Adenoids

1. Adenoids Dr. Priyanjal Gautam PG-3 rd Yr. (MS-ENT) NIMS, Jaipur

2. Synonym: Nasopharyngeal tonsil Adenoids is the hypertrophied mass of lymphoid tissue situated at the junction of roof & post. wall of nasopharynx . The mass of lymphoid tissue is termed as Adenoids only when it is hypertrophied. It usually undergoes atrophy by puberty (13-14 yrs)

3. FEATURES : Pink, globular mass Vertical ridges on its surface No crypts Lined by ciliated columnar epithelium No capsule

4. BLOOD SUPPLY : Ascending palatine branch of facial artery Ascending pharyngeal artery Pharyngeal branch of 3 rd part of maxillary artery

5. LYMPHATIC DRAINAGE : Upper deep jugular nodes Retropharyngeal nodes Parapharyngeal nodes

6. X-Ray Nasopharynx  enlarged adenoids

7. ETIOLOGY : Hereditary Cold climate Specific infection like tuberculosis Physiological hypertrophy may be seen between 3-10 yrs

8. SYMPTOMS : LOCAL B/L nasal obstruction Snoring Mouth breathing Rhinolalia clausa Frequent rhinorrhoea Epistaxis Feeding problems in children Conductive deafness due to ET block Cervical lymphadenopathy Otitis media Adenoids facies Bronchitis GENERAL Anorexia Lethargy Poor physical & mental development Bed-wetting Pigeon chest Protuberent abdomen

9. Adenoids Facies Sunken eyes Narrow pinched nostrils Open mouth High-arched palate Crowded teeth Dull mask-like face Protruding teeth Drooling saliva Everted upper lip Rhinorrhoea Loss of nasolabial fold

10. Aural manifestations in Adenoids Otalgia Secretory otitis media Acute otitis media Atelectasis of TM ET block Chonic otitis media

11. Diagnosis : H/O nasal obstruction, rhinorrhoea Pink globular mass with vertical ridges on post. rhinoscopy B/L retracted ear drums X-ray nasopharynx Lat. View shows soft tissue mass

12. Differential diagnosis : Thornwaldt’s cyst High arched palate

13. Complications: Adenoid facies Otitis media with effusion Recurrent acute otitis media Rhinolalia clausa Chronic sinusitis Sleep apnea syndrome Decreased mental/physical development

14. Treatment : MEDICAL Adequate nutrition Antibiotics Anti inflammatory analgesics Nasal decongestant drops SURGICAL Adenoidectomy Myringotomy with grommet insertion

15. Adenoidectomy

16. Indications : 1. Adenoid hypertrophy causing snoring, mouth breathing, sleep apnoea syndrome or speech abnormalities, i.e. ( rhinolalia clausa ). 2. Recurrent rhinosinusitis . 3. Chronic secretory otitis media associated with adenoid hyperplasia.

17. 4. Recurrent ear discharge in benign CSOM associated with adenoiditis/adenoid hyperplasia. 5. Dental malocclusion. Adenoidectomy does not correct dental abnormalities but will prevent its recurrence after orthodontic treatment.

18. Contraindications : 1. Cleft palate 2. Haemorrhagic diathesis. 3. Acute URTI

19. Anaesthesia : Always general, with oral endotracheal intubation.

20. Neck is extended by a sand bag under the shoulders and the head is supported on a ring. Downloaded from: StudentConsult (on 6 December 2012 06:54 PM) © 2005 Elsevier Rose's position

21. Steps of Operation : 1. Boyle-Davis mouth-gag is inserted. Before actual removal of adenoids, nasopharynx should always be examined by retracting the soft palate with curved end of the tongue depressor and by digital palpation, to confirm the diagnosis, to assess the size of adenoids mass and to push the lateral adenoid masses towards the midline.

22. 2. Proper size of "adenoid curette with guard" is introduced into the nasopharynx till its free edge touches the posterior border of nasal septum and is then pressed backwards to engage the adenoids. At this level, head should be slightly flexed to avoid injury to the odontoid process.

23. Adenoid curette With guard Without guard

24. 3. With gentle sweeping movement, adenoids are shaved off . Lateral masses are similarly removed with smaller curettes; small tags of lymphoid tissue left behind are removed with punch forceps. 4. Haemostasis is achieved by packing the area for sometime. Persistent bleeders are electro-coagulated under vision. If bleeding is still not controlled, a postnasal pack is left for 24 hours.

25. Adenoidectomy .

26. Endoscopic Adenoidectomy These days adenoids can be removed more precisely by using a debrider under endoscopic control

27. Nasal endoscopic adenoidectomy using curette

28. Oral endoscopic adenoidectomy using curette

29. Micro debrider Micro debrider Micro debrider -tip blade

30. Microdebrider adenoidectomy

31. Mirror assisted microdebrider adenoidectomy

32. Coblation adenoidectomy It is also other wise known as cold abalation . This technique utilises a field of plasma, or ionised sodium molecules, to ablate tissues. The heat generated varies from 40 - 80 degrees centigrade, much lower than that of electro cautery . The major advantage of this procedure is reduced bleeding and reduced post operative pain .

33. Coblation adenoidectomy

34. Post-operative Care : 1 . Immediate general care (a) Keep the patient in coma position until fully recovered from anaesthesia . (b) Keep a watch on bleeding from the nose and mouth. (c) Keep check on vital signs, e.g. pulse, respiration and blood pressure.

35. Post-operative Care cont.. 2. Diet When patient is fully recovered he/she is to take liquids, e.g. cold milk or ice cream. 3. Nasal saline drops

36. Post-operative Care cont.. 4. Analgesics : I/V or oral 5. Antibiotics : Orally or I/V for a week. Patient is usually sent home 24 hours after operation unless there is some complication. Patient can resume his normal duties within 2 weeks.

37. Complications : 1. Haemorrhage 2. Injury to eustachian tube opening 3. Injury to pharyngeal musculature and vertebrae 4. Griesel syndrome . Patient complains of neck pain and develops torticollis . Mostly it is due to spasm of paraspinal muscles, but can be due to atlanto -axial dislocation requiring cervical collar and even traction.

38. 5. Nasopharyngeal stenosis 6. Recurrence

39. Thank You…