Lupine Publishers | Adenoid Hypertrophy in Adults- A Prospective Study

 Lupine Publishers | Journal of Otolaryngology

 

Abstract

Adenoid enlargement is uncommon in adults and because examination of nasopharynx by indirect posterior rhinoscopy is inadequate, many cases of enlarged adenoid in adults are misdiagnosed and accordingly maltreated. Though adenoid hypertrophy is rare in adults, all patients presenting with nasal obstruction should undergo diagnostic nasal endoscopic examination. In the presence of hypertrophied adenoids, though the other causes of nasal obstruction are treated, symptoms may not be relieved unless patient undergoes adenoidectomy. In the present study, 36 cases of adenoid hypertrophy in adult patient is presented along with the review of literature.

Keywords: Adenoid; hypertrophy; adults

Introduction

The submucosal lymphoid tissue at the junction of roof and posterior wall of nasopharynx are known as adenoids. These are predominantly B cell organs amongst which the B cell lymphocytes comprise 50-65% of all adenoids and approximately 40% are T cell lymphocytes 3% are mature plasma cells [1]. Adenoids shows physiological enlargement up to 6 years of age and then they regress gradually during puberty and almost disappear completely by 16 years of age[2]. The enlargement of adenoid is uncommon in adults and most cases of enlarged adenoid in adults are misdiagnosed and they are maltreated[3]. Cases of adenoid hypertrophy in adults could be due to compromised immunity, especially those patients receiving organ transplants and in patients who are infected with human immunodeficiency virus (HIV)[2]. Enlarged adenoids can obstruct the airway resulting in nasal obstruction of varying degree, mouth breathing, snoring, nasal discharge, and nasal intonation of voice. Hypertrophied adenoids can also result in varied otologic symptoms due to blockage of Eustachian tube[4,5].

Objective

This descriptive study was done to evaluate the signs and symptoms associated with adenoid hypertrophy in adults.

Materials and Methods

This was a 3 years prospective descriptive study of adult patients, all aged more than 18 years with symptoms of nasal obstruction.

Study design: Prospective descriptive study

Inclusion Criteria

a) Patients who are willing to give an informed written consent.
b) Patients with history of nasal obstruction with enlarged adenoids on investigations.
c) Age of the patient more than 18 years.
d) Patients who are willing for a regular follow up.

Exclusion criteria

a) Patients who are not willing to give informed written consent
b) Patients who are not willing for a regular follow up

Methods

The present study was conducted in the Department of Otorhinolaryngology, Bangalore Medical College and Research Institute, between January 2014 to December 2018. All the patients fulfilling the inclusion/ exclusion criteria were enrolled in the study. Detailed medical history was taken. Relevant past and family history were also taken into consideration. Anterior rhinoscopy wad done to find out deviated nasal septum, septal spur, hypertrophied turbinate’s, nasal polyp, foreign body. Posterior rhinoscopy was done to examine the nasopharynx. The diagnosis of adenoid hypertrophy was made on the basis of the medical history, X-ray nasopharynx soft tissue lateral view, and endoscopy was obtained in an erect position with neck extended to visualize the shadow of the adenoid.Radiological assessment and grading of the size of adenoid was done accordingly [6]

a) Grade I: Soft tissue mass obstructing less than 25% of the nasopharyngeal airway.
b) Grade II: Soft tissue mass obstructing 25- 50 % of the nasopharyngeal airway.
c) Grade III: Soft tissue mass obstructing 50- 75 % of the nasopharyngeal airway.
d) Grade IV : Soft tissue mass obstructing more than 75 % of the airway.

In endoscopic assessment, the size of the adenoid was determined according to Clemen’s et al. grading[6]

a. Grade I:Adenoid tissue filling 1/3rd of the vertical height of the choanae.
b. Grade II: Filling 2/3rd of the vertical height of the choanae.
c. Grade III: 2/3rd to nearly completely filling the choanae.
d. Grade IV: Completely filling the choanae.

After confirmation of the mass, adenoidectomy was performed and then the mass was sent for histopathological examination. The other causes of nasal obstruction if found on clinical assessment, such as deviated nasal septum were also treated simultaneously.

Results

The study group consisted of 36 cases. The ages ranged from 20- 40 years. 25 patients were between 20- 30 years of age and 11 patients belonged to 30- 40 years (Table 1). Out of the 36 cases, 20 patients were males and 16 patients were female (Table 2& Figure1). Patients with adenoid hypertrophy were in 3rd decade of life and in our study we found that males were commonly affected than females in the ratio of 5:1.The presenting symptom was nasal obstruction in 34 patients, snoring was the main complaint in about 2 cases(Figures 2-4). 22 patients were diagnosed with adenoid hypertrophy during diagnostic nasal endoscopy for nasal obstruction, 14 patients were diagnosed with the adenoid hypertrophy with deviated nasal septum.Out of the 36 patients, 24 patients had Grade IV adenoid hypertrophy, 2 patients had grade 2 adenoid hypertrophy and in the remaining 10 patients adenoid tissue was found to fill more than 2/3rd of the vertical height of the choanae (Table 3& Figure5).

Table 1: Showing age distribution.

Table 2: Showing gender distribution.

Figure 1: Showing gender distribution.

Figure 2: Nasal endoscopic picture showing Grade IIadenoid hypertrophy [filling 2/3rd of the vertical height of the choanae].

Figure 3: Nasal endoscopic picture showing Grade IIIadenoid hypertrophy [ 2/3rd to nearly completely filling the choanae].

Figure 4: Nasal endoscopic picture showing Grade IVadenoid hypertrophy [completely filling the choanae].

Figure 5: Showing endoscopic grading distribution.

Table 3: Showing endoscopic grading distribution.

Discussion

The submucosal lymphoid tissue at the junction of roof and posterior wall of nasopharynx are called adenoids[6]. The nasopharyngeal lymphoid aggregate or Lushka’s tonsil was described by Santorini in 1724.Nasopharyngeal vegetations were then described by Wilhem as “Adenoids” in 1870. Adenoids along with palatine tonsil, lingual tonsils, tubal tonsils, and lateral pharyngeal bands forms the inner Waldeyer’s ring[6]. These are predominantly B cell organs which comprises of 50-65% of all adenoid lymphocyte and 40 % are T cell lymphocytes and about 3 % are mature plasma cells[1]. During the age of 3 and 10 years it shows greatest immunological activity and hence are most prominent during this period of childhood, and later shows involution[2].All the components of the Waldeyer’s ring play a very important role in the immunological memory. The epithelium contains a system of specialized channels lined by M cells that take up antigens into the vesicles and transport them to the intra- and subepithelial spaces. Here they are presented to lymphoid cells. After passing through the epithelium, inhaled or ingested antigens reach the extrafollicular region or the lymphoid follicles. In the extrafollicular region, interdigitating cells (IDC) and macrophages process the antigens and present them to CD4+ T lymphocytes. Helper T cells then stimulate the proliferation of follicular B lymphocytes and their development into either antibody-expressing B memory cells capable of migration to the nasopharynx and other sites, or plasma cells that produce antibodies, and release them. The contact of memory B cells in the lymphoid follicles with antigen is an essential part of the generation of a secondary immune response.

Among the Ig isotypes, IgA may be considered the most important product of the adeno tonsillar immune system. In its dimeric form, IgA can attach to the transmembrane secretory component (SC) to form secretory IgA (SIgA), which is a critical component of the mucosal immune system of the upper airway. This component is necessary for the binding of IgA monomers to each other and to the SC and is an important product of B cell activity in the tonsil follicles. While the tonsils produce immunocytes bearing the J (joining) chain carbohydrate, the SC is produced only in the adenoid and extra tonsillar epithelium, and therefore, only the adenoid possesses a local secretory immune system[6].Adenoid enlargement is uncommon in adults and many cases of adenoid hypertrophy in adults are misdiagnosed[3]. Involuted adenoidal tissue may re-proliferate in response to infections and irritants resulting in adenoid hypertrophy. Adenoid hypertrophy in adults may occur in immunocompromised state, especially in those patients receiving organ transplants and also in those patients infected with having human immunodeficiency virus[5].

Conclusion

Though adenoid hypertrophy is rare in adults, all patients presenting with nasal obstruction should undergo diagnostic nasal endoscopic examination. In the presence of hypertrophied adenoids, even though the other causes of nasal obstruction are treated, symptoms may not be relieved unless patient undergoes adenoidectomy.

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Lupine Publishers | A Case Report on The Child with Two Coins Ingested Foreign Bodies in The Esophagus During the Lockdown in COVID 19 Pandemic

 Lupine Publishers | Journal of Otolaryngology

 

Abstract

A 4-year-old child presented to the emergency department with an acute onset of dysphagia and vomiting. A plain X-ray soft tissue neck lateral view revealed a double circular opacity in the cervical oesophagus consistent with an ingestion of multiple foreign bodies. Preoperative planning and SARS-CoV2 testing is of particular importance for the pediatric population and if testing cannot be performed, patients in all age groups should be handled as though they are positive for COVID-19, and appropriate precautions should be taken. The child was taken to the theatre for rigid pharyngo-oesophagoscopy and removal of the coins. After the first coin was removed subsequent endoscopic examination revealed a second coin at the same location. This extremely rare case of two ingested coins becoming impacted with perfect radiological alignment, we would therefore advocate having a low threshold for performing a ‘second look’ endoscopy after removal of the first foreign body with postoperative X-rays.

Keywords: COVID-19 Pandemic; otolaryngology; foreign body coin

Abbreviations: PPE: Personal protective equipment; COVID-19: Coronavirus disease 2019; SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2

Introduction

A global pandemic, COVID 19 has become a major concern across the world. Long term home isolation has potentially increased the risk of domestic accidents in children like lodgement of foreign bodies in Ear, Nose and Throat. Foreign bodies in the airway are commonly seen in the pediatric population [1,2]. Single coin is a very common foreign body found in esophagus, but paired coin foreign body occurrence is quite rare. When any patient has history of ingested foreign body, investigations are mandatory regardless of the age or apparent absence of signs and symptoms [3]. This paper reports a case of double coin lodgment in the esophagus.

Case Report

We report a case of 4-year-old female child who presented to Department of otolaryngology, Government Medical College, Amritsar, Punjab, North India with the complaints of multiple episodes of vomiting, throat pain and foreign body sensation since 12-14 hours. There was no history of respiratory distress. As per patient’s father child was apparently alright and playing at home. Then suddenly she started vomiting and was quite frightened with pale look. She had three episodes of vomiting further which consisted of food particles mainly. On further enquiry and prior assurance to patient she revealed that she kept coins in her mouth while playing. She also complained of foreign body sensation and she hid the truth due to fear of scolding. The patient presented in ENT emergency for diagnosis and management. On careful examination there was no abnormality in mouth and throat. Respiratory rate was normal. On auscultation air entry was bilaterally equal with no signs of cyanosis or adventitious sound. The radiograph of neck and chest in anteroposterior view revealed the disc shaped circular foreign body as suspected. But to our surprise the soft tissue radiograph of neck lateral view revealed foreign bodies in oesophagus at the level of seventh cervical vertebra (C7) and first thoracic vertebra (T1) which appeared to be double and superimposed because of irregularity of border of coin (Figure 1). Later under general anesthesia rigid esophagoscope was inserted and foreign body coin was visible. The foreign body was held with forceps and then both coins removed carefully avoiding damage to surrounding structures. No intra-operative complications were seen. As suspected from radiographs two coins i.e. one rupee and two-rupee coins stick with mucus were retrieved (Figure 2). The esophagus was inspected again. The patient was then kept under observation under antibiotic and analgesic cover. Postoperative event was uneventful. The patient was stable and discharged with adequate medical advice.

Figure 1: Radiograph of chest in anteroposterior single coin shadow and lateral view of Soft tissue neck showing double shadows of foreign body coins (Bigger coin anteriorly placed and smaller posteriorly).

Figure 2: Foreign body two coins removed.

Discussion

Foreign bodies in the throat are often medical emergencies that could potentially progress to surgical emergencies. Coins remain the most commonly ingested foreign body in children, accounting for as many as 60% of such cases [4]. Typically, coins become impacted in the proximal esophagus at the level of the crico pharynx [5] and removal within 24–48 hours is generally recommended [6]. The ingestion of multiple coins by children is a rare case. As per a clinical study two radiological views are recommended in the assessment of esophageal foreign bodies [7]. Radiographs of neck anteroposterior and lateral view soft view should be performed in cases of foreign body ingestion. Direct laryngoscopic visualization during intubation may reveal a proximal foreign object that can be removed with Magill forceps [8]. Complications include airway obstruction, laryngeal edema, and pushing the foreign body into the subglottic space, esophagus, or trachea [9]. Foreign bodies that are not removed may later result in infection or perforation.

Rigid esophagoscopy is a safe and effective procedure for foreign body esophagus. It should be done early to reduce mortality and morbidity. In present case rigid pharyngo-esophagoscopy was done under general anaesthesia and foreign body removal was performed with forceps. Acute complications of an impacted coin include oesophageal perforation, [10-12] respiratory distress and even death [13]. Long-term sequelae include formation of an esophageal structure [14] or tracheoesophageal fistula [15]. Early intervention is therefore paramount in preventing these lifethreatening complications, and identification of multiple coins is therefore paramount to avoid unnecessary complications that may arise from assuming the foreign body has been removed.

Conclusion

The foreign bodies should be carefully enquired while taking history and appropriate investigations should be done before reaching at final diagnosis. Serial radiograph could be advised if multiple foreign bodies are suspected to diagnose the exact location. Preoperative planning and SARS-CoV2 testing is of particular importance for the pediatric population and if testing cannot be performed, patients in all age groups should be handled as though they are positive for COVID-19, and appropriate precautions should be taken.

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Lupine Publishers | Tympanolith under the Protiniculum - A Case Report

 Lupine Publishers | Journal of Otolaryngology

 

Abstract

Background: A tympanolith is a calcified body found impacted in mucosa of the middle ear. It is thought to be intrinsic deposition of calcium over a nidus of mucous plug whereas a foreign body is usually extrinsic.

Case Report: A young male with bilateral ear inactive chronic mucosal type of otitis media was posted for tympanoplasty. A full cuff incision and exploration of ear showed a smooth gritty hard stone stuck in the hypotympanum later confirmed to be a tympanolith. Middle ear anatomy of hypotympanum was studied with straight and angled endoscope. A type A configuration of bony crest of Protiniculum was found to be the reason for formation of mucus plug and lith.

Discussion: Tympanolith is a rare condition which is known to occur in a chronically discharging ear, due to calcium deposition on a mucus plug or biofilm formation. Tympanolith is a bony crest in hypotympanum with variable anatomy.

Conclusion: Every nook and corner of the middle ear should be inspected while doing a tympanoplasty to rule out tympanolith, foreign body or granulations. Either a full cuff incision microscopic tympanoplasty or an inspection of middle ear by angled endoscope in every case are suggested options.

Keywords: Tympanolith;protiniculum;protympnanum

Introduction

Foreign body in the external auditory canal is common and often treated in an outpatient basis. The foreign bodies commonly found in the external auditory canal include animate and inanimate objects like stones, insects, erasers, buttons, vegetable pieces, cereals and pulses, cotton ball, bits of metal from welding, most common being beads, paper/tissue paper or popcorn kernels[1,2]. A tympanolith (stone in the middle ear) is a calcified body in the tympanic cavity, which can be extrinsic (foreign body) or intrinsic ( purulent dried discharge or stagnant mucus acting as a nidus for calcification) [3]. Anything small enough to pass the isthmus of the external auditory canal and missed may cause a perforation of the tympanic membrane, to ultimately find its way into the middle ear. Also,an extrinsic foreign body can travel through the perforated ear drum and get impacted in the mucosa of the middle ear. A tympanolith is a rare condition and there are very few cases reported in literature. Gapany-gapanavicius et al. publication is one of those few cases reported[4]. Long standing ear diseases may harbor a tympanolith. Small ones may be asymptomatic and accidentally diagnosed during examination and surgery of the ear. Larger ones usually present with symptoms like ear discharge, earache, aural fullness, decreased hearing.Protiniculum has been described as a bony ridge extending from the promontory towards the protympanum on the medial wall of the middle ear cavity, across the inferior wall and merging with the lateral wall. The medial aspect of the ridge is marked by the end of the most anterior hypotympanic air cell and start of the pro tympanum, consistently[5]. This lies inferior to the ET tube opening.

A 24-year-old male, salesman by profession came with complaints of bilateral intermittent ear discharge since three years to the outpatient department of a rural tertiary care hospital in western India . The discharge was mucopurulent, non-foul smelling and non-blood stained. There was history of similar episodes of ear discharge in childhood. A diagnosis of bilateral mucosal chronic otitis media was made.The patient also emphasized on difficulty in hearing which had become more evident in the last three years, more in right ear. There was no history of trauma or foreign body insertion in the ear. After achieving the inactive stage of the disease with topical and systemic medications, the pure tone audiometry was done, and it showed bilateral mild conductive hearing loss. The right large central perforation with left medium sized central perforation was confirmed with examination under microscope.
The patient was prepared and posted for right tympanoplasty under general anaesthesia.With a post aural approach and full cuff tympan meatal flap elevation, the ossicular continuity was checked. The temporalis fascia graft was planned to be placed by underlay technique to achieve a type I tympanoplasty. During flap elevation on the anterior wall of the external auditory canal, a shiny blackish brown about 4 mm sized structure was noticed just below the eustachian tube opening. It was initially thought to be a clot. It was palpated with a probe and found to be hard in consistency. The zerodegree endoscope was introduced to confirm this. The structure did not loosen up on suctioning and tactful manipulation was done with a ball probe and suction to dislocate it from the mucosal bed and removed. The graft was placed as planned. It was 4 mm in size, oblong, gritty and hard, surface was irregular, blackish brown, and was sent for further analysis. The chemical analysis confirmed it to be a calcium containing lith. Post operatively patient received antibiotics and the graft was successfully taken up.

Discussion

A tympanolith is a calcified body in the tympanic cavity, known to occur from long standing chronic suppurative otitis media with central perforation, like a rhinolith in the paranasal sinuses. The frequent ear discharge and stagnant mucus in the middle ear acts as a nucleus for the calcium salt deposition[3].The protympanum is a middle ear space anterior to the mesotympanum, confluent with the epitympanum superiorly and hypo tympanum inferiorly. It has been infrequently examined in the past due to difficulty in visualization with a microscope. The area is now gaining relevance with more frequent uses of endoscopes during middle ear surgeries. The protympanum serves as the final common pathway between the tympanic cavity and the external environment. Its boundaries being more defined now with use of straight and angled endoscopes. Inferior boundary of the protympanum is marked by an oblique bony ridge called protiniculum, posteriorly, extending anteriorly with the presence of protympanic air cells, which is an anterior extension of hypotympanic air cells[5]. The protympanic crest was described by Abou-Bieh and colleagues in 79 percent of temporal bones studied radiologically and directly[6]. This bony ridge has been named the protiniculum from the latin word “protinus “which means forward or farther on[7]. This nomenclature is similar to the other promontorial bony ridges. It has three conformations:

a) Type A: Ridge, with no air cells medial to it.

b) Type B: Bridge , hypotympanic air cells extending into the protympanum.

c) Type C: Absent , no discernible protiniculum, the hypotympanum fused with protympanum(Figure 1) [5].

Our patient seemed to have a type A protiniculum and the foreign body was located just inferior to the ridge (Figure 2). There is a possibility of the inspissated stagnant mucus which may have not drained into the protympanum due to the ridge superiorly and acted as a nidus for calcium salts to deposit(Figure 3).The protympanic area has pseudo stratified ciliated columnar epithelium with mucus secreting cells like the nasal mucosa. The physiological function is predominantly mucociliary clearance towards the eustachian tube[8]. When inflamed, protympanic epithelium thickens and becomes polypoidal. The ciliated cells decrease, residual cilia collapse and leads to stagnation of mucus secretion.Mucosal cells contain numerous secretory granules. Polymorphonuclear cells are present submucosally and bacteria on the mucosal surface[9]. The biofilm formation is more likely to be present in the pro tympanum in cases of chronic suppurative otitis media[10,11].

Figure 1: Protiniculum in the hypotympanum[5].

Figure 2: Endoscopic view of middle ear showing tympanolith below the bony crest (protiniculum) in the hypotympanum.

Figure 3: Microscopic view of middle ear after removal of tympanolith.

Conclusion

The protympanum and protiniculum are very important areas and the final common pathway of ventilation of middle ear and mastoid system. The use of angled (30 and 45 degree) and straight (0 degree) endoscopes allows easy access and complete examination of these areas, including removal of polyp, granulation or as in this case, foreign bodies. The use of endoscopes as an adjunct to microscope in ear surgeries seems essential now. And with complete understanding of the middle ear endoscopic anatomy and ventilation pathways we can achieve a more physiological goal during surgeries. An incidental tympanolith in our patient reemphasizes the importance of the habit of inspecting middle ear, every nook and cranny if possible, during every tympanoplasty with a straight or angled endoscope.

Conflicts of Interests

The authors declare that they have no conflicts of interests

Acknowledgements

Dr Nirmal Patel, Australia for permission to share illustration (Figure 1).

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