Adenoiditis

Adenoiditis (retronasal tonsillitis, chronic inflammation of the pharyngeal tonsil ) is an infectious-allergic process that develops as a result of a disturbance in the physiological balance between the macro- and microorganism, followed by a distortion of local immunological processes in the area of the pharyngeal tonsil.

Epidemiology

Adenoiditis is mainly observed in early childhood; if hypertrophy of the pharyngeal tonsil persists, acute retronasal tonsillitis may also develop in adults.

[ 1 ]

Causes adenoiditis

Acute adenoiditis usually develops against the background of acute respiratory diseases, with inflammation of the lymphoid apparatus of other parts of the pharynx.

The main etiologic factors of chronic adenoiditis include the current inflammatory process, immune response in the form of lymphoid tissue hyperplasia, immunoreactive state associated with increased bacterial contamination, and restructuring of the body due to past physical and immune reactions. The cause of acute adenoiditis is considered to be the activation of opportunistic microflora of the nasopharynx with weakly expressed antigenic properties. Under the influence of frequently recurring local inflammatory changes against the background of failure and imperfection of general immunological processes in young children, adenoids themselves gradually become a source of pathogenic infection, in their folds and bays they can contain abundant bacterial microflora and contribute to the development of recurring acute and chronic inflammation of the nasopharynx, which in turn cause a recurrent course of chronic otitis, tracheobronchitis, sinusitis and other diseases.

Pathogenesis

Chronic adenoiditis develops, as a rule, against an allergic background with weakened phagocytosis, a state of dysfunction of immune processes. Due to frequent infectious diseases, lymphoid tissue experiences significant functional stress, the dynamic balance of the processes of alteration and regeneration of the lymphoid tissue of the adenoids is gradually disrupted, the number of atrophic and reactive follicles increases as a manifestation of the stress of adaptation mechanisms in conditions of imbalance of immune cells.

Symptoms adenoiditis

Acute adenoiditis is observed mainly in children during the development of the pharyngeal tonsil as a complication of the inflammatory process in the paranasal sinuses and with various infections. If hypertrophied lymphoid tissue of the pharyngeal tonsil is preserved, acute adenoiditis can also develop in adults. Acute onset of the disease with hyperthermia, intoxication, and obsessive cough are characteristic. Patients complain of headache and pain deep in the nose, behind the soft palate when swallowing, radiating to the back of the nasal cavity and to the ears, accumulation of viscous sputum in the nasopharynx, sometimes a dull pain in the back of the head, a feeling of irritation, tickling and pain in the throat, hearing loss and even pain in the ears due to the spread of edema to the area of the Rosenmüllerian fossae, a sharp violation of nasal breathing, a dry obsessive cough. In infants, there is a sucking disorder, mucopurulent yellow-greenish discharge flowing down the back wall of the pharynx, an obsessive wet cough, hyperemia of the posterior palatine arches, the back wall of the pharynx with an increase in lymphoid follicles or lateral pharyngeal ridges. During posterior rhinoscopy, the pharyngeal tonsil is hyperemic, edematous, with a fibrinous coating, as in lacunar tonsillitis, its grooves are filled with mucopurulent exudate. The disease adenoiditis in children occurs with severe lymphadenopathy. Regional submandibular, posterior cervical and occipital lymph nodes are enlarged and painful. In young children, the disease can be accompanied by attacks of suffocation such as subglottic laryngitis. In older children, headaches, severe nasal breathing problems, pronounced nasal speech, hyperemia and swelling of the adenoid tissue, mucopurulent secretion, hyperemia and swelling of the mucous membrane of the posterior pharyngeal wall and nasal cavity are visible. In infants, the disease is severe, with severe intoxication, difficulty sucking, dysphagia syndrome, parenteral dyspepsia.

Indirect signs of inflammation of the pharyngeal tonsil include elongation and swelling of the uvula, posterior palatine arches, bright red strands on the lateral walls of the pharynx, and millet-like tubercles (clogged mucous glands) on the surface of the soft palate in infants and young children (Geppert's symptom).

Posterior rhinoscopy reveals hyperemia and swelling of the pharyngeal tonsil, plaque and viscous mucopurulent discharge in its grooves.

Acute adenoiditis usually lasts up to 5-7 days, has a tendency to relapse, can be complicated by acute otitis media, sinusitis, damage to the lacrimal and lower respiratory tract, the development of laryngotracheobronchitis, bronchopneumonia, and in children under 5 years of age - retropharyngeal abscess.

In chronic adenoiditis, patients are bothered by difficulty in nasal breathing, frequent runny nose, snoring and restlessness during sleep, hearing loss, persistent wet cough in the morning, subfebrile temperature, manifestations of intoxication and hypoxia, absent-mindedness, increased irritability, pale skin and visible mucous membranes, enuresis and other symptoms characteristic of hyperplasia of adenoid vegetations.

[ 2 ]

Stages

A distinction is made between acute and chronic adenoiditis. Acute adenoiditis is defined as retronasal tonsillitis. Chronic adenoiditis has various clinical and morphological variants depending on the predominant type of inflammatory reaction in the patient, the degree of allergization and immunological reactivity. Several classifications of chronic adenoiditis are known.

• Catarrhal, exudative-serous and mucopurulent.
• According to the nature of the inflammatory reaction of adenoid tissue, lymphocytic-eosinophilic with weak exudation, lymphoplasmacytic and lymphoreticular with serous exudate, and neutrophilic-macrophage variant of inflammation with purulent exudate are distinguished.
• Taking into account the degree of allergization and the state of immunity, the following forms of chronic adenoiditis are determined: adenoiditis with a pronounced allergic component, adenoiditis with a predominance of the activity of reactions of the humoral link of immunity (hyperimmune component), hypoimmune adenoiditis with insufficient functional activity of lymphocytes and purulent-exudative adenoiditis with increased activity of neutrophils and macrophages, decreased phagocytosis, increased killer activity of T-lymphocytes.
• According to the degree of expression of local signs of inflammation and damage to adjacent anatomical structures, compensated, subcompensated and decompensated adenoiditis; superficial and lacunar adenoiditis are distinguished.

[ 3 ]

Forms

Surgical diseases of tonsils and adenoids:

• J 35.1 Tonsil hypertrophy (enlargement of the tonsils).
• J 35.3 Hypertrophy of tonsils with hypertrophy of adenoids.
• J 35.8 Other chronic diseases of tonsils and adenoids.
• J 35.9 Chronic disease of tonsils and adenoids, unspecified.

Diagnostics adenoiditis

[ 4 ]

Physical examinations

X-ray of the nasopharynx.

[ 5 ]

Laboratory research

Cytological examination of smears from the surface of adenoid vegetation to determine the quantitative ratio of inflammatory cells, paying attention to the lymphocytic-eosinophilic reaction of the lymphoid tissue of the adenoids (lymphocytes, neutrophils, macrophages, plasma cells, fibroblast clusters). Immunological studies (determination of the amount of circulating immune complexes, IgA, IgM, in blood plasma, the number of B-lymphocytes and their subpopulations, etc.). Microbiological examination of smears from the surface of adenoid tissue for microflora and sensitivity to antibiotics.

[ 6 ]

Instrumental research

Posterior rhinoscopy, rigid endoscopy and fibroendoscopy of the nasopharynx.

Screening for adenoiditis

Digital examination of the nasopharynx in children (available at any stage of medical care).

[ 7 ], [ 8 ]

Differential diagnosis

Symptoms of acute adenoiditis may occur in the initial stages of diseases such as measles, rubella, scarlet fever and whooping cough, and when headaches are added - meningitis and poliomyelitis. In this regard, in all doubtful cases, it is necessary to closely monitor the development of the disease and, if necessary, make appropriate changes to the treatment plan.

[ 9 ], [ 10 ]

Treatment adenoiditis

The goals of adenoiditis treatment are to eliminate the bacterial focus in the parenchyma of the adenoid vegetations to prevent recurrent inflammation in the nasopharynx with spread to the nasal cavity, paranasal sinuses, middle ear, and tracheal tree.

[ 11 ], [ 12 ]

Indications for hospitalization

Urgent hospitalization for severe retronasal tonsillitis with severe intoxication and purulent complications (retropharyngeal abscess, etc.). Planned hospitalization for adenotomy.

[ 13 ], [ 14 ], [ 15 ], [ 16 ]

Non-drug treatment of adenoiditis

In acute adenoiditis, a tubular quartz and helium-neon laser are used endonasal and on the back wall of the pharynx, diathermy and electrophoresis of drugs on the regional lymph nodes. Sanatorium and spa treatment is a combination of local treatment methods with general treatment using natural physical factors of the resort. Endonasal electrophoresis of mud solution, phototherapy (laser action on the nasopharynx through a light guide or nasal cavity, NK laser on the submandibular zone).

In case of chronic adenoiditis, health-improving measures are taken (therapeutic breathing exercises, hardening, foot temperature-contrast baths), physiotherapy, helium-neon laser irradiation of adenoid tissue through the mouth and endonasal, mud therapy, cryooxygen therapy, ozone-ultrasound treatment, lymphotropic therapy (ultraphonophoresis of 5% ampicillin ointment or other drugs on the area of the upper cervical lymph nodes - regional for the pharyngeal tonsil).

[ 17 ], [ 18 ]

Drug treatment of adenoiditis

Acute adenoiditis is treated in the same way as acute tonsillitis. At the onset of the disease, they try to limit the development of inflammation and prevent the development of the suppurative process. If there is a fluctuation, the abscess is opened. Antibacterial, hyposensitizing detoxification, irrigation therapy, aerosol inhalations of antiseptic agents are carried out. Additionally, vasoconstrictor nasal drops or nasal sprays, irrigation therapy, nasopharyngeal disinfectants (silver proteinate, collargol, iodinol, 0.1% oxyquinoline solution in 20% glucose solution) are prescribed.

Organ-preserving treatment methods taking into account the participation in the regulation of humoral and cellular immunity at the local and systemic levels. Taking into account the significant role of the lymphoid tissue of the tonsils as an immune organ that forms the immune barrier of the mucous membrane of the upper respiratory tract, conservative organ-preserving therapy tactics for chronic adenoiditis in the early stages of the disease are followed. 3-4 times a year, cycles of complex therapy are carried out, including direct impact on the inflammatory process in the nasopharynx and general therapy aimed at strengthening the child's condition, correcting immunity, and stopping allergic manifestations.

General therapy includes detoxifying measures, immunomodulatory treatment, relief of allergic manifestations. Local treatment excludes irrigation therapy, the so-called nasal douche to eliminate antigens from the mucous membrane of the nasal cavity and nasopharynx using herbal and biological preparations, mineral water, antiseptics. Local therapy includes medicinal solutions and emulsions at a temperature of 37 C; rinsing the nasal cavity and nasopharynx with solutions of St. John's wort, calendula and propolis; injections of antiseptic drugs into the nasal cavity: aerosol vacuum therapy and aerosol inhalations of homeopathic preparations; irrigation with emulsions of Kalanchoe, propolis, eucalyptus; instillation of medicinal solutions and oils, immunomodulators into the nose; infusion of drops based on starch-agar gel into the nose. Widely used are tonic intranasal glucocorticoids fluticasone, sofradex in the form of nasal sprays. Immunotherapy is carried out using leukocyte interferon, lactoglobulin, thymus extract, levamisole. Etiotropic homeopathic drugs are prescribed internally: umckalor, lymphomyosot, tonsilgon, tonsilotren, nov-malysh in age-related dosage according to various schemes. A good therapeutic effect was noted when using a 15% solution of dimephosphone, instillations into the nasal cavity of a freshly prepared solution of superlymph (a drug for local cytokine therapy).

Measures to restore nasal breathing are mandatory (suction of nasal discharge in infants and young children, instillation of vasoconstrictor solutions, collargol or silver proteinate, soda-tannin drops. If complications are suspected, antibiotics are prescribed.

Nasal sprays containing vasoconstrictors should not be used in infants, as they may cause reflex laryngospasm or bronchospasm.

An obligatory component of complex conservative treatment is hyposensitizing therapy, vitamin therapy and immunorehabilitation taking into account the state of the immune status. Sanitation of other inflammatory foci is indicated.

Surgical treatment of adenoiditis

In case of persistent hyperplasia of adenoid vegetations with corresponding clinical symptoms, complications from the nasal cavity, paranasal sinuses, middle ear, tracheobronchial tree, development of secondary autoimmune diseases, frequent exacerbations of adenoiditis, failure of conservative treatment, adenotomy is performed with subsequent anti-relapse treatment.

Further management

Hardening, prevention of respiratory viral diseases, timely sanitation of the oral cavity, gargling with antiseptics.

[ 19 ]

Indications for consultation with other specialists

The presence of associated diseases of internal organs and body systems, endocrine disorders, allergic reactions, a thorough examination by a therapist before surgery.

Prevention

Removal of adenoids in cases of frequently recurring adenoiditis, implementation of health measures, timely sanitation of other foci of infection.

Forecast

Adenoiditis has a generally good prognosis. Timely diagnosis and rational therapy of acute tonsillitis of the pharyngeal tonsil helps prevent severe purulent complications. Outpatient observation and timely treatment of chronic adenoiditis in some cases eliminates the need for adenotomy, and most importantly, prevents the development of associated infectious and allergic diseases of internal organs and ENT organs.