Case Report

Adenoid Hypertrophy

Presentator :
Valentina Dian Juwitawati

Moderator :
Dr. dr. Siswanto Sastrowiyoto, Sp.T.H.T.K.L(K)., M.H.

Otorhinolaryngology Head and Neck Surgery Department

Faculty of Medicine, Public Health and Nursing Gadjah Mada University
Dr. Sardjito Hospital
Yogyakarta
2019
INTRODUCTION The incidence of sleep-disordered
Adenoid hypertrophy is defined as breathing is known to peak during early
the unusual growth (hypertrophy) of the childhood and to affect 1% to 4% of
adenoid (pharyngeal tonsil). Tonsils are children. In addition, older children and
lymphoid organs that develop from young adults are more frequently being
components of surface epithelium enveloped treated for sleep-disordered breathing with
by mesenchymal stroma and subsequently tonsillectomy and adenoidectomy.4
populated by lymphocytes and immunologic
Adenoid hypertrophy is a common
mediators. Adenoids, also known as the
cause of nasal obstruction in children. It can
pharyngeal tonsils, develop in close
present as chronic or recurrent nasal
approximation to mucous glands along the
discharge, snoring, sleep-disordered
posterior surface of the nasopharynx.1
breathing, recurrent otitis media, or
In the early and midportion of the Eustachian tube dysfunction. Physical
20th century, tonsillectomy and examination often elicits a history of mouth
adenoidectomy was the most common breathing, hyponasal voice, and the classic
surgical procedure in the United States, with “adenoid facies”, characterized by an
the indication primarily being recurrent incompetent lip seal, a narrow upper dental
throat infections. Secondary to a public arch, increased anterior face height, a steep
backlash and scrutiny of tonsillectomy for mandibular plane angle, and a retrognathic
unscrupulous indications and unproven mandible. This development occurs as the
efficacy in the late 1970s and early 1980s, result in the changes in head and tongue
there was a decline by about 50% to 75% in position and muscular balance secondary to
the number of tonsillectomy and the open mouth breathing that accompanies
adenoidectomy procedures performed. nasopharyngeal obstruction. Recent studies
However, since then, the frequency of confirm that there are changes in facial
tonsillectomy and adenoidectomy has almost growth and development among children
doubled, with the most common indication with adenoid hypertrophy. These changes
at present being sleep-disordered breathing are characterized by increased total and
as opposed to recurrent throat infections.2,3 inferior anterior heights of the face, as well
as more anterior and inferior position of the
hyoid bone.5,6,7

1
 Obstructive adenoid hypertrophy is underlying etiology and can include medical
diagnosed by clinical evaluation. Mouth and surgical approaches. Surgical removal
breathing, snoring, and hyponasal speech are of the adenoids is a procedure called
common presenting complaints. Rhinorrhea, adenoidectomy, which is carried out through
postnasal drip, and chronic cough are the mouth under a general anaesthetic. The
common and nonspecific findings. A adenoids being curetted, cauterised, lasered,
thorough physical examination includes at a or otherwise ablated. Adenoidectomy is
minimum anterior rhinoscopy, which is most often performed because of nasal
easily facilitated in the cooperative child, obstruction, but is also performed to reduce
with the use of nasal speculum. This allows middle ear infections and fluid (otitis
the clinician to distinguish possible sources media). The procedure is often carried out at
of nasal obstruction within the anterior nasal the same time as a tonsillectomy, since the
cavity, such as turbinate hypertrophy, adenoids can be clearly seen and assessed by
edematous mucosa, or foreign body and to the surgeon at that time.1,8
differentiate these from sources within the
CASE REPORT
nasopharynx.1,5
A 3 years old boy came to ENT
Evaluation of the adenoids in an
clinic of Dr. Sardjito Hospital with chief
uncooperative child can be difficult and can
complaint of mouth breathing. The parents
be accomplished using lateral neck
told that the complaint was started since
radiographs, although these are often
three months ago and worsened in the last
superfluous compliments to physical
one month. The parents also complained that
examination and history. More recently, an
the child stopped breathing during sleep ± 3
increasing number of children have been
times a week accompanied by snoring
evaluated using office nasopharyngoscopy.
during sleep. The patient got no fever,
This technique allows for direct
cough, and runny nose. Complaints of the
visualization without radiation exposure.
ears and nose were denied. The parents told
Nasopharyngoscopy offers an excellent view
that the patient often affected by cough and
of the adenoids and adjacent structures.1
cold. History of allergy was denied and there
Management of a child with was no history of similar complaint in
adenotonsillar disease depends on the patient’s family.

2
 The general condition of the patient approximation to mucous glands along the
was good and the vital signs was normal. posterior surface of the nasopharynx. The
The patient’s heart rate was 120 x/minute, basic structure of the adenoids is
respiratory rate 24 x/minute, and body characterized by multiple shallow sagittal
temperature 36,0 0C. The patient’s body folds and plicae covered by respiratory
weight was 15 kg. From the physical epithelium. Lymphoid follicles develop
examination of the ear was obtained right around the crypts and adjacent glandular
and left auricula within normal limit, from ducts. Crypts begin to develop at 3 months
otoscopy examination obtained right and left of gestation and are fully developed by the
tympanic membrane intact with positive seventh month. Immunoglobulin populations
cone of light reflex. On anterior rhinoscopic have been found present in embryonal
examination there were within normal limit. adenoid tissue. The adenoids will often
Posterior rhinoscopic was difficult to do. On increase in size until the sixth to seventh
oropharynx examination there were within year of life at which point they begin to
normal limit. Neck examination showed no diminish and subsequently atrophy by early
palbable lump or lymphnode enlargement. puberty.1
On endoscopic examination there was an Adenoid hypertrophy is a common
third grade of adenoid hypertrophy. From X- cause of nasal obstruction in children. It can
ray examination found that adenoid- present as chronic or recurrent nasal
nasopharyngeal ratio with the Fujioka index discharge, snoring, sleep-disordered
was 0,93. breathing, recurrent otitis media, or
Eustachian tube dysfunction. Physical
Based on the history taking, physical
examination often elicits a history of mouth
examination, endoscopy, and X-ray, the
breathing, hyponasal voice, and the classic
patient was diagnosed with adenoid
“adenoid facies”, characterized by an
hypertrophy and underwent an
incompetent lip seal, a narrow upper dental
adenoidectomy. The issue of this case is
arch, increased anterior face height, a steep
about the treatment.
mandibular plane angle, and a retrognathic

DISCUSSION mandible. This patient came with complaints

Adenoids, also known as the of mouth breathing, snoring, and stopped

pharyngeal tonsils, develop in close breathing during sleep ± 3 times a week.

3
These clinical manifestations were suitable
with the signs and symptoms of adenoid
hypertrophy.1,5
Estimation of the adenoid-
nasopharyngeal (A/N) ratio (Fujioka
Method) 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. The
normal adenoid-nasopharyngeal ratio at
three years old child is 0,567 with a standard
deviation of 0,102. Therefore it can be
concluded that the patient has an adenoid
hypertrophy.9
Adenoid hypertrophy is common
among children. The enlargement of the
adenoid may be physiologic or secondary to
viral or bacterial infection, allergy, irritants,
and possibly gastroesophageal reflux. Other
risk factors include ongoing exposure to
bacterial or viral infection (eg to multiple
children at a child care center). Severe
hypertrophy can obstruct the eustachian
tubes (causing otitis media), posterior
choanae (causing sinusitis), or both. The
parents told that patient often affected by
cough and cold. The exposure to bacterial or
4
viral infection can be the risk factor for
adenoid hypertrophy in this patient.10
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 problem.1
Recurrent or chronic adenoiditis due
to infection should be treated with an
antimicrobial agent effective against beta-
lactamase 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.1,3
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 obstructive sleep apnea, so it was
an absolute indication for adenoidectomy.11
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
5
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.1,8
Adenoidectomy has its own
attendant risks. Postoperative hemorrhages,
velopharyngeal insufficiency, persistent
Eustachian tube dysfunction from iatrogenic
manipulation, nasopharyngeal stenosis, c-
spine subluxation from hyperextension
during surgery are all known risks for
children undergoing adenoidectomy. Special
attention must be given to children with
Down syndrome because of the risk of
atlantoaxial subluxation. The most common
complaint in children undergoing
adenoidectomy is persistent postoperative
malodorous breath, which may persist for up
to two weeks. Although postoperative
hemorrhage is not as common in children
undergoing adenoidectomy alone, other
rates of complications are encountered with
frequency similar to that of tonsillectomy.1
SUMMARY
It has been reported that a three years
old boy came with complaints of mouth
breathing, snoring, and stopped breathing assisted methods. Laryngoscope. 2014;
112: 23-25.
during sleep ± 3 times a week. From the
9. Acar M, Kankilic ES, Koksal AO,
history taking, physical examination, Yilmaz AA, Kocaoz D. Method of the
diagnosis of adenoid hypertrophy for
endoscopy, and X-ray, the patient was
physicians: adenoid-nasopharynx ratio.
diagnosed with adenoid hypertrophy and J Craniofac Surg. 2014 Sep; 25(5):
e438-40.
underwent an adenoidectomy.
10. Sasaki CT. Adenoid Disorders in Ear,
Nose, and Throat Disorders. MSD
Manual. 2018.
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Electrocautery adenoidectomy
compared with currettage and power-