Adenoid_Hypertrophy_-1.pptx for medical student

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1. Medical Management of Adenoid Hypertrophy Dr Mukesh Verma MBBS, MD Pediatrics Senior Consultant Pediatrics Medical Director Aarogya Ruchi Hospital, Delhi Secretary IAP Delhi -2023 DMA Excellence Award 2020 NNF President’s Award 2018 DMA Distinguished Service Award 2016 Master trainer IAP United Airways Module.

2. What is adenoids or pharyngeal tonsil ? # it i s a si n gl e mass of py r a m id a l lymphoid tissue wit h i ts ba s e on the poster i or na s oph a ryn g ea l wall an d i t ’ s apex pointed toward the nasal septum # The tons i ls an d adenoi d s ar e par t of the secondary immune System. #Atrophy by puberty 13-14 years

3. Fu nction and Im m unology Without afferent lymphatics the lymphoid nod u le s i n t h es e structures ar e exposed to ant i gen only i n the crypts of the palat i ne tons i l s an d the fol d s of the adeno i d s . Th e s e ar e i nvolved i n the product i on of mo stl y secreto r y Ig A , wh i ch i s tran s porte d to the surface prov i d i ng local immune protection.

4. Causes for Adenoid Hypertrophy The adenoids become enlarged when the body is trying to fight off infection or an allergy #Recurrent infection - Adenoiditis due to bacterial as well as viral. #Allergies - Recurrent exposure to allergies. Allergic Rhinitis & Adenoid Hypertrophy is closely associated.

5. 🞇 Acute ad enoi d itis sympto m s i n c l ude purule n t r h i nor r he a , n a sa l ob s truct i o n , fe v er, and sometime s otitis media. 🞇 This can be diff i cu l t to differentia t e from an acute upper re spi r ator y i n fectio n bu t tends to ha v e a lo n ger an d more se v ere cou r se.

6. 🞇 Recurrent acute adenoiditi s is 4 or more episodes of acute adenoiditis in a 6 - month p e r i od w i th i nte r v e n i ng per i ods of wellness. 🞇 Chronic adenoiditis symptoms include per s i st e nt rhinorrhe a , postnasal drip, malodorous breath, and associated otitis media or ex t ra esophageal reflux las t i ng a t leas t 3 months.

7. Obstructive adenoid hyperplasia include s symptom s of chronic nasal obstruction, rhinorrhea, snoring , mout h breathin g , an d a hyponasal voice. SDB - Sleep Disordered Breathing & Obstructive sleep apnea in children is clinically marked by lou d snoring , apneic episodes whil e sleeping , daytime somnolence , behavioural proble m s , an d enuresis

8. SYMPTOMS OF ADENOID HYPERTROPHY 1. Nasal obstruction 2. Snoring - identify & ask !! snoring is not normal in children 3. Mouth breathing 4. Nasal intonation 5. Rhinorrhea 6. Epistaxis 7. Feeding difficulties 8. Otitis Media & conductive deafness 9. Adenoid facies 10. Sleep disorders / Bed Wetting/ behaviour issues. This is a more serious problem then identified.

9. Adenoid facies or “l ong face # I t i s the long, open - mouthed , face of chi ldre n w i th adeno i d hypertrophy. # T he mouth i s alway s o p en because upper airway congest i on has m a de p at i ents obligatory mouth breathers . # T he mo s t common presenting symptoms are chronic mouth b r eath i ng an d sno r i ng. # T he most dangero u s sy m pto m i s sleep apnea

10. The charac t erist i c facial appear a nce con s ist s of: # Underdeveloped th i n nostr i ls # Shor t upper lip # Pro m inen t up p er teeth # Crowded teeth # Narrow upper alveolus

11. # High - arche d palate # Hypoplast i c maxilla # Eustach i a n bl o ckage causing glue ear- deafness # The deafn e s s and inattentiveness i nte r fer es w i th t h e learning # Ch i l d grows w i th lowered intelligence and understanding

12. Diagnosis

13. Poster ior Rhinoscopy

14. Nasopharygoscopy /trans nasal Endoscopy

15. Nasopharygoscopy /trans nasal Endoscopy

16. X- Ra y soft tissue nasopharynx- lateral view

17. Medical Management of Adenoid Hypertrophy # Antibiotics - Not to be used as First line. However a short case in selected few might be needed . Augmentin/ Azithromycin / Clindamycin & other few 7-10 day course. # Topical Antibiotics - No benefits # NSAIDS - Not to be used as first line . Low Benefit # Systemic Steroids - No use & not to be used . However can be given in very severe cases if really needed.

18. #Nasal Steroids - FIRST LINE TREATMENT. Will do symptoms relief & reduction of Adenoid size . Fluticasone/ Momentasone / 8-12 Weeks #AntiHistamines - should be used only in patients with concomitant Allergic Rhinitis #Nasal & Systemic Decongestant - both Shouldn’t be used #Mucolytics - Not as First line but can be given in selected patients where thinning of mucus is needed. #Nasal Saline irrigation - can be done #Leukotine inhibitors - As first line in patients with Rhinitis/ Asthma in others if alllergy is suspected. Medical Management of Adenoid Hypertrophy

19. Role of Allergy Management Allergic Rhinitis & Adenoid Hypertrophy often associated. Most Children will improvement both in Respiratory symptoms & Reduction of Adenoid Size. Avoidance of Allergies & Treatment with intranasal steroids/antihistamines/ leukotriene inhibitors . Lifestyle changes & Few home remedies.

20. What’s going to work 1. Intranasal Steroids 2.AntiHistamines 3.Leukotriene Inhibitors 4.Life Style modifications. 5.Thorough Workup .

21. Adenoidectomy-Indications # Four or more episodes of recurrent pu r ulen t rhi n orr h e a in prio r 1 2 months in a chil d <12 . On e episode documented by intranasal exa min a t i on or diagnost i c i m aging # Persisting symptoms of adenoiditis afte r 2 courses of a nti b iot i c therap y # Sleep disorderd Breathing SDB wi t h nasal a i rw a y obstruct io n persistin g for a t leas t 3 months. # Hyponasa l or nasal speech #Selected Cormorbidities

22. Adenoidectomy-Indications # Oti t is media with effusio n >3 m onths or s e c o nd s e t of tubes # Dental malocclusion or orofacial growth disturbance documented by orthodontist. # C a r d iopul m ona r y complic a tions i ncl u d i ng c o r pu l m onale , pu l m o nary hypert e ns i on, r i ght vent r i cu l ar hypertrophy as s o c i ate d w i th upper a i rway o b struct i on. # Oti t is media with effusio n over a g e 4.

23. Medical Therapy 1.Watchful wait in children awaiting evaluation/ Definitive diagnosis. 2.Mild to moderate disease with no OSA or definite indications for Sx. 3. If there are no complications or selected comorbidities.

24. TAKE HOME MESSAGE 1. Early diagnosis & early medical management is saviour. 2. Allergy management & Lifestyle management. 3.Watchful waiting with Support care- has as Good Results. 4.Sleep Studies should be considered in all cases. 5. Surgical Management should be reserved for complicated & patients with comorbidities. 6. But timely Refer / Team work/ surgery should not be delayed in needful children. CHILDREN FIRST/ Team Work / Good Work up & Followup.