Large Adenoids: Problems They Cause & Treatment
by Dr. Christopher Chang, last modified on
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Unlike tonsils which are located in the back of the mouth, adenoids are located in the back of the nose. In spite of the different locations, adenoids are essentially still tonsils and play a similar role to them as well. A little known fact is that we all have tonsils in the back of the tongue as well called lingual tonsils! The adenoids generally regress in size with age to the point they can be quite small in adults. However, it is not unusual for children to have enormous adenoids (including tonsils) the size of walnuts and even ping pong balls.
When they become quite large, they can cause a multitude of problems that may be confused for allergies and sinusitis including:
Due to reduced nasal airflow.
Due to reduced normal mucus flow into the throat.
Due to physical blockage of the eustachian tube.
Due to sudden excessive drainage into throat when some of the backed up mucus in the nose manages to escape into the throat.
The reason how it can cause all these problems is due to the location. Given its location in the very back of the nose (against the back wall in fact), it is immediately behind the eustachian tube. If the adenoids become large, they can physically block the eustachian tubes resulting in great difficulty in getting the ears to pop (if at all) resulting in a persistent clogged ears.
Furthermore, given the nose normally produces an estimated one liter of mucus/fluid to humidify and warm the air that is breathed, if the adenoids are large, all that mucus backs up in the nose as it is not able to easily drain into the throat resulting in symptoms of runny/snotty nose, allergies, and colored nasal drainage from the front of the nose. Not only do large adenoids prevent normal mucus production from flowing into the throat, it also prevents air movement as well causing symptoms of nasal obstruction and congestion as well as a nasal sounding (hyponasal) speech. Pinch your nose and talk (go ahead and do it now)... you will notice that because of reduced nasal airflow, you will now have nasal obstruction, congestion, and a nasal quality speech. If you release your pinched nose, all these symptoms immediately disappears!
Given the location of the adenoids in the back of the nose, the only way to directly visualize the adenoids is by endoscopy which can be performed comfortably in children as young as 5 years of age as well as adults in the office without sedation. One can also obtain a neck xray, though given the radiation exposure, that is not generally recommended.
Watch a video of a child undergoing just such an endoscopic exam:
Here is an actual video footage of what is being seen on endoscopy in a teenager who has adenoids the size of a golf ball. Picture shown to the right.
The adenoids are the pink cauliflower-looking-like ball hanging down from the top.
Typically before nasal endoscopy is performed, the nose is sprayed with lidocaine, a topical numbing agent. After a few minutes, the lining of the nose should become numb... BUT, the patient will still feel the scope passing through the nose, but it should not hurt. When the scope passes through the nose, it is typically described as a pressure sensation.
The aforementioned alternative to nasal endoscopy to evaluate for large adenoids is a neck xray which obviously causes no discomfort, but does expose the patient to radiation.
Take a look at the xrays below to see what a normal xray looks like compared to a neck xray with large adenoids. If large adenoids are present, there will be a white-colored soft tissue mass present in the nasopharynx (shaded in blue in the 3rd picture for reference). If you look at the normal xray (first picture), you will see only black coloration in the same location. Just like the black color around the head is air, black in the nasopharynx means only air is present or absent large adenoids.
Adenoids that obstruct the nasopharynx by at least 65% is considered obstructive and would be considered a candidate for further treatment [more info]. If the adenoids are both large AND low-lying, they can potentially even be visible looking in the mouth. They appear as an irregular surfaced lump that hangs down from behind the soft palate.
There are essentially two interventions that can help with large adenoids thereby resolving symptoms a patient may have.
The first is medical management using steroid nasal sprays which can be prescribed as young as 2 years of age as well as a prescription for singulair (montelukast). These medications have been shown to shrink the adenoid tissue over 2-3 months. Read a research abstract here, Cochrane review here, and meta-analysis here.
The second option is surgically removing the adenoids (adenoidectomy). This surgery is performed outpatient under general anesthesia and takes about 10 minutes to perform. It is performed through the mouth so there are no incisions made on the face, nose, or neck. The adenoids are removed by several different methods depending on the surgeon and may involve use of electro-cautery ablation or curette. Watch a video here of an adenoidectomy being performed by suction cauterization. Coblation may also be used in some situations as depicted in the illustration below. Recovery is generally fairly quick (~3-5 days).
For more information on tonsillectomy, click here.
If adenoid hypertrophy leading to nasal obstruction is not addressed, it may lead to actual facial deformity called adenoid facies as well as malocclusion. In rare cases, adenoid removal may cause a condition called velopharyngeal insufficiency.
If large adenoids are affecting quality of life, please contact our office for an appointment.
If the patient is a child, below are some safe videos you can watch with your child to prepare them for day of surgery!
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