Summary for adenoids anatomy, physiology, disorders and treatment:

Adenoids sit in the back of the nose, where the nose joins the throat. The tissue is lymphatic tissue which is part of the immune system. Adenoids are part of the initial immune response to pathogens that are inhaled. In some children the tissue may grow to the point that it causes blockage of the airway, therefore making it very difficult for the child to breathe through their nose. An adenoidectomy is the removal of the adenoid tissue in the operating room.

Airway blockage before adenoidectomy, note that some air might get through, but sometimes the children can breathe through their noses. CamachoMD.com
Airway blockage before adenoidectomy, note that some air might get through, but sometimes the children can breathe through their noses.

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Background

Adenoids anatomy:

Adenoids are tissues that sit in the back of the nose, just above and behind the soft palate.

The tissue is part of a collection of tissues known as Waldeyer’s ring (adenoid tissue and tonsil tissue in the nose and throat).[1]

Upper airway with the black arrow pointing to the adenoids (which are enlarged). CamachoMD.com
Upper airway with the black arrow pointing to the adenoids (which are enlarged).

Adenoids physiology:

Adenoids are lymphatic tissues that are part of the immune system. The immune system helps to fight infections.

Because of their location in the back of the nose, when a pathogen is inhaled, the adenoids help the body identify the organism and the body then starts to form an immune response.[1]

Since the adenoids are part of the immune system, their enlargement can be caused by infections and by allergies.

Diagnosis

Symptoms of adenoid enlargement:

Children may have nasal congestion when their adenoids are enlarged. The larger the adenoids, the more congestion and mouth breathing they may have.

Airflow through the mouth before an adenoidectomy. CamachoMD.com
Airflow through the mouth before an adenoidectomy.

Signs of adenoid enlargement:

  • allergic rhinitis;
  • allergic shiners (dark bags under the eyes);
  • chronic ear fluid (middle ear effusion);
  • chronic mouth breathing;
  • obstructive sleep apnea;[2]
  • recurring ear infections (otitis media),
  • sneezing;
  • snoring;[2] and
  • thick eyelashes.

Signs of adenoid infection:

  • fever,
  • runny nose,
  • runny nose with thick mucous – yellow or green colored, 

What do children with chronic mouth breathing look like? 

Adenoid faces is a description that is given to the typical appearance of the face of a child with chronic adenoid enlargement. The face has the following appearance[3]:

  • long and narrow face;
  • breathing with the mouth open;
  • a short upper lip;
  • prominent upper teeth (incisors); and
  • high arched palate.
Long face syndrome in a child. Note the mouth is open so he can breathe. The airway is shown. The blue arrows show the path that the air takes in the upper airway. SkullMD.com
Long face syndrome in a child. Note the mouth is open so he can breathe. The airway is shown. The blue arrows show the path that the air takes in the upper airway.

Causes and risk factors for developing adenoid enlargement:

  • environmental allergies; and
  • family history of allergies or enlarged adenoids or tonsils.

How do surgeons assess whether or not adenoids are enlarged?

Enlargement of the adenoids can be verified by using flexible nasopharyngeal endoscopy or by using a lateral cephalogram (x-ray of the head from the side).[4]

Flexible nasopharyngoscopy is when an ENT surgeon uses a thin endoscope, about the thickness of a large spaghetti noodle. 

Nasal endoscopy in a girl with large adenoids. Note the scope goes into the nose and the image can be seen on the screen or viewer depending on the type of scope. BladeMD.com
Nasal endoscopy in a girl with large adenoids. Note the scope goes into the nose and the image can be seen on the screen or viewer depending on the type of scope.

When comparing the accuracy of the radiological reading of the adenoid size (the adenoid to nasopharynx ratio), the evaluation with nasopharyngeal endoscopy was found to be more accurate, compared to lateral cephalograms.[4]

What is the grading scale that is used to determine the size of adenoid tissue?

Josephson and colleagues[5] studied the size of adenoid tissue in 150 children and used a 25% grading scale in which the volume of the adenoid tissue was estimated based on how much the tissue filled the nasopharynx:

  • Grade 0: no adenoid tissue is present,
  • Grade 1: 1-25% of the volume,
  • Grade 2: 26-50% of the volume,
  • Grade 3: 51-75% of the volume, and 
  • Grade 4: 76-100% of the volume.[5]
Adeniods in a child. A) Small, B) Medium, C) Large, and C) Extra large. BladeMD.com
Adeniods in a child. A) Small, B) Medium, C) Large, and C) Extra large.

Treatments for adenoid enlargement:

The natural history of observation:

Depending on the cause of the adenoid enlargement, there is a possibility that the tissue could get smaller, but generally, it can take a long time, so the symptoms will likely persist.

Medical management of adenoid enlargement:

Management can consist of either medications that affect the whole body (oral medications) or topical medications (sprays or rinses).

Oral medications include:

  • allergy medications (antihistamines such as cetirizine);
  • oral anti-leukotrienes (such as montelukast); 
  • antibiotics in children with an adenoid infection; and
  • oral steroids (such as prednisone).

Topical medications (nasal sprays) include:

  • allergy nose sprays (such as azelastine);
  • steroid nose sprays (such as mometasone); and
  • nasal rinses (professionally made and approved)

Surgery for adenoid enlargement (an adenoidectomy): 

Adenoidectomy is a surgery that removes the adenoid tissue in an operating room which is located either in a surgical center or in a hospital.

The steps of an adenoidectomy are:

  • the child is put to sleep with an anesthetic medication;
  • a breathing tube (endotracheal tube) is placed into their airway;
  • the surgeon then removes the tissue by going through the mouth or through the nose; and
  • once the surgeon is done and has stopped any bleeding, the child is turned over to the anesthesia provider who then wakes up the child.
Adenoidectomy in a child. The adenoids are large. The surgeon is using a mirror to look at the adenoids through the mouth. BladeMD.com
Adenoidectomy in a child. The adenoids are large. The surgeon is using a mirror to look at the adenoids through the mouth.

What is the International Classification of Diseases (ICD-10) Code for enlarged adenoids?

The ICD-10 Code for hypertrophy of the adenoids is J35.2.

References:

1.            Masters, K.G. and S. Lasrado, Anatomy, Head and Neck, Tonsils, in StatPearls. 2019, StatPearls Publishing

StatPearls Publishing LLC.: Treasure Island (FL).

2.            Reckley, L.K., et al., Adenoidectomy can improve obstructive sleep apnoea in young children: systematic review and meta-analysis. J Laryngol Otol, 2016. 130(11): p. 990-994.

3.            Rappai, M., et al., The nose and sleep-disordered breathing: what we know and what we do not know. Chest, 2003. 124(6): p. 2309-23.

4.            Lertsburapa, K., J.W. Schroeder, Jr., and C. Sullivan, Assessment of adenoid size: A comparison of lateral radiographic measurements, radiologist assessment, and nasal endoscopy. Int J Pediatr Otorhinolaryngol, 2010. 74(11): p. 1281-5.

5.            Josephson, G.D., L. Duckworth, and J. Hossain, Proposed definitive grading system tool for the assessment of adenoid hyperplasia. Laryngoscope, 2011. 121(1): p. 187-93.