Iwona Łapińska, *Lidia Zawadzka-Głos
Adenoid and tonsils hypertrophy – symptoms and treatment
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
Summary
Introduction. Adenoid and tonsil hypertrophy is widespread in the pediatric population, affecting primarily younger children, aged 3 to 6 years. In 1884, a German pathologist, von Waldeyer-Hartz, first described clusters of lymphoid tissue in mucosa of the throat, which he named facial lymphatic ring, known today as Waldeyer’s tonsillar ring. Waldeyer’s ring plays a significant role in the development of immune response by allowing the contact of the immune system with multiple antigens and thus, enabling the development of the specific immunological response. The main points of contact of the body with the external environment are the mucous membranes of the digestive and respiratory systems. Waldeyer’s ring, being at the opening of both systems, has a particular role in the development of immune response, especially during the first years of life.
Aim. The aim of the study was to analyze the symptoms presented by children hospitalized in the Clinic of Pediatric Otolaryngology of the Medical University of Warsaw that had been qualified for the surgical removal of the adenoid and/or tonsils.
Material and methods. All the patients underwent physical examination, and filled in a survey. The study included 59 hospitalized patients, 2 of which refused to disclose the symptoms associated with adenoid and tonsil hypertrophy that was diagnosed in them.
Results. The study involved 59 children aged from 2 to 13 years old. The mean age was 6.2 years. The patients were qualified for adenoidectomy or adenotonsillotomy. In 26 cases, at least one of the parents of the patient smoked in the presence of the child. 28 patients reported nasal obstruction, and 29 denied such symptoms. As many as 41 patients (71.9%) reported snoring during sleep. 45 patients (78.9%) breathed through the mouth. Based on the medical history collected from the parents, 22 patients (37.3%) had upper respiratory tract infection at least once a month, 7 patients – every two weeks, 9 – every two months, 15 – every three months, 5 – every 6 months, and one – once a year.
Conclusions. 1. The most common symptom in pediatric patients with adenoid and tonsil hypertrophy is snoring. 2. 1/3 of the children with enlarged tonsils is diagnosed with allergies. 3. Almost 45% of children with hypertrophy of the tonsils are exposed to tobacco smoke. 4. Children with enlarged tonsils have upper respiratory tract infections on average once a month.
INTRODUCTION
Adenoid and tonsil hypertrophy is widespread in the pediatric population, affecting primarily younger children, aged 3 to 6 years. The symptoms of tonsillar hypertrophy are one of the most common reasons for pediatric or ENT visits in children. Therefore, physicians must be aware of the possible complications of the tonsil hypertrophy and of the indications for surgery. Therefore, the physiology of tonsils, their role for the immune system, as well as the early and late consequences of tonsil hypertrophy must also be known. Multiple diagnostic tests enable the physician to decide between conservative and surgical treatment options (4, 5, 8).
In 1884, a German pathologist, von Waldeyer-Hartz, first described clusters of lymphoid tissue in mucosa of the throat, which he named facial lymphatic ring, known today as Waldeyer’s tonsillar ring. The ring includes the following structures (1, 2):
– 1 pharyngeal tonsil (also known as nasopharyngeal tonsil, because of its location, and as adenoid when inflamed/swollen). It is located on the upper wall of nasopharynx, inferior to the sphenoid bone,
– 2 tubal tonsils (bilaterally). It is located at the opening of the Eustachian tube into the nasopharynx,
– 2 palatine tonsils (frequently referred to as “tonsils” in medical slang; also known as faucial tonsils). They are located in the oropharynx,
– 1 lingual tonsil. Located on the posterior part of the tongue.
Waldeyer’s ring plays a significant role in the development of immune response by allowing the contact of the immune system with multiple antigens and thus, enabling the development of specific immunological response. The main points of contact of the body with the external environment are the mucous membranes of the digestive and respiratory systems. As our organisms are continuously exposed to various infectious agents, many non-specific and specific defense mechanisms have been developed. Lymphoid tissue associated with mucous membranes (MALT) is of primary importance for the immune system. MALT can be further divided into the lymphatic tissue of the digestive system (GALT), of the bronchial tree (BALT), and of the nose and throat (NALT) (6, 8, 9).
During the childhood, an intensive growth of the adenoid and tonsils is observed. The enlargement of tonsils is physiological from the 3rd to the 7th year of age, as they are very immunologically active. From the 8th year of age to the end of the puberty, adenoid gradually reduces its size. Tonsils, on the other hand, start to atrophy at about 17-20 years of age. Pathological hypertrophy affects primarily the adenoid, especially in younger children. Tonsils hypertrophy less frequently and are usually accompanied by adenoid hypertrophy (3, 8, 9).
Therefore, the main functions of tonsils include:
– providing contact with antigens,
– providing a first line of defense for respiratory and digestive tract,
– the promotion of the development of humoral and cellular immunity.
The role of tonsils is especially big during the first years of life. Infants start to lose passive immunity from their mothers at about 6 months of age and start to develop their own immunological response. Tonsils grow and acquire their proper shape. The physiological growth of tonsils concerns especially adenoid and tonsils. The speed of growth of the tonsils is influenced by infectious agents. Moreover, it is also hypothesized that dietary habits and hormonal status can also affect their growth (5, 8).
The tonsils reach their peak size at about 6-7 years of age and it is also the time of their biggest activity. After the puberty, adenoid and tonsils undergo involution and lymphoid follicles of the back and lateral sides of the throat are in the state of functional hypertrophy until 40 years of age. After that, they undergo involution and lingual tonsil hypertrophies until 60 years of age, when it, in turn, begins its involution (5, 8).
AIM
The aim of the study was to analyze the symptoms presented by children hospitalized in the Clinic of Pediatric Otolaryngology of the Medical University of Warsaw that had been qualified for the for the surgical removal of the adenoid and/or tonsils.
MATERIAL AND METHODS
The study was based on physical examination, a subjective examination and a written survey of children hospitalized in the Clinic of Pediatric Otolaryngology of the Medical University of Warsaw. The survey consisted of two surveys, once, my authority survey and the second one standardized survey, Child Health Questionnaire (CHQ-PF28). The questionnaires were dedicated to parents of children which were hospitalized due to adenoid hypertrophy and /or palatine tonsils. The study included 59 hospitalized patients, 2 of which refused to disclose the symptoms associated with hypertrophy adenoids and/or tonsils.
RESULTS
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Piśmiennictwo
1. Baugh RF, Archer AM, Mitchell RB et al.: Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 144: 1-30. 2. Paradise J, Bluestone C, Bachman R: Efficacy of tonsillectomy for recurrent throat infection in severely affected children. N Engl J Med 1984; 310: 674-683. 3. Paradise J, Bluestone C, Colborn K: Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002; 110: 7-15. 4. Marseglia GL, Caimmi D, Pagella F: Adenoids during childhood: the facts. Int J Immunopathol Pharmacol 2011; 24 (suppl. 4): 1-5. 5. Zautner AE: Adenotonsillar disease. Recent Pat Inflamm Allergy Drug Discov 2012; 6(2): 121-129. 6. Jakóbisiak M: Immunologia. PWN, Warszawa 1995. 7. Goldstein NA, Pugzhendhi V: Clinical assessment of pediatric obstructive sleep apnea. Pediatrics 2004; 114: 33-43. 8. Zawadzka-Głos L, Chmielik M, Wąsik M: Immunological cellular response in hypertrophied palatine tonsil in children. New Med 1997; 1: 9-10. 9. Zawadzka-Głos L, Chmielik M, Wąsik M: Immunological response in hypertrophied palatine tonsils and blood pre- and post adenotonsillotomy. New Med 1999; 3: 72-73.
