eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Adenoidectomy: Workup

Author: John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School
Contributor Information and Disclosures

Updated: Oct 30, 2008

Workup

Laboratory Studies

  • No standard preoperative laboratory evaluation exists for adenoidectomy. Most surgeons do not order preoperative laboratory tests.
  • Intraoperatively, the adenoid can be sent for pathologic and histologic evaluation. It can also be sent for culture to evaluate the pathogens present.

Imaging Studies

  • Lateral neck radiograph
    • The main imaging study to evaluate the adenoid is a lateral neck radiograph (see Image 9).
    • Over the years, various dimensions in the nasal cavity and nasopharynx have been measured to assess the degree of obstruction caused by adenoids (see Image 10).
    • Confusion related to the usefulness of the lateral neck radiograph and its capability to help evaluate adenoid size is based partly on the 4 different techniques described.
    • The goal of all techniques is to correlate the measurements with the clinical efficacy of adenoidectomy. Most techniques focus on the size of the nasopharyngeal stripe, which indicates the amount of airflow through the nasopharynx. This measurement seems to be most accurate. When the nasopharyngeal stripe is half the size of the soft palate, significant obstruction occurs. However, studies indicate that improvement in rhinosinusitis symptoms or recurrent or persistent otitis media occurs as a result of adenoidectomy, independent of the size of the adenoid. Thus, for those indications, knowing the size of the adenoid preoperatively has no bearing on surgical judgment and is unnecessary.
  • CT scan
    • CT scan is not normally used to evaluate the adenoids. However, when a CT scan is performed to evaluate the sinuses, the choana and nasopharynx are occasionally imaged, providing information on the size of the adenoids.
    • If the CT scan does not involve the nasopharynx, information on the adenoids may be obtained from the plain sagittal scout film performed along with the CT scan.
  • CT scan or MRI
    • If the adenoids look abnormal or if a mass is present in the nasopharynx in an older child or in an adult, an imaging study (eg, CT scan, MRI) is obtained to rule out a lesion other than an adenoid.
    • The adenoids, by the time an individual is a teenager or older, usually regress in size and are not usually causing an obstruction.

Diagnostic Procedures

  • Flexible or rigid nasopharyngoscopy
    • To evaluate the adenoid in a clinic, a flexible or rigid nasopharyngoscopy can be performed.
    • The progression of evaluation with nasopharyngoscopy along the floor of the nose can be observed in Images 5-8.
  • Biopsy
    • Occasionally, if a nasopharyngeal mass is encountered in an older child or an adult or if the lesion of the nasopharyngeal mass of tissue in a younger child does not appear exactly like adenoid, a biopsy can be performed to ensure a correct diagnosis.
    • Biopsy is rarely necessary; however, if it is necessary in young children, perform the biopsy in an operating room.
    • Teenagers and adults may tolerate a biopsy of the nasopharyngeal mass with adequate topical anesthesia in the clinic.
    • If any finding indicates that the lesion may be vascular, obtain preoperative imaging with a CT scan, MRI, or magnetic resonance angiography and perform the biopsy in the operating room.

Histologic Findings

The adenoid is composed of lymphoid tissue, similar to a lymph node, without an afferent blood supply (see Image 11). The adenoid has germinal centers where the antibodies are produced (see Images 12-13). The epithelium over the adenoid is the same as the respiratory epithelium in the nasal cavities and sinuses, which is a pseudostratified, ciliated, columnar epithelium.

The immunological function of the adenoid has been studied by evaluating the types and numbers of different immunological components, such as immunoglobulins (antibodies), antigen-presenting cells, neutrophils, and dendritic cells. Additional function of the adenoid may be based on the ratio of respiratory to squamous epithelium and the amount of functioning cilia present, which help nasal flow. All of these immunological and protective functions are detrimentally affected by chronic infection in the adenoids.

Staging

Adenoid size is often graded similarly to tonsil size as 1+, 2+, 3+, or 4+. This grading of the observed size of the adenoid while the patient is in the supine position during surgery coordinates to 25%, 50%, 75%, or 100% obstruction of the choana, respectively. Alternatively, the percentage of obstruction of the choana can be mentioned and ranges from 0-100%. Remember that the degree or obstruction of the choana appears different depending on if the adenoids are visualized while the patient is in the sitting position in the clinic or if the patient is lying supine in the operating room with the palate reflected superiorly (see Images 14-15).

More on Adenoidectomy

Overview: Adenoidectomy
Workup: Adenoidectomy
Treatment: Adenoidectomy
Follow-up: Adenoidectomy
Multimedia: Adenoidectomy
References
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References

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Further Reading

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Keywords

adenoidectomy, tonsillectomy adenoidectomy, adenoids, adenoid, adenoid surgery, adenoid removal, infected adenoids, pediatric adenoidectomy, pediatric adenoid removal, pediatric adenoid surgery, tonsillectomy and adenoidectomy, T&A, adenoiditis, tonsillectomy, middle ear effusion, otitis media, OM, middle ear infection, rhinosinusitis, ear infection, ear disease, chronic sinusitis, COM, AOM, acute otitis media, chronic otitis media, otitis media with effusion, OME, adenoid curette, adenoid punch

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Contributor Information and Disclosures

Author

John E McClay, MD, Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School
John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ari J Goldsmith, MD, Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center
Ari J Goldsmith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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