Anatomy of adenoids

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Adenoids in children

Diagnosis and treatment of adenoids in children. Adenoids in children: symptoms and treatment.

Where are the adenoids located: anatomical and clinical excursion

04/20/2017 admin 0 Comments

Where are the adenoids located: anatomical and clinical excursion

So, where are the adenoids in children, which cause so many problems for children’s health if they become inflamed and hypertrophied by adenoid vegetation?

Table of contents:

An anatomical and clinical excursion will tell you in detail about their location and significance. We will once again draw the attention of parents to the pathogenetic phenomenon - inflammation of the adenoids (glands) in the children's nasopharynx. Let us recall the dislocation “strategic” bridgehead of placement in the child’s body – the nasopharyngeal tonsils, and their clinical significance for the life of the child’s growing body.

I. Anatomical supremacy of the tonsil glands

If someone thinks that in our body there are especially necessary and important organs, and there are also those that we can do without, this is an absolutely wrong opinion. Everything is important, everything is thought out, all organs and systems are vital. Even the supposedly “extra” process of atavism – the appendix. Not to mention how important and significant the glands are in the body. There are very few of them, these unique and inimitable, unlike anything else biological structures. The porous, lobulated delicate lymphobiological tissue (sponge-type) of the glandular organ is represented by:

  1. Pancreas;
  2. Thyroid gland;
  3. Nasopharyngeal tonsils, also called adenoids.

The gene-cellular basis of the glands is called the visceral epidermis in medicine. The entire organ, with all its morpho-anthropological components, is parenchyma. Diseases, pathogenic processes that affect either the outer layer of the epidermis, or the inner one, or the parenchyma of the organ as a whole, are called pathogenesis, pathoinvasion, pathointoxication, adenoid vegetation.

What super-tasks and functions nature has endowed, for example, the almond glands of the nasopharynx in the life-supporting cycle of the human body, will be discussed in the next section. We certainly emphasize the extraneous, mutually significant connection of these glands with all organic systems and organs. But, in this section, we will return to the factor of the successful anatomical location of the tonsils in the nose/pharynx/larynx.

The presented diagram shows the listing and location of the tonsils, which are included in a single nasopharyngeal sector.

Look and pay attention - all types of lymphoid glandular parenchyma of the tonsils are concentrated in a close radius from the brain. From the organ on whose healthy functionality human life depends. If the brain dies (fatal), all organs of the body stop functioning, even if they are not affected.

Tonsils infected with adenoid intoxication primarily pose a threat to the brain. This close proximity of the tonsils is determined for a reason. If the tonsils are overly invaded, then the brain also first of all sends signals to strengthen the protective functions in this organ.

The gray brain matter does not need such a sick neighborhood at all; it poses a danger to it. Therefore, nature wisely placed the tonsils in the main information and vital center of the human body - in the head. The glands took not only the highest position in the anatomical structure, but also acquired, thanks to the brain, supreme importance.

To make it easier and more accessible to understand (consolidate the information received) where the adenoids are located in children, according to the anatomical diagram, the clinical aspect (whether they can arise in another organ, area of ​​the body), we will present a description in the form of questions and answers. It should be noted that the questions and answers are real, from materials from practicing experienced otolaryngologists, which are most often asked by parents at appointments:

Answer: No, they cannot, this is excluded due to anatomical parameters. Adenoid growths, in other words, adenoids in the nose, in the larynx, on the back wall of the oral cavity, arise due to hypertrophic degeneration of glandular tissue - tonsils (elongated epidermal organs). Even the pancreas and thyroid glands, although they consist of similar lymphoid tissue, cannot be affected by adenoid vegetation.

Answer: Previously, until the mid-twentieth century, the method of obstetrics used was the application of forceps. That is, pulling out the baby’s emerging head with forceps, if the baby was large and the woman in labor could not give birth to him by pushing on her own. But, mechanical damage to the child’s skull has nothing to do with the formation of adenoid hyperemic growths and the tendency to adenoid invasion. Rather, intrauterine placental invasion by the adenoid pathomicroflora of the baby (from a pregnant woman whose adenoid vegetation is progressing) may occur. In modern obstetrics, “forceps application” has been abolished, and caesarean section is practiced.

These, of course, are not all the questions of an anatomical nature that are raised at appointments with pediatric ENT doctors about where the adenoids are located in children, what anatomical indicators play a role in their location and clinical significance.

II. Clinical impact and significance of the location of the tonsils (adenoids)

The functionality of the nasopharyngeal tonsils is part of the body's unified immune system. Tonsils or adenoids perform important and significant tasks - sorption, retention of pathogenic flora that penetrates into the body. They produce lymphoid phagocyte cells that destroy pathogenic strains of viral, bacterial, and malicious microinfections.

A decrease in their reproductive capacity as a protective organ, a barrier, opens up free access for diseases to the human body.

The tonsils signal their painful condition due to oversaturation with the pathogenic mass by adenoid growths. In these new foci, viruses, pathogenic microorganisms and microbes mature and are produced, which then penetrate into the deep locations of the body - the liver, lungs, brain, kidneys.

Adenoid toxins affect the visual and auditory apparatus, interfere with the bone marrow, destroying the skeletal framework. Children who often and severely suffer from adenoid disease lag behind their peers in psychophysical development and visually differ in facial deformations from the healthy children's “community”.

Due to the fact that adenoid growths are located in the upper part of the body, in the craniofacial location, adenoid intoxication (from top to bottom) most quickly reaches the most remote areas of the anatomical structure.

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ADENOIDS

Accent placement: ADENO`IDS

ADENOIDS (Greek adēn - gland and eidos - type; synonym: adenoid vegetations, adenoid growths) - pathological hypertrophy of the “third”, or pharyngeal (nasopharyngeal) tonsil (tonsilla pharyngea), located in the vault of the nasopharynx. This tonsil, together with the lingual and palatine tonsils, is part of the lymphadenoid pharyngeal “ring”. The thickness of the pharyngeal tonsil is on average 5-7 mm , width 20 mm and length 25 mm . The gaps between the ridges have the form of straight or arcuate grooves along the periphery, parallel to each other or converging posteriorly. The deepest groove, located in the midline, ends posteriorly with a depression called the pharyngeal bursa (bursa pharyngea). The pharyngeal tonsil is developed only in childhood; from about 12 years of age it begins to decrease in size. By the age of 16-20, only small remnants of lymphadenoid tissue usually remain, and in adults, complete atrophy usually occurs.

Rice. 1 and 2. Adenoids. Rice. 1. Sagittal section of the nose and nasopharynx. Rice. 2. Posterior rhinoscopy

The pharyngeal tonsil, mentioned in the work of Santorini (GD Santorini), is described in more detail by N. Luschka, after whom it is often called Lushka’s tonsil. N.I. Pirogov pointed out that between the vault of the pharynx and the main part of the occipital bone there is an accumulation of mucous follicles and that it is necessary to look for the primary focus of retropharyngeal abscesses in them.

In a patient, A. was first discovered by Czermak (JN Czermak, 1860) using the method of posterior rhinoscopy he proposed. But the most complete clinical description based on 48 observations was given by the Danish physician N. W. Meyer in 1873.

The symptomatology of adenoid growths has been significantly enriched after the connection between nasal diseases and general disorders in the body was proven. Research by virologists has revealed that the pharyngeal and palatine tonsils are a reservoir of both latent and epidemic adenoviruses, where they create a permanent focus of infection and sensitization, periodically causing not only exacerbations of chronic adenoiditis, but also repeated acute respiratory diseases and exacerbations of bronchopulmonary processes.

Adenoid growths are of great importance in the pathology of the upper respiratory tract and hearing organ. The presence of A. causes not only local disorders in the form of difficulty in nasal breathing, hearing impairment, and voice changes, but often adversely affects the general condition of the body.

A. are formed as a result of pathological proliferation of lymphadenoid tissue of the pharyngeal tonsil (color table, Fig. 1).

With hypertrophy, the pharyngeal tonsil extends anteriorly to the choanae and vomer, posteriorly to the pharyngeal tubercle (tuberculum pharyngeum), laterally to the pharyngeal pouches (Rosenmüllerian fossae) and the bells of the auditory (Eustachian) tubes. A.'s dimensions are (somewhat arbitrarily) determined using posterior rhinoscopy (color table, Fig. 2).

There are three degrees of proliferation of the pharyngeal tonsils: I degree - A. cover the upper part of the vomer, II degree - the upper two-thirds of the vomer and III degree - large adenoids, covering completely or almost completely the vomer.

A. are observed equally often in children of both sexes, usually between the ages of 3 and 10 years, but they also occur both in the first months and years of life, and after puberty and (as an exception) in old and even senile age. Among outpatients (when adults and children are seen together), the percentage of those suffering from A. reaches 6-7; in children's outpatient clinics this figure is much higher.

Etiology. The causes of hypertrophy of the nasopharyngeal tonsil are varied. Often the rapid growth of A. is the result of childhood infectious diseases (measles, whooping cough, scarlet fever, diphtheria, influenza, etc.), causing an inflammatory reaction in the nasal mucosa and lymphadenoid tissue of the nasopharynx. Unfavorable living conditions (damp, dark and poorly ventilated rooms, qualitative and quantitative insufficient nutrition, etc.) reduce the body's protective functions and often lead to acute and chronic inflammation of the upper respiratory tract, predisposing to the development of A.

Pathological anatomy. Adenoids are a pale pink tumor-like mass located on a broad base in the vault of the pharynx. With their uneven surface, they sometimes resemble a cockscomb (Fig. 1). In addition to the main mass of A., lateral formations that arise as a result of hypertrophy of the follicular apparatus of the pharyngeal mucosa are of great importance; they often fill the pharyngeal pockets and the mouths of the auditory tubes. In children at the beginning of their development, A. usually has a soft, doughy-loose consistency. With age and as a result of repeated inflammation, atrophy of the lymphoid tissue begins and, accordingly, the proliferation of connective tissue occurs. A. at the same time gradually become more dense and decrease in volume. At the same time, their color changes - from red to pale pink or gray-pink. Histological examination of removed A. in the lymphoid tissue often reveals signs of inflammation. Regardless of the severity of hyperplasia of lymphadenoid tissue, in 75-80% of cases or more various forms of chronic adenoiditis (see).

Rice. 1. Removed adenoids

Clinical picture. A.'s symptoms are very diverse. The main ones are periodic or constant nasal congestion with copious secretions filling the nasal passages, which impairs blood circulation in the nasal cavity and nasopharynx. Congestion occurs in the nose and even in its paranasal sinuses, leading to chronic swelling and inflammation of the nasal mucosa, especially the posterior ends of the turbinates, and to an abundant accumulation of thick viscous mucus. Chronic runny nose often develops. As a result of difficulty in nasal breathing, children with A. sleep with their mouths open, their sleep is usually restless, often accompanied by loud snoring and even attacks of suffocation due to retraction of the root of the tongue with a drooping lower jaw; In the morning, children get up lethargic and apathetic, often with a headache.

With large A., filling the entire vault of the pharynx, and due to swelling of the nasal mucosa, phonation disturbances are noted, the voice loses its sonority, takes on a dull tint - closed nasality (rhinolalia clausa).

Rice. 2. Typical facial expression with adenoids

By closing the openings of the auditory tubes, A. sometimes lead to a significant decrease in hearing, especially during an acute runny nose. Periodic hearing loss often causes the child to become distracted and inattentive. Due to hearing loss, young children sometimes take a long time to learn to speak or have difficulty mastering speech. When A. is combined with exudative diathesis, thick viscous nasal discharge causes skin irritation, swelling of the upper lip, and sometimes eczematous lesions at the entrance to the nose. Due to the fact that the child’s mouth is constantly open, his lower jaw droops, and the nasolabial folds are smoothed out. Prolonged mouth breathing can lead to various growth abnormalities of the facial skeleton. The shape of the upper jaw changes especially noticeably: it seems to be compressed from the sides, lengthens and appears wedge-shaped, the hard palate takes on the so-called shape. Gothic vault. Sometimes there is an incorrect arrangement of teeth: the upper incisors protrude significantly forward compared to the lower ones or are located in two rows, since they do not fit into the narrow alveolar process of the upper jaw.

A change in the shape of the face and upper jaw, a constantly open mouth, a sluggish and indifferent expression (Fig. 2) is called adenoid face, or external adenoidism (habitus adenoidicus, facies adenoidica).

Prolonged difficulty in nasal breathing can lead to improper development of the chest. Many disorders caused by A. should be interpreted not only as a consequence of a mechanical obstacle that complicates nasal breathing and disrupts blood circulation and lymph flow in the nasal cavity, but also as a result of reflex influences caused by irritation of receptors embedded in the adenoid growths.

Features of the course of the disease at different ages . In newborns, the choanae are round in shape, but the cavity of the nasopharynx is lower, so the choanae are closed by adenoid growths more than in adults. Infants suffer from difficulty in nasal breathing more severely than older children. Restless sleep, disturbance of the act of sucking leads to underfeeding; Night cough or attacks of false croup are often observed. Infected A. in infants is often the cause of the development of bronchitis and bronchopneumonia. Older children often experience headaches, which can occur as a result of congestion that impedes the outflow of venous blood and lymph from the cranial cavity. The sometimes observed nighttime urinary incontinence, laryngospasm phenomena, chorea-like movement of the facial muscles (grimaces), asthmatic attacks, etc. are of a reflex nature.

Dysfunction of the gastrointestinal tract. tract (poor appetite, repeated vomiting, constipation and diarrhea) and breathing (insufficient oxygen supply) lead to anemia and emaciation (adenoid thinness).

Complications . When breathing, cold, unhumidified and insufficiently purified air entering through the mouth leads to frequent colds - runny nose, sore throat, laryngitis, tracheitis and bronchitis. Descending catarrhs ​​of the upper respiratory tract recur especially easily in the presence of infected adenoid growths. Complications also arise from the ears. Acute adenoiditis, which is a common cause of acute otitis media, is especially dangerous. In all cases of chronic inflammation of the auditory tube, catarrhal and chronic purulent otitis media, it is necessary to carefully examine the nasopharynx, since the presence of even small A. is often the cause of the chronic course of otitis media.

Diagnosis. Recognizing A. usually does not present great difficulties. In some cases, based on the appearance of the child, the presence of A. can be suspected, but the final diagnosis is made only after posterior rhinoscopy and palpation of the nasopharynx with a finger. Posterior rhinoscopy is not always successful, especially in young children; in these cases, finger examination of the nasopharynx should be used. To examine the nasopharynx with a finger, the child is seated on a chair; the assistant sits opposite, holding the patient's hands and diverting his attention. The doctor stands behind, to the right of the patient; With the index finger of his left hand, he lightly presses the child’s left cheek between the teeth to prevent finger biting, then with a quick movement he inserts the disinfected index (or middle) finger of his right hand along the back wall of the pharynx upward to the vault of the pharynx. Turning the end of the finger in different directions, the doctor feels the vault of the pharynx, choanae, posterior ends of the shell, tubal ridges and pharyngeal pockets. The examination should be carried out quickly, within 3-5 seconds. Often, when examining the pharynx with a finger, anomalies of the vault and posterior wall are determined, which cannot be determined with such accuracy with posterior rhinoscopy. In some cases, X-ray examination is also used: in pictures in various projections, the auricles are contoured against the background of the air column of the nasopharynx. The data obtained during the study must be taken into account during the operation.

When making a differential diagnosis, it should be borne in mind that difficulty in nasal breathing can be caused by a number of reasons: curvature of the nasal septum, hypertrophy of the posterior ends of the inferior turbinates, nasal polyps, choanal polyp, benign or malignant tumors (fibroma, endothelioma, nasopharyngeal sarcoma). Sometimes the so-called is very similar to A. fibroma of adolescence (during the period of initial development). If a tumor is suspected, as well as recurrence of removed A., a histological examination should be performed. Acute inflammatory processes in the nasopharynx, acute inflammation of the tissue of the pharyngeal tonsil (acute adenoiditis), and retropharyngeal abscess occur at elevated temperatures, which makes it easy to differentiate them from A.

The prognosis for A. is favorable in most cases; it worsens if there are significant constitutional and hereditary changes in the form of diffuse hyperplasia of the lymphadenoid apparatus of the pharynx.

Treatment of pharyngeal tonsil proliferation, especially in grades II and III, is usually surgical.

The indications for surgery are not so much the absolute value of A., but the disturbances in the body caused by them. In infants, indications for adenotomy are chronic runny nose, severe difficulty in nasal breathing, as well as recurring adenoiditis (acute inflammation of hyperplastic adenoid tissue), especially accompanied by acute recurrent otitis media. In older children, the need for adenotomy arises with persistent hypersecretory runny nose, persistent nasal breathing disorders and ear diseases. In adults, the need for surgical intervention most often occurs with complications from the ears. In this case, it is necessary to take into account not only the size of A., but also the extent to which they are a source of infection.

Contraindications to surgery are: general weakening of the body after recent acute infectious diseases (influenza, measles, scarlet fever, tonsillitis), blood diseases (especially hemophilia). Before the operation, in addition to a general examination, it is necessary to exclude congenital syphilis, tuberculosis, and severe diseases of the cardiovascular system. Surgery should not be performed in case of acute inflammatory diseases of the respiratory tract, if an infectious disease is suspected, or during epidemics (influenza, etc.).

Operation technique . Immediately before the operation, a general blood test, a blood clotting test, a determination of bleeding time and platelet count, as well as a study of mucus from the nose and throat for diphtheria bacilli should be performed.

For young children, due to the fact that the operation is short-term and less painful, anesthesia is not used; if necessary, they resort to premedication with various combinations of analgesics, neuroplegics and antihistamines; Anesthesia is rarely used - more often during adenotonsillectomy.

Rice. 3. Removal of adenoids

For older children, the most sensitive side walls of the nasopharynx are lubricated through the nose and mouth with a 1-2% solution of dicaine or a 5% solution of cocaine with adrenaline (some authors use spraying of the oropharynx with the same solutions instead of lubricating). It is better to perform the operation in the morning on an empty stomach. For the operation, ring-shaped knives are most often used - Beckmann adenotomes (see Otorhinolaryngological instruments ), which come in five sizes depending on the size of the nasopharynx. Some doctors prefer to remove A. nasopharyngeal forceps of Stein, Denker or adenotomes with a Schitze-type guillotine. Instruments for removing A. are selected based on the shape of the nasopharynx and the location of A. in a given patient.

During the operation, for better fixation, the child is placed on the assistant’s lap, who clamps the patient’s legs between the knees, depriving him of the ability to lean on the floor; With one hand he holds the head, and with the other he tightly grasps the patient’s hands. It is better to wrap small children in a sheet. Using a spatula, the tongue is pressed downwards and the adenoid is inserted behind the soft palate, positioned strictly along the midline, moved upward anteriorly, touching the posterior edge of the nasal septum, then pressed upward against the arch of the nasopharynx. Then, with quick movements from front to back along the dome and then from top to bottom along the back wall of the nasopharynx, A. is cut off (Fig. 3). If there are scraps of tissue hanging down the throat, they are bitten off with a conchotome or cut off with curved scissors. Removal of A. is usually accompanied by bleeding, which quickly stops. After cleaning the nasal cavity by alternately blowing your nose (or sipping air from the nose to the throat), disinfectant powder (for example, a mixture of sulfonamides) is blown through the nose. If the operation was performed in an outpatient clinic, the child is detained for 1 1/2 -2 hours, after which, after making sure that there is no bleeding, they are sent home. During the first 2-3 days after surgery, bed rest is recommended and room rest for another 2-3 days. The food temperature should be between 18-20°. The room where the patient is located is cleaned using a wet method.

Complications . Complications can arise both during surgery and in the postoperative period. During surgery, if there is insufficient fixation of the patient and his active resistance, rough holding of the end of the adenotome can lead to injury to various parts of the oral cavity, soft palate, tearing off the uvula (palatal), etc. In the nasopharynx itself, the posterior edge of the vomer, the posterior ends can be subjected to such injury inferior conchae, auditory tube ridges. Novice surgeons usually do not carry the end of the adenotome high enough, as a result of which only the lower part of the hypertrophied tonsil is removed. Sometimes too much pressure applied by a sharpened knife leads to the removal of deeper tissues, right down to the prevertebral fascia. Cases have been described in which the bone plate of the body of a protruding vertebra (the so-called vertebra prominens) was cut off by adenototomy. Removed A. can enter the nasal cavity or be aspirated into the larynx; during an operation without anesthesia, they are immediately thrown out with a strong cough impulse. Sometimes A. are swallowed by patients.

The most common complication is postoperative bleeding, which occurs immediately after surgery or several hours or even one to three days later. In a significant proportion of cases, the cause of such bleeding is fragments of A that have not been completely removed. In some cases of bleeding, repeated curettage of the nasopharynx with an adenotomy is necessary.

The cause of later bleeding may also be the rejection of the wound scab, which is usually observed on the 4th or 5th day after surgery, especially in restless children. General measures include calcium supplements, serum injections, or blood transfusions. In case of severe bleeding (in rare cases), posterior tamponade has to be performed. A tampon inserted into the nasopharynx poses a danger to the middle ear, and therefore longer than 24 hours. it should not be left. After removal of A., relatively often in the first 2-3 days after surgery there is a slight rise in temperature (up to 37°), which does not pose a danger. Only an increase in temperature above 38° for several days should cause concern. An increase in temperature to 38° and above sometimes occurs with acute inflammation of regional lymph nodes or acute inflammation of the middle ear, which are often observed after adenotomy. It is better to hospitalize such patients. Diphtheria of the wound surface, purulent meningitis, and sepsis after adenotomy were observed in some cases by a number of authors. Rare complications of adenotomy include tuberculous meningitis, which occurs as a result of injury to an unrecognized tuberculous lesion in the tonsil. Prevention of such complications is a thorough and comprehensive examination of patients before surgery.

Relapses of A. with a correctly performed operation are rare (approximately 2-3% of cases), mainly in early childhood. If A. is not completely removed, especially at an early age, a relapse of the disease may occur. If adenotomy surgery is contraindicated, you can resort to radiotherapy.

Bibliography : Likhachev A. G. , Konstantinova N. P. and Ritova V.V. The role of adenoviruses in the etiology and pathogenesis of chronic tonsillitis and adenoiditis, Vestn. otorhinol., t. 35, no. 3, p. 3, 1972, bibliogr.; Multi-volume guide to otorhinolaryngology, ed. A. G. Likhacheva, vol. 3, p. 208, M, 1963, bibliogr.; Mostovoy S. I. and Marchenko E. D. Adenoid growths in children of the first year of life, Kyiv, 1970, bibliogr.; Surgical diseases of the nose, paranasal sinuses and nasopharynx, ed. Ya. S. Temkin and D. M. Rutenburg, p. 568, M., 1949; Linder-Aronson S. Adenoids, Uppsala, 1970, bibliogr.

  1. Big medical encyclopedia. Volume 1/Editor-in-Chief Academician B.V. Petrovsky; publishing house "Soviet Encyclopedia"; Moscow, 1974.- 576 p.

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Anatomy of adenoids

ADENOIDS (Greek aden - gland and eidos - type; synonym: adenoid vegetations, adenoid growths ) - pathological hypertrophy of the “third”, or pharyngeal (nasopharyngeal), tonsil (tonsilla pharyngea), located in the vault of the nasopharynx. This tonsil, together with the lingual and palatine tonsils, is part of the lymphadenoid pharyngeal “ring”. The thickness of the pharyngeal tonsil is on average 5-7 mm, width 20 mm and length 25 mm. The gaps between the ridges have the form of straight or arcuate grooves along the periphery, parallel to each other or converging posteriorly. The deepest groove, located in the midline, ends posteriorly with a depression called the pharyngeal bursa (bursa pharyngea). The pharyngeal tonsil is developed only in childhood; from about 12 years of age it begins to decrease in size. By the age of 16-20, only small remnants of lymphadenoid tissue usually remain, and in adults, complete atrophy usually occurs.

The pharyngeal tonsil, which was mentioned in the work of Santorini (GD Santorini), is described in more detail by N. Luschka, after whom Luschka’s tonsil is often called. N.I. Pirogov pointed out that between the vault of the pharynx and the main part of the occipital bone there is an accumulation of mucous follicles and that it is necessary to look for the primary focus of retropharyngeal abscesses in them.

ADENOIDS were first discovered in a patient by Czermak (JN Czermak, 1860) using the method of posterior rhinoscopy he proposed. But the most complete clinical description based on 48 observations was given by the Danish physician N. W. Meyer in 1873.

The symptomatology of adenoid growths has been significantly enriched after the connection between nasal diseases and general disorders in the body was proven. Research by virologists has revealed that the pharyngeal and palatine tonsils are a reservoir of both latent and epidemic adenoviruses, where they create a permanent focus of infection and sensitization, periodically causing not only exacerbations of chronic adenoiditis, but also repeated acute respiratory diseases and exacerbations of bronchopulmonary processes.

Adenoid growths are of great importance in the pathology of the upper respiratory tract and hearing organ. The presence of adenoids causes not only local disorders in the form of difficulty in nasal breathing, hearing impairment, and voice changes, but often adversely affects the general condition of the body.

ADENOIDS are formed as a result of pathological proliferation of lymphadenoid tissue of the pharyngeal tonsil (color Fig. 1).

With hypertrophy, the pharyngeal tonsil extends anteriorly to the choanae and vomer, posteriorly to the pharyngeal tubercle (tuberculum pharyngeum), laterally to the pharyngeal pouches (Rosenmüllerian fossae) and the bells of the auditory (Eustachian) tubes. The size of the adenoids (somewhat arbitrarily) is determined using posterior rhinoscopy (color Fig. 2).

There are three degrees of proliferation of the pharyngeal tonsils: I degree - the adenoids cover the upper part of the vomer, II degree - the upper two-thirds of the vomer and III degree - large adenoids covering completely or almost completely the vomer.

Adenoids are observed equally often in children of both sexes, usually between the ages of 3 and 10 years, but they also occur both in the first months and years of life, and after puberty and (as an exception) in old and even senile age. Among outpatients (when adults and children are seen together), the percentage of those suffering from adenoids reaches 6-7; in children's outpatient clinics this figure is much higher.

Content

Etiology

The causes of hypertrophy of the nasopharyngeal tonsil are varied. Often the rapid growth of ADENOIDS is the result of childhood infectious diseases (measles, whooping cough, scarlet fever, diphtheria, influenza, etc.), causing an inflammatory reaction of the nasal mucosa and lymphadenoid tissue of the nasopharynx. Unfavorable living conditions (damp, dark and poorly ventilated rooms, qualitative and quantitative insufficient nutrition, etc.) reduce the body's protective functions and often lead to acute and chronic inflammation of the upper respiratory tract, predisposing to the development of adenoids.

Pathological anatomy

Adenoids are a pale pink tumor-like mass located on a broad base in the vault of the pharynx. With their uneven surface, they sometimes resemble a cockscomb (Fig. 1). In addition to the bulk of the adenoids, lateral formations that arise as a result of hypertrophy of the follicular apparatus of the pharyngeal mucosa are of great importance; they often fill the pharyngeal pockets and the mouths of the auditory tubes. In children, at the beginning of development, adenoids usually have a soft, doughy-loose consistency. With age and as a result of repeated inflammation, atrophy of the lymphoid tissue begins and, accordingly, the proliferation of connective tissue occurs. A. at the same time gradually become more dense and decrease in volume. At the same time, their color changes - from red to pale pink or gray-pink. Histological examination of removed adenoids often reveals signs of inflammation in the lymphoid tissue. Regardless of the severity of hyperplasia of lymphadenoid tissue, in 75-80% of cases or more various forms of chronic adenoiditis are determined (see).

Clinical picture

Symptoms of ADENOIDS are very diverse. The main ones are periodic or constant nasal congestion with copious secretions filling the nasal passages, which impairs blood circulation in the nasal cavity and nasopharynx. Congestion occurs in the nose and even in its paranasal sinuses, leading to chronic swelling and inflammation of the nasal mucosa, especially the posterior ends of the turbinates, and to an abundant accumulation of thick viscous mucus. Chronic runny nose often develops. As a result of difficulty in nasal breathing, children with adenoids sleep with their mouths open, their sleep is usually restless, often accompanied by loud snoring and even attacks of suffocation due to retraction of the root of the tongue with a drooping lower jaw; In the morning, children get up lethargic and apathetic, often with a headache.

With large adenoids filling the entire vault of the pharynx, and due to swelling of the nasal mucosa, phonation disturbances are noted, the voice loses its sonority, takes on a dull tint - closed nasality (rhinolalia clausa).

By closing the openings of the auditory tubes, the adenoids sometimes lead to a significant decrease in hearing, especially during an acute runny nose. Periodic hearing loss often causes the child to become distracted and inattentive. Due to hearing loss, young children sometimes take a long time to learn to speak or have difficulty mastering speech. When adenoids are combined with exudative diathesis, thick viscous nasal discharge causes skin irritation, swelling of the upper lip, and sometimes eczematous lesions of the nasal opening. Due to the fact that the child’s mouth is constantly open, his lower jaw droops, and the nasolabial folds are smoothed out. Prolonged mouth breathing can lead to various growth abnormalities of the facial skeleton. The shape of the upper jaw changes especially noticeably: it seems to be compressed from the sides, lengthens and appears wedge-shaped, the hard palate takes on the so-called shape. Gothic vault. Sometimes there is an incorrect arrangement of teeth: the upper incisors protrude significantly forward compared to the lower ones or are located in two rows, since they do not fit into the narrow alveolar process of the upper jaw.

A change in the shape of the face and upper jaw, a constantly open mouth, a sluggish and indifferent expression (Fig. 2) is called adenoid face, or external adenoidism (habitus adenoidicus, facies adenoidica).

Prolonged difficulty in nasal breathing can lead to improper development of the chest. Many disorders caused by adenoids should be interpreted not only as a consequence of a mechanical obstacle that complicates nasal breathing and disrupts blood circulation and lymph flow in the nasal cavity, but also as a result of reflex influences caused by irritation of the receptors embedded in the adenoid growths.

Features of the course of the disease at different ages. In newborns, the choanae are round in shape, but the cavity of the nasopharynx is lower, so the choanae are closed by adenoid growths more than in adults. Infants suffer from difficulty in nasal breathing more severely than older children. Restless sleep, disturbance of the act of sucking leads to underfeeding; Night cough or attacks of false croup are often observed. Infected adenoids in infants often cause the development of bronchitis and bronchopneumonia.

Older children often experience headaches, which can occur as a result of congestion that impedes the outflow of venous blood and lymph from the cranial cavity. The sometimes observed nighttime urinary incontinence, laryngospasm phenomena, chorea-like movement of the facial muscles (grimaces), asthmatic attacks, etc. are of a reflex nature.

Disorders of the gastrointestinal tract (poor appetite, repeated vomiting, constipation and diarrhea) and breathing (insufficient oxygen supply) lead to anemia and emaciation (adenoid thinness).

Complications

When breathing, cold, unhumidified and insufficiently purified air entering through the mouth leads to frequent colds - runny nose, sore throat, laryngitis, tracheitis and bronchitis. Descending catarrhs ​​of the upper respiratory tract recur especially easily in the presence of infected adenoid growths. Complications also arise from the ears. Acute adenoiditis, which is a common cause of acute otitis media, is especially dangerous. In all cases of chronic inflammation of the auditory tube, catarrhal and chronic purulent otitis media, it is necessary to carefully examine the nasopharynx, since the presence of even small ADENOIDS is often the cause of the chronic course of otitis media.

Diagnosis

Recognizing ADENOIDS usually does not present much difficulty. In some cases, based on the appearance of the child, the presence of adenoids can be suspected, but the final diagnosis is made only after posterior rhinoscopy and palpation of the nasopharynx with a finger. Posterior rhinoscopy is not always successful, especially in young children; in these cases, finger examination of the nasopharynx should be used. To examine the nasopharynx with a finger, the child is seated on a chair; the assistant sits opposite, holding the patient's hands and diverting his attention. The doctor stands behind, to the right of the patient, with the index finger of his left hand he lightly presses the child’s left cheek between the teeth to prevent a finger bite, then with a quick movement he inserts the disinfected index (or middle) finger of his right hand along the back wall of the pharynx upward to the vault of the pharynx. By turning the end of the finger in different directions, the doctor feels the vault of the pharynx, choanae, posterior ends of the shell, tubal ridges and pharyngeal pockets. The study should be carried out quickly, within 3-5 seconds. Often, when examining the pharynx with a finger, anomalies of the vault and posterior wall are determined, which cannot be determined with such accuracy during posterior rhinoscopy. In some cases, X-ray examination is also used: in pictures in various projections, the adenoids are contoured against the background of the air column of the nasopharynx. The data obtained during the study must be taken into account during the operation.

When making a differential diagnosis, it should be borne in mind that difficulty in nasal breathing can be caused by a number of reasons: curvature of the nasal septum, hypertrophy of the posterior ends of the inferior turbinates, nasal polyps, choanal polyp, benign or malignant tumors (fibroma, endothelioma, nasopharyngeal sarcoma). The so-called fibroma of adolescence (during the period of initial development) is sometimes very similar to adenoids. If a tumor is suspected, as well as recurrence of removed adenoids, a histological examination should be performed. Acute inflammatory processes in the nasopharynx, acute inflammation of the tissue of the pharyngeal tonsil (acute adenoiditis), and retropharyngeal abscess occur at elevated temperatures, which makes it easy to differentiate them from adenoids.

Forecast

The prognosis for ADENOIDS is favorable in most cases; it worsens if there are significant constitutional and hereditary changes in the form of diffuse hyperplasia of the lymphadenoid apparatus of the pharynx.

Treatment

Treatment of pharyngeal tonsil proliferation, especially in grades II and III, is usually surgical.

The indications for surgery are not so much the absolute value of ADENOIDS as the disturbances they cause in the body. In infants, indications for adenotomy are chronic runny nose, severe difficulty in nasal breathing, as well as recurring adenoiditis (acute inflammation of hyperplastic adenoid tissue), especially accompanied by acute recurrent otitis media. In older children, the need for adenotomy arises with persistent hypersecretory runny nose, persistent nasal breathing disorders and ear diseases. In adults, the need for surgical intervention most often occurs with complications from the ears. In this case, it is necessary to take into account not only the size of the adenoids, but also the extent to which they are a source of infection.

Contraindications to surgery are: general weakening of the body after recent acute infectious diseases (influenza, measles, scarlet fever, tonsillitis), blood diseases (especially hemophilia). Before the operation, in addition to a general examination, it is necessary to exclude congenital syphilis, tuberculosis, and severe diseases of the cardiovascular system. Surgery should not be performed in case of acute inflammatory diseases of the respiratory tract, if an infectious disease is suspected, or during epidemics (influenza, etc.).

Operation technique

Immediately before the operation, a general blood test, a blood clotting test, a determination of bleeding time and platelet count, as well as a study of mucus from the nose and throat for diphtheria bacilli should be performed.

For young children, due to the fact that the operation is short-term and less painful, anesthesia is not used; if necessary, they resort to premedication with various combinations of analgesics, neuroplegics and antihistamines; Anesthesia is rarely used - more often during adenotonsillectomy.

For older children, the most sensitive side walls of the nasopharynx are lubricated through the nose and mouth with a 1-2% solution of dicaine or a 5% solution of cocaine with adrenaline (some authors use spraying of the oropharynx with the same solutions instead of lubricating). It is better to perform the operation in the morning on an empty stomach. For the operation, ring-shaped knives are most often used - Beckmann adenotomes (see Otorhinolaryngological instruments), which come in five sizes depending on the size of the nasopharynx. Some doctors prefer Stein, Denker nasopharyngeal forceps or adenotomes with a Schitze-type guillotine to remove adenoids. Instruments for removing adenoids are selected based on the shape of the nasopharynx and the location of the adenoids in a given patient.

During the operation, for better fixation, the child is placed on the lap of an assistant, who clamps the patient’s legs between his knees, depriving him of the ability to lean on the floor; With one hand he holds the head, and with the other he tightly grasps the patient’s hands. It is better to wrap small children in a sheet. Using a spatula, the tongue is pressed downwards and the adenoid is inserted behind the soft palate, positioned strictly along the midline, moved upward anteriorly, touching the posterior edge of the nasal septum, then pressed upward against the arch of the nasopharynx. Then, with quick movements from front to back along the dome and then from top to bottom along the back wall of the nasopharynx, the adenoids are cut off (Fig. 3). If there are scraps of tissue hanging down the throat, they are bitten off with a conchotome or cut off with curved scissors. Removal of the adenoids is usually accompanied by bleeding, which quickly stops. After cleaning the nasal cavity by alternately blowing your nose (or sipping air from the nose to the throat), a disinfectant powder (for example, a mixture of sulfonamides) is blown through the nose. If the operation was performed in an outpatient clinic, the child is detained for 1-2 hours, after which, after making sure that there is no bleeding, they are sent home. During the first 2-3 days after surgery, bed rest is recommended and room rest for another 2-3 days. The food temperature should be between 18-20°. The room where the patient is located is cleaned using a wet method.

Complications

Complications can arise both during surgery and in the postoperative period. During surgery, if there is insufficient fixation of the patient and his active resistance, rough holding of the end of the adenotome can lead to injury to various parts of the oral cavity, soft palate, tearing off the uvula (palatal), etc. In the nasopharynx itself, the posterior edge of the vomer, the posterior ends can be subjected to such injury inferior conchae, auditory tube ridges. Novice surgeons usually do not carry the end of the adenotome high enough, as a result of which only the lower part of the hypertrophied tonsil is removed. Sometimes too much pressure applied by a sharpened knife leads to the removal of deeper tissues, right down to the prevertebral fascia. Cases have been described in which the bone plate of the body of a protruding vertebra (the so-called vertebra prominens) was cut off with an adenotomy. Removed adenoids may enter the nasal cavity or be aspirated into the larynx; during an operation without anesthesia, they are immediately released with a strong potassium push. Sometimes adenoids are swallowed by patients.

The most common complication is postoperative bleeding, which occurs immediately after surgery or several hours later or even one to three days. In a significant proportion of cases, the cause of such bleeding is not completely removed fragments of adenoids. In some cases of bleeding, repeated curettage of the nasopharynx with an adenotomy is necessary.

The cause of later bleeding may also be the rejection of the wound scab, which is usually observed on the 4th or 5th day after surgery, especially in restless children. General measures include calcium supplements, serum injections, or blood transfusions. In case of severe bleeding (in rare cases), posterior tamponade has to be performed. A tampon inserted into the nasopharynx poses a danger to the middle ear, and therefore longer than 24 hours. it should not be left. After removal of the adenoids, relatively often in the first 2-3 days after surgery there is a slight rise in temperature (up to 37°), which does not pose a danger. Only an increase in temperature above 38° for several days should cause concern. An increase in temperature to 38° and above sometimes occurs with acute inflammation of the regional lymph nodes or acute inflammation of the middle ear, which are often observed after adenotomy. It is better to hospitalize such patients. Diphtheria of the wounded surface, purulent meningitis, sepsis after adenotomy were observed in individual cases by a number of authors. Rare complications of adenotomy include tuberculous meningitis, which occurs as a result of injury to an unrecognized tuberculous lesion in the tonsil. Prevention of such complications is a thorough and comprehensive examination of patients before surgery.

Relapses

Relapses of ADENOIDS with correctly performed surgery are rare (approximately 2-3% of cases), mainly in early childhood. If the adenoids are not completely removed, especially at an early age, a relapse of the disease may occur.

If adenotomy surgery is contraindicated, you can resort to radiotherapy.

Bibliography: Likhachev A. G., Konstantinova N. P. and Ritova V. V. The role of adenoviruses in the etiology and pathogenesis of chronic tonsillitis and adenoiditis, Vestn. otorhinol., t. 35, M 3, p. 3, 1972, bibliogr.; Multi-volume guide to otorhinolaryngology, ed. A. G. Likhacheva, vol. 3, p. 208, M., 1963, bibliogr.; Mostovoy S.I. and Marchenko E.D. Adenoid growths in children of the first year of life, Kyiv, 1970, bibliogr.; Surgical diseases of the nose, paranasal sinuses and nasopharynx, ed. Ya. S. Temkin and D. M. Rutenburg, p. 568, M., 1949; Linder-Agonvop S. Adenoids, Uppsala, 1970, blbliogr.

Source: http://xn--90aw5c.xn--c1avg/index.php/%D0%90%D0%94%D0%95%D0%9D%D0%9E%D0%98%D0%94%D0 %AB

Adenoids

Table of contents

Adenoids

Adenoids (Greek aden - gland and eidos - type; synonyms: adenoid vegetations, adenoid growths) - pathological hypertrophy of the “third”, or pharyngeal (nasopharyngeal) tonsil (tonsilla pharyngeal located in the vault of the nasopharynx. This tonsil, together with the lingual and palatine tonsils, is included part of the lymphadenoid pharyngeal "ring". The thickness of the pharyngeal tonsil is on average 5-7 mm, width 20 mm and length 25 mm. The gaps between the ridges have the form of straight or arcuate grooves along the periphery, parallel to each other or converging posteriorly. The deepest, located along the midline, the groove ends posteriorly with a depression called the pharyngeal bursa (bursa pharyngea). The pharyngeal tonsil is developed only in childhood, and from about 12 years of age it begins to decrease in size. By the age of 16-20, only small remnants of lymphadenoid tissue are usually preserved, and in In adults, complete atrophy usually occurs.

The pharyngeal tonsil, which was mentioned in the work of Santorini (GD Santorini), is described in more detail by N. Luschka, after whom it is often called Luschka’s tonsil. N.I. Pirogov pointed out that between the vault of the pharynx and the main part of the occipital bone there is an accumulation of mucous follicles and that it is necessary to look for the primary focus of retropharyngeal abscesses in them.

Cermak (JN Gzermak, 1860) first discovered adenoids in a patient using the method of posterior rhinoscopy he proposed. But the most complete clinical description based on 48 observations was given by the Danish physician N. W. Meyer in 1873.

The symptomatology of adenoid growths has been significantly enriched after the connection between nasal diseases and general disorders in the body was proven. Research by virologists has revealed that the pharyngeal and palatine tonsils are a reservoir of both latent and epidemic adenoviruses, where they create a permanent focus of infection and sensitization, periodically causing not only exacerbations of chronic adenoiditis, but also repeated acute respiratory diseases and exacerbations of bronchopulmonary processes.

Adenoid growths are of great importance in the pathology of the upper respiratory tract and hearing organ. The presence of adenoids causes not only local disorders in the form of difficulty in nasal breathing, hearing impairment, and voice changes, but often adversely affects the general condition of the body.

Adenoids are formed as a result of pathological proliferation of lymphadenoid tissue of the pharyngeal tonsil (Fig. 1).

With hypertrophy, the pharyngeal tonsil extends anteriorly to the choanae and vomer, posteriorly to the pharyngeal tubercle (tuberculum pharyngeum), laterally to the pharyngeal pouches (Rosenmüllerian fossae) and the bells of the auditory (Eustachian) tubes. The size of the adenoids (somewhat arbitrarily) is determined using posterior rhinoscopy (Fig. 2).

There are three degrees of proliferation of the pharyngeal tonsils: I degree - adenoids cover the upper part of the vomer, II degree - the upper two-thirds of the vomer and III degree - large adenoids covering completely or almost completely the vomer.

Adenoids are observed equally often in children of both sexes, usually between the ages of 3 and 10 years, but they also occur both in the first months and years of life, and after puberty and (as an exception) in old and even senile age. Among outpatients (when adults and children are seen together), the percentage of those suffering from adenoids reaches 6-7; in children's outpatient clinics this figure is much higher.

Etiology.

The causes of hypertrophy of the nasopharyngeal tonsil are varied. Often the rapid growth of adenoids is the result of childhood infectious diseases (measles, whooping cough, scarlet fever, diphtheria, influenza and others) causing an inflammatory reaction of the nasal mucosa and lymphadenoid tissue of the nasopharynx. Unfavorable living conditions (damp, dark and poorly ventilated rooms, qualitative and quantitative insufficient nutrition, and so on) reduce the body's protective functions and often lead to acute and chronic inflammation of the upper respiratory tract, predisposing to the development of adenoids.

Sagittal section of the nose and nasopharynx.

Pathological anatomy.

Adenoids are a pale pink tumor-like mass located on a broad base in the vault of the pharynx. With their uneven surface they sometimes resemble a cockscomb (Fig. 3). In addition to the bulk of the adenoids, lateral formations that arise as a result of hypertrophy of the follicular apparatus of the pharyngeal mucosa are of great importance; they often fill the pharyngeal pockets and the mouths of the auditory tubes. In children, at the beginning of development, adenoids usually have a soft, doughy-loose consistency. With age and as a result of repeated inflammation, atrophy of the lymphoid tissue begins and, accordingly, the proliferation of connective tissue occurs. The adenoids gradually become denser and decrease in volume. At the same time, their color changes - from red to pale pink or gray-pink. Histological examination of removed adenoids often reveals signs of inflammation in the lymphoid tissue. Regardless of the severity of hyperplasia of lymphadenoid tissue, in 75-80% of cases or more various forms of chronic adenoiditis are determined. Clinical picture. The symptoms of adenoids are very varied. The main ones are periodic or constant nasal congestion with copious secretions filling the nasal passages, which impairs blood circulation in the nasal cavity and nasopharynx. Congestion occurs in the nose and even in its paranasal sinuses, leading to chronic swelling and inflammation of the nasal mucosa, especially the posterior ends of the turbinates, and to an abundant accumulation of thick viscous mucus. Chronic runny nose often develops. As a result of difficulty in nasal breathing, children with adenoids sleep with their mouths open, their sleep is usually restless, often accompanied by loud snoring and even attacks of suffocation due to retraction of the root of the tongue with a drooping lower jaw; In the morning, children get up lethargic and apathetic, often with a headache.

With large adenoids filling the entire vault of the pharynx, and due to swelling of the nasal mucosa, phonation disturbances are noted, the voice loses its sonority, takes on a dull tint - closed nasality (rhinolalia clausa).

By closing the openings of the auditory tubes, the adenoids sometimes lead to a significant decrease in hearing, especially during an acute runny nose. Periodic hearing loss often causes the child to become distracted and inattentive. Due to hearing loss, young children sometimes take a long time to learn to speak or have difficulty mastering speech. When adenoids are combined with exudative diathesis, thick viscous nasal discharge causes skin irritation, swelling of the upper lip, and sometimes eczematous lesions of the nasal opening. Due to the fact that the child’s mouth is constantly open, his lower jaw droops, and the nasolabial folds are smoothed out. Prolonged mouth breathing can lead to various growth abnormalities of the facial skeleton. The shape of the upper jaw changes especially noticeably: it seems to be compressed from the sides, lengthens and appears wedge-shaped, the hard palate takes the shape of the so-called Gothic vault. Sometimes there is an incorrect arrangement of teeth: the upper incisors protrude significantly forward compared to the lower ones or are located in two rows, since they do not fit into the narrow alveolar process of the upper jaw.

Typical facial expression with adenoids.

A change in the shape of the face and upper jaw, a constantly open mouth, a sluggish and indifferent expression (Fig. 4) is called adenoid face, or external adenoidism (habitus adenoidicus, facies adenoidica).

Prolonged difficulty in nasal breathing can lead to improper development of the chest. Many disorders caused by adenoids should be interpreted not only as a consequence of a mechanical obstacle that complicates nasal breathing and disrupts blood circulation and lymph flow in the nasal cavity, but also as a result of reflex influences caused by irritation of the receptors embedded in the adenoid growths.

Features of the course of the disease at different ages.

In newborns, the choanae are round in shape, but the cavity of the nasopharynx is lower, so the choanae are closed by adenoid growths more than in adults. Infants suffer from difficulty in nasal breathing more severely than older children. Restless sleep, disturbance of the act of sucking leads to underfeeding; Night cough or attacks of false croup are often observed. Infected adenoids in infants often cause the development of bronchitis and bronchopneumonia.

Older children often experience headaches, which can occur as a result of congestion that impedes the outflow of venous blood and lymph from the cranial cavity. The sometimes observed nighttime urinary incontinence, laryngospasm phenomena, chorea-like movement of the facial muscles (grimaces), asthmatic attacks, and so on are of a reflex nature.

Disorders of the gastrointestinal tract (poor appetite, repeated vomiting, constipation and diarrhea) and breathing (insufficient oxygen supply) lead to anemia and emaciation (adenoid thinness).

Complications.

When breathing, cold, unhumidified and insufficiently purified air entering through the mouth leads to frequent colds - runny nose, sore throat, laryngitis, tracheitis and bronchitis. Descending catarrhs ​​of the upper respiratory tract recur especially easily in the presence of infected adenoid growths. Complications also arise from the ears. Acute adenoiditis, which is a common cause of acute otitis media, is especially dangerous. In all cases of chronic inflammation of the auditory tube, catarrhal and chronic purulent otitis media, it is necessary to carefully examine the nasopharynx, since the presence of even small adenoids is often the cause of the chronic course of otitis media.

Diagnosis.

Recognizing adenoids is usually not very difficult. In some cases, based on the appearance of the child, the presence of adenoids can be suspected, but the final diagnosis is made only after posterior rhinoscopy and palpation of the nasopharynx with a finger. Posterior rhinoscopy is not always successful, especially in young children; in these cases, finger examination of the nasopharynx should be used. To examine the nasopharynx with a finger, the child is seated on a chair; the assistant sits opposite, holding the patient's hands and diverting his attention. The doctor stands behind, to the right of the patient; With the index finger of his left hand, he lightly presses the child’s left cheek between the teeth to prevent finger biting, then with a quick movement he inserts the disinfected index (or middle) finger of his right hand along the back wall of the pharynx upward to the vault of the pharynx. Turning the end of the finger in different directions, the doctor palpates the vault of the pharynx, choanae, posterior ends of the shell, tubal ridges and pharyngeal pockets. The study should be carried out quickly, within 3-5 seconds. Often, when examining the pharynx with a finger, anomalies of the vault and posterior wall are determined, which cannot be determined with such accuracy during posterior rhinoscopy. In some cases, X-ray examination is also used: in pictures in various projections, the adenoids are contoured against the background of the air column of the nasopharynx. The data obtained during the study must be taken into account during the operation.

When making a differential diagnosis, it should be borne in mind that difficulty in nasal breathing can be caused by a number of reasons: curvature of the nasal septum, hypertrophy of the posterior ends of the inferior turbinates, nasal polyps, choanal polyp, benign or malignant tumors (fibroma, endothelioma, nasopharyngeal sarcoma). The so-called fibroma of adolescence (during the period of initial development) is sometimes very similar to adenoids. If a tumor is suspected, as well as recurrence of the removed adenoids, a histological examination should be performed. Acute inflammatory processes in the nasopharynx, acute inflammation of the tissue of the pharyngeal tonsil (acute adenoiditis), and retropharyngeal abscess occur at elevated temperatures, which makes it easy to differentiate them from adenoids.

Forecast

The prognosis for adenoids in most cases is favorable; it worsens if there are significant constitutional and hereditary changes in the form of diffuse hyperplasia of the lymphadenoid apparatus of the pharynx.

Treatment

Treatment of pharyngeal tonsil proliferation, especially in grades II and III, is usually surgical.

The indications for surgery are not so much the absolute size of the adenoids, but the disorders they cause in the body. In infants, indications for adenotomy are chronic runny nose, severe difficulty in nasal breathing, as well as recurring adenoiditis (acute inflammation of hyperplastic adenoid tissue), especially accompanied by acute recurrent otitis. In older children, the need for adenotomy arises with persistent hypersecretory runny nose, persistent nasal breathing disorders and ear diseases. In adults, the need for surgical intervention most often occurs with complications from the ears. In this case, it is necessary to take into account not only the size of the adenoids, but also the extent to which they are a source of infection.

Contraindications to surgery are: general weakening of the body after recent acute infectious diseases (influenza, measles, scarlet fever, tonsillitis), blood diseases (especially hemophilia). Before the operation, in addition to a general examination, it is necessary to exclude congenital syphilis, tuberculosis, and severe diseases of the cardiovascular system. Surgery should not be performed in case of acute inflammatory diseases of the respiratory tract, if an infectious disease is suspected, or during epidemics (influenza and others).

Technique of operation.

Immediately before the operation, a general blood test, a blood clotting test, a determination of bleeding time and platelet count, as well as a study of mucus from the nose and throat for diphtheria bacilli should be performed.

For young children, due to the fact that the operation is short-term and less painful, anesthesia is not used; if necessary, they resort to premedication with various combinations of analgesics, neuroplegics and antihistamines; Anesthesia is rarely used - more often during adenotonsillectomy.

For older children, the most sensitive side walls of the nasopharynx are lubricated through the nose and mouth with a 1-2% solution of dicaine or a 5% solution of cocaine with adrenaline (some authors use spraying of the oropharynx with the same solutions instead of lubricating). It is better to perform the operation in the morning on an empty stomach. For the operation, ring-shaped knives are most often used - Beckmann adenotomes (see Otorhinolaryngological instruments), which come in five sizes depending on the size of the nasopharynx. Some doctors prefer Stein, Denker nasopharyngeal forceps or adenotomes with a Schitze-type guillotine to remove adenoids. Instruments for removing adenoids are selected based on the shape of the nasopharynx and the location of the adenoids in a given patient.

During the operation, for better fixation, the child is placed on the lap of an assistant, who clamps the patient’s legs between his knees, depriving him of the ability to lean on the floor; With one hand he holds the head, and with the other he tightly grasps the patient’s hands. It is better to wrap small children in a sheet. Using a spatula, the tongue is pressed downwards and the adenoid is inserted behind the soft palate, positioned strictly along the midline, moved upward anteriorly, touching the posterior edge of the nasal septum, then pressed upward against the arch of the nasopharynx. Then, with quick movements from front to back along the dome and then from top to bottom along the back wall of the nasopharynx, the adenoids are cut off (Fig. 5). If there are scraps of tissue hanging down the throat, they are bitten off with a conchotome or cut off with curved scissors. Removal of the adenoids is usually accompanied by bleeding, which quickly stops. After cleaning the nasal cavity by alternately blowing your nose (or sipping air from the nose to the throat), a disinfectant powder (for example, a mixture of sulfonamides) is blown through the nose. If the operation was performed in an outpatient clinic, the child is detained for 1.5-2 hours, after which, after making sure that there is no bleeding, they are sent home. During the first 2-3 days after surgery, bed rest is recommended and room rest for another 2-3 days. The food temperature should be between 18-20°. The room where the patient is located is cleaned using a wet method.

Complications.

Complications can arise both during surgery and in the postoperative period. During surgery, if there is insufficient fixation of the patient and his active resistance, rough holding of the end of the adenotome can lead to injury to various parts of the oral cavity, soft palate, tearing off the uvula (palatine) and so on. In the nasopharynx itself, the posterior edge of the vomer, the posterior ends of the inferior conchae, and the ridges of the auditory tubes may be subject to such trauma. Novice surgeons usually do not carry the end of the adenotome high enough, as a result of which only the lower part of the hypertrophied tonsil is removed. Sometimes too much pressure applied by a sharpened knife leads to the removal of deeper tissues, right down to the prevertebral fascia. Cases have been described in which the bone plate of the body of a protruding vertebra (the so-called vertebra prominens) was cut off with an adenotomy. Removed adenoids may enter the nasal cavity or be aspirated into the larynx; during an operation without anesthesia, they are immediately thrown out with a strong cough impulse. Sometimes adenoids are swallowed by patients.

The most common complication is postoperative bleeding, which occurs immediately after surgery or several hours later or even one to three days. In a significant proportion of cases, the cause of such bleeding is not completely removed fragments of adenoids. In some cases of bleeding, repeated curettage of the nasopharynx with an adenotomy is necessary.

The cause of later bleeding may also be the rejection of the wound scab, which is usually observed on the 4th or 5th day after surgery, especially in restless children. General measures include calcium supplements, serum injections, or blood transfusions. In case of severe bleeding (in rare cases), posterior tamponade has to be performed. A tampon inserted into the nasopharynx poses a danger to the middle ear, and therefore should not be left in place for more than 24 hours. After removal of the adenoids, relatively often in the first 2-3 days after surgery there is a slight rise in temperature (up to 37°), which does not pose a danger. Only an increase in temperature above 38° for several days should cause concern. An increase in temperature to 38° and above sometimes occurs with acute inflammation of regional lymph nodes or acute inflammation of the middle ear, which are often observed after adenotomy. It is better to hospitalize such patients. Diphtheria of the wound surface, purulent meningitis, and sepsis after adenotomy were observed in some cases by a number of authors. Rare complications of adenotomy include tuberculous meningitis, which occurs as a result of injury to an unrecognized tuberculous lesion in the tonsil. Prevention of such complications is a thorough and comprehensive examination of patients before surgery.

Relapses of adenoids with correctly performed surgery are rare (approximately 2-3% of cases), mainly in early childhood. If the adenoids are not completely removed, especially at an early age, a relapse of the disease may occur.

If adenotomy surgery is contraindicated, you can resort to radiotherapy.

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