Adenoids

ADENOIDS (from Greek aden- gland and eidos- form). Adenoid vegetations, adenoid growths represent proliferations of adenoid (more correctly lympho-adenoid) tissue of the nasopharynx. The mucous membrane of the pharynx and nasopharynx contains special inclusions having the appearance of nodules that elevate the mucosa in the form of small elevations (granules) and consist of adenoid tissue (see). These formations are called lymphoid follicles. In certain places, accumulations of the aforementioned lympho-adenoid tissue form larger structures designated as tonsils. The latter include the palatine tonsils, situated between the anterior and posterior palatine arches; the so-called lateral ridges, located in the lateral walls of the pharynx immediately behind the posterior arch; the lingual tonsils of the root of the tongue; and finally, the pharyngeal tonsil (tonsilla pharyngea), lying beneath the mucosa of the vault of the nasopharynx. All these follicular and tonsillar-type formations, taken together, participate in the formation of the so-called Waldeyer's pharyngeal lymphatic ring. The basis of adenoids, adenoid vegetations, is the pathological enlargement of the pharyngeal tonsil, and often of the lymphoid follicles of the nasopharynx due to hyperplasia of their tissue. Adenoids are most commonly observed in children in the latter half of the first seven years of life, but sometimes may appear earlier, for example, from the second year of life; by the time of sexual maturity, adenoids usually undergo involution (see below), but not always: they can often be found in adults and even in elderly people. The etiology of adenoids is not always uniform. In some cases, adenoid vegetations represent a manifestation of a general tendency of lymphatic tissue toward hyperplasia (the so-called status lymphaticus); this condition, classified as a constitutional anomaly, is often hereditary, which forms the basis of the hereditary transmission of a predisposition to adenoids in some families. Adenoids of this type may appear in children from the earliest childhood. On the other hand, inflammatory processes of the nasopharynx involving the pharyngeal tonsil and follicles play an important role in the origin of adenoids. Acute inflammations usually arise in connection with acute infectious diseases, especially measles, scarlet fever, diphtheria, whooping cough, and influenza, and manifest as acute catarrh of the mucosa with inflammatory hyperplasia of the lympho-adenoid tissue of the tonsils and follicles. Chronic inflammation may result from the transition to a chronic state of one of the above forms of acute inflammation or develops independently from causes not always entirely clear. In chronic inflammation, in addition to the phenomena of chronic catarrh of the mucous membrane, significant enlargement of the pharyngeal tonsil and follicles often occurs, giving the picture of adenoids. It is important to note that once inflammation has developed, adenoids act as a factor maintaining the inflammation, and the latter in turn promotes the growth of adenoids; a sort of circulus vitiosus results. Patho-anatomically, adenoids appear as a tumor-like mass having the appearance of a solid node sitting on a broad base in the region of the vault of the nasopharynx, or hanging in the form of a collection of separate (4-6) lobes arranged in the sagittal direction and divided by slit-like depressions, which gives such adenoids a resemblance to a rooster's comb. In addition to the aforementioned main mass of adenoids originating from the pharyngeal tonsil, smaller accessory adenoids originating from the follicles and located on the sides of the main mass may be observed; they may extend to the Rosenmüller's fossae and even into the openings of the Eustachian tubes (the so-called amygdala tubaria). The color of adenoids, depending on the degree of vascularity, can range from pinkish-gray to dark red. The consistency of adenoids in children, depending on the predominance of lymphoid tissue, is soft and succulent; at a later age, due to the reduction of lymphoid tissue and the proliferation of connective tissue, it is firmer. The size of the tumor-like mass of adenoids can vary greatly, and it should be borne in mind that the degree of pathological significance of adenoids does not always correspond to their size. In some cases, widely proliferated adenoids do not cause special pathological symptoms, and conversely, sometimes with small sizes of adenoids, sharply expressed pathological symptoms are observed. The microscopic structure of adenoids corresponds to the structure of adenoid tissue (see): the basis (stroma) consists of delicate reticular connective tissue forming a network with its fibers; in the loops of this network lie lymphoid cells (lymphocytes). In places, this lympho-adenoid tissue forms follicles, which are round bodies clearly distinguishable from the rest of the tissue by their finer and smaller-meshed reticular network and the denser arrangement of small lymphoid elements; the center of each follicle is distinguished by its light appearance because it consists of larger cells. The surface of this tissue is covered with a mucous membrane with stratified epithelium. The tissue of adenoids is usually rich in blood vessels, the network of which reaches the epithelial covering, so that even with slight contact with adenoids, bleeding often occurs. The above-described structure is found in those adenoids observed in childhood and of not long duration; with prolonged existence of adenoids, a gradual disappearance of lymphoid elements, atrophy of follicles, and subsequent proliferation and coarsening of the connective tissue basis occur, in connection with which adenoids decrease and become denser. Essentially, adenoids represent benign hyperplasias, but sometimes malignant neoplasms (sarcomas) may originate from them. During posterior rhinoscopy in a living person, adenoids appear as the above-described nodules, lobes, or papillary projections that, when of considerable size, close off the upper part of the posterior face of the NASAL SEPTUM.

A. Abricosov.

Clinical picture of adenoids. From a clinical standpoint, adenoids have been studied since W. Meyer (1873), who first described hypertrophy of the third (pharyngeal) tonsil as a special disease with a whole range of pathological manifestations. Already by virtue of their topographical position, hypertrophy of the tonsils, i.e., adenoids (see separate table, fig. 2), causes disorders in neighboring organs; but, besides the mechanical effect, it is necessary to acknowledge the influence of the pathologically altered tissue on the surrounding parts, since even with poorly developed A., the pathological signs can still be sharply expressed. The symptoms of the disease manifest, mainly, as conditions of the upper respiratory tract, especially of the nose, organ of hearing, voice, digestive tract, as well as in the form of a whole range of reflex phenomena from even very distant organs. The most frequent complaint with which patients come is - difficulty in breathing through the nose. Although with A. the mass of adenoid tissue never completely closes both choanae and even in the most severe cases the lower third of them remains free, complete nasal obstruction can occur due to the accumulation of abundant, thick and viscous mucus; the main cause of obstruction, however, is that in these cases there is always a disturbance of blood circulation in the nose and stagnant phenomena in it, which leads to relaxation of the tone of the cavernous tissue, to chronic swelling of the nasal mucous membrane and to hypertrophic changes in the tissue. The discharge of mucus accumulating in the posterior parts of the nose further impedes breathing. To the signs of chronic rhinitis is often added weakening of the sense of smell and taste, nasal bleeding, headaches, a nasal voice and change in the timbre of the voice. The inability to breathe through the nose leads the patient to constantly keep the mouth open, which in turn leads to relaxation of the muscles of the lower jaw: it hangs down, the nasolabial fold is smoothed out; for the same reason, incorrect growth of the facial skeleton and deformation of the bones occurs, the nasal cavity is often very narrow, the nasal septum is curved to one side, the hard palate assumes a high position, and the entire upper jaw is poorly developed, it seems to be compressed from the sides and lengthened, and in connection with this, the process of growth of teeth often proceeds incorrectly, very long incisors and canines are often encountered, and they are arranged in two rows. The protruding forward head and the listed signs give the face a special expression of mental underdevelopment and dullness and together bear the name of "external adenoidism". A very characteristic feature is the inability of children suffering from A. to blow their nose and to breathe deeply. A peculiar nasal tone in speech, especially in the pronunciation of consonants: g, k, h, m, n, or a lisp and snoring at night complete a very definite picture of the presence of A. in a child. From other nearby organs, the condition of the ears is particularly important. The blocked condition of the nose and nasopharynx leads to an inflammatory or edematous condition of the Eustachian tube and middle ear, which is accompanied by subjective noises, hearing impairment, a feeling of stuffiness in the ear and pains. Due to insufficient ventilation of the middle ear, the eardrum is often retracted and becomes cloudy, the auditory ossicles are restricted in their mobility. All these phenomena are accompanied by a sharp change in hearing, which sometimes reaches a significant loss of it, as a result of subsequent changes in the inner ear due to atrophy of the elements of the organ of Corti. Particularly dangerous for the ear is the tendency of the nasal mucosa to frequent exacerbations of inflammation, which easily complicates into acute otitis, which then often passes into a chronic form. It has been noted that in infectious diseases, the ears of children suffering from A. are to a greater extent in danger of becoming ill than the ears of normal children. Even with the mildest influenza-like illness, the ear first reacts with redness of the eardrum, so that in some children the ears become ill several times a year. The inflammatory process from the nasopharynx often spreads downward to the pharynx, larynx and bronchi, which is facilitated by breathing through the mouth; therefore, persistent cough is a common occurrence in such individuals. The unfavorable influence of A. can also extend to distant organs. With prolonged difficulty in breathing through the nose, deformation of the chest develops, consisting in expansion of its upper half and collapse of the lower part. From the side of the digestive tract, sometimes disturbance of gastric activity, vomiting, constipation or diarrhea, attacks of appendicitis, poor appetite, difficulty in swallowing, disturbance of the chemistry of digestion from swallowing a large amount of mucus, premature caries of the teeth, and finally, disturbances of nutrition and metabolism are noted. A. are also the cause of a number of nervous phenomena and many pathological reflexes: children usually sleep poorly, at night they startle from nightmares or attacks of suffocation (ravor nocturnus), from restless sleep they get up listless and tired. In many cases, attacks of true bronchial asthma (see Bronchial asthma) are associated with A.; the same should be said about nocturnal enuresis. Headaches arise not only in connection with stagnant phenomena in the meninges, but also due to the increased excitability of the nervous system; to these also belong the phenomena of spasmophilia - laryngospasm, eclampsia, weakening of vision, asthenopia, grimaces, snorting, etc. Among the general phenomena, it is necessary to point to physical underdevelopment, so-called adenoid emaciation, occurring from oxygen and food starvation, and changes in the blood composition; to these also belong indefinite elevations of body temperature and swelling of the lymphatic glands. On mental development, A. exert a strongly retarding influence, which usually manifests itself at a more advanced age. Children seem listless, inattentive, not disposed to work, unable to concentrate (aprosexia nasalis).

Diagnosis of A. usually presents no difficulty; they can often be detected at a glance at the patient and from the enumeration of complaints, but a definitive diagnosis is made by means of posterior rhinoscopy or palpation with a finger. Treatment of A. is resorted to in the case when they become the cause of one or another suffering, and the treatment consists, mainly, in surgical removal of A. Treatment with other external and internal means is not beneficial and even dangerous, as it delays the necessary operation. However, there are strict indications for the operation; they can be absolute and relative, depending on the importance of the symptoms. The technique of adenotomy is not difficult (see fig.); usually the operation is performed with a knife (adenotome) by Beckmann, anesthesia is resorted to only in rare cases, since the pain during the operation is insignificant, in adults it is better to lubricate the mucous membrane with 10% cocaine. Contraindications to the operation are hemophilia and other diseases with decreased blood clotting, weakening of the body after severe illnesses and infectious diseases. Among the complications after the operation, it is necessary to note bleeding, septic diseases, lymphadenitis, angina, purulent otitis, torticollis, general sepsis and purulent meningitis. After the operation, in the first few days, the temperature often rises to 38° and higher. In all cases of operation, the patient must remain in bed on a liquid diet for the first two days.