All about inflammation of adenoids

What are they

Adenoids are rectangular masses consisting of lymphatic tissue.

They are located at the top of the throat, behind and above the tonsils, right where the nasal cavities connect with the throat, also known as the pharyngeal vault.

In fact, adenoids – just like the tonsils placed on the palate – are lymphatic glands and, therefore, another name by which they are known is pharyngeal tonsils.

However, while the palatine tonsils are visible through the mouth, the adenoids remain hidden, because they are located higher up in the airways.

In addition, although both adenoids and tonsils consist mainly of lymphoid tissue, due to their different localization the problems associated with infections affecting the adenoids may be different from those induced by infections of the tonsils.

Like the tonsils, adenoids are part of the lymphatic system, whose task is to fight infectious diseases and keep body fluids in balance.

In both cases these are larger structures in the first years of life, especially in the age group between 2 and 6 years.

During childhood, adenoids are responsible for the production of antibodies, which help the child’s body to counteract infections of the respiratory system: to do so, they trap germs that try to enter the body through the mouth and nose.

From the age of eight onwards (sometimes as early as five years) the adenoids undergo spontaneous atrophy, that is, they shrink, and disappear almost definitively in adolescence. From this moment on, the body will use other defense weapons to fight and defeat microbes.

It is no coincidence that problems with these components of the lymphatic system are particularly frequent in pediatric age: as long as the adenoids remain active, they can become inflamed as a result of infection by germs, giving rise to adenoiditis.

The risk is particularly high in children struggling with infections of bacterial or viral origin, as can happen to children who attend kindergartens.

Sometimes, however, the process of atrophy that normally occurs with growth is not complete (presence of adenoid vegetation in the adult), so you can experience inflammation of the adenoids as a result of flu or repeated colds.

Among the microbes most often associated with adenoid problems include:

• Haemophilus influenzae,
• beta-hemolytic streptococcus of group A,
• Staphylococcus aureus,
• Moraxella catarrhalis,
• Streptococcus pneumoniae.

The pathogens involved can vary depending on the disease related to the enlargement of the adenoids and the age at which the problem appears.

In addition, allergies (both seasonal and those that affect throughout the year), exposure to irritants and, at least so it seems, even gastroesophageal reflux can cause an enlargement of the adenoids and tonsils.

However, both in preschool children and adolescents it can happen that the adenoids, as well as the tonsils, appear enlarged without any obvious cause.

Symptoms

Inflammation of the adenoids (adenoiditis) is manifested by a swelling that can cause obstruction of the airways at the level of the nose, throat and Eustachian tube (the duct that connects the nasopharyngeal area with the eardrum case).

Hearing problems and difficulty breathing arise, which can be mild or severe.

Other possible symptoms are:

• sleep apnea,
• restless sleep,
• noisy breathing,
• breathing through the mouth (resulting from nasal obstruction),
• snoring (due to airway obstruction),
• nasal voice, “off” (closed rhinolalia),
• discharge from the nose (rhinorrhea) associated with coughing,
• ear infections, especially recurrent secretory otitis media, which cause persistent ear pain.

Generally, among the first signs of the appearance of the disease, we note the habit of keeping the mouth open: the child, unable to breathe through the nose, constantly keeps his mouth open. The result is that, in the long run, the palate rises, assuming an oval or “domed” shape, while the dental bite moves forward, and the child takes on a characteristic expression, known in medicine as “adeinoid facies”.

In addition, forced breathing through the mouth, imposed by nasal obstruction, can cause dryness of the oral cavity, also triggering bad breath.

Just as the enlargement of the adenoids can interfere with breathing, that of the palatine tonsils can make swallowing difficult.

Other symptoms of inflammation of the tonsils are:

• enlargement and redness of the tonsils,
• visible plaques on the mucous membranes that surround them,
• sore throat also severe,
• presence of swollen glands at the level of the neck,
• bad breath,
• fever.

Aftermath

Typically, once the infection is defeated, both the adenoids and palatine tonsils return to their normal size.

However, it may happen that the enlargement remains, especially in the case of children who have had to deal with frequent or chronic infections.

If left untreated, inflamed adenoids can lead to chronic sinusitis (persistent inflammation of the paranasal sinuses, due to stagnation of catarrhal secretions) and recurrent ear infections that respond poorly to antibiotic treatment.

In severe cases, the Eustachian tubes can become clogged and fluid can accumulate in the middle ear (i.e. inside the ear); as a result, ear infections can become chronic and in some cases even lead to hearing loss.

In addition, in cases where enlarged adenoids cause snoring and interrupt breathing during sleep, blood oxygen levels can drop significantly, leading to frequent awakenings.

All this can happen even if the interruption is short: it is the so-called “obstructive sleep apnea“, a problem that can also have among its consequences drowsiness during the day.

In addition, in rare cases sleep apnea can lead to serious complications, such as pulmonary hypertension, a condition characterized by excessive elevation of blood pressure values in the arteries of the lungs.

Parents generally notice that children stop breathing during sleep; In these cases, the doctor may recommend a particular analysis – polysomnography – which involves measuring certain parameters (including blood oxygen levels) while the baby is sleeping.

Finally, children with adenoid or tonsil problems may also lose weight or not grow as much as they should.

This is because pain due to infections or the continuous efforts required to breathe can lead them to not eat enough.

Diagnosis

Diagnosis of adenoid hypertrophy includes:

• analysis and evaluation of the patient’s medical history,
• palpation of the neck,
• an inspection of the ears, throat and mouth.

However, since the adenoids are located higher than the throat, the doctor – usually during an ENT visit – may need to use some tools to check for their enlargement.

Sometimes the otolaryngologist uses a particular mirror to be inserted into the mouth, performing what in jargon is called “posterior rhinoscopy“. Other times, however, to visualize them, it may be necessary to do a nasal fibroscopy, or an examination that involves the use of an endoscope (a long flexible tube with lighting) or the use of a lateral x-ray may be more suitable.

Therapies

Le adenoiditi sono difficili da diagnosticare perché i sintomi sono comuni a numerose altre malattie ed è spesso difficile capire se l’ingrossamento delle adenoidi ne sia la causa o la conseguenza.

As in the case of tonsillitis, tonsillectomy can be used, so, even in the case of enlarged adenoids, the treatment of choice consists in their surgical removal (adenoidectomy); In many cases the two operations are performed simultaneously (and then we speak of adenotonsillectomy).

Clinical indications for adenoidectomy are:

• recurrent adenoiditis or sinusitis,
• discharge of yellowish mucus from the nose (or serous rhinorrhea),
• forced oral breathing,
• sleep apnea,
• snoring
• sleep disorders,
• bedwetting (or bedwetting),
• daytime drowsiness,
• recurrent catarrhal otitis, hearing loss (hearing loss),
• growth disorders,
• difficulty feeding, speech alterations and nasal voice.

Adenoidectomy seems to have all the characteristics of a safe intervention: the complication rate is low, the duration of the operation is short and the children undergoing the operation begin to recover within 2 or 3 days; however, a complete recovery may take longer.

There are no absolute contraindications to the operation, except in cases where it is not possible to subject the patient to general anesthesia.

On the other hand, there are relative contraindications:

• diseases at risk of serious bleeding, which can however be addressed with the administration of appropriate drugs or the execution of particular treatments before, during and after adenoidectomy surgery
• the risk of insufficiency of the velopharynx (that is, the inability of the soft palate and associated structures to close the upper tract of the pharynx, nasopharynx). This risk may be associated with disorders such as short palate, cleft palate and submucosal cleft palate, muscle weakness or hypotonia associated with a neurological problem, velo-cardiofacial syndrome or Kabuki syndrome (two rare diseases). This is a relative contraindication because it can be solved by opting for a partial adenoidectomy or by planning an appropriate rehabilitation therapy after surgery.
• the laxity of the atlanto-axial joint (or atlanto-axial instability), a condition present in 10% of children with Down syndrome that can however be addressed with appropriate surgical measures.

Regardless of the size of the adenoids, their removal may be associated with improvement of rhinosinusitis symptoms and reduction of episodes of acute otitis media with the presence of phlegm in children over 3 years of age.

It does not appear that either adenoidectomy or tonsillectomy can help reduce the frequency or severity of problems such as colds.

In general, both the removal of hypertrophic adenoids and that of the tonsils seems to be useful only when the discomfort caused by enlargement is very intense, when they cause respiratory problems and when they are associated with recurrent infections, and before arriving at surgery for their removal it is possible to try to intervene even in a less invasive way.

Possible non-surgical approaches depend on the cause that triggered the enlargement.

In some cases, the treatment of adenoid hypertrophy may require the use of allergy medications, such as corticosteroid-based nasal sprays or antihistamines to be taken orally, or mucolytics and cortisone to be administered by aerosol therapy.

In the event that the problem is based on infection by bacteria, the doctor or pediatrician may prescribe treatment based on antibiotics.