What are adenoids? Adenoid Hypertrophy, Clinical features and Adenoidectomy

Grade 4 adenoid hypertrophy

This article is mainly intedend for use by medical professionals.

Adenoids are a subepithelial collection of lymphoid tissue, which is present at the junction of the roof and posterior wall of the nasopharynx. They increase in size up to the age of 6 years and after that gradually atrophies.
  • Adenoids are part of Waldeyer’s ring of lymphoid tissue at entry of upper respiratory tract. These are sites of first immunological contact for inhaled antigen in childhood.
  • The word adenoid was coined by Wilhelm Meyer. They are also known as Lushka’s tonsil (by Santorini), Nasopharyngeal vegetations/ and nasopharyngeal tonsils.


  • Adenoids consists of vertical ridges of lymphoid tissues separated by deep clefts and covered by ciliated epithelium.
  • Unlike palatine tonsils, adenoids have no crypts or capsules.


  • By around 4-6 weeks of gestational age, lymphoid tissues can be identified with in mucus membrane of roof and posterior wall of nasopharynx.
  • These lymphoid tissues may extend to fossa of Rossenmuller and to eustachian tube orifice (Tubal tonsils / Gerlach’s tonsil)
  • Adenoids can be identified by MRI from 4th month in 18% children and by 5th month in all children.
  • Growth continues rapidly during infancy and plateaus between 2-14 years.
  • Largest in 7th year, but clinical symptoms are more common in young age group due to
    • Relatively small volume of nasopharynx
    • Increased frequency of Upper respiratory tract infections
  • Regression occurs rapidly after 15 years and completely disappears by 20 years.

Blood supply and Venous drainage

  • Blood supply via
    • Ascending palatine branch of facial artery
    • Ascending pharyngeal branch of External Carotid Artery (ECA)
    • Pharyngeal branch of third part of maxillary artery
    • Ascending cervical branch of inferior thyroid artery of thyrocervical trunk
  • Venous drainage to IJV and Facial vein.
  • Lymphatic drainage to retropharyngeal LN, upper deep cervical LN (post triangle)
  • Nerve supply – Sensory branches of vagus and glossopharyngeal.

Functions of adenoid

  • Produce B cells, producing IgG, IgA Ab.
  • Forms immunologic memory in younger children.

Pathological effects

  • Can act as a focus of sepsis / infection.
  • Recurrent Otitis Media with Effusion (OME)
    • Due to anatomical obstruction of eustachian tube along with recurrent Acute or chronic inflammation of adenoid and increased bacterial load (particularly H. influenza).
    • Biofilm formation
      • Biofilms are structured bacterial cells enclosed in a self-produced polymeric matric, adherent to an inert of living surface)
      • Causes squamous cell metaplasia – reticular epithelium extension – fibrosis of interfollicular connective tissues – reduced mucociliary clearance – biofilm formation.
    • Chronic GERD is also implicated in inflammation of nasopharynx and adenoids leading to recurrent OME.
  • Recurrent Acute Otitis Media (AOM)
    • Evidence says that adenoidectomy is not effective in reducing episode of AOM in children <2 years.
    • Low dose prophylactic antibiotics, until maturation of immune system is preferred to adenoidectomy in these children to prevent recurrence.
  • Upper airway obstruction
    • Nasal obstruction is the most common symptom.
    • Mouth breathing interferes with feeding or suckling in child leads to failure to thrive.
  • Obstructive Sleep Apnea (OSA)
    • Incidence of OSA in children is approximately 1% with equal sex ratio.
    • Peak incidence at 3-6 years.
    • Airway obstruction by adenoid causes – decreased PaO2, Increased PaCO2, and decreased IGF-1. All returns to normal after adenoidectomy.
    • Radiographic findings of adenoids correlate well with PSG findings.
  • Rhinitis
    • Due to choanal obstruction, normal nasal secretions cannot drain into nasopharynx.
  • Chronic rhinosinusitis
    • Improvement noted in majority of children following adenoidectomy.
    • Due to biofilm formation
  • Olfaction
    • Olfactory sensitivity is reduced in relation to adenoid size and improves after adenoidectomy.
    • May be leads to poor appetite in children with adenoid hypertrophy.
  • Nocturnal enuresis
    • Significant relief after adenoidectomy.
    • Adenotonsillectomy can improve bedwetting in kids – Read article.
      • Upper airway obstruction causes deep inspiration, leads to increased venous return to mediastinum. This will cause dilatation of atrial muscles, which in turn cause release of ANP/BNP. As a result, diuresis happens.
  • Pulmonary hypertension
    • In long standing nasal obstruction.
  • Neoplasia
    • Unsuspected neoplasia of adenoid and tonsil in childhood is rare.
    • Atypical lymphadenopathy, persistent and asymmetric enlargement of adeno-tonsills in absence of infection are suspicious of malignant transformation – needs early imaging and biopsy.
    • Diagnosis is mainly overlooked for infections.

Assessment and Management

  • Clinical history
    • Full pediatric ENT history
    • Special attention to symptoms of middle ear disease, nasal obstruction.
    • Specific questions regarding sleep disturbances, eating and atopic symptoms.
    • Aprosexia – loss of concentration.
    • Full history of previous treatment and medications.
    • Family history of unusual bleeding / bleeding tendency, if planning for surgery.
  • Examination
    • Adenoid facies
      • Due to chronic nasal obstruction and mouth breathing.
      • Elongated face with dull expression, dark circles under eyes.
      • Open mouth, Retrognathic mandible, hitched up upper lip, prominent and crowded upper teeth, pinched up nose (due to disuse atrophy of alae nasi).
      • High arched / Gothic palate due to loss of molding action of tongue on palates.
      • External nose – skin crease in supratip region indication frequent rubbing due to rhinitis.
      • Anterior rhinoscopy – Cold spatula test, using Lack’s tongue depressor to assess airway patency.
      • Diagnostic Nasal Endoscopy with topical intranasal anesthetic spray is the gold standard.
        • Well tolerated in children
        • For treatment decision prior to adenoidectomy
        • Endoscopic grading system co-relates well with symptoms of nasal obstruction, snoring, tympanometry. But no co-relation with purulent rhinorrhea.
  • Imaging
    • Xray Neck Lateral View Showing Adenoid Hypertrophy
      Xray Neck Lateral View Showing Adenoid Hypertrophy

      Soft tissue Xray neck Lateral View is also a good alternative to nasal endoscopy, indicated if child is not co-operative for nasal endoscopy.
      (Click here to read doctor’s own study on this subject.)

    • Clemens et al radiographic grading
      • Grade I – Adenoid tissue filling 1/3rd of vertical portion of choanae.
      • Grade II – Adenoid tissue filling 1/3rd to 2/3rd of vertical portion of choanae.
      • Grade III – Adenoid tissue filling 2/3rds to nearly complete obstruction of choanae.
      • Grade IV – Complete choanal obstruction
    • Acoustic rhinomanometry and MRI are not applicable in clinical practice.


  • Surgical procedure for removing of enlarged adenoids (Adenoid Hypertrophy).
  • Unless specifically indicated, combining tonsillectomy with adenoidectomy is not recommended. This is because compared to adenoidectomy, tonsillectomy is associated with a significantly increased mortality of 1:10,000 to 1:35,000, increased complication rates, treatment costs and with a post op bleeding rate of 0.6% to 4%, occurring in the immediate perioperative period and up to two weeks postoperatively.
  • Indications
    • Symptomatic patients.
    • Generally, if >45% obstruction of airway is there (Grade 2 adenoids), it is considered as an indication.
  • Impact of adeno-tonsillectomy
    • Adenoid hyperplasia in childhood is common and self-limiting usually.
    • Removal at young age (< 3 years) may be immunologically undesirable, unless highly indicated.
    • Between 4-10 year, adeno-tonsillectomy doesn’t cause immune deficiency.
  • Procedure
    • Under General Anesthesia with child in tonsillectomy position (Rose’s position).
    • Traditionally
      • Assessment of adenoids done by digital palpation and soft palate for any submucosal cleft.
      • Removal is by blind curettage with St. Clair Thomson’s curette with guard – chance of left over tissue, leading to recurrence.
      • Hemostasis achieved by gauze swab tamponade.
      • More blood loss (>50ml)
    • Other options
      • Under Endoscopic Visualization
        • Less blood loss (<4ml)
        • Near total removal – very minimal chance of recurrence.
        • Avoiding trauma to eustachian tube
      • Microdebrider – 20% faster
      • Suction coagulator – significantly cheaper than debrider
      • Coblation assisted – costly, but less painful.
      • KTP laser – High incidence of post op nasopharyngeal stenosis – not recommended.
  • Complications
    • Dental trauma
      • Usually rare.
      • May be accidental due to slippage of gag or support.
      • When loose dentition present, needs to be removed prior to surgery.
      • Parents should be warned about damage to teeth.
    • Bleeding
      • Primary / Reactionary hemorrhage (within 6-24 hours) is less than 0.7%
      • If severe, Posterior nasal packing for 4 hours has shown same efficacy as 24hours. Immediate return to theatre also needed.
      • Less chance following endoscopic resection.
      • Usually due to bleeding from aberrant ascending pharyngeal artery
      • Secondary hemorrhage (after 24 hours) is rare.
      • Clotting disorders – Needs hematological advice.
    • Retained swab.
      • Count should be made before removal of gag and reversal of anesthesia.
      • Swab may be retained in nasopharynx or laryngopharynx.
    • Nasopharyngeal blood clot
      • Gentle suction before removal of gag.
      • If not done, clot will fall to larynx during extubating causing fatal acute airway obstruction – Coroner’s Clot.
    • Infections
      • Uncommon.
      • Fetor (bad breath) may be common for a week.
      • Rarely retropharyngeal and mediastinal abscess ay occur due to trauma and secondary infection of adenoid bed.
    • Cervical spine injury
      • Griesel syndrome – non-traumatic atlanto axial subluxation is rare.
      • Mostly due to spasm of paraspinal muscles – associated with overuse of diathermy – minimum power settings are recommended.
      • More prone in patients with Down syndrome – due to laxity of ligaments. Prior plain imaging of cervical spine needed.
      • Patient present with torticollis, neck pain.
      • Velopharyngeal dysfunction
      • Severe dysfunction seen in 1:1500-10,000 cases.
    • Velopharyngeal Insufficiency
      • Hypo nasal speech, swallowing, nasal regurgitation of food.
      • Prior to surgery, palate and uvula needs to assess for submucosal cleft, palatal dysfunction.
      • In children with bifid uvula or with submucosal cleft, partial removal under endoscopic guidance with clearing of choanal airway but leaving adenoid intact at velopharyngeal junction is done by some – controversial.
      • Long term velopharyngeal insufficiency is rare, reconstructive surgery to correct hyper nasal speech and swallowing.
    • Other complications
      • Injury to eustachian tube
      • Injury to pharyngeal musculature and vertebrae
    • Regrowth
      • If needed, repeat surgery can be done.
      • More in traditional blind curettage
  • Post op care
    • Mostly day care procedure
    • Based on social & geographic factors, surgical & anesthetic techniques, fluid replacement, Antibiotics & analgesia – child can be discharged within 6 hours.


Dr. Sanu. P. Moideen, MBBS, MS (ENT), DNB (ENT), FHNOS, is an otolaryngologist (ENT surgeon), head and neck oncosurgeon practising in Muvattupuzha, Kerala, India. After finishing his postgraduate training, he pursued specialist training in paediatric ENT and head and neck oncosurgery from eminent institutions in India and the US.

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