Adenoid Enlargement in children.pptx
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The document provides information about adenoid enlargement in children. It discusses the anatomy and embryology of the adenoids. The adenoids are part of Waldeyer's ring and provide immune protection by producing IgA. Common diseases include acute and chronic adenoiditis. Enlargement can cause airway obstruction and symptoms like snoring. Diagnosis involves history, examination, and imaging like X-rays. Management includes watchful waiting, intranasal steroids, or adenoid removal for recurrent infections or sleep disturbances. Intranasal steroids may provide temporary symptom relief but removal is usually needed for long-term management of adenoid enlargement.
Adenoid Enlargement in children.pptx
- 1. [email protected] [email protected] Dr.Azad A Haleem AL.Mezori MRCPCH,DCH, FIBMS Assistant Professor University Of Duhok College of Medicine Pediatrics Department Adenoid Enlargement in children Scan For Contact
- 2. Key points • Anatomy • Embryology • Function and Immunology • Common Diseases of the Tonsils and Adenoids • Pathophysiology • Diagnosis • Management.
- 3. Anatomy • The lymphoid tissue of the nasopharynx and oropharynx is composed of the adenoids, the tubal tonsils, the lateral bands, the palatine tonsils, and the lingual tonsils. • These structures form a ring of tissue named Waldeyer’s ring after the German anatomist who described them.
- 5. Embryology • The formation of the adenoids begins in the 3rd month of fetal development. • In the 5th month: the pharyngeal crypts will develop. The surface is covered with pseudostratified ciliated epithelium. • By the 7th month of development the adenoids are fully formed.
- 6. Function and Immunology • The tonsils and adenoids are part of the secondary immune system. • Lymphoid tissue of Waldeyer ring is most immunologically active between 4 and 10 yr of age, with a decrease after puberty. • These are involved in the production of mostly secretory IgA, which is transported to the surface providing local immune protection.
- 7. Common Diseases of the Tonsils and Adenoids 1. Acute adenoiditis/tonsillitis 2. Recurrent/chronic adenoiditis/tonsillitis 2. Obstructive hyperplasia 3. Malignancy
- 8. Pathology • Acute Infection • Most episodes of acute pharyngotonsillitis are caused by viruses. • Group A β-hemolytic streptococcus (GABHS) is the most common cause of bacterial infection in the pharynx . • Chronic Infection • The tonsils and adenoids can be chronically infected by multiple microbes, which can include a high incidence of β-lactamase– producing organisms. • Both aerobic species, such as streptococci and Haemophilus influenzae, and anaerobic species, such as Peptostreptococcus predominate.
- 9. • Airway Obstruction: • Both the tonsils and adenoids are a major cause of upper airway obstruction in children. • Airway obstruction in children is typically manifested in sleep-disordered breathing, including obstructive sleep apnea, obstructive sleep hypopnea, and upper airway resistance syndrome which may cause growth failure. • Tonsillar Neoplasm • Rapid enlargement of one tonsil is highly suggestive of a tonsillar malignancy, typically lymphoma in children.
- 10. The adenoids or pharyngeal tonsil enlargement • The adenoid is a single mass of pyramidal tissue with its base on the posterior nasopharyngeal wall and it’s apex pointed toward the nasal septum. • The surface is invaginated in a series of folds. • The epithelium is pseudostratified ciliated epithelium and is infiltrated by the lymphoid follicle
- 11. The adenoids or pharyngeal tonsil enlargement - Peak between 2 – 8 years - Allergy - Recurrent RTI - Genetics - Obstructive adenoid hyperplasia includes symptoms of chronic nasal obstruction, rhinorrhea, snoring, mouth breathing, and a hyponasal voice.
- 12. The adenoids enlargement may cause: • Acute adenoiditis • Recurrent acute adenoiditis • Chronic adenoiditis • Obstructive sleep apnea
- 13. • Acute adenoiditis symptoms include • purulent rhinorrhea, • nasal obstruction, • fever, and • sometimes otitis media due to their proximity to the Eustachian tubes • the patient may also present with: • swallowing difficulties • speech anomalies (hyponasal speech) • sleep-disordered breathing • This can be difficult to differentiate from an acute upper respiratory infection but tends to have a longer and more severe course.
- 14. • Recurrent acute adenoiditis is 4 or more episodes of acute adenoiditis in a 6- month period with intervening periods of wellness. • Chronic adenoiditis symptoms include • persistent rhinorrhea, • postnasal drip, • malodorous breath, and • associated otitis media or extra esophageal reflux lasting at least 3 months.
- 15. • Obstructive sleep apnea in children is clinically marked by: • loud snoring, apneic episodes while sleeping, daytime somnolence, behavioral problems, and enuresis.
- 16. Diagnosis • Clinical as History & clinical examination: • Radiological examination (PNS) • Endoscopy • Rhinoscopy • CT scan
- 17. Always think about detalis history o Clinical classification: o Nasal obstruction, snoring, and nasal discharge o By asking the parents and caregivers : o Grade 0: never seen, o Grade 1: seen during URTI, o Grade 2: frequently seen, o Grade 3: always occurs.
- 18. Adenoid facies or “long face syndrome”. • It is the long, open-mouthed, face of children with adenoid hypertrophy. • The mouth is always open because upper airway congestion has made patients obligatory mouth breathers.
- 19. • The characteristic facial appearance consists of: • Underdeveloped thin nostrils • Short upper lip • Prominent upper teeth • Crowded teeth • High-arched palate • Hypoplastic maxilla • Eustachian blockage causing glue ear- deafness • The deafness and inattentiveness interferes with the learning • Child grows with lowered intelligence and understanding
- 20. Nasopharyngeal X Ray Adenoid tissue enlargement was graded according to the Adenoidal-nasopharyngeal ratios (ANR). The ANR was obtained by dividing the measurement for adenoid tissue density by the value for nasopharyngeal space in millimeters as described by Fujioka. It was rated as: Grade 1: > 6 mm, Grade 2: 4-6 mm, and Grade 3: < 3 mm.
- 21. Lateral neck radiograph • The main imaging study to evaluate the adenoid is a lateral neck radiograph, as in the images below.
- 23. Complications • If adenoid hypertrophy left untreated may cause many serious problems such as: • Cognitive and behavioral disorders, • Systemic and pulmonary hypertension • Enuresis • Developmental delay.
- 24. MANAGEMENT • Management options include 1. Wait until they involute 2. Non surgical management include- intranasal corticosteroids 3. surgical removal (ADENOIDECTOMY)
- 25. Medical Management • Chronic adenoiditis: No good evidence supports any curative medical therapy for chronic infection of the adenoids. • Systemic antibiotics have been used long-term (ie, 6 weeks) for lymphoid tissue infection, but eradication of the bacteria failed. • In fact, with the current trend of resistant bacteria, the use of prophylactic or long-term antibiotics has been decreased to prevent the formation of resistant bacteria.
- 26. • The adenoids enlargement: • Some studies indicate a benefit with using topical nasal steroids in children with adenoid hypertrophy. • Studies indicate that while using the medication, the adenoid may shrink slightly , which may help relieve some nasal obstruction. • However, once the topical nasal steroid is discontinued, the adenoid can again hypertrophy and continue to cause symptoms. • In a child with nasal obstructive symptoms with or without presumed allergic rhinitis, a trial of topical nasal steroid spray and saline spray may be considered for effective control of symptoms. Medical Management
- 27. Topical nasal steroids in children • Mometasone furoate intranasal spray 50 mcg – 100 mcg /day for 6 to 8 weeks for children more than 2 years. • Fluticasone propionate nasal spray of 400 microg/day for 8 weeks for children more than 4 years. • Beclomethasone intranasal spray 50 mcg /day for 8 weeks for children more than 3 years.
- 28. Evidences • Using nasal steroids to treat nasal obstruction caused by adenoid hypertrophy: Does it work? • Data Sources: Published studies indexed in the MEDLINE (1951 to 2008), EMBASE (1974 to 2008), and the Cochrane databases (Issue 3, 2008). • Conclusion: The available evidence suggests that nasal steroids may significantly improve nasal obstruction symptoms in children with adenoid hypertrophy. This improvement appears to be associated with a reduction of adenoid size. Evidence of long-term efficacy is limited but suggests that in many children maintenance therapy is needed if symptom-relief is to persist. Further studies are required to support the use of nasal steroids as a first-line approach in these children.
- 29. Evidences Using nasal steroids to treat nasal obstruction caused by adenoid hypertrophy: Does it work? Data Sources: more than 100 studies improve no side effect and improvement reaching 77.7% ? Alexopoulos EI, Kaditis AG, Kalampouka E, Kostadima E, Angelopoulos NV, Mikraki V. Nasal corticosteroids for children with snoring. Pediatr Pulmonol 2004;38:161-7. -Fujioka M, Young LW, Girdany BR. Radiographic evaluation of adenoidal size in children: adenoidal- nasopharyngeal ratio. Am J Roentgenol 1979;133:401- 4. -Demain JG, Goetz DW. Pediatric adenoidal hypertrophy and nasal airway obstruction: reduction with aqueous nasal beclomethasone. Pediatrics 1995;95:355-64. - Lepcha A, Kurien M, Job A, Jeyaseelan L, Kurien T. Chronic adenoid hypertrophy in children - is steroid nasal spray beneficial? Indian J Otolaryngol Head Neck Surg 2002;54:280- 4. Kheirandish L, Goldbart AD, Gozal D. Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing following tonsillectomy and adenoidectomy in children. Pediatrics 2006;117:e61-6. -Jung YG, Kim HY, Min JY, Hun JD, Seung KC. Role of intranasal topical steroid in pediatric sleep disordered breathing and influence of allergy, sinusitis, and obesity on treatment outcome. Clin and Exp Otorhinolaryngol 2011;4:27-32. the treament of children with otitis media with effusion and/or adenoid hypertrophy. Int J Pediatr Otorhinolaryngol 2006;70:639-45.
- 30. Adenoidectomy-Indications • Four or more episodes of recurrent purulent rhinorrhea in prior 12 months in a child <12 (documented by intranasal examination or diagnostic imaging) • Persisting symptoms of chronic adenoiditis after 2 courses of antibiotic therapy. • Sleep disturbance with nasal airway obstruction persisting for at least 3 months. • Otitis media with effusion >3 months or second set of tubes (persistent Otitis media with effusion over age 4 ).
- 31. • Dental malocclusion or orofacial growth disturbance documented by orthodontist. • Nasal speech • Cardiopulmonary complications including cor pulmonale, pulmonary hypertension, right ventricular hypertrophy associated with upper airway obstruction. Adenoidectomy-Indications