Adenoiditis is an acute or chronic inflammation of the pharyngeal tonsil of the lymphopharyngeal ring. The main symptoms include a feeling of discomfort inside the nose, night snoring, lack of nasal breathing, mucous or purulent discharge, closed nasal nasal, dry paroxysmal cough, intoxication syndrome, sleep disorders. Diagnosis is based on the patient’s survey data, mesopharyngoscopy, posterior rhinoscopy, laboratory tests, radiography or computed tomography of the nasopharynx. In the treatment of adenoiditis, local and systemic medications, physiotherapy are used, and adenoidectomy is performed less often.
J35 Chronic diseases of the tonsils and adenoids
Adenoiditis (retronasal angina, or epipharyngitis) is the most common disease in pediatric otolaryngology. It is most often observed in children of preschool and primary school age – from 3 to 9 years. It is rare in adults, which is associated with age-related involution of the lymphoid tissue of the nasopharyngeal tonsil. According to statistics, this pathology occurs in 5-28% of the general child population and in 70% of frequently ill children and adolescents. The primary incidence rate of chronic adenoiditis is 1.8-2.7 per 1,000 children. Pathology is equally common among male and female representatives, in 35-45% of cases it is accompanied by recurrent or chronic diseases of the bronchopulmonary system.
Causes of adenoiditis
Retronasal angina is a polyethological disease. Inflammation of the adenoids is provoked by viruses or pathogenic bacteria. The group of viruses includes adenoviruses and herpes viruses, including herpes virus type 4 – Epstein-Barr. In bacterial associations, the deficiency of permanent (indigenous) pharyngeal flora and an increase in the number of transient microflora of the genera Moraxella (M.catarrhalis), Bacillus, Micrococcus, Pseudomonas, Enterobacteria (K.pneumoniae, K.oxytoca, E.coli), staphylococci (S.aureus), streptococci (Str.pneumoniae, Str.pyogenes) are crucial. The following factors can also contribute to the development of adenoiditis:
- Frequent acute respiratory infections. Constant high antigenic load due to contact with a large number of viruses in combination with the immaturity of the immune system of children leads to disruption of normal immunological processes in the pharyngeal amygdala, the formation of adenoiditis.
- Concomitant diseases. They include recurrent or chronic diseases of the upper respiratory tract, which are foci of infection – rhinitis, nasopharyngitis, tubotitis, sinusitis, tonsillitis, stomatitis. Separately, GERD is isolated, in which hydrochloric acid supports chronic inflammation of the adenoids.
- Immunopathological conditions. The list includes diabetes mellitus, hypothyroidism, HIV infection, genetically determined immunodeficiency, allergic pathologies. In young children, the absence of breastfeeding, vitamin D deficiency and rickets developing against this background are important.
- Innate features. They include a hereditary tendency to the proliferation of adenoid vegetations and their inflammation, constitutional anomalies by the type of exudative-catarrhal diathesis. An important role is played by malformations that disrupt nasal breathing – curvature of the nasal septum, deformities of the nasal shells, etc.
- External influence. The environmental situation is important: excessively dry or polluted by industrial emissions, enhanced radiation background. Contributing factors include hypothermia, steam burns of the nasopharynx, inhalation of chemical vapors and volatile poisons.
The pathogenesis of adenoiditis is based on damage to the ciliated epithelium located on the surface of the pharyngeal tonsil, provoked by physical, thermal, chemical or biological factors. On this soil, so-called areas of “baldness” are formed, vulnerable to the penetration of pathogenic bacteria and viruses, compensatory hyperplasia of lymphoid tissue develops. With excessive antigenic load, regeneration processes in the amygdala are disrupted, the alteration of its cells increases. As a result, atrophied and reactive follicles appear, which in combination with inhibition of phagocytosis, deficiency of indigenous microflora and immaturity of the child’s immune system leads to the development of inflammation.
Depending on the duration of the course, severity of symptoms and clinical and morphological characteristics of adenoiditis, there are several classifications of inflammation of the nasopharyngeal tonsil. This division of the disease into forms is due to the need to use different therapeutic schemes in different situations. Based on the duration of the course , the following variants of adenoiditis are distinguished:
- Acute. It includes episodes of inflammation of the adenoids lasting up to 2 weeks and repeated no more than 3 times a year. The average duration is from 5 to 10 days. Most often, the pathology develops acutely, against the background of acute respiratory infections or children’s drip infections.
- Subacute. As a rule, it is a consequence of an untreated acute process. It is typical for children with hypertrophied pharyngeal tonsil. The average duration of the disease does not exceed 20-25 days. Residual phenomena in the form of subfebrility can be observed for up to 30 days.
- Chronic. This includes adenoiditis, the clinical symptoms of which persist for more than 1 month or are repeated more than 4 times a year. The role of pathogens is a combination of bacterial and viral infection. There are both primary chronic epipharyngitis and the consequences of inadequate therapy of the subacute form.
Chronic adenoiditis can manifest itself by various morphological changes in the parenchyma of the amygdala. Its main forms include:
- Edematous-catarrhal. Exacerbation of the disease is accompanied by activation of inflammatory reactions in the amygdala, its pronounced swelling. The clinical picture is dominated by catarrhal symptoms.
- Serous-exudative. It is characterized by the accumulation of a large number of pathogenic microorganisms and purulent masses in the recesses of the parenchyma. As a result, the amygdala becomes edematous and hypertrophied.
- Mucopurulent. The inflammatory process is accompanied by the continuous release of a large volume of mucus with an admixture of purulent exudate. In parallel, the adenoid tissue progressively increases in size.
Based on the general condition of the patient and the severity of the existing clinical symptoms , it is customary to distinguish 3 degrees of severity of adenoiditis:
- Compensated. It is often a physiological response to infectious agents. The deterioration of the general condition is poorly expressed or completely absent. Occasionally there is a violation of nasal breathing, night snoring.
- Subcompensated. Clinical manifestations gradually increase, systemic intoxication occurs, corresponding to acute epipharyngitis. In the absence of proper treatment, the disease goes into a state of decompensation.
- Decompensated. In this case, the pharyngeal tonsil loses its functions, turning into a focus of chronic infection. Local immunity is completely absent. Clinically, this is accompanied by pronounced symptoms.
Symptoms of adenoiditis
The disease has no pathognomonic symptoms or complaints. The primary manifestations are tickling sensations, scratching in the deep parts of the nose, noisy breathing during sleep. Another of the early signs is night snoring, as a result of which the child’s sleep becomes restless, superficial. After a while, deterioration of nasal breathing in the daytime, mucous discharge from the nose are added. Most patients have a dry or unproductive cough of a paroxysmal nature, which worsens at night and in the morning.
In the future, intoxication syndrome develops – an increase in body temperature to 37.5-39 ° C, diffuse headache, general weakness, drowsiness, deterioration or loss of appetite. Previously arisen paresthesias gradually transform into dull pressing pains without a clear localization, which increase when swallowing. The volume of mucous discharge from the nose increases, a purulent admixture appears in them. The drainage function of the auditory tubes is disrupted, which leads to the appearance of pain in the ears, conductive hearing loss. Nasal breathing becomes impossible, and the patient is forced to breathe through the mouth, as a result of which the latter is constantly ajar. At the same time, due to the obturation of the hoan, there is a change in the voice by the type of closed nasal.
With a prolonged neglected course due to chronic hypoxia, neurological disorders develop – the child becomes sluggish, apathetic, his ability to concentrate on something, memory, and school performance deteriorates. There is a distortion of the facial skull according to the type of “adenoid face”: the hard palate becomes narrow and high, the production of saliva increases, subsequently flowing from the corner of the mouth. The upper jaw is also deformed – the upper incisors protrude forward, which is why the nasolabial folds are smoothed, the bite is distorted.
Complications of adenoiditis are associated with the spread of pathogenic microflora with purulent masses into the nasal cavity, down the tracheobronchial tree. This causes the development of chronic rhinosinusitis, pharyngitis, laryngitis, tricheobronchitis, pneumonia. At the age of 5 years, there is a risk of the formation of a pharyngeal abscess. Prolonged rhinorrhea provokes eczema of the vestibule of the nose and other dermatological lesions of this area. Concomitant inflammation of the tubal tonsils with blockage of the pharyngeal openings of the auditory tubes leads to eustachiitis, purulent otitis media and severe hearing disorders in the future. Prolonged oxygen starvation of the brain is manifested by a delay in the mental development of the child, persistent neurological disorders.
The diagnosis is made on the basis of anamnestic data, complaints of the child and parents, the results of physical and instrumental research methods. Laboratory tests play the role of auxiliary methods to clarify the etiology of the disease and determine therapeutic tactics. A full-fledged diagnostic program consists of:
- Physical examination. During the general examination, the otolaryngologist pays attention to the patient’s voice and speech, the nature of nasal breathing. At the same time, closed-type nasal twang, difficulty or complete absence of breathing through the nose are revealed. Palpation of the lymph nodes determines moderately enlarged, painless submandibular, occipital, anterior and posterior cervical groups.
- Mesopharyngoscopy. When examining the pharynx, a large amount of light yellow or yellow-green discharge is visualized, flowing down the hyperemic posterior wall of the pharynx. There is also redness of the palatine arches, an increase in lymphoid follicles or lateral pharyngeal rollers.
- Posterior rhinoscopy. It makes it possible to identify an enlarged, hyperemic, edematous nasopharyngeal tonsil covered with fibrinous plaque. Visible lacunae are filled with purulent or mucous exudative masses.
- Laboratory tests. With viral adenoiditis, the UAC displays a shift of the leukocyte formula to the right, an increase in the number of lymphocytes and ESR. The addition of bacterial flora is accompanied by leukocytosis, a shift in the formula towards rod-shaped and young neutrophils. Additionally, a microbiological examination of nasal secretions is carried out.
- Radiation diagnostic methods. Radiography of the nasopharynx in direct and lateral projections is used. It allows you to identify hypertrophy of the lymphoid tissue of the pharyngeal tonsil, which overlaps the holes of the hoan. In the later stages, the radiograph shows the deformation of the hard palate, the upper jaw. CT of the facial skeleton with contrast enhancement is used to differentiate with tumors.
Treatment of adenoiditis
The purpose of treatment is to eliminate the focus of infection, prevent the chronization of the pathological process, its spread into adjacent anatomical structures. For this purpose, topical and systemic pharmacological agents, physiotherapy procedures are prescribed. In severe cases, with concomitant pronounced overgrowth of adenoid vegetations or the development of complications, surgical treatment is indicated. Thus, with adenoiditis,:
- Drug therapy. It is represented by antibacterial or antiviral drugs, hyposensitizing agents, detoxification measures, immunomodulators, vitamin complexes. Vasoconstrictive drops, topical corticosteroids, disinfectants in the form of sprays, inhalation of antiseptics are prescribed as local therapy.
- Adenoidectomy. Surgical treatment consists in excision of hypertrophied lymphoid tissue that blocks the lumen of the nasal passages and prevents normal nasal breathing. The operation can be performed in a classical way using a scalpel or using endoscopic techniques.
- Physical therapy. Widely used: tube quartz, irradiation of the nasal cavity and the back wall of the pharynx with a helium-neon laser, electrophoresis of medications on regional lymph nodes, respiratory gymnastics. The sanatorium-resort treatment is effective, the course of which includes cryoxygen and ozone-ultrasonic therapy, mud procedures.
Prognosis and prevention
With a full-fledged, properly selected treatment, the prognosis for life and health is favorable. The risk of developing dangerous complications in such situations is extremely low – no more than 0.3-1%. No specific preventive measures have been developed for this pathology. Non-specific prevention of acute or exacerbations of chronic adenoiditis includes early diagnosis and treatment of adenoid vegetation growths, infectious diseases and abnormalities of the nasal cavity, strengthening the body’s general defenses, avoiding hypothermia, thermal and chemical burns of the nasopharynx, full and balanced nutrition, active sports, regular check-ups by an otolaryngologist.