Adenoids

Adenoids (adenoid vegetations) - hypertrophy of the pharyngeal tonsil, which occurs under certain circumstances. Observed more often in children aged 2-10 years.

The pharyngeal tonsil as a part of the lymphoid glandular ring of Valdeier-Pirogov, possessing all the properties of immunocompetent organs, performs an important protective and immunological function when the organism adapts to environmental factors.

[1], [2], [3]

Epidemiology

Adenoids diagnose more than 90% of children of early and preschool age. In the absence of appropriate treatment of adenoiditis as a response to any inflammatory process of the upper respiratory tract, they relatively quickly increase in size, leading to a sharp disruption of nasal breathing and the development of concomitant diseases of the ENT organs, as well as other organs and systems of the body.

Chronic adenoiditis, accompanied by hypertrophy of the pharyngeal tonsil, is affected mainly by children from 3 to 10 years (70-75%), other diseases occur at older ages. Hypertrophy of the pharyngeal tonsil can occur in mature, elderly and even old age, but these age categories fall on average not more than 1% of cases.

[4], [5], [6], [7], [8], [9], [10], [11],

Causes of the adenoids

In young children, hypertrophy of adenoid tissue up to a certain age can be attributed to a physiological phenomenon that reflects the formation of a protective system in the path of penetration of microorganisms from the air stream into the upper respiratory tract.

Being part of a single barrier structure, adenoid tissue first reacts to the infectious effect by mobilizing compensatory possibilities. Over time, the process of physiological regeneration of lymphoid tissue is disrupted, and the number of atrophied reactive and then regenerating follicles is gradually increasing.

The causes of adenoids are varied, but more often they are based on an infection that is introduced from the outside (for example, with the milk of a mother infected with staphylococcus) into the amygdala parenchyma and the protective hypertrophy that causes it. Often the rapid growth of adenoids provokes childhood infections (measles, scarlet fever, whooping cough, diphtheria, rubella, etc.). In 2-3% of cases, adenoid vegetations can be infected with MBT in children with tuberculosis of different localization. A specific role in the emergence of adenoids can play a syphilitic infection. Thus, A. Marfan from 57 infants with a clinically established diagnosis of "adenoid vegetations" in 28 found the presence of congenital syphilis, and in 11 children the presence of this disease was determined as very likely. However, most often hypertrophy of the pharyngeal tonsil and developing chronic adenoiditis occur with lymphatic diathesis, which is characterized by systemic morphological and functional changes in lymphatic organs, manifested by absolute and relative lymphocytosis in the blood, enlarged lymph nodes and lymphoid formations of the nasopharynx. The latter circumstance favors the development of the pharyngeal tonsil infection and its further hypertrophy. Often with lymphatic diathesis, an increase in the thymus gland is found. As Y. Veltishchev (1989) notes, children suffering from lymphatic diathesis have a large body weight, but pasty, with a reduced resistance to infection. They are pale, with tender, easily injured skin, with cervical micro-pole, hypertrophied lymphoid formations of the pharynx, more and more often pharyngeal tonsils. They often have acute respiratory diseases, tonsillitis, otitis, tracheobronchitis, pneumonia, the stridor is easily developed. Often adenoids in such children are combined with anemia and thyroid dysfunction. There are cases of sudden death of children with lymphatic diathesis, which is associated with the characteristic for this type of diathesis insufficiency of the sympathetic-adrenal system, hypofunction of the adrenal cortex. At the same time, the nearest relatives show adenoids, chronic tonsillitis and other signs of hyperplasia and insufficiency of the lymphatic system.

[12], [13],

Risk factors

Predisposing factors for hypertrophy of adenoid tissue may be the age-related imperfection of immunological processes, inflammatory diseases of the pharynx, various childhood infectious diseases and increased allergization of the child's organism due to frequent acute respiratory viral diseases, endocrine disorders, hypovitaminosis, constitutional abnormalities, fungal invasion, adverse social and living conditions, radiation and other kinds of influence, which reduce the reactivity of the organism. The increase in adenoids is one of the manifestations of the organism's adaptation to the changed conditions in response to a significant functional tension as a result of frequent inflammatory processes. One of the causes of hypertrophy of the pharyngeal tonsil is considered to be disorders in the system of cytokines serving as immune regulators, in particular the inflammatory process along with the hypofunction of the cortical layer of the adrenal glands.

[14], [15], [16], [17], [18]

Pathogenesis

With nasal breathing, the first solitary lymphadenoidal formation located on the path of inhaled air containing antigen-forming elements and a number of atmospheric hazards is the pharyngeal tonsil (BS Preobrazhensky and A. Kh. Minkovsky considered it more correct to call this lymphadenoid formation "nasopharyngeal tonsil") or adenoid vegetation (pharyngeal tonsil, or 3rd amygdala). The normal pharyngeal tonsil has a thickness of 5-7 mm, a width of 20 mm and a length of 25 mm. For the first time in man, the third amygdala was discovered by J. Cermak in 1860, and G. Lushka described the clinical picture of chronic hypertrophic adenoiditis in 1869 and Mayer in 1870. It was Mayer who called the pathologically hypertrophic pharyngeal tonsil "adenoid vegetation."

Macroscopically it is represented in the form of rolls located along its length, between which there are furrows. Furrows end in the back, converging at one point, forming a kind of bag, which, according to the views of G. Lushka, is the rudiment of the once existing pituitary canal. The pharyngeal tonsil is well developed only in childhood. At birth, the pharyngeal tonsil in appearance can be different aspects. So, L.Testut distinguished three types of pharyngeal tonsils in newborns - a fan-shaped with small lymphoid rollers, a type of large lymphoid rollers (circum-valata) and a type with additional granules located on the surface of lymphoid rollers.

Adenoid vegetations in childhood appear soft and elastic, but eventually they become denser because part of the lymphoid tissue is replaced by connective tissue, which is the beginning of the process of their involution. The pharyngeal tonsil is richly vascularized, the mucous glands located in them secrete a large amount of mucus containing leukocytes, lymphocytes and macrophages. From the age of 12, the pharyngeal tonsil begins to progressively decrease, and by 16-20 years only small remains of the adenoid tissue are usually retained, and in adults their atrophy often occurs. When there are pathological changes in the pharyngeal tonsil, it increases due to hyperplasia, i.e., true hypertrophy of the lymphadenoid formations. Therefore, with hypertrophy of the pharyngeal tonsil, it retains the same morphological structure as the normal tonsil, but with certain characteristics characteristic of chronic inflammation.

Morphologically the pharyngeal tonsil is represented in the form of a pale pink formation, located on a wide base in the area of the dome of the nasopharynx. With hyperplasia, it can reach the front of the khohan and the opener, posteriorly the pharyngeal tubercle, lateral pharyngeal pockets, and nasopharyngeal openings of the auditory tube. Usually, the size of the hypertrophic pharyngeal tonsil is subdivided according to the degrees determined visually in the posterior rhinoscopy:

• I degree of hypertrophy (small size) - lymphadenoid tissue covers the upper third of the opener;
• II degree (medium size) - the lymphadenoid tissue covers the upper 2/3 of the opener (the level of the posterior end of the middle nasal shell);
• III degree - covers completely the khoni (the level of the posterior ends of the inferior nasal concha). In addition to the basic, solitary lymphadenoidal formation located in the dome of the nasopharynx, the lateral formations arising as a result of hypertrophy of the follicular apparatus of the mucous membrane are of great clinical importance. They often fill the pharyngeal pockets and the mouth of the auditory tube (tubal tonsils).

The surface of the pharyngeal tonsil is covered with the same mucosa as the other lymphadenoid formations. The crypts and the rest of the nasopharynx are covered with multilayered ciliated epithelium. With hypertrophy and inflammation of the mucous membrane that covers the pharyngeal tonsil, it acquires a bright pink or red color, sometimes with a bluish tinge, can be covered with mucopurulent discharge, abundantly flowing down the back wall of the pharynx. The negative role of adenoids is usually not limited to the violation of nasal breathing, but is also due to the fact that with hypertrophy of the pharyngeal tonsil there is a disturbance of blood circulation in the nasal cavity and nasopharynx, which can cause stagnant phenomena not only in the nose and paranasal sinuses (as a rule), but also in the pituitary-selly region, thereby violating the functions of one of the most important endocrine glands, closely related to the hypothalamus and other endocrine systems of the body, the pituitary gland. Hence - various somatic and psychoemotional disorders of the developing child's organism.

[19], [20], [21], [22], [23], [24], [25],

Symptoms of the adenoids

The main symptoms are a violation of nasal breathing and a persistent rhinitis. Adenoids in most children form a characteristic type of person (habitas adenoideus): apathetic expression and pallor of the skin, half-open mouth, flattening of nasolabial folds, small exophthalmos, drooping of the lower jaw. The formation of facial bones is disrupted: the dentoalveolar system, especially the alveolar process of the upper jaw with its narrowing and wedge-shaped anteriority, develops incorrectly; expressed constriction and high standing of the sky (Gothic sky - hypsystaphilia); incorrectly developed upper incisors, they protrude considerably forward and are randomly arranged; early there is tooth decay; a high standing hard sky leads to a curvature of the nasal septum and narrowness of the nasal cavity.

Children are slowed by growth, speech formation, they lag behind in physical and mental development. The voice loses sonority, there is a nasal congestion due to occlusion of the nose from the side of the khohan ("closed nasal"), the sense of smell is reduced. Increased adenoids interfere with normal breathing and swallowing. Nose functions are disrupted, sinusitis develops. Discharge from the nose with a persistent runny nose cause irritation of the skin of the vestibule of the nose and nasolabial area, and frequent swallowing of discharge is a violation of the gastrointestinal tract.

Prolonged oral surface and frequent breathing causes the development of a difficult cell ("chicken breast"), anemia. Sleep restless with an open mouth, accompanied by snoring. Dissipation, weakening of memory and attention are reflected in school performance. Continuous inhalation through the mouth of untreated cold air leads to the development of angina, chronic tonsillitis, laryngotrahebronchitis, pneumonia, less often to disruption of the cardiovascular system. Stagnant changes in the mucous membrane of the nasal cavity with violation of aeration of the paranasal sinuses and outflow of secret from them contribute to their purulent lesion. Closure of the pharyngeal mouth of auditory tubes is accompanied by a decrease in hearing by a coked type, the development of recurrent and chronic diseases of the middle ear.

Simultaneously, the general condition of children is disturbed. They note irritability, tearfulness, apathy. There is a malaise, pallor of the skin, decreased nutrition, increased fatigue. A number of symptoms are caused not only by a violation of breathing. They are based on a neural-reflex mechanism. These are psychoneurological and reflex disorders (neuroses), epileptiform seizures, bronchial asthma, bedwetting (enuresis), an obsessive paroxysmal cough, a tendency to spasm of vocal folds, vision damage, and choreal movements of facial muscles.

The overall immune reactivity decreases, and adenoids can also become a source of infection and allergization. Local and general disorders in the child's body depend on the duration and severity of the difficulty of nasal breathing.

In adenoids that fill the entire arch of the nasopharynx and prevent free nasal breathing, i.e., excluding the resonator and lantern functions of the nasal cavity, there is a violation of phonation. Pronouncing the consonants "M" and "H" is difficult, they sound like "B" and "D". This pronunciation of "nasal" vowels has been termed closed nasal, in contrast to open nasal congestion arising from paralysis of the soft palate or its anatomical deficit (cicatricial disfigurement, cleft palate, etc.).

The effect of adenoids on the auditory tube - obturation of the nasopharyngeal opening, hyperplasia of the tubal tonsil, infection of the mucous membrane of the auditory tube (chronic eustachiitis, tubo-otitis) in the vast majority of cases leads to periodic or constant hearing loss, which causes a delay in the development of the child, his absent-mindedness, and inattention. Children of an early age, because of the deafness of the tube genesis, can hardly master speech, which they often distort.

Persistent thick viscous discharge from the nose causes irritation and maceration of the skin of the upper lip, its puffiness and eczematous lesion of the skin of the vestibule of the nose.

In "adenoid" children, constant breathing through the mouth causes various anomalies in the development of the facial skeleton. Especially noticeable is the shape of the upper jaw. There is a narrowing and elongation anteriorly, which gives it a wedge-like shape. The alveolar process and teeth are protruded forward and beyond the arch of the lower jaw, which causes the upper teeth to cover the vestibular surface of the lower teeth (the so-called upper prognathia), which leads to an abnormal bite. The firm sky, continuing to develop, extends into the cavity of the nose in the form of a deep depression resembling a vault of a Gothic cathedral ("gothic" sky). At the same time, the lower jaw (microgenia) lags behind in development, which further emphasizes the deformation of the facial skeleton and increases the bite violation.

With not sanitized adenoids in time, complications that are manifested by numerous violations of the child's somatic and mental development, as well as many violations of the functions of the sensory organs and internal organs, are unavoidable. However, numerous clinical observations have established that there is no correlation between the magnitude of adenoids and the frequency, diversity and severity of complications. Often, small adenoids can provoke significant complications from various organs and systems. This phenomenon is explained by the fact that there are small but numerous abscessing follicles in the parenchyma of the adenoid vegetation, which, in view of the rich blood supply and lymph drainage, is not only contaminated by nearby anatomical organisms but also by organs and systems located far beyond the nasopharynx.

Hypertrophy of adenoids is a reversible process. During puberty, they undergo reverse development, but the complications that have arisen remain and often lead to disability.

[26], [27], [28]

Stages

There are three degrees of hypertrophy of the pharyngeal tonsil:

• I degree - adenoid tissue occupies the upper third of the nasopharynx and covers the upper third of the opener;
• II degree - adenoid tissue occupies half of the nasopharynx and covers half of the opener;
• III degree - adenoid tissue occupies the entire nasopharynx, covers the opener completely, reaches the level of the posterior end of the inferior nasal shell; significantly less enlarged adenoids protrude into the lumen of the oropharynx.

[29], [30], [31], [32]

Complications and consequences

Among the complications most often chronic, often aggravated adenoiditis, acute inflammation of the tonsils, laryngotracheitis and pneumonia, catarrh of the auditory tube, tubootids, acute purulent otitis media. Young children do not know how to cough up sputum, which enters the throat part of the pharynx from the nasopharynx, so they swallow it. Often because of swallowing infected mucus, they have abnormalities of the gastrointestinal function.

Often, eye complications in the form of blepharitis, conjunctivitis, ulcerative keratitis.

Often, adenoidal lesions lead to disorders of skeleton development that are ricket-like in nature: a narrow "chicken" breast, kyphosis and scoliosis of the spine, deformity of the lower extremities, etc. These changes are associated with a frequent violation in adenoids of metabolic processes associated with hypovitaminosis D.

Hyperplasia of the pharyngeal tonsil is usually accompanied by a chronic inflammation of its parenchyma, but the accumulation of pathogenic microorganisms in its grooves greatly aggravates the inflammatory process, turning the pharyngeal tonsil into a pus-impregnated sponge. This sluggish current inflammation is called chronic adenoiditis; it significantly complicates the course of adenoidism in children and most often leads to various purulent complications.

The inflammatory process from the nasopharynx easily spreads to the pharynx, larynx and bronchi, especially with acute catarrh and frequent and long-lasting inflammatory diseases of the upper respiratory tract. The flow of mucopurulent discharge into the larynx causes persistent cough, especially at night. Regional lymph nodes (cervical, submandibular and occipital) are often significantly enlarged. Periodically occurring exacerbations of chronic adenoiditis are accompanied by an increase in body temperature, scraping local pain in the nasopharynx, an increase in mucopurulent discharge, irradiation of pain to the base of the skull, occiput, orbit. The pharyngeal tonsil, already hypertrophied, sharply increases, completely obturating the choana. The general condition of the child in such cases is significantly deteriorating. The child becomes sluggish, irritable, often crying because of pain in the nasopharynx, loses appetite, often during eating, he vomits.

Another complication associated with nidus in adenoid infection is acute adenoiditis, which is a retro-nasal or nasopharyngeal angina. In some cases, this complication proceeds according to the type of catarrhal inflammation, in rare cases - according to the type of follicular sore throat. The disease occurs, as a rule, in young children and begins suddenly with a high body temperature (39-40 ° C). At the same time there is a complete obstruction of nasal breathing, pain in the ears and paroxysmal cough at night. Acute adenoiditis can occur spontaneously, in the absence of pathological hyperplasia of the pharyngeal tonsil, but more often it is the infection of the amygdala with this hyperplasia that causes the emergence of an acute inflammatory process in it. Symptoms, usually the same as with exacerbation of chronic adenoiditis, the difference is only in the severity of the inflammation and an even worse overall condition, while the regional lymph nodes increase and become painful. Allocations from the nasopharynx become abundant and purulent. The child literally chokes on them and, unable to cough up and spit, swallows them, which often causes acute inflammation of the mucous membrane of the stomach and dyspeptic disorders. The presence in childhood of a shorter and wider auditory tube contributes to infection in the middle ear, especially if the parents are trying to teach the child to blow his nose. The increase in pressure in the nasopharynx with these attempts facilitates the entry of a purulent discharge into the middle ear, and acute purulent otitis media develop.

Acute adenoiditis, if there were no complications with it, ends, like ordinary sore throat, on the 3-5th day of recovery with appropriate intensive treatment.

Another group of complications are reflex disorders, which, according to AG Likhachev (1956), can originate from the nerve receptors of the pharyngeal tonsil or occur as a result of concomitant changes in the nasal mucosa. Histological studies carried out by different authors in the middle of the 20th century established that the pharyngeal tonsil is provided with numerous pulp and nonfatty nerve fibers, as well as receptor devices that end both in the stroma of the tonsil and in its parenchyma. These nerve formations, reacting to the air flow passing through the nasopharynx, play an important role in the morphological development of the entire anatomical region of the upper respiratory tract, as they are closely linked by means of vegetative structures with the hypothalamus, pituitary gland and other subcortical nerve centers that play an important role in trophic support of the organism and reflex regulation of its functions.

Reflex disorders can include night incontinence, headaches, asthmatic attacks, laryngospasm, choreopodobnye contractions of the face, resembling arbitrary children's grimaces, etc.

Neuropsychiatric disorders in "adenoid" children, such as memory loss, slowing of intellectual development, constant inhibition and drowsiness, violations of attention fixation, are caused by the pathological effect of adenoid vegetation on the pituitary gland, which has close connections with the pharyngeal tonsil, not only mediated through neural formations, but also direct due to the presence in children of the embryonic craniopharyngeal canal, originating in the so-called Lutka bag and leading directly to the pituitary gland. Through this channel, vascular connections are carried out with the anterior lobe of the pituitary gland responsible for the somatic development of the organism. Hypofunction of this lobe leads to a child's lag in growth and puberty. The removal of adenoids compensates for this deficiency and leads to the elimination of most of the reflex disorders associated with the niches.

[33], [34]

Diagnostics of the adenoids

A child with a hypertrophic pharyngeal amygdala is recognized by a characteristic appearance.

And anamnesis is an indication of frequent respiratory-viral diseases with protracted coryza and subsequent subfebrile condition, a progressive violation of the general condition of the child with the defeat of other ENT organs.

Physical examination

The dimensions and consistency of adenoids are determined with posterior rhinoscopy and by finger examination of the nasopharynx. The degree of adenoid enlargement is refined with lateral radiography of the nasal cavity and nasopharynx.

[35], [36], [37], [38], [39]

Laboratory research

Clinical analyzes of blood and urine, bacteriological examination of nasopharyngeal discharge on microflora and sensitivity to antibiotics, cytological examination of prints from the surface of adenoid tissue.

Instrumental research

Direct detailed examination of the nasopharynx is performed by the method of posterior rhinoscopy, in which the adenoid vegetations are visualized as irregularly shaped formations with a wide base located on the nasopharynx arch. They are 4-6 longitudinal crevices, of which the deepest is located in the middle. Less commonly encountered is an expansion with a spherical surface, on which separate deep pockets are marked.

Adenoid vegetations in children are characterized by a soft consistency and pink color. In adults, they are usually somewhat denser and paler. In rare cases, there are sclerosized, very dense formations. Visible mucous discharge, filling the nasopharynx and nasal passages, swelling, or hypertrophy of nasal concha. After anemia of the mucous membrane of the nasal cavity during phonation with anterior rhinoscopy, one can see how the adenoid growths move along the posterior wall of the pharynx. Indirect signs of adenoids are enlarged palatine tonsils and especially hypertrophic lymphoid follicles of the posterior pharyngeal wall. Characteristic limitation of mobility of the soft palate.

Lateral radiography of the nasopharynx is an objective method of determining the degree of hypertrophy of the adenoid tissue, which also allows to reveal the features of the structure of the nasopharynx, which has definite value in surgical intervention. When it is difficult to conduct a posterior rhinoscopy in children of early age, finger research of the nasopharynx is widely used.

In histological examination, adenoids consist of a reticular connective tissue, the loops of which are made by lymphocytes. In the embryonic centers of the follicles, lymphocytes are seen in different stages of karyokinetic fission. The surface of the adenoids is covered with a multilayer cylindrical ciliated epithelium. In some areas, the epithelium is permeated with emigrating lymphocytes.

Differential diagnosis

Differential diagnosis of adenoids is a very important step in the examination of the patient, since the nasopharynx is the area in which numerous voluminous diseases, principally different from adenoids, can develop. Applying to some of the non-operative or surgical methods used in adenoids can lead to irreparable consequences. To differentiate adenoids follows from all diseases of the nasal cavity, accompanied by difficulty in nasal breathing, mucopurulent discharge from the nose and nasopharynx, from voluminous benign and malignant nasopharyngeal tumors, specific granulomas, congenital anomalies of the nose and nasopharynx (for example, atresia of the khohans). Particular attention should be paid to recurrent adenoids, especially in adults. In these cases, the examination of the patient should be conducted in the direction of eliminating the tumor process (inverted papilloma, epithelioma, sarcoma), for which a biopsy is performed before the next surgery.

Treatment of the adenoids

Adenoids are treated for the purpose of restoring free nasal breathing, preventing the development of concomitant diseases of the ENT organs, internal organs and body systems caused by frequent diseases of the upper respiratory tract and prolonged disruption of nasal breathing.

Indications for hospitalization

Need for an operation of adenotomy.

Non-drug treatment of adenoids

KUF tube to posterior wall of pharynx and endonasal, helium-neon laser action on adenoid tissue, diathermy and UHF on regional posterior, occipital and occipital lymph nodes, irrigation therapy (so-called "nasal douche") for the length of elimination of antigens from the mucous membrane of the nasal cavity and nasopharynx with the use of mineral water, nasal sprays "Aqua Maris" and "Physiomer", ozonotherapy, oxygen cocktails, mud therapy. Sanatorium treatment (climatic and balneogrased resorts during the warm season): vacuum hydrotherapy with sea undiluted and iodide-bromine water, mud solution, inhalation therapy after washing with nasopharynx with carbonic acid, mud, phytoncides, vegetable oils, endonasal mud electrophoresis, phototherapy (for example , laser radiation of the nasopharynx through the light guide or the nasal cavity).

Medication for adenoids

Homeopathic lymphotropic medications: umcalor, tonzigon, tonsilotrene, baby-teens at age dosage according to various schemes for 1-1.5 months. The effectiveness of lymphomyositis in adenoids has not been proven.

Surgical treatment of adenoids

Adenotomy, cryo-, laser- and ultrasonic destruction of adenoid tissue.

Treatment of adenoids should be comprehensive, combining the methods of local and general effects, especially in neglected cases, when an inflammatory process develops in the lymphadenoid tissue, and somatic and psycho-intellectual disorders are noted. Such children, according to testimony, should be examined by a pediatrician, child psychotherapist, endocrinologist, internist, surdologist, phoniatrist and other specialists in accordance with psychosomatic and functional impairments.

Treatment of adenoids is mainly surgical (adenotomy and adenectomy, the difference between these types of surgery is that when the adenotomy is removed, only the hypertrophied pharyngeal tonsil itself, and for adenectomy, the remaining lymphoid tissue that is accessible to removal on the side walls of the nasopharynx), especially in adenoids II and III degree.

When is operative treatment of adenoids shown?

Adenotomy is carried out at any age if there are appropriate indications.

In infants, surgical treatment of adenoids is mandatory for violations of nasal breathing, with noisy breathing during sleep (especially when there is a breath of breath), with difficulty sucking (the baby leaves the chest to "take a breath" or even refuse it). The operation is also indicated for repeated adenoiditis, salpingotitis, tracheobronchitis, etc. In children of this age group, who have frequent otitis media, long periods of subfebrile condition, which can not be explained by other causes, long periods of septicemia in the absence of other significant foci of infection (eg, chronic tonsillitis ), the phenomenon of neurotoxicosis (seizures, meningism, changes in somatic reflexes), adenotomy is allowed even in the period of exacerbation of chronic adenoiditis under the "cover" of the corresponding anti bacterial preparations.

Children aged 5-7 years are subject to surgical treatment for adenoidal origin of obstruction of nasal breathing, violation of phonation, inflammatory diseases of the middle ear and their complications; Adenotomy at this age is also produced with cervical adenitis, lymphatic fever, or subfebrile condition of unclear etiology, recurrent adenohydalitis, rhinitis, sinusitis, eye infections, laryngotraheronritis, gastrointestinal disturbances, facial skeletal and thoracic deformities, reflex disorders (larynx spasms and bedwetting , seizure convulsive cough, headaches, etc.).

Adenotomy in adults is made even in cases when the lymphadenoid tissue of the nasopharynx is concentrated around the mouths of the auditory tube and prevents recovery in catarrhal and purulent otitis, rhinosinusitis, chronic bronchopneumonia.

Some foreign authors recommend that patients of all ages (in the presence of adenoids) who underwent operative treatment of adenoids of anthrocellotomy or mastoidectomy for a more favorable course of the postoperative period of the main operative intervention be performed. This applies equally to surgical interventions on the paranasal sinuses.

Contraindications

Adenotomy is not produced in cases where the pharyngeal tonsil, even if it is enlarged, does not cause the phenomena of adenoidism and complications described above. Surgical treatment of adenoids is not performed in the presence of local and general inflammatory processes of banal etiology (acute adenoiditis and tonsillitis, adenovirus infection of the upper respiratory tract, acute rhinitis, etc.). Operative intervention is performed 2-3 weeks after the completion of these diseases. Surgical intervention does not produce during epidemics of contagious diseases, for example, influenza, as well as tuberculosis in the active phase, the presence of foci of infection in the dentoalveolar region, seropositive syphilis, decompensated states with heart and kidney disease, hemophilia. Operative treatment of adenoids is postponed in other diseases that are amenable to effective treatment. Removal of adenoids with congenital defects of the soft and hard palate (cleft), as well as with pronounced atrophy of the mucous membrane of the pharynx, the pre-oesophageal state and the lake lead to aggravation of functional and trophic disorders of the underlying disease.

[40], [41], [42], [43]

How is the surgical treatment of adenoids?

Before the surgical treatment of adenoids, great attention must be given to preoperative preparation, which, in accordance with generally accepted rules, includes a number of measures (unfortunately, these rules are often not completely observed and preparations for surgical treatment for adenoids are carried out according to the "shortened program ", Which often leads to serious, sometimes fatal complications):

1. carefully collect anamnesis, find out whether the child has recently suffered from any infectious diseases, whether he has not been in contact with sick children in recent weeks or whether he was in an epidemically dangerous environment; Does the child suffer from increased hemorrhage, ascertain the hereditary characteristics;
2. conduct a number of examinations (chest radiography, blood tests (general clinical and haemostatic indicators), urine, serological tests for tuberculosis and syphilis and, according to testimony, other studies, examine swabs from the pharynx for Carrier diphtheriac;
3. the child is examined by a pediatrician to identify contraindications to surgical intervention, a dentist and, according to testimony, other specialists;
4. if the operation is planned under general anesthesia, the day before the child is examined by an anesthesiologist-resuscitator.

Before the surgery, many ENT pediatricians recommend the use of local preventive antiseptic treatment to prevent postoperative purulent-inflammatory complications. For this 3-4 days before surgery, the child is prescribed 3% protargol solution or 20-30% solution of sulfacyl sodium (Albucida) in the form of drops in the nose, as well as 1 week before the surgery to improve the haemostatic parameters - vitamin C, calcium gluconate, etc.

Surgical treatment of adenoids should be equipped with everything necessary to assist with nasopharyngeal bleeding (a posterior tamponade of the nose, a ligation of the external carotid artery), asphyxia (tongue-tie, sets for intubation and tracheotomy), pain shock and collapse (a set of medications , stimulating the activity of the cardiovascular and respiratory systems, the pituitary-adrenal cortex system that increase blood pressure) in agreement with the reanimatologist.

For adenotomy, the following surgical instruments are needed: the rotator, the tongue, the Beckman adenotomes of two sizes, chosen according to the rule of VI Voyachek (the volume of the nasopharynx, its width is equal to the two folded lateral surfaces of the distal phalanges of the first fingers of the hands), Lucas nasal forceps, long curved scissors and nasopharyngeal forceps of the Lube - Barbon type for infants.

To carry out surgery under general anesthesia, appropriate means for intubation anesthesia are needed.

It is recommended to wrap it tightly in the sheet before immobilization of the extremities before the operation. The child is seated on the left thigh of the assistant, who covers the legs of the child with his legs, with the right hand - the baby's breast, holding his left hand, and fixes the right hand. Left hand fixes the child's head.

Anesthesia

To thoracic children and children till 2-3 years operative treatment of adenoids is made without any anesthesia in out-patient conditions. After 2-3 years, some authors recommend to conduct short-term mask anesthesia with ether. Older children and adults undergo an application anesthesia by 3-4 times lubricating the posterior sections of the nasal mucosa and the nasopharyngeal arch with 1-3% solution of dicaine or 5-10% with a solution of cocaine. Especially carefully anesthetize the posterior end of the opener. Anesthetize also the posterior wall of the nasopharynx and the nasopharyngeal surface of the soft palate. If, for one reason or another, local anesthesia is not possible, the operation is performed under intubation anesthesia.

[44], [45], [46], [47], [48]

Adenotomy technique

Adenotomy consists of several stages:

1. After squeezing the tongue downward with an angled spatula, the adenotome ring is inserted behind the soft palate, while the handle of the instrument is held so that the finger fixes the shaft of the adenotome; the adenotome ring is rotated 90 ° relative to the tongue surface, advanced along the spatula toward the posterior pharyngeal wall and, reaching the soft palate, a ring is formed behind it and unfolded in the opposite direction so that the blade occupies a horizontal position and the arch of the ring is directed toward the oral opening, ie, the cutting part - to the posterior wall of the pharynx.
2. The complex movement of the adenotoma (tilting the handle down, simultaneous movement of the ring up to the nasopharynx arch, pressing the ring arch to the opener without losing contact with the latter, erecting the ring with an emphasis in the angle formed by the vomer and the vault of the nasopharynx, slight inclination of the baby's head anteriorly) provide a "starting position"
3. Rapid movement along the nasopharynx arch, pressing the adenotome ring up and back, cut off the adenoids and along with the knife they carry them into the oral cavity and further into the kidney basin. During the cutting of the adenoids, the assistant or the surgeon himself tilts the child's head downwards, thus achieving a close contact of the blade with the object being removed and a smooth sliding of the knife along the back wall of the nasopharynx. Once the adenoids have been removed, the baby's head is immediately inclined downwards so that the blood does not get into the respiratory tract in case of profuse but short-term bleeding, but is poured through the nose and mouth. Sometimes the removed adenoids remain on the flap of the mucous membrane of the posterior pharyngeal wall and hang over the soft palate. They are seized with a clip and cut with scissors.
4. After some pause, determined by the surgeon, the whole procedure is repeated using an adenotomy of a smaller size to complete the "medial" adenotomy and remove the laterally located adenoid remnants that cover the nasopharyngeal openings of the auditory tube; for this adenotum is administered two more times. To prevent mental traumatization of the child, AAGorlina (1983) recommends, during the adenoid cutting stage, to lead the adenot from top to bottom in a zigzag manner, so that they are more completely removed;
5. Upon completion of the operation, the child is offered to blow his nose and check the quality of nasal breathing, and it should be borne in mind (which is established before the operation) that nasal breathing can not significantly improve due to rhinogenic causes (polyps of the nose, hypertrophic rhinitis, curvature of the septum and other). In addition, finger tests of the nasopharynx are performed to control the thoroughness of the adenotomy. Further, the remote adenoids are examined and compared with the picture in vivo. The removed adenoids should be shown to the parents of the child so that they can be sure of the quality of the operation performed, but they should also be warned that in rare cases, despite a well-done operation, relapses are possible.

[49], [50], [51], [52], [53]

Complications after adenotomy

Complications during and after adenotomy, although rare, can cause life-threatening abnormalities and cause significant difficulties in eliminating them.

The most common complication after adenotomy is bleeding, which occurs immediately after surgery or a few hours after surgery. Under all other favorable conditions, the cause of such bleeding is the incomplete removal of adenoid tissue, which may depend on the following circumstances: the mismatch between the size of the adenotome and the size of the nasopharynx, the insufficiently high position of the knife in cutting off the adenoids, which can be determined by the non-arcing of the ring to the opener and insufficiently pressing the blade upper-posterior wall of the nasopharynx arch, and also if the patient is lifted during cutting of adenoids. With this kind of bleeding, it is necessary to repeat the operation and carefully remove the adenoid tissue and all fragments of the mucous membrane on the back wall of the pharynx with a concactom. If bleeding continues, then it is necessary to perform a posterior tamponade of the nose or take other measures.

Complications from the middle ear (salpingoitis, catarrhal and acute purulent otitis media) are caused by tubal or hematogenous infection. Treatment usual.

Postoperative increase in body temperature to 37.5-38 ° C for no apparent reason is a frequent occurrence, lasting no more than 2 days. At a higher and prolonged temperature, it is necessary to suspect sepsis, diphtheria, pneumonia, exacerbation of pulmonary tuberculosis. Conducted activities should be aimed at establishing the cause of hyperthermia and its elimination.

Vomiting of blood can occur a short time after surgery, if during the removal of adenoids, it swallowed. Occurrence of this vomiting after a few hours indicates a renewed bleeding. Such a child should be immediately delivered to a hospital to determine the cause of this complication.

Sometimes there is a jammed adenotoma in the nasopharynx, manifested in the fact that it is impossible to finish the operation and bring the knife into the mouth. The reason for this is most often an excessive inclination of the head during the cutting of adenoids or abnormal standing of the anterior tubercle I of the cervical vertebra. In the first case, to start the knife out, the head is given the initial position. In the second case, if the adenotome removal fails, the head is given a slight inclination, and the obstacle in the path of the knife is cut by forced movement. There are also such incidents as the breakage of the ring (knife) and its jam in the nasopharynx. This happens in those cases where there is a material or structural defect in the ring or the end of the shaft of the adenotome to which the knife is welded. In such cases, without any haste, Mikulich's finger or clamp, Lube-Barbon forceps inserted into the nasopharynx, grope for the remaining metal object, grab it and carefully remove it. An unsuccessful adenotomy is immediately repeated or, if a nasopharynx injury was caused during removal of a foreign body that appeared during the operation, a second operation is postponed for 1 month.

Traumatic complications occur with rough surgery. For example, with a significant pressure of the adenotom on the back wall of the nasopharynx, the mucous membrane is deeply damaged and later there may be cicatricial nasopharyngeal stenosis. Synechia and scar deformations of the soft palate after adenotomy occur in children with congenital syphilis. Crooked neck and neck stiffness are rare and occur as a result of damage to the adenotome of the aponeurosis and prevertebral muscles with infection of damaged tissues and the development of an inflammatory cicatricial process. This complication occurs when, during curettage, the patient's head is not tilted forward and poorly fixed by an assistant, but on the contrary, the child sharply deflects it posteriorly, which significantly increases the natural cervical lordosis, the bulge of which falls under the blade of the adenotome. This complication gives itself out as the forced position of the child's head, which is characterized by the immobility and extensionality of the head. Cases of subluxation of the atlant are also described; the disease was called "nasopharyngeal torticollis," or Grisel syndrome, named after the French physician P.Grisel in 1930. The syndrome of nasopharyngeal torticollis is characterized by the shift of the atlas to the position of luxe-rotation, but because of the unilateral contracture of the prevertebral muscles. The child, operated on the eve of adenoids, wakes up in the morning with his head turned and tilted to one side. With deep palpation at the angle of the lower jaw, the child experiences acute pain. On the roentgenogram of the upper cervical vertebrae, the sign of the Atlantean-rotation-rotation is revealed. The use of antibiotics, decongestants, hydrocortisone, physiotherapy for several days leads to recovery.

The result of traumatizing the nasopharyngeal mucosa may be atrophic epipharyngitis, which occurs after repeated adenotomy, performed by different specialists for incorrect indications.

The results of the operation in most children are positive; nasal breathing is restored, existing inflammatory diseases of the upper respiratory tract are quickly eliminated, appetite is returned, physical and mental activity is increased, and the child's further physical and intellectual development is normalized. However, statistical data show that recurrences of adenoids occur in 2-3% of cases and, first of all, in children suffering from allergies manifested by atonic asthma, Quinck edema, urticaria, seasonal bronchitis, etc. As a rule, the recurrence of adenoids occurs when they are not completely removed and not earlier than 3 months after the operation, and is manifested by a gradual increase in the difficulty of nasal breathing and all other signs of adenoidism that were observed before surgery. Conducting an adenotomy under the control of vision under general anesthesia and using modern video-surgical methods dramatically reduces the number of relapses.

It should be borne in mind that in children after adenotomy, even with absolutely free nasal breathing, the habit of keeping the mouth open, especially at night, remains. To eliminate this habit with these children, special respiratory gymnastics courses, certain educational activities, sometimes tie the lower jaw with a handkerchief.

If the adenoid treatment for a child is performed on an outpatient basis, he is left in the medical institution for an hour (lying on the couch) during which the doctor or an experienced nurse periodically examines him to make sure that there is no bleeding and then goes home. At home, appoint bed rest for 2-3 days, exclude hot food and drinks for 7-10 days. In the following days, the child's physical activity is limited to 2 weeks, schoolchildren are released from classes for 2 weeks, from physical education for 1 month. Older children and adults after removal of adenoids are detained in the hospital for 3 days with the appointment of bed rest and, according to the indications, the corresponding symptomatic means. To alleviate nasal breathing and remove bloody crusts formed in the postoperative period, oily drops are prescribed in the nose 3-4 times a day.

[54], [55], [56]

Non-operative treatment of adenoids

This treatment of adenoids is only an auxiliary method, complementary to surgical treatment. Its effectiveness in developed adenoids is reduced only to a reduction in inflammatory phenomena and the preparation of the soil for a more favorable course of the postoperative period. At the earliest stages of adenoid sprouting (I degree), this treatment can yield positive results only with an integrated approach to it and especially when eliminating the cause of the disease. To do this, antiallergic and desensitizing treatment of adenoids is performed, strengthening of the body's immune functions, systematic hardening, sanitizing foci of infection, saturate the body with vitamins A and D and necessary for the harmonious development of the organism with microelements. Essential role in non-operative treatment is given to heliotherapy, UFO-therapy, and in recent years - to laser therapy.

Further management

Observation of the otolaryngologist, respiratory gymnastics and health-improving activities.

Prevention

Timely carrying out preventive vaccinations against the most common childhood infectious diseases, tempering the body, early diagnosis and rational treatment of inflammatory diseases of the upper respiratory tract and adenoiditis, increasing immunological resistance of the body.

[57], [58], [59], [60], [61], [62], [63],

Forecast

The prognosis depends on the general condition of the child, against which adenoidism developed. If the cause of adenoids was vulgar infection, then with its elimination and removal of adenoids, the disease stops. If the cause of hyperlasia of the pharyngeal tonsil is lymphatic diathesis, then with the removal of adenoids the systemic disease does not disappear, but can manifest similar changes elsewhere. The prognosis for the deformities of a person arising during a long course of the disease is determined by the age of the patient. If the removal of adenoids is carried out during the period of the continuing development of the skeleton, some correction of the shape of the face is possible, but this correction never reaches the limiting effect, and the pathomorphological changes that have arisen as a result of adenoids influence remain for life.

With timely diagnosis and adequate therapy, the prognosis is good in terms of persistent recovery of nasal breathing and prevention of the development of concomitant diseases of internal organs and ENT organs.

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