Describe adenoid hypertrophy and adenoidectomy.

Adenoid Hypertrophy

• The adenoid (nasopharyngeal tonsil) is subepithelial lymphoid tissue in the roof and posterior wall of the nasopharynx, part of waldeyer’S ring.
• It enlarges from infancy to 5 or 6 years and then atrophies, being insignificant after puberty.
• Adenoid hypertrophy is physiological in childhood and becomes pathological only when it produces symptoms — so size on a radiograph is not the indication for surgery

Adenoidectomy

• Indications — obstructive sleep apnoea or significant sleep-disordered breathing.
• Contraindications — cleft palate, submucous cleft, and a bifid uvula with a notched hard palate, all of which risk velopharyngeal insufficiency; a short or immobile palate; bleeding disorders; and acute infection
• Always palpate the palate and look AT the uvula before adenoidectomy — a submucous cleft is invisible on inspection alone and is felt as a notch in the posterior hard palate, with a bifid uvula and a bluish midline zona pellucida. Missing it is the classical cause of a preventable disaster
• Technique — general anaesthesia with a cuffed tube, the patient supine with the head extended, a Boyle-Davis gag, and removal with a ST CLAIR thomson curette with a guard, an adenotome, suction diathermy, or a microdebrider under endoscopic vision — the last two being increasingly preferred because they allow precise removal under direct vision with less bleeding
• Haemostasis by postnasal packing and pressure, or diathermy
• Complications — haemorrhage, primary or reactionary, which is the commonest; velopharyngeal insufficiency giving hypernasal speech and nasal regurgitation of fluids, temporary but permanent if a cleft was missed; injury to the eustachian cushion causing stenosis; nasopharyngeal stenosis from over-aggressive removal; atlantoaxial subluxation (GRISEL syndrome), a rare but classical complication presenting with neck pain and torticollis after surgery; injury to the teeth or lips; and recurrence, since adenoid tissue can regrow
• The postoperative bleed is managed as an emergency — resuscitate, take blood, and return to theatre, remembering that a child may swallow a large volume before it is apparent, so tachycardia and repeated swallowing are the early signs rather than visible blood
• Adenoidectomy is frequently combined with tonsillectomy for OSA (adenotonsillectomy), which is the standard operation for paediatric sleep-disordered breathing and is highly effective
• IN AN adult, adenoidal tissue is abnormal and must be biopsied rather than simply curetted — to exclude nasopharyngeal carcinoma, lymphoma and HIV-associated lymphoid hyperplasia
• Feel the palate before every adenoidectomy; a submucous cleft is invisible and removing the adenoid causes permanent hypernasality