Adenoid Hypertrophy in Adults: An Underdiagnosed Entity?

The adenoids (or pharyngeal tonsil) is a condensation of lymphoid tissue in the posterosuperior wall of the nasopharynx. It forms a part of Waldeyer’s ring of lymphoid tissue at the portal of entry of the upper respiratory tract [1]. In early childhood it is the fi rst site for immunological contact of inhaled allergens. Adenoids are present at birth, show physiological enlargement upto 6 years of age, atrophy at puberty and almost completely disappear by 20 years of age [2]. Clinical symptoms are common in young age due to small volume of nasopharynx and the increased frequency of upper respiratory tract infections. It appears to have an important role in the development of immunological memory in younger children [3]. Adenoid hypertrophy was considered uncommon in adults as examination of the nasopharynx by posterior rhinoscopy was inadequate. Many cases were misdiagnosed and accordingly maltreated [4]. However, in the current clinical practice, with the advent of nasal endoscopes and improved imaging modalities, adenoidal tissue is not uncommonly found in adults. Insipite of these developments, there is lack of data regarding adenoid hypertrophy in adults. We studied the varied presentation of two cases of adult adenoid hypertrophy who presented with nasal obstruction and snoring; and nonresolving chronic otitis media.


Introduction
The adenoids (or pharyngeal tonsil) is a condensation of lymphoid tissue in the posterosuperior wall of the nasopharynx. It forms a part of Waldeyer's ring of lymphoid tissue at the portal of entry of the upper respiratory tract [1]. In early childhood it is the fi rst site for immunological contact of inhaled allergens. Adenoids are present at birth, show physiological enlargement upto 6 years of age, atrophy at puberty and almost completely disappear by 20 years of age [2]. Clinical symptoms are common in young age due to small volume of nasopharynx and the increased frequency of upper respiratory tract infections. It appears to have an important role in the development of immunological memory in younger children [3]. Adenoid hypertrophy was considered uncommon in adults as examination of the nasopharynx by posterior rhinoscopy was inadequate. Many cases were misdiagnosed and accordingly maltreated [4]. However, in the current clinical practice, with the advent of nasal endoscopes and improved imaging modalities, adenoidal tissue is not uncommonly found in adults. Insipite of these developments, there is lack of data regarding adenoid hypertrophy in adults. We studied the varied presentation of two cases of adult adenoid hypertrophy who presented with nasal obstruction and snoring; and nonresolving chronic otitis media.

Case 1
A 45 year old male presented to the ENT OPD, Lok Nayak Hospital, with complaints of nasal obstruction, snoring and repeated awakening at night due to apnea spells. On detailed history, it was found that patient was a chronic smoker for past 25 years. On examination, nasal endoscopy revealed a pale lobulated mass in the nasopharynx (Figure 1). Contrast enhanced CT scan showed a non-enhancing mass in the nasopharynx, extending upto bilateral nasal cavity, suggestive of adenoid hypertrophy ( Figure 2). Nasal endoscopic biopsy was done which was suggestive of lymphoid hyperplasia. After one year follow up, the patient was asymptomatic. There was no residual tissue in the nasopharynx or any recurrence.

Case 2
A 35 year old male presented with bilateral chronic otitis media with mucosal disease. Even after tympanoplasty with cortical mastoidectomy, patient had persistent ear discharge.
There was only temporary relief of symptoms and an underlying Abstract Adenoid enlargement is uncommon in adults. We studied the varied presentation of adenoid hypertrophy in two adults. A 45 year old male who presented with nasal obstruction and snoring, and a 35 year old male who presented with non resolving chronic otitis media. In both the patients, adenoid hypertrophy was diagnosed by nasal endoscopy and confi rmed by CT scan. Adenoidectomy in these patients resulted in symptomatic improvement. Therefore, adenoid hypertrophy should also be considered as a cause or contributing factor in nasal obstruction and related pathologies in adults. Adenoids are present at birth, show physiological enlargement upto 6 years of age, atrophy at puberty and almost completely disappear by 20 years of age [2]. Although adenoid tissue undergoes regression towards the adolescent period, but adenoid hypertrophy is also seen in the asymptomatic adult population. Adenoid enlargement was considered uncommon in adults as examination of the nasopharynx by posterior rhinoscopy was inadequate and hence, many cases of adenoid hypertrophy in adults were misdiagnosed and accordingly maltreated [4]. However, with the routine use of nasal endoscopes in the OPD and increasing availability of imaging modalities like CT scans, adenoid hypertrophy is increasingly being diagnosed in adults. In our cases, adenoid hypertrophy was diagnosed with the help of nasal endoscopy and confi rmed by CT scan.
Although the exact cause of adenoid hypertrophy in adults is not known, but various aetiopathogenetic mechanisms have been proposed. The persistence of childhood adenoids could be due to chronic infl ammation [4] or re-proliferation of regressed adenoid tissue in response to infection or irritants [6]. Finkelstein et al. [7], reported the presence of obstructed adenoids in 30% of heavy smokers. Our fi rst case was a chronic smoker as well. Adenoid hypertrophy caused by viruses in adults with compromised immunity, especially those receiving organ transplantation and those with HIV, is a well-known phenomenon [8]. However, this has been excluded as a reason for adenoid hypertrophy in our study.
There are various clinical features that can be associated with adenoid hypertrophy. Patients can have nasal obstruction, which may result in oral breathing, recurrent nasal infections and hypo nasal speech [4]. Higher percentage of children with adenoid hypertrophy have been reported to suffer from snoring compared to adults [2]. It can also be associated with varied ear symptoms due to Eustachian tube blockage, such as, otitis media with effusion, retraction, non-healing chronic otitis media, as seen in our second case. Kamel et al. These results underline the importance of considering adenoid hypertrophy as a cause or contributing factor in nasal obstruction and related pathologies in adults and support the theory that it represents a long standing infl ammatory process rather than being a novel clinical entity.
There is scarcity of data regarding incidence and etiological factors responsible for adenoid hypertrophy in adults. Kapusuz [9], reported the prevalence of adenoid hypertrophy in adults as 26.28% (139 out of 525 patients) in Turkey, Hamad [10], 17% (24 out of 140 patients) and Rout [5], 21% (21 out of 100 patients). In studies where they have been compared to normal sized adenoids, a chronic infection with Hemophilus infl uenza, normal bacteria of the upper respiratory tract, has been identifi ed. There may be some adenoidal enlargement occurring with chronic allergic states. In adult adenoid hyperplasia, malignancies of B type blood cells (lymphoma palsmacytoma) or HIV must be considered [5]. In a series by Rout et al. [5], allergy was associated with 30% of the adult adenoid hypertrophy. HIV infection was associated with 3.3% of the cases and non-Hodgkin's and other sinonasal malignancy was associated with 3.3% cases each.
Adenoid hypertrophy can be reduced by long term steroid nasal spray. Surgery is indicated in those individuals who don't respond to medical management. In a study by Demirhan et al, [11], in 2010, showed that in 76% of patients with adenoid hypertrophy, surgery was eliminated with fl uticasone proprionate nasal spray. However, if the adenoid re-enlarges and recreates the symptoms, surgery would be necessary, as in our cases.
The adenoid enlargement in adults is not uncommon, and often underestimated in adults with nasal obstruction and should always be borne in mind as a cause for otology or rhinology symptoms, as seen in both our patients. However, more studies are required to fi nd out the incidence of adenoid hypertrophy in adults and its relation with smoking and allergy.