14 14 post nasal drip, etc. Features suggestive of adenoid are described in Table 1, 2 and 3. The period of study is Halitosis 05 05 between June 2017 to November 2018, after obtaining Anosmia 02 02 proper ethical committee clearance. Patients are subjected Snoring 04 04 to routine clinical examination, external nasal examination, anterior rhinoscopy, posterior rhinoscopy Table 2: Clinical signs of adenoid hypertrophy in and diagnostic nasal endoscopy. The presence of adenoid adults. and its extension recorded and graded accordingly. Clinical signs No. of cases % Inclusion criteria Deviated nasal septum 79 79 Spur 25 25 All patients with symptoms described in Table 1, 2, 3 Concha bullosa 07 07 who are above 16 years of age are considered for the Hypertrophied inferior 12 12 study. turbinate Polypoidal mucosal 04 04 Exclusion criteria change High arched palate 04 04 Patients below 16 years and subjects who have undergone Supernumery teeth 01 01 adenoidectomy previously are excluded from the study. Deviated nasal septum with spur was the most common Statistical tool anterior rhinoscopic finding 79 cases (79%), with spur 25 cases (25%), hypertrophied inferior turbinate 12 cases Descriptive statistics, frequency and percentages were (12%), concha bullosa 7 cases (7%), high arched palate 4 calculated by using SPSS (version 24.0). Graphs were cases (4%) and supernumerary teeth in 1 case (1%) plotted by using Microsoft Excel. shown in Table 2. RESULTS Other associated findings were tonsillar hypertrophy 10 cases (10%), bilateral OME 2 cases (2%), ASOM 1 case 100 Patients were included in the study, males are 51 (1%), CSOM 1 case (1%) and retraction of tympanic (51%) and female 49 (49%) shown in Figure 1. membrane 1 case (1%) as shown in Table 3. Clinically majority of the patients presented with nasal The patients above the age of 16 years are selected with obstruction 88 cases (88%), headache 26 patients (26%), no upper age limit. 16 to 20 years maximum cases are and bleeding nose 4 cases (4%), nasal speech 2 cases recorded 39 (39%), followed by 21-30 years 34 cases (2%), post nasal drip 14 cases (14%) and allergic (34%), 31-40 years 17 cases (17%), 41-50 years 7 cases symptoms 11 cases (11%) as shown in Table 1. International Journal of Otorhinolaryngology and Head and Neck Surgery | March-April 2019 | Vol 5 | Issue 2 Page 413 Thimmappa TD et al. Int J Otorhinolaryngol Head Neck Surg. 2019 Mar;5(2):412-415 (7%) and least occurrence is between age group 51-60 Zero degree 4 mm wide angle nasal endoscope is reliable, years 2 cases (2%) shown in Figure 2. safe, and easily tolerated which gives 3 dimentional picture of well illuminated and magnified image and play Table 3: Other associated findings. important role in differentiation of adenoid from other post nasal space mass such as cyst, tumor etc.6 Findings No. of cases % Tonsillar Size of the adenoid alone is not very important, it is in 10 10 hypertrophy ratio with nasopharynx is significant. Adenoid/ Tympanic membrane nasopharynx ratio is calculated on lateral cephalometric 1. B/L OME 02 02 graphics, significant obstruction was observed by Kamal et al, if posterior choana above 60% in grade 2 and 3 2. Central perforation 01 01 7 3. ASOM 01 01 based on clinical and air flow models. 4. Retraction 01 01 Yildirim et al in his study observed adult adenoid was associated with nasal septum deviation in 25% of cases. 45 Histopathological features of adenoid lymphoid tissue 40 were dissimilar in two groups: numerous lymph follicles 35 with prominent germinal centers was the chief finding in 30 childhood adenoids where as in adults adenoids showed 25 inflammatory cell infilteration with secondary changes 8 20 (squamous metaplasia). In contrary our study showed 15 79% of DNS and 25% with spur. 10 5 The exact cause of adenoid hypertrophy in adults is not 0 known but various etiopathological mechanisms and few 16-20 years 21-30 years 31-40 years 41- 50 years 51-60 years theories have been proposed, Persistence of childhood adenoid, reactivation of atrophied adenoid. In our study 4 cases of high arched palate and 1 case of supernumerary teeth favours persistence and continuation of childhood Figure 2: Age distribution. adenoid pathology. Endoscopic finding of grade I adenoid hypertrophy was As reported by Finkelstein et al adenoid enlargement and observed in 26 cases (26%) grade II in 48 cases (48%), obstruction in 30% of heavy smokers.9 Moazzez et al grade III in 20 cases (20%) and grade IV in 6 cases (6%) stated that Infection such as bacterial and viral (Human as shown in Figure 3. Immunodeficiency Virus), allergies and immune- compromised state noticed as a result of organ 60 transplantation and those who receive anti malignant 10 50 drugs and corticosteroids. 40 CONCLUSION 30 20 Adenoid hypertrophy in adults is not uncommon condition.