The adenoids are a grouping of lymphoid tissue located on the posterior wall of the nasopharynx behind the soft palate. The adenoids, along with the palatine tonsils, lingual tonsils, and tubal tonsils of Gerlach make up what is known as Waldeyer’s ring. Together, these tissues function as an essential part of the human immune system. Antigens, introduced through the oral and nasal cavities, come into contact with the immune cells of Waldeyer's ring. These cells can then produce immunologic memory of the antigens and fight them by producing IgA antibodies.
The adenoids are present at birth and enlarge throughout childhood. In most individuals, they will regress in size during puberty and may be nearly absent by adulthood. For this reason, adenoiditis is commonly a problem of childhood and adolescence. Adenoiditis occurs when there is inflammation of the adenoid tissue resulting from infection, allergies, or irritation from stomach acid. Adenoiditis rarely occurs on its own and is more often involved in a more extensive disease process such as adenotonsillitis, pharyngitis, rhinosinusitis, etc. Continual irritation may lead to adenoid hypertrophy which is responsible for many of the complications of adenoid disease. Adenoiditis can be classified as acute or chronic.
The adenoids receive their blood supply from the ascending pharyngeal artery, maxillary artery, and facial artery. Venous drainage occurs through the pharyngeal veins. Nervous innervation is through the vagus nerve and glossopharyngeal nerve. Adenoid size grading is on a scale of zero to four:
0 absent1+ <25% obstruction of the nasopharynx2+ 25-50% obstruction3+ 50-75% obstruction4+ >75% obstruction
Many agents and pathogens can cause inflammation of the adenoid tissue. A viral upper respiratory tract infection (URTI) often precedes acute adenoiditis. In this vulnerable state, bacterial pathogens can infect the tissues and proliferate.
The most common bacterial pathogens cultured from adenoid specimens are:
Haemophilus influenzaeStrep pneumonia Strep pyogenesStaph aureus Chronic adenoiditis is more often a polymicrobial infection and may include anaerobic pathogens and biofilm development.
Allergies are believed to play a role in adenoiditis and subsequent adenoid hypertrophy. Allergens inhaled through the nose come in contact with the adenoid tissue. The tissues will proliferate in order to create a response to allergens and produce IgA.
Chronic irritation from stomach acid in the setting of gastroesophageal reflux disease (GERD) may also play a role in adenoiditis and adenoid hypertrophy.
Exact statistics on adenoiditis alone are unclear as it is usually addressed in the context of a more extensive disease process such as rhinosinusitis and adenotonsillar disease. Since adenoid tissue atrophies during puberty, adenoiditis is typically a disease of children. Current literature does not suggest a predilection for gender, race, region, socioeconomic class in this disease.
Adenoiditis is often indistinguishable from bacterial sinusitis. Statistics on sinusitis in children, therefore, may give us some idea of the frequency of adenoiditis. Estimates are that children have six to eight viral URTIs per year. Five to thirteen percent of these viral URTIs result in bacterial sinusitis which may have adenoiditis as a component of the illness.
Acute adenoiditis often occurs after a viral upper respiratory tract infection (URTI). Bacterial agents proliferate and infect the adenoids and surrounding tissue resulting in inflammation and increased production of exudates. Symptoms include rhinorrhea, post-nasal drip, nasal obstruction, snoring, fever, and halitosis. Chronic adenoiditis shows many of the same symptoms but on a persistent basis lasting 90 days and is often caused by polymicrobial infections and biofilm formation.
Another cause of adenoiditis may also be environmental allergens or caustic irritation from stomach acid in the presence of GERD.
Any form of chronic inflammation may lead to the proliferation of lymphoid tissue and subsequent adenoid hypertrophy. This hypertrophy can lead to nasal airway obstruction and obstruction of the Eustachian tubes which in turn leads to other problems such as obstructive sleep apnea (OSA) and acute otitis media.
Adenoid tissue typically regresses around puberty. Therefore, the typical patient with adenoiditis is a prepubescent child with a recent history URTI. The patient may also have a history of acute otitis media, obstructive sleep apnea, or GERD.
Physical findings include purulent rhinorrhea, post-nasal drip, nasal obstruction, snoring, fever, mouth breathing, and halitosis. Indirect mirror exam may allow the practitioner to observe enlarged adenoids with exudates. A flexible nasolaryngoscope exam can allow for direct observation of the adenoids but is often not tolerated by children and requires advanced training to use.
Long-standing adenoiditis with subsequent adenoid hypertrophy can lead to the development of what is known as adenoid facies or long face syndrome. Enlarged adenoids block the nasopharynx and result in obligate mouth breathing, which can lead to craniofacial abnormalities including a high-arched palate and retrognathic mandible.
The diagnosis of acute adenoiditis is made clinically based on the findings of:FeverPurulent rhinorrheaPost-nasal dripHalitosisNasal obstruction Throat painHalitosis
Visual inspection of the adenoids may be attempted using a laryngeal mirror or flexible nasolaryngoscope.
Laboratory TestingRapid strep testCulturesAllergy testing
If it presents in the context of pharyngitis, the clinician may want to perform a rapid strep test. The purpose of doing so is two-fold. First, this will give a definitive diagnosis of the patient’s condition and help guide antibiotic therapy. Second, the doctor’s office will have a record of positive and negative strep tests which will play an important role when deciding whether an adenoidectomy, plus or minus tonsillectomy, is indicated.
In cases of persistent infection despite antibiotic therapy, the clinician may choose to perform throat cultures to help identify the causative agent and guide therapy as direct cultures of adenoids may be difficult in the office setting.
If the adenoiditis is believed to be the result of seasonal or environmental allergies, allergy skin testing may be useful in directing therapy.
Radiology TestingLateral neck X-rayCT sinus
Sinus x-rays or sinus CT’s may be obtained to look for a source of infection in the sinuses. Lateral neck X-rays are an effective way to evaluate specifically for adenoid hypertrophy. In a patient with adenoid hypertrophy who snores a sleep study can be ordered to rule out obstructive sleep apnea.
Adenoiditis is often seen clinically as a component of rhinosinusitis or pharyngitis. Due to this fact, practitioners often use clinical management guidelines for rhinosinusitis and pharyngitis when approaching the treatment of adenoiditis.
Watch and waitIf the clinician believes the cause of adenoiditis is by the common cold or other common viral infection they should refrain from using antibiotics. Typically, uncomplicated upper respiratory viral infections will resolve within 5-7 days.
Antibiotic treatmentIf symptoms continue or clinical presentation is suggestive of bacterial etiology, such as a high fever or purulent discharge from the nose or throat, the first line management is antibiotics covering the most common pathogens. Amoxicillin is a commonly used first due to its good coverage and tolerability. Alternatively, cefdinir or cefuroxime may be first-line treatment. If the patient has a penicillin allergy, alternatives include clarithromycin or azithromycin. Effective antibiotic treatment should yield an improvement of symptoms in 48-72 hours. Sources suggest that treatment duration should be ten days. If the condition fails to improve after a course of amoxicillin or other first-line agents, amoxicillin-clavulanate should be prescribed to eliminate potential beta-lactamase producing organisms.
Allergy treatmentIf the adenoiditis is believed to be secondary to environmental allergies, the patient can be given a trial of nasal steroid sprays, oral steroids, oral antihistamines, or some combination thereof to see if this produces any relief in symptoms. The patient may also receive formal allergy testing followed by immune-modulating therapy to provide relief.
Reflux treatmentIf the adenoiditis is believed to be secondary to GERD treatment of this condition using lifestyle and diet modification with or without the use of H2 blockers or proton-pump inhibitors may provide sufficient relief of symptoms.
AdenoidectomyIn the absence of symptomatic improvement after treatment with amoxicillin-clavulanate or if the patient has multiple episodes of adenoiditis requiring antibiotic treatment, referral to an otolaryngologist is warranted for further evaluation and potential surgical intervention. Depending on the individual circumstances, surgical procedures may include adenoidectomy with or without tonsillectomy or functional endoscopic sinus surgery. If the patient meets the Paradise criteria for tonsillectomy, most otolaryngologists will remove the adenoids at the same time to remove another possible source of recurrent infections.
Differential diagnosis includes:
The medical treatment available for treating adenoiditis should be capable of treating most cases successfully. For those with recurrent disease, an adenoidectomy surgery provides a definitive solution by removing all the tissues.
If adenoiditis is left untreated, the patient may develop a chronic low-level infection of the adenoids which in some cases can lead to the development of a biofilm. The adenoids may then serve as a nidus of infection for other closely related structures and lead to rhinosinusitis, pharyngitis, tonsillitis, and acute otitis media.
Adenoid hypertrophy is responsible for some of the more common complications related to disease of the adenoids. As they enlarge the tissues can create a significant obstacle to the flow of air through the nasopharynx. This enlargement can cause mouth breathing, snoring, and OSA. OSA can be a life-threatening disease if left untreated. Removing the adenoids can increase the flow of air through the nasopharynx, decreasing obstructive episodes and leading to better CPAP compliance.
Enlarged adenoids may also obstruct the opening of the Eustachian tubes in the nasopharynx. Without proper function of the Eustachian tube, negative pressure can build in the middle ear. This negative pressure can lead to the formation of an effusion which can cause conductive hearing loss and serve as a breeding ground for bacteria.
Long-standing adenoiditis with subsequent adenoid hypertrophy can lead to the development of what is known as adenoid facies or long-face syndrome. Enlarged adenoids can block the nasopharynx and result in obligate mouth breathing, which can lead to craniofacial abnormalities including a high-arched palate and retrognathic mandible.
Patients with recurrent adenoiditis or the complications of adenoid hypertrophy should obtain a referral to an otolaryngologist for further evaluation and treatment. Other disciplines that may need to be involved in the care of the patient include sleep medicine, allergy specialists, and gastroenterology depending on the individual’s needs.
Adenoiditis is a common issue in children and may be unavoidable since they are frequently in contact with the common pathogens and allergens that cause the inflammation. However, it is essential to seek treatment before chronic adenoiditis, and adenoid hypertrophy can take hold, as these can lead to sometimes serious complications and decreased quality of life.
Because causes of adenoiditis can include a number of different factors including recurrent bacterial infections, allergies, and GERD, treatment of adenoiditis and its complications may require the care of multiple specialists. These specialists should work in close coordination to maximize patient outcomes. It is important to find the root cause/s and treat them, or the problem may never fully resolve and lead to further complications. Healthcare team members should pay close attention to the signs and symptoms of OSA as this is the most serious complication of adenoid disease.