If your child has repeated colds and snores while sleeping, beware of adenoids hypertrophy! Surgery is recommended in this case!

Author: Dai Jinsheng, attending physician, Beijing Chaoyang Hospital, Capital Medical University

Reviewer: Zhang Juan, Chief Physician, Beijing Chaoyang Hospital, Capital Medical University

Adenoids are a mass of lymphoid tissue located in the middle of the posterior wall of the nasopharynx. They are an immune organ of the human body and have immune functions. Adenoids begin to develop 6 months after birth, and their proliferation is more active at the age of 2 or 3. They grow to their maximum size at the age of 6 to 7, and gradually shrink after the age of 10. Adenoids tissue basically disappears in adulthood.

If the adenoids are overly enlarged and cause a series of corresponding symptoms, it is called adenoid hypertrophy. Adenoid hypertrophy is a pathological phenomenon that is common in children and is often combined with chronic tonsillitis or tonsil hypertrophy.

The intrinsic factors of adenoids hypertrophy in children are mainly related to genetics. If parents suffer from allergic rhinitis, chronic rhinosinusitis or recurrent tonsillitis in their childhood, accompanied by adenoids hypertrophy, their children are often more likely to develop this condition.

External factors are related to repeated inflammatory stimulation, such as frequent colds, acute and chronic nasopharyngitis, sinusitis, and repeated attacks of tonsillitis. Inflammation of these surrounding tissues and organs can spread to the nasopharynx, causing abnormal proliferation of the adenoids under repeated stimulation of local inflammation. Conversely, once the adenoids are repeatedly infected, related bacteria and viruses will remain inside, which can easily lead to upper respiratory tract infections. The two affect each other, forming a vicious cycle.

In addition, children suffering from allergic rhinitis, gastroesophageal reflux, active lymphoid tissue hyperplasia and other diseases may also increase the risk of glandular tissue hyperplasia and hypertrophy.

In childhood, if the adenoids proliferate and hypertrophy due to repeated inflammatory stimulation, even if they gradually shrink after puberty, they may not completely disappear after adulthood, leaving behind adenoid remnants.

Excessive enlargement of adenoids in children will block the posterior nasal passages, resulting in poor nasal ventilation. When sleeping at night, especially in the supine position, the soft palate muscles are in a relaxed state, and the uvula falls down, which together with the enlarged adenoids will block the posterior nasal passages, leading to airway stenosis, snoring, mouth breathing, and even respiratory interruption, which is sleep apnea. In more serious cases, it will cause suffocation and wakefulness, seriously affecting the oxygen supply and sleep quality at night.

There is a tube between the middle ear tympanic cavity and the nasopharynx, called the Eustachian tube, through which the middle ear communicates with the outside world through the nasal cavity. When the outside air pressure changes, the Eustachian tube opens up to allow gas to enter and exit, so that the pressure in the middle ear tympanic cavity can be balanced with the outside world. When the adenoids are enlarged, the enlarged glandular tissue may compress the nasopharyngeal opening of the Eustachian tube, causing the Eustachian tube to be unable to open normally, the tympanic cavity to be isolated from the outside world, and after the gas in the tympanic cavity is gradually absorbed, the outside gas cannot enter to replenish, thus forming a negative pressure inside the tympanic cavity, and tissue fluid exudation leads to effusion, which reduces the conduction efficiency of the middle ear sound transmission structure and causes conductive deafness. This is what we often call secretory otitis media. Earache and hearing loss in children after upper respiratory tract infection are often related to it. In addition, swelling of the nasal cavity and Eustachian tube mucosa during a cold will further aggravate the dysfunction of the Eustachian tube, and when flying, the rapid and drastic changes in the outside air pressure will cause a greater pressure difference between the inside and outside of the tympanic cavity. Therefore, secretory otitis media is more likely to occur when you have a cold or fly, and is also called aerotitis media.

The openings of the sinuses are in the nasal cavity, of which the maxillary sinus, the anterior ethmoid sinus, and the frontal sinus open into the middle nasal meatus, and the posterior ethmoid sinus and the sphenoid sinus open into the superior nasal meatus. The normal drainage route of nasal secretions is from the nasopharynx to the oropharynx, and the hypertrophic adenoid tissue can easily block this channel, causing drainage obstruction of sinus secretions, thus causing sinusitis. If the problem of adenoid hypertrophy is not resolved, this type of sinusitis will recur.

Long-term mouth breathing during childhood will significantly increase the amount of air breathed through the mouth, which will cause the hard palate to gradually move upward, the upper teeth to protrude forward, and the mandible to appear smaller due to developmental restrictions. This breathing pattern can also cause disuse stunted development of the nasal cavity, manifested as a collapsed nose bridge, and eventually form the so-called adenoid face, manifested as a high arched hard palate, uneven teeth, elongated maxilla, and wider eye distance. In addition, the reduction of the nasal cavity will also have an adverse effect on the development of the nasal septum, restricting its normal growth, thereby increasing the risk of nasal septum deviation.

Figure 1 Original copyright image, no permission to reprint

Snoring and apnea during sleep can cause hypoxia and decreased blood oxygen saturation, which can cause waking up. Repeated awakening and hypoxia during long-term sleep can affect children's intellectual development, learning, and height and weight development. In addition, repeated waking up can also lead to bedwetting and other conditions.

At present, the simplest and most accurate method for diagnosing adenoids hypertrophy is endoscopic examination. A soft electronic nasopharyngeal endoscope or a thin nasal endoscope is introduced through the nasal cavity, so that the adenoids can be visually seen, thereby observing the size of the adenoids, whether there is inflammatory reaction, congestion, and the degree of blockage of the posterior nasal cavity.

Figure 2 Original copyright image, no permission to reprint

If adenoids hypertrophy in children is new, the main symptoms are congestion and swelling. Drug treatment is the first choice, mainly local hormone drugs. Antibacterial, antiviral or hormone drugs can also be used to rinse the nasal cavity. If there is a bacterial or viral infection, oral antiviral and antibacterial drugs are needed. If allergic reaction factors are considered, antiallergic drugs need to be added.

For adenoids hypertrophy that is not responsive to drug treatment, if it persists within half a year or a year, or if a respiratory tract infection occurs less than half a month after a cold, and is accompanied by symptoms of adenoids hypertrophy such as secretory otitis media and snoring during sleep, and repeated drug treatment is required, surgical treatment, namely adenoidectomy, can usually be chosen.

At present, adenoidectomy in children is quite mature and minimally invasive. It can be performed under endoscope guidance using various physical instruments such as low-temperature plasma. The adenoids can be accurately removed while protecting normal tissues such as the Eustachian tube and occipital bone. The operation is small in scope, with minimal trauma and very little bleeding. Endoscopic adenoidectomy can be performed orally or nasally, and general anesthesia is generally used. The patient feels very little pain after the operation, which hardly affects normal life. Nasal constrictors are generally used to ensure nasal patency, and systemic antibiotics are used for 3-5 days to prevent infection.

Although adenoids are lymphoid tissues with immune functions, there are also immune tissues such as palatine tonsils, lymphoid tissues at the base of the tongue, and lymphoid tissues at the pharyngeal wall in the throat. Therefore, after the adenoids are removed, there are still many immune organs in the body that can replace the adenoids, and clinically, no cases of low immune function due to adenoids removal have been found. However, for children with impaired immune function, careful consideration should be given when deciding to remove the adenoids.