Adenoidectomy Workup

• 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.

• Lateral neck radiograph

  • The main imaging study to evaluate the adenoid is a lateral neck radiograph, as in the image below. Normal lateral neck x-ray film evaluating the adenoids and nasopharynx.
  • Over the years, various dimensions in the nasal cavity and nasopharynx have been measured to assess the degree of obstruction caused by adenoids, as shown below. Different measurements for the choanae show (1) measurement of the adenoids, (2) horizontal measurement of the nasopharyngeal stripe followed by horizontal measurement of the adenoid pad and diagonal thickness of the adenoid pad, (3) horizontal measurement from the choanae to the adenoids and the adenoid pad, and (4) the thickness of the palate in comparison to the thickness of the nasal pharyngeal air stripe.
  • 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.

• 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 the images below. A rigid rhinoscopy photograph of the left anterior nasal cavity. The middle turbinate is superior in the midline, and the inferior turbinate is to the right. The septum is to the left. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks. A rigid rhinoscopy photograph taken in the mid portion of the left nasal cavity showing the septum on the left, the inferior turbinate on the right, and the middle turbinate superiorly. The choanae is seen in the dark area in the center. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks. A rigid rhinoscopy photograph taken two thirds of the way back along the floor of the nose of the left nasal cavity. This photograph shows the septum on the left, the choanae straight ahead, and the posterior portion inferior turbinate to the right. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks. A rigid rhinoscopy photograph taken all the way back into the choanae of the left nasal cavity. The photograph shows the septum on the left, the small adenoids on the posterior superior wall of the nasopharynx in the center, and the eustachian tube orifice on the right. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks.
• 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.

The adenoid is composed of lymphoid tissue, similar to a lymph node, without an afferent blood supply, as shown below.

The adenoid has germinal centers where the antibodies are produced. See the images below. 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.

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, depicted below.