Comprehensive Overview of Adenoids & Adenoid Facies
Overview
The adenoids are part of Waldeyer’s ring — the body’s first line of immune defense in the upper airway. In children, they’re physiologically large and shrink after puberty. Chronic hypertrophy leads to mouth breathing, sleep issues, and the classic facial changes called “adenoid facies”.
What is Adenoids?
Adenoids is the nasopharyngeal tonsil. A collection of lymphoid tissue in the roof and posterior wall of the nasopharynx.
What is Adenoid facies?
Adenoid facies is the constellation of craniofacial, dental, and facial soft-tissue changes resulting from long-term nasopharyngeal obstruction and obligate mouth breathing during growth.
Anatomy & Histology - Nasopharynx & Position
Figure 1
Location of adenoids.
Blood Supply
Arterial supply: Primarily the ascending pharyngeal artery branch of external carotid. Also contributions from the ascending palatine, pharyngeal branch of maxillary, and sphenopalatine arteries.
Venous drainage: Via the pharyngeal venous plexus and internal jugular vein.
Lymphatic Drainage
Drains to the retropharyngeal nodes, then to the deep cervical chain, especially the upper jugulodigastric nodes. This is why nasopharyngeal infections can present with upper neck nodes.
Contraindications for adenoidectomy
1. Cleft palate or submucus palate
2. Acute upper respiratory infection
3. Bleeding order
4. Other medical problem where surgery or anesthesia is contraindicated.
Innervation
1. Sensory: Maxillary nerve V2 via the pharyngeal branch and sphenopalatine ganglion.
2. Autonomic: Parasympathetic from the sphenopalatine ganglion.
Nasopharyngeal Tonsils (adenoids) vs Palatine Tonsil
| Adenoids | Tonsils | |
|---|---|---|
|
Location |
Roof / posterior nasopharynx, midline. |
Oropharynx, between palatoglossal & palatopharyngeal arches |
|
Capsule |
No true capsule |
Encapsulated |
|
Crypts |
No deep crypts |
Multiple deep crypts |
|
Surface Epithelium |
Respiratory epithelium |
Non-keratinized stratified squamous |
|
Peak Size |
3 – 6 years old |
6 – 10 years old |
Development of Adenoids
Present at birth. Arise from lymphoid tissue aggregation in the nasopharyngeal submucosa. Become prominent after exposure to antigens in infancy.
Growth Pattern of Adenoids:
Birth – 3y: Rapid growth
3 – 6y: Peak size, often largest relative to nasopharyngeal airway
After puberty: Physiological involution/atrophy due to hormonal changes. Rarely symptomatic in adults unless pathologic.
Investigations
1. Plain X – ray of soft tissues of nasopharynx in lateral view.
2. Digital palpitation of adenoid with index fingure.
Figure 2
X-ray of the nasopharynx
Physiology of Adenoids
Part of the mucosal immune system. Trap inhaled antigens, produce IgA, and initiate immune responses. They are not essential after early childhood because other lymphoid tissue compensates.
Bacteria & Viruses That Infect Adenoids
Viruses: Adenovirus, RSV, rhinovirus, influenza, EBV
Bacteria: 2Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Group A
Streptococcus: These form biofilms and can be a reservoir for chronic rhinosinusitis or otitis media.
Enlarged Adenoids
Aetiology of Enlarged Adenoids
Recurrent infection / inflammation: Repeated viral/bacterial URIs
Allergy: Allergic rhinitis and chronic mucosal edema
Genetic / familial: Tendency to lymphoid hyperplasia
Environmental: Smoke exposure, pollution
Clinical Features of Enlarged Adenoids
Nasal: Chronic nasal obstruction, mouth breathing, hyponasal / “blocked” voice, rhinorrhea, snoring, OSA
Aural: Eustachian tube obstruction and otitis media with effusion, conductive hearing loss, “glue ear”
Craniofacial: See “adenoid facies” below
Adenoidectomy
Figure 3
Adenoidectomy
Adenoidectomy may be indicated alone or combined with tonsillectomy. Adenoids are removed first and nasopharynx packed before starting tonsillectomy.
Adenoid Facies: Features & Explanation
This develops over years of chronic nasal obstruction during facial growth. It’s a clinical sign, not a diagnosis.
Figure 4
Adenoid Facies – Child, Frontal View
To conclude,
Many children have 1 – 2 features without adenoid issues.
Diagnosis requires ENT exam, nasal endoscopy, or lateral cephalogram / X-ray + correlation with symptoms.
Adenoids Summary
- Definition
Definition: Nasopharyngeal tonsil. Lymphoid tissue on roof/posterior wall of nasopharynx. Part of Waldeyer’s ring.
- Anatomy / Histology
Midline nasopharynx. Covered by respiratory epithelium. Non-encapsulated with lymphoid follicles.
- Blood Supply
Arterial: Ascending pharyngeal, ascending palatine, sphenopalatine.
Venous: Pharyngeal plexus IJV.
- Lymphatic Drainage
Retropharyngeal nodes deep cervical chain.
- Innervation
Sensory V2 via sphenopalatine ganglion. Parasympathetic from same.
Development & Physiology
Development:
- Present at birth, grow with antigen exposure.
Growth Pattern:
- Rapid 0-3y, peak 3-6y, involutes after puberty
Physiology:
- Mucosal immunity, IgA production. Not essential later in life.
Aetiology of Hypertrophy:
- Recurrent infection, allergy, genetics, smoke/pollution.
Viruses:
- Adenovirus, RSV, EBV.
Bacteria:
- S. pneumoniae, H. influenzae, M. catarrhalis, GAS.
Clinical Features of Hypertrophy
Adenoid Facies: Features & Why
Management: Adenoidectomy + bilateral grommet insertion. At 6 weeks: TM clear, tympanometry Type A, speech therapy started. Hearing normalized.
Key point: Address adenoids in < 4yr olds.
Clinical Note: Medical trial 6 – 12 weeks is common before surgery, unless severe OSA, growth failure, or recurrent infection are present.
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