Adenoid Growth – Adenoid Hypertrophy
What is an Adenoid?
This is the Nasal Cavity (Epipharynx) found at the back of the nasal structure. The passageway from the nose leads to this nasal cavity. The Nasal Cavity is also referred to as the upper throat. Air passing through the nose, down the throat, larynx and trachea is directed from there.
Located on the sides of the Nasal Cavity are the ‘Eustachian’ channels, which carry air to the middle ear. The ‘Eustachian’ channels enable us to adapt to changes in air pressure; this is a fundamental requirement for the middle ear ventilation, to receive air from the openings of the Eustachian channels via the nose passage.
The Adenoid is located at the top of the Nasal Cavity as a protective tissue. It is considered to be equivalent to our tonsils in the throat. The Adenoid is a very hard working part of the throat formation, especially during childhood.
In the early stages of our lives the Adenoid works actively. Its structure is formed with indented and protruding tissues. Due to this structure, it consists of a large surface area, albeit, located in a very small narrow space it is however powerfully equipped to fight off germs. This defense structure is formed with lymphocytes cell that secrete sIgA.
What is an Adenoid Growth?
In some cases of children the Adenoid may grow excessively during childhood. This growth can also be a result of the child’s genetic structure, from the frequency of illnesses and from the environment they live in… The growth may be evaded by taking certain measures – a leading one is avoiding kindergartens or nursery schools. By refraining from sending the child to these establishments, has in many cases, shown a decrease in illnesses thus reducing the growth of the Adenoid.
However there are times when there is no known reason for the growth of the Adenoid. Moreover, continuation of the child’s education is of course necessary, the family may have no other option than to send their child to a nursery/kindergarten, plus in cases where the Adenoid has become very enlarged, the time and effort needed to research into the reasons for the growth and the application for improving the situation may not always be a practical option.
What can an enlarged Adenoid lead to?
Uncomfortable respiration/breathing: Excessive growth of the Adenoid will primarily block the airflow of the nose passage. Children who have enlarged Adenoids sleep with their mouths open, have difficulty eating, have their mouths open in a resting/sitting position, sometimes they dribble saliva…The discomfort the Adenoid gives to the child is equivalent to the discomfort given to adults who have blocked noses. Alas the child is not in a position to explain their discomfort.
Days, nights, weeks, months pass with the child’s problem escalating to a point that their discomfort is not only being able to breath. These children grow up in many ways affected by their present case but also pave the way for future developments that may adversely affect their daily life.
Sleep Disturbance: Let us firstly look at how the child is affected. Sleep pattern is very uncomfortable. The sleep period for the child is restless. Sometimes they may sweat profusely. The child may wake up frequently. As a result these children can show the following temperaments during the day; excessive restlessness, can also become hyperactive or may be prone to day sleep. If the child is of school age this may adversely affect their productivity and lessons.
Some children may also develop a condition called ‘Sleep Apnea’ – this is when the breathing pattern is broken by short interruptions of breathlessness. In adults the interruptions of breathlessness can be detected quite easily due to noisy and rare sleep patterns but with little children this can go undetected due to their sleep patterns being more frequently broken and a less noisy breathing pattern.
Sleep Apnea’s sneaky and sly character will initially initiate restless sleep, night sweats, daytime restlessness that can be coped with but may cause more serious adverse disorders such as heart failure, stroke or even lead to sudden death.
The main reason for the development of Sleep Apnea is the obstruction of the upper respiratory airway. The most common results that arise from the obstruction of the upper respiratory airway in children are an enlarged adenoid and tonsillitis.
Loss of Appetite: Loss of appetite is a common feature in these patients. Every parent wishes for their child to have a heartily, healthy eating routine. Though sometimes parents can exaggerate their child’s loss of appetite. However, it is quite natural that a child that who has an enlarged Adenoid will experience loss of appetite. It is also interesting to note that a certain children who suffer from an enlarged Adenoid can also be overweight.
Growth retardation: These children have been found to suffer from an unhealthy growth and underdevelopment in their achievement progress. Deterioration of the quality of sleep, frequent awakenings, resulting in the release of growth hormone decreases during sleep and the resultant decrease in the rate of growth and development of children may be observed.
Deterioration of the jawbone and teeth: Children who suffer from enlarged Adenoids usually have their nasal breathing passage blocked and thus suffer from forced mouth breathing. If these dysfunctional breathings continue for a long period of time, eventually the child will suffer from structural upper jaw and lower jaw deformations. Some of the most common deformations are of the dome of the upper jaw, commonly is the shrinkage of the upper jaw, being unable to develop forward features, which can be seen as flatness in the features.
These children’s facial features display as symptom known as ‘Adenoid faces’ (Facies Adenoids). Top and lower jaw disorders affect the chewing capability of the contact capability of the teeth, thus leading to tooth decay commonly seen in these children.
Sinusitis: Along with enlarged and problematic Adenoids it is common to find patients also suffering from troubled stubborn nasal problems, some of which can lead to chronic sinusitis. These children may suffer from the following symptoms such as a yellowish green nasal discharge which may also have a foul smell, sometimes a mild to high fever, headaches, periods of malaise fatigue needing thus needing frequent treatments with antibiotics. The treatments with drugs usually get make the child better for short periods of time but they are susceptible to getting ill again with the slightest sign of a cold or with fatigue. These situations can lead to chronic sinusitis and the underlying factor is the role of the enlarged Adenoid.
Middle Ear Diseases: Located right next to the Adenoid is the Eustachian Tube thus it is inevitable for it not to be affected from the disorders of a problematic Adenoid. The pressure from the Adenoid growth will in turn block the microbes located in Eustachian Tube and in turn this will cause chemicals to be released in order to fight the blockage leading to a problems of the Eustachian Tube. The Eustachian Tube is the only channel by which air to the middle ear cavity can be circulated.
Two major issues seen as a result of the affected Eustachian Tube are:
- Accumulation of fluid in the Middle Ear giving rise to Tympanic membrane breakdown
- Middle ear infection
Middle Ear Fluid is a more insidious condition. The effect creates a curtain, which results in a slight loss of hearing. Due to the loss of hearing usually being slight may result in the problem being overlooked or undetected in normal day-to-day living circumstances. Parents how careful they may be, may not be able realize the situation.
Fluid in the Middle Ear, which only lasts a short period, are mainly considered insignificant. However, if the fluid has remained in both ears and has lasted more than three months without treatment this may lead to an underdevelopment of the child’s hearing center, thus affecting speech in older age, resulting in negative school achievement.
Middle Ear Infections can sometimes be painful and result in feverish watches. Therefore, it is difficult to be overlooked. During childhood it is not unusual to see otitis media (ear infection). However, frequent recurrent otitis media is often indication of other problems and often the problem is adenoid related.
- Protective Solutions
- Radical Solutions
Protective solution – some of the options used to prevent the child’s illness (withholding the child from nursery school), usage of medication (cortisone nasal spray) or leaving the situation to time, are to name a few.
By withholding the child from going to school may improve the situationa and gain some time. Though this varies from child to child and some may improve whilst with others there may be no improvement at all. It is not possible to state how long a period the child should be kept away from school. This can be from a couple of weeks or even months.
I have very often witnessed in Turkey the wide usage of nasal sprays with cortisone. Most often if a child is being treated for allergies most probably one of the prescribed medication will be nasal spray with cortisone. Even though ther is no proven evidence that these drugs reduce the size of the adenoid, some clinical studies have reported beneficial results.
There is no clear set period for the usage of these drugs, though some write-ups report a result with a minimum usage period of about 4-8 weeks.
Leaving things to time is also an option that can be taken. As the child grows the adenoid will not grow at the same rate; therefore, the air passageway in the nasal cavity will have more space for airflow and the size of the problem will decrease. Though this process may take many years. If a child is correctly monitored and problems arising from an adenoid growth such as excessive blockage or obstruction in the nasal passage are seen to be at a minimum, then this may be a viable option.
The radical solution is for the Adenoid to be surgically removed. This surgery is performed under general anesthesia. The main conditions that require surgical removal of the adenoid is if the child gets sick very often due to adenoid and / or is experiencing symptoms of heavy nasal congestion.
The Route leading to Surgery
Prior to a child being advised for surgery, a period of procedures is lived. Frequent doctor visits, frequent use of antibiotics, at times a high temperature, sometimes a nose runny, coughing, sleeping uncomfortably with an open mouth, at times snoring and at other times these paths may lead to the dentist. After a certain phase the family and physicians come to agree that surgery is a better solution, thus surgery can be discussed at length.
Pre-operative Evaluation, Preparation
Once the ENT physicians confirm the diagnosis, talks with the family will ensue whereby the specialists aim to give detailed information about the processes involved and the surgical procedure. Not only will the physicians discuss this with the parents but also if appropriate, the child will be informed about the process. The whole pre-operative process, surgery and post-operative process will be summarized and clarified.
In many centers, hospital admission is the first process that will need to be taken care of; this usually starts with signing of contacts and documents. After this the patient is taken to their room and hospital clothing for surgical preparation is given for the patient to wear. Next the hospital anesthesia physician will visit and check that the patient is fit for surgery, once approved they will ask the nurses to administer a tranquillizer that can be taken orally with some fruit juice.
Once the child is seen to be ready and is compatible, a sample of blood will be taken from a vein and a catheter (intravenous plastic tube) will be mounted (which will remain until after surgery). If this procedure cannot be administered to the child, if deemed necessary by the physician, they may take the sample blood and mount the catheter in the operating room once the child has been put into a deeper sleep state.
By adhering to necessary legal procedures, the blood will be tested. They will evaluate the results of the blood test, especially checking to see if the child suffers from thrombosis and also the general well being indications of the result in order to decided whether to proceed or not with the surgery.
From an early stage the physicians will advise the family as to which part of the body the surgery will be performed on, the duration, the risks, length of hospital stay and post-op situations will be among the topics that will be discussed.
Receiving Adenoid Surgery
Once all the pre-op preparations have been completed and the physician is confident that the child is fully asleep the surgery will be performed without the receipt of any incision. I will summarize my own approach.
Initially the inside of the nose and the nasal cavity will be examined with an endoscope. The physician can diagnose the size of the adenoid and start the removal of the problem.
A metal utensil is placed to keep the mouth open (mouth gag). A small scraping instrument is used to scrape and remove the Adenoid, which is located at the back of the tongue. The process usually is a very short time; in general completed within around 1-2 minutes. At this stage there will be a small amount of bleeding. Therefore swabs are placed in the immediate area; the mouth gag is removed and a waiting period of about 5-6 minutes is given to see for any adverse reactions.
After the appropriate waiting time the mouth is opened. The swabs are removed. If bleeding continues, the source of bleeding can be cauterized or a new swab can be placed for a few more minutes.
When it is confirmed that the bleeding has stopped once again the nasal cavity is examined with the endoscope via the nose canal. This will show if there is any residue that may need to be removed. The removal will be carried out using the supervision of the endoscope via the nose. Once it is certain that the adenoid and any residue is totally remove the operation will come to an end.
Adenoid surgery can take between 15 to 45 minutes.
Risks of Surgery
Like any surgery, surgery for the removal of the Adenoid also has risks. Though in comparison to some surgeries the risk possibilities are comparatively very low; the risks can be handled in two main categories:
- Risks related to anesthesia
- Risks related to surgery
Of the risks related to anesthesia we can come across are drug allergies, sore throat, damage to vocal cords. More detailed information on this topic can be obtained from the appropriate specialized anesthesiologist.
Of the risks related to surgery, bleeding comes at the highest of risks. The risk of bleeding is reported as 0.8%. In addition, cervical spine injury has been reported but very rarely. Dental injury and contraction of the palate are reported complications.
Immediately after surgery
Once surgery is completed the anesthesiologist attends to the process of waking up the patient safely. The patient is given time to regain consciousness and then taken to their room.
The child is kept under observation for a few hours and later given something to eat. After this the child is aided to stand up and go to the toilet. During this observation process, if the child is understood to be doing well the child will be discharged.
The Evening of Surgery
On the evening of surgery, children are generally back to their cheerful and pleasant self as before. There may be a little unrest. Painkillers may be required. When the child falls asleep it will be quite obvious, when observed that they can sleep with their mouths shut and quietly without unrest. As for the parents who would have spent the whole day with concerns will finish the day exhausted and relieved.