Throat Pharynx Adenoids ENT Lectures

7/29/2019 Throat Pharynx Adenoids ENT Lectures

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ADENOIDSDisclaimer: The pictures used in thispresentation have been obtained from anumber of sources. Their use is purely foracademic and teaching purposes. The

contents of this presentation do not have anyintended commercial use. In case the ownerof any of the pictures has any objection andseeks their removal please contact [email protected]. The sepictures will be removed immediately.
mailto:[email protected]:[email protected]:[email protected]


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Embryology

The formation of the adenoids begins in the3rd month of fetal development. This startswith glandular primordia in the posteriornasopharynx becoming associated with

infiltrating lymphocytes. In the 5th month sagittal folds are formed

which are the beginnings of pharyngealcrypts. The surface is covered withpseudostratified ciliated epithelium.

By the 7th month of development theadenoids are fully formed.


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Anatomy

The lymphoid tissue of the nasopharynx andoropharynx is composed of the adenoids,the tubal tonsils, the lateral bands, thepalatine tonsils, and the lingual tonsils.

There are also lymphoid collections in theposterior pharyngeal wall and in thelaryngeal ventricles.

These structures form a ring of tissue named

Waldeyers ring after the German anatomistwho described them.


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The adenoids or pharyngeal tonsil

It is a single mass of pyramidal tissuewith its base on the posteriornasopharyngeal wall and its apex

pointed toward the nasal septum.The surface is invaginated in a series of

folds.

The epithelium is pseudostratifiedciliated epithelium and is infiltrated bythe lymphoid follicles.


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Blood supply is from

the:

Ascending palatinebranch of the facialartery

Pharyngeal branch

of the internalmaxillary artery

Artery of thepterygoid canal

Ascending cervicalbranch of thethyrocervical trunk.


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Venous drainage is through the

pharyngeal plexus and thepterygoid plexus flowingultimately into the facial andinternal jugular veins.

Innervation is derived from theglossopharyngeal and vagusnerves.

Efferent lymphatics drain to theretropharyngeal nodes and theupper deep cervical nodes.


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Function and Immunology

The tonsils and adenoids are part of thesecondary immune system.

Without afferent lymphatics the lymphoid

nodules in these structures are exposed toantigen only in the crypts of the palatinetonsils and the folds of the adenoids where itis transported through the epithelial layer.

These are involved in the production ofmostly secretory IgA, which is transported tothe surface providing local immune

protection.


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Acute adenoiditis symptoms include purulentrhinorrhea, nasal obstruction, fever, and sometimes

otitis media. This can be difficult to differentiate from an acute

upper respiratory infection but tends to have alonger and more severe course.


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Acute adenoiditissymptoms include

purulent rhinorrhea,nasal obstruction,fever, andsometimes otitis

media. This can be difficult

to differentiate froman acute upper

respiratory infectionbut tends to have alonger and moresevere course.


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Recurrent acuteadenoiditis is 4 ormore episodes of

acute adenoiditis in a6-month period withintervening periods ofwellness.

Chronic adenoiditissymptoms includepersistent rhinorrhea,postnasal drip,malodorous breath,

and associated otitismedia or extraesophageal refluxlasting at least 3months.


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Obstructive adenoid hyperplasia

includes symptoms of chronicnasal obstruction, rhinorrhea,snoring, mouth breathing, and ahyponasal voice.

Obstructive sleep apnea inchildren is clinically marked byloud snoring, apneic episodeswhile sleeping, daytimesomnolence, behavioralproblems, and enuresis


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Adenoid facies or long facesyndrome. It is the long, open-mouthed,

face of children with adenoidhypertrophy.

The mouth is always open

because upper airwaycongestion has made patientsobligatory mouth breathers.

The most common presenting

symptoms are chronic mouthbreathing and snoring.

The most dangerous symptom issleep apnea


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The characteristicfacial appearance

consists of:Underdeveloped

thin nostrils

Short upper lipProminent upper

teeth

Crowded teeth

Narrow upperalveolus


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High-arched palate

Hypoplastic maxilla

Eustachian blockagecausing glue ear-deafness

The deafness andinattentivenessinterferes with thelearning

Child grows withlowered intelligence

and understanding


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Diagnosis


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Posterior Rhinoscopy


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Nasopharygoscopy


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Nasopharygoscopy


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Nasopharygoscopy


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X-Ray soft tissue nasopharynx-

lateral view


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X-Ray soft tissue nasopharynx-

lateral view


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CT Scan


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Adenoidectomy-Indications

Four or more episodes of recurrentpurulent rhinorrhea in prior 12 monthsin a child


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Adenoidectomy-IndicationsOtitis media with effusion >3 months or

second set of tubes

Dental malocclusion or orofacial growthdisturbance documented by

orthodontist.Cardiopulmonary complications

including cor pulmonale, pulmonaryhypertension, right ventricular

hypertrophy associated with upperairway obstruction.

Otitis media with effusion over age 4.


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ContraindicationsA submucous cleft palate which may lead to

velopharyngeal insufficiency after surgery. Ifthe adenoid obstruction is severe enough,then only superior half adenoidectomy isperformed.

Avoid surgery in patients with hemoglobin lessthan 10.

Perform surgery at least 2 weeks after the last

attack of acute tonsillitis.Wait at least 6 weeks after polio vaccination.

Avoid surgery in patients with uncontrolledsystemic diseases (ie. leukemia).


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Jennings's Mouth Gag


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St. Claire Thomson Adenoid

Curette


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Position for Adenoidectomy


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Adenoidectomy


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Adenoidectomy Specimen


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Complications

The incidence of mortality fromadenotonsillar surgery ranges from 1 in16,000 to 1 in 35,000 cases.

Anesthetic complications and hemorrhage

cause the majority of deaths.

The prevalence of hemorrhage ranges from

0.1% to 8.1%.

It is divided into primary bleeding, in the first24 hours, and secondary bleeding, around7-10 days post operatively.


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Other risks include:

Vomiting

Dehydration

Airway obstruction due to edema

Pulmonary edema Fever, velopharyngeal insufficiency

Dental injury

Burns Nasopharyngeal stenosis.


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Atlantoaxial subluxation can occur in

patients with Down syndrome.Atlantoaxial joint laxity because of Grisels

syndrome. This is vertebral bodydecalcification and laxity of the anteriortransverse ligament between the atlas andthe axis from inflammation or infection in thenasopharynx.

Spontaneous subluxation occurs about 1week post operatively with pain andtorticollis.

Throat Pharynx Adenoids ENT Lectures

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