SELECTIVE DORSAL RHIZOTOMY Department of Neurosurgery MOST EXPERIENCED IN THE WORLD St. Louis Children'sHospital • 2,500 employees • 700 medical staff • 1,300 auxiliary members • More than 30 pediatric subspecialty departmentsand divisions • Level I Pediatric Trauma Center, the highest level ofemergency care available
Asram.inIndian J Otolaryngol Head Neck Surg Adenoid Hypertrophy in Adults: A case Series Manas Ranjan Rout • Diganta Mohanty •Y. Vijaylaxmi • Kamlesh Bobba • Chakradhar Metta Received: 5 March 2012 / Accepted: 11 March 2012Ó Association of Otolaryngologists of India 2012 Adenoid hypertrophy is common in children.
adenoid hypertrophy should be treated seriously to exclude Size of the adenoid increases up to the age of 6 years, then the dangerous causes.
slowly atrophies and completely disappears at the age of16 years. Adenoid hypertrophy in adults is rare. Present Waldeyer's Ring Tonsillectomy study shows that adenoid hypertrophy is now increasing in Adenoidectomy Rhinoscopy adults because of various causes. Study has been conductedin the Department of ENT and Head & Neck Surgery, AlluriSitarama Raju Academy of Medical science, Eluru, Andhra Pradesh, India. Study shows that incidence of adenoidhypertrophy is increasing as the cause of nasal obstruction in Adenoid is the condensation of lymphoid tissue at the back adults. This study identified the different causes of adenoid of nose or on the postrosuperior wall of nasopharynx.
hypertrophy in adult patients. The common causes of ade- Adenoid is the part of Waldeyer's Ring. It appears to have noid hypertrophy in adults are chronic infection and allergy.
an important role in the development of an ‘immunological Pollution and smoking are also important predisposing fac- memory' in younger children Adenoids hypertrophy tors. Sometimes it is also associated with sinonasal malig- occurs physiologically in children between the age of nancy, lymphoma and HIV infection. Study shows that 21 % 6–10 years, then atrophy at the age of 16 years of adult nasal obstruction is due to adenoid Revised Proof Adenoid enlargement is uncommon in adults and in case of the patient with chronic tonsillitis only 9 % were because examination of the nasopharynx by indirect pos- associated with adenoid hypertrophy. Males are more com- terior rhinoscopy is inadequate, many cases of enlarged monly involved (70 %) then female, may be because of out adenoid in adults are misdiagnosed and accordingly mal- door activities and more commonly exposed to pollutants.
treated Presence of lymphoid hyperplasia in the adult And most commonly involved age group is 16–25 years nasopharynx, including the persistence of childhood ade- (60 %). Majority of the cases with adenoid hypertrophy are noids is associated with chronic inflammation. Regressed associated with infection and allergy i.e. descending infec- adenoidal tissue may re-proliferate in response to infec- tion in 33.3 % cases, ascending infection in 20 % cases and tions and irritants.
allergic rhinitis in 30 % cases. Association of malignant Adenoid Hypertrophy in adults may be due to compro- sinonasal tumors, non Hodgkin's lymphoma and HIV mised immunity, especially those receiving organ trans- infections are rare i.e. 3.3 % each. So any cases of adult plants and those having human immunodeficiency virus(HIV) infection.
Enlarged adenoids can become nearly the size of a ping M. R. Rout (&) D. Mohanty Y. Vijaylaxmi pong ball and completely block airflow through the nasal K. Bobba C. Metta passages. Even if enlarged adenoids are not substantial Department of ENT and Head & Neck Surgery, ASRAM enough to physically block the back of the nose, they can Medical College, Eluru, W. G District, Andhra Pradesh obstruct airflow enough so that breathing through the nose 534005, Indiae-mail: [email protected] requires an uncomfortable amount of work and occurs Indian J Otolaryngol Head Neck Surg through an open mouth. Adenoids can also obstruct the Pregnancy and breast feeding nasal airway enough to affect the voice without completely Throat complaint not related to tonsillitis.
stopping nasal airflow.
Present study is a series of adult patients' age more then Procedure and Technique 16 years having enlarged adenoid mass in the nasopharynx,some are isolated and some associated with chronic tonsillitis.
First of all, the patients attending ENT out patient depart- We have tried to find out the causes of the enlarged adenoid.
ment were divided into two categories.
Different symptomatologies are reviewed. Here also we have First category having patients complaining of nasal given emphasis on the management of these atypical cases.
obstruction and it may be unilateral, bilateral, continuousor intermittent. History of those patient were taken thor-oughly regarding other symptoms like sneezing, rhinor- Materials and Methods rhoea, itching of the nose, headache, fever, loss of smell,cough etc. Relevant past history and family history were also taken into consideration. This was followed by detailclinical examination including both general and local This was a 2 years prospective study of 200 adult patients, examination. Anterior rhinoscopy was useful to detect all aged more than 16 years. Out of those, 100 patients deviated nasal septum, septal spur, hypertrophic turbinates, having complaint of nasal obstruction were reviewed. Rest nasal polyp, foreign body, rhinolith etc. Posterior rhinos- 100 patients planned for tonsillectomy were screened for copy was possible only in few cases to examine the nasopharynx thoroughly. So most of the cases, it was not somuch informative regarding adenoid hypertrophy and nasal obstruction. All the routine investigations were doneincluding test for HIV infection. Investigations like X-ray This was a hospital based study conducted in the Department PNS water's view, X-ray nasopharynx lateral view and of ENT and Head & Neck Surgery, Alluri Sitarama Raju nasal endoscopy were done routinely in all the cases. X-ray Academy of Medical science, Eluru, Andhra Pradesh, India.
nasopharynx was obtained in an erect position with theneck extended and the mouth opened in order to visualize the shadow of the adenoid. The palatal airway was evalu-ated as described by Bitar . The degree of nasopharyn- February 2010–January 2012 geal obstruction was determined by assessing the ratio ofadenoid shadow diameter to the nasopharyngeal diameter.
Sampling Criteria Mild if 50 % of the palatal airway was obstructed,moderate if [50 % was obstructed but not up to 100 % and All the adult patients aged more than 16 years with adenoid severe if there was complete nasopharyngeal obstruction hypertrophy were taken into study. In this study 30 adult and no air column was seen on the post nasal space. Some patients having adenoid hypertrophy were found out by cases were reviewed with CT scan. CT scan gives much screening 100 adult patients having nasal obstruction and clearer picture of adenoid and nasopharyngeal space, but 100 patients planed for tonsillectomy. These 30 patients more important is the nature of the tumor such as extension were evaluated and studied.
and bone destruction, which implies a malignant tumour.
More over CT scan is also useful to diagnose chronic Inclusion Criteria's sinusitis. If adenoid or adenoid like masses were found inthe nasopharynx, then our next step was endoscope guided Patient giving consent for study on him or her.
punch biopsy and sending the mass for histopathological Patient willing for all the required investigations study. In all the cases of adenoid enlargement, we were Patient coming for regular follow up sending the throat swab for culture and sensitivity test and Age of the patient should be more than 16 years antibiotics were started accordingly. As well as all cases Patients having enlarged adenoid on investigations were tested for allergy by blood differential count of leu-cocytes, absolute eosinofil count, nasal smear for eosinofil Exclusion Criteria's and serum Ig E level.
And after conformation of mass, adenoidectomy were Patient not giving consent for the study on him or her performed and the mass were again sent for histopa- Patient not coming for regular follow up thological study. In case of simple adenoid mass, Indian J Otolaryngol Head Neck Surg adenoidectomy was the treatment of choice and response obstruction is 21 %. Those 21 patients of adenoid hyper- was very good.
trophy were taken from this category for study.
Second category of the patients was having symptoms Table showed the sex distribution of the patients diag- like throat pain, dysphagia, foreign body sensation of nosed as chronic tonsillitis and planned for surgery. Out of 100 throat, recurrent attacks of fever and throat pain. By proper adult patients 91 patients were having only tonsilar enlarge- history taking and thorough clinical examination these ment without adenoid hypertrophy (male—51, female—40) patients were diagnosed as chronic tonsillitis. Tonsilar and only 9 patients were having adenoid hypertrophy along enlargements were graded as per Brodsky grading method with tonsilar enlargement (male—7, female—2). So preva- . Grade 1? means tonsils were completely in the tons- lence of adenoid hypertrophy is 9 % in adult tonsillitis. Those ilar fossa and rarely seen behind the anterior pillars. Grade 9 patients with adenotonsillitis were taken into study.
2? means tonsils were visible behind the anterior pillars.
Out of above two categories total 30 adult patients were Grade 3? means tonsils extended 3/4th of the way to found to have adenoid hypertrophy and considered for midline. Grade 4? means tonsils were touching each other study. Table showed the age and sex distribution of the and completely obstructing the airway. Then all the patents with adenoid hypertrophy. Out of 30 patients 21 investigations mentioned in first category were performed were male and 9 were female. Most commonly involved to find out adenoids. Those patients having adenoid age group was 16–25 years i.e. 18 patients (male—12, hypertrophy, both adenoidectomy and tonsillectomy were female—6), then 26–35 years i.e. 8 patients (male—6, done and the adenoid masses were sent for histopatholo- female—2) and least common was from 36 to 45 years i.e.
gical study. Rest of the patients were undergone only 4 patients (male—3, female—1). So it showed that males are more commonly involved than female.
Now the patients of both the categories having adenoid As per habitat distribution 26 patients out of 30 were enlargement were studied.
from urban areas and only 4 patients were from rural areas.
On observing the occupation of the patients it was found that majorities were working in the road side (10 patients), Results and Observation factories (8 patients) and doing agriculture (4 patients).
This implies that pollution may be an important factor in In this study first category of patients having nasal development of adenoid hypertrophy. It also showed that obstruction were reviewed. Table showed the causes of persons working in AC office room are more prone to nasal obstruction in these patients. Out of 100 patients 60 develop the disease in comparison to patient working in were male and 40 were female. Most common pathology in open office room. But this is not conclusive because of less this category was found to be deviated nasal septum and/or sample size and further study is required for this.
septal spur i.e. 45 cases and next common group was theadenoid hypertrophy i.e. 21 cases (male—15 and female—6). Other causes were inferior turbinate hypertrophy (14cases), nasal polyp (6 cases), allergic rhi Revised Proof nitis (11 cases), Table 2 Sex distribution of patient with chronic tonsillitis and ade-noiditis (n = 100) rhinolith (1 case), nasal tumor (1 case) and atrophic rhinitis(1 case).So prevalence of adenoid hypertrophy in nasal Only chronic tonsillitis Chronic tonsillitis with Table 1 Causes of nasal obstruction (n = 100) Table 3 Age and sex distribution of the patients with adenoid hypertrophy (n = 30) Atrophic rhinitis Allergic rhinitis Adenoid hypertrophy a Inferior turbinate hypertrophy
Indian J Otolaryngol Head Neck Surg By using above all diagnostic methods we had tried to identify the predisposing factors for adenoid hypertrophy inthese 30 adult patients. Out of 21 male patients 10 mem-bers and out of 9 female patients 2 members are having thehabits of smoking. Table Table showed the predisposing factors for adenoid hypertrophy in our series. Commonest factor here wasthe descending infections like chronic sinusitis, rhinitisand otitis media i.e. in 10 patients (male—7, female—3).
Next common cause was allergic rhinitis i.e. in 9 patients(male—7, female—2).One more important cause was theascending infection from tonsil, pharynx and teeth i.e. in6 patients (male—3, female—3).Rare factors associatedwith adenoid hypertrophy in our series were nasal polypand benign tumors (2 patients), non Hodgkin's lymphoma Fig. 1 Hypertrophied adenoid (1 male patient), malignant sinonasal tumour (1 malepatient) and HIV infection was associated finding in onemale case. Therefore common causes of adenoid hyper- trophy in adult patients may be due to either chronicinfection or allergy. Less commonly but more impor- Adenoid is the condensation of lymphoid tissue at the back tantly it may be associated with the malignant diseases of of nose or on the posterosuperior wall of nasopharynx.
nose and paranasal sinuses and sometimes lymphomas Santorini described the nasopharyngeal lymphoid aggre- gate or ‘Lushka's tonsil' in 1724. Wilhelm coined the termadenoid to apply to what he described as ‘nasopharyngealvegetations' in 1870.
The adenoid, along with the tonsils at the back of the mouth and tonsilar tissue at the base of the tongue form a Table 4 Occupation of the patients (n = 30) ring of tissue (Waldeyer's ring) that assists in preventing bacteria, viruses, and toxins from entering the body. Theadenoid and the tonsilar tissues are largely composed of a group of blood cells termed B lymphocytes, which make antibody. This antibody binds bacteria, viruses, and other toxins and inactivates them, thus keeping them away from entering into the body and causing disease. Unlike the a Air conditioned tonsils which can be seen by looking directly through the mouth, the adenoid is positioned at the backmost part of the nasal cavity and up behind the soft palate. The adenoid,like tonsilar tissue, can be involved with both acute and Table 5 Predisposing factors for adult adenoid hypertrophy (n = 30) Descending infection like chronic sinusitis, rhinitis and otitis media Allergic rhinitis Ascending infection like chronic tonsillitis, pharyngitis and dental infection Polyp and benign tumour Malignant sinonasal tumour Non Hodgkin's lymphoma Indian J Otolaryngol Head Neck Surg chronic infections. With ongoing infection or inflamma- There were, however, significant differences in otitis media tion, the adenoid can progressively enlarge. Since it sits at rate, with effusion and dullness, and retraction in the ear- the backmost part of the nasal cavity, its main symptoms drum both more prevalent in childhood adenoid hypertro- affect nasal function.
phy. Adult adenoid hypertrophy was associated with nasal Adenoid appears to have an important role in the septum deviation in 25.0 % of patients (45 % in our series).
development of an ‘immunological memory' in younger Histopathological features of adenoidal lymphoid tissue children. Removal of the adenoid at a young age may be were dissimilar in the two groups: numerous lymph folli- immunologically undesirable but there appears to be no cles with prominent germinal centres were the chief finding decrease in IgE levels after adenoidectomy Adenoid in childhood adenoids, whereas adult adenoids showed hypertrophy, physiologically in children between the ages chronic inflammatory cell infiltration and secondary chan- of 6 and 10 years, then atrophies at the age of 16 years ges (e.g. squamous metaplasia). These results underline the Age related changes assessed by CT, MRI and positron importance of considering adenoid hypertrophy as a cause emission scan (PET) also demonstrated a significant or contributing factor in nasal obstruction and related decrease in the size of adenoids with aging. Although pathologies in adults and support the theory that it repre- adenoid tissue undergoes regression toward the adolescent sents a long-standing inflammatory process rather than period but Adenoid hypertrophy is also seen in the being a novel clinical entity.
normal adult population . Adenoid enlargement is Head and neck manifestations of acquired immunode- uncommon in adults and because examination of the ficiency syndrome (AIDS) are among the most common nasopharynx by indirect posterior rhinoscopy is inade- complications of this disease. Some of these manifestations quate, many cases of enlarged adenoid in adults are mis- are the initial signs of HIV infection, and others are asso- diagnosed and accordingly maltreated .
ciated with full-blown AIDS. Adenoid hypertrophy can be Although the cause of adenoid hypertrophy is not a presentation of HIV infection [ exactly known but certain reasons have been proposed.
In studies where they have been compared to more Presence of lymphoid hyperplasia in the adult nasophar- normal-sized adenoids, a chronic infection with Hemo- ynx, including the persistence of childhood adenoids is philus influenza, normal bacteria of the upper respiratory associated with chronic inflammation Regressed ade- tract, has been identified. The adenoid can also hypertrophy noidal tissue may re-proliferate in response to infections from chronic irritation from infected or inflamed nasal and irritants [Finkelstein et al. [reported the secretions being swept back over it. There may be some presence of obstructive adenoids in 30 % of heavy smokers adenoidal enlargement occurring with chronic allergic but in another study percentage of smokers was not sig- states. Adenoidal hyperplasia in adults is quite rare. If it is nificantly higher than in males of the same age ]. In our identified, malignancies of the type B white blood cell study 12 members were having history of smoking (10 (lymphoma plasmacytoma) or HIV must be considered. In male, 2 female).
our series Allergy was associated with 30 % of the adenoid In a study by Hamdan et al. ] prevalence of adenoid hypertrophy in adult. HIV infection was associated with 3.3 hypertrophy in adults with nasal obst ruction approached % cases and non Hodgkin's and other sinonasal malig- 63.6 % in patients with nasal obstruction and 55.1 in the nancy was associated with 3.3 % cases each. Descending control group (p = 0.007). In our study the prevalence of infection is responsible for 33.3 % cases of adenoid adenoid hypertrophy in patients with nasal obstruction is hypertrophy where as ascending infection is responsible for There are various clinical features associated with ade- Long-term adenoidal enlargement can lead to ear dis- noid hypertrophy. All patients have nasal obstruction ease and chronic mouth-breathing. There is some concern which may result in oral breathing, recurrent nasal that chronic mouth-breathing in children may result in infection and hypo nasal speech. Higher percentage of elongation of the middle part of the face and a narrow, children with Adenoid Hypertrophy was reported to suffer high-arched palate that can result in orthodontic abnor- from snoring compared with adults malities. Undiagnosed obstructive sleep apnea may cause A study conducted by Yaldrim et al.  in 2008 showed pulmonary hypertension, poor mental alertness, and etiology and pathological characteristics of adult and hypertrophy of the right side of the heart.
childhood adenoid hypertrophy (AH). Clinical and mor- If the adenoidal enlargement is fairly acute, it will often phological features and accompanying otolaryngological respond to antibiotics and oral steroids. In some individuals pathologies were recorded in 40 adults and 23 children a big adenoid can be reduced by long term nasal steroid undergoing adenoidectomy for obstructive adenoid hyper- sprays. In those who do not respond to these forms of trophy. Both adenoid hypertrophy forms were similar in medical management, surgery is often employed. In a study terms of symptomatologies and associated inflammations.
by Demirhan et al. in 2010 showed that 76 % patients Indian J Otolaryngol Head Neck Surg having adenoid hypertrophy, surgery was eliminated by depends upon early diagnosis and treatment these should using fluticasone propionate nasal drop.
not be neglected.
If the adenoid is acutely enlarged and responds well to So early identification of adults with adenoid hypertro- antibiotic and steroid therapy, then it will return to a phy should be considered for early management.
smaller size, with lessening of the amount of nasalobstruction. However, if the adenoid re-enlarges and re-creates the symptoms, surgery would then be necessary.
Typically those individuals who have required adenoidec- tomy have an improvement in eustachian tube function and 1. Wysocka J, Hassmann E, Lipska A, Musiatowicz M (2003) Naı¨ve lessening of their nasal obstruction and excessive nasal and memory T cells in hypertrophied adenoids in children discharge; and in those children who have had their ade- according to age. Int J Pediatr Otorhinolaryngol 67:237–241 noid removed for chronic sinus disease, 25 % of them will 2. Yildrim N, Sahan M, Karsliglu Y (2008) Adenoid hypertrophy in have their sinus disease resolve.
adults: clinical and morphological characteristics. J Int Med Res36:157–162 In adult, adenoid hypertrophy can be very dangerous as 3. Kamel RH, Ishak EA (1990) Enlarged adenoid and adenoidec- it is associated with lymphoma and other malignancy and tomy in adults: endoscopic approach and histopathological study.
sometimes with HIV infection. With early treatment J Laryngol Otol 104:965–967 prognosis may be good. So any case of adult adenoid 4. Bitar MA, Rahi A, Khalifeh M, Madanat LM (2006) A suggested clinical score to predict the severity of adenoid obstruction in hypertrophy should not be neglected.
children. Eur Arch Otorhinolaryngol 263:924–928 5. Brodsky L (1989) Modern assessment of tonsils and adenoids.
Pediatr Clin North Am 36:1551–1569 6. Brandtezaeg P (2003) Immunology of the tonsils and adenoids: everything the ENT surgeon needs to know. Int J PediatrOtorhinolaryngol 67:69–76 In conclusion adenoid hypertrophy is common and a nor- 7. Modrzynski M, Zawisza E, Rapiejko P (2003) Serum immuno- mal finding in children. And it is an uncommon finding in globulin E levels in relation to Waldeyer's ring surgery. Przegl adults. Now the incidence of adult adenoid hypertrophy is 8. Yuce I, Somdas M, Ketenci I, Caqli S, Unlu Y (2007) Adenoidal increasing because of allergy, chronic infection and vegetation in adults: an evaluation of 100 cases. Kulak Burun malignancy. Pollution is thought to be a predisposing Boqaz Ihtis Derg 17(3):130–132 factor. It is also found associated with HIV infection which 9. Minnigerode B, Blass K (1974) Persistent adenoid hypertrophy is now increasing through out the world.
22:347–349 [in German] Study shows that 21 % of adult nasal obstruction is due 10. Frenkiel S, Black MJ, Small P (1980) Persistent adenoid pre- to adenoid hypertrophy. But in case of the patient with senting as a nasopharyngeal mass. J Otolaryngol 9:357–360 chronic tonsillitis only 9 % were associated with adenoid 11. Finkelstein Y, Malik Z, Kopolovic J et al (1997) Characterization hypertrophy. Males are more commonly involved (70 %) then female may be because of out door activities and more 12. Barcin C, Tapan S, Kursakloglu H et al (2005) Tu¨rkiye!de commonly exposed to pollutants. And Revised Proof sag¢likli genc¸ eris¸kinlerde koroner risk fakto¨rlerinin incelenm- involved age group is 16–25 years (60 %). Majority of the esi: Kesitsel bir analiz. Tu¨rk Kardiyoloji Dern Ars 33:96–103 cases with adenoid hypertrophy are associated with infec- 13. Hamdan AL, Sabra O, Hadi U (2008) Prevalence of adenoid hypertrophy in adult with nasal obstruction. J Otolaryngol Head tion and allergy i.e. descending infection in 33.3 % cases, Neck Surg 37(4):469–473 ascending infection in 20 % cases and allergic rhinitis in 14. Moazzez AH, Alvi A (1998) Head and neck manifestations of AIDS in adults. Am Fam Physician 57(8):1813–1822 Association of malignant sinonasal tumors, non Hodg- 15. Demirhan H et al (2010) Medical treatment of adenoid hyper- trophy with fluticasone propionate nasal drop. Int J Pediatr kin's lymphoma and HIV infections are rare i.e. 3.3 % each. Still as these are dangerous conditions and prognosis
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