Diseases of the nasopharynx: classification, causes, diagnosis, treatment

Nasopharyngeal diseases are a common group of pathologies, especially in children. They are associated with impaired function of lymphoid tissue located in this area, and can lead to a significant deterioration in the quality of life, nasal breathing difficulties, sleep disorders, hearing loss and other complications. The most common are adenoid hypertrophy and adenoiditis, and less commonly hypertrophy of the tubal tonsils. These conditions require timely diagnosis and comprehensive treatment, including both conservative and surgical methods.

Definition of nasopharyngeal diseases

Adenoid hypertrophy is a pathologic overgrowth of the nasopharyngeal tonsils that occurs more often in childhood.

Tubal valvular hypertrophy is a pathologic overgrowth of lymphoid tissue of the tubal tonsils located in the area of the mouth of the auditory tubes (tubal valleys).

Adenoiditis is an inflammation of the nasopharyngeal tonsils.

Classification of diseases of the nasopharynx

1. Adenoid hypertrophy:

• 1st degree hypertrophy;
• 2nd degree hypertrophy;
• Third-degree hypertrophy.

2. Hypertrophy of the tubal shafts.
3. Inflammation of the adenoids:

• Acute adenoiditis;
• Chronic adenoiditis.

Etiology

The nasopharyngeal tonsil (adenoids) enlarges on average at the age of 3 years and occurs in children until puberty, then it involves and is defined as a small mass by the age of 20 years. It is observed quite frequently ~35.0 per 1000, which is more than 50% of all children who consult an otorhinolaryngologist. They are sometimes found in younger children and may persist into adulthood. The tubal tonsil is also enlarged in preschool children, but quite rarely.

The causes of these conditions are identical, as adenoids and trumpet tonsils are represented by lymphoid tissue and are located in the nasopharynx. The most common is an infectious factor, in which bacteria, viruses and fungi cause antigenic stimulation, but the lymphoid tissues are immature and produce insufficient antibodies, in connection with this and their compensatory hypertrophy occurs. Subsequently, after immunity has formed, there is a decrease in tissue size. Also increase in adenoids and tubal tonsils contribute to household and food allergens, as well as GERD (gastroesophageal reflux disease), in which there is irritation of nasopharyngeal tissues with hydrochloric acid vapor. According to research, the size of the nasopharyngeal tonsils is also affected by parental smoking and hereditary predisposition.

Viruses and bacteria play a leading role in the development of adenoiditis. The most common among them are MS viruses, adenoviruses, influenza and parainfluenza viruses, herpes viruses, including. Epstein-Barr virus, streptococci (St. pneumoniae, St. pyogenes), staphylococci(S. aureus, S. epidermidis), Pseudomonas aeruginosa, Moraxella catarrhalis, as well as activation of opportunistic microflora of the nasopharynx. Concomitant pathologies such as recurrent or chronic upper respiratory tract diseases (rhinitis, sinusitis, bronchitis), GERD, allergies can contribute to the development of the disease and worsen the course. The presence of hormonal or immune disorders (diabetes mellitus, thyroid pathology, HIV infection) also adversely affects the development of the disease. Lack of a history of breastfeeding and vitamin D deficiency, among others, worsen and prolong the course of adenoiditis. Do not forget about the state of the environment: dry air, inadequate temperature regime, littering of premises, work at harmful enterprises negatively affect the state of the upper respiratory tract and also aggravate the manifestation of the disease.

Anatomy

Adenoids are located in the upper vault of the nasopharynx, and depending on their size and protrusion into the lumen of the nasopharynx, they are divided into degrees.

Adenoids of the 1st degree are located in the upper part of the nasopharynx and close ⅓ of the scolex, 2nd degree – occupy ½ of the nasopharynx and close ½ of the scolex, 3rd degree, respectively, almost completely block the lumen of the nasopharynx and descend into the oropharynx, close the scolex.

The structure of the nasopharyngeal tonsil is a heterogeneous elastic lumpy substance of pink color, about 5-7mm thick and 20-25mm in diameter, with longitudinal furrows of different sizes.

The tubal tonsils are small areas of lymphoid tissue (up to 7 mm) located cranially in the area of the auditory tube orifices. If they are hypertrophied, the orifices are blocked and the exit from the eustachian tube is blocked.

In inflammation of the nasopharyngeal tonsil, its barrier function is impaired, the cilia of the epithelium are destroyed, adenoid vegetations are hyperemic and infiltrated, covered with fibrinous plaque, a large amount of serous or mucopurulent content is found in the grooves. Mucus flow is also noted along the posterior wall of the pharynx, lymphoid follicles are enlarged, hyperemia of the posterior palatine glands, the lateral wall of the pharynx is determined. By the nature of the discharge adenoiditis is divided into catarrhal, exudative-serous and mucous-purulent.

Clinical manifestations

Hypertrophied adenoids are characterized by a rich clinical picture. The most common complaint of parents is constant difficulty in nasal breathing, snoring, noisy breathing. In small children due to nasal breathing disorders, eating is difficult. With a pronounced degree of hypertrophy develops nasality. Due to respiratory disorders, children sleep worse at night, often wake up, some have COAS (obstructive sleep apnea syndrome) in which there are respiratory arrests up to 1 minute, all this leads to increased fatigue, decreased performance. There is also a concept of habitus adenoideus or adenoid type of face, such children have a flattened nose bridge, half-open mouth, bite disorder (mandibular pronation), protruding forward upper incisors, gothic palate, small exophthalmos, elongated shape of the face.

Hypertrophied tubal tonsils do not cause clinical manifestations per se; their effect on the airway is mediated by the auditory tube block.

Hypertrophied adenoids as well as tubal tonsils block the mouths of the auditory tubes and lead to tubo-otitis, recurrent acute otitis media or flaccid exudative otitis media, in some cases with conductive hearing loss, sometimes this is the only complaint.

Clinically, adenoiditis is divided into acute (up to 7-10 days), subacute (from 10 days to 1 month) and chronic (over 1 month), but in practice this division is conditional. Due to the fact that in adenoiditis occurs edema of lymphoid tissue clinic is similar to the manifestation of hypertrophy of adenoids. In addition to the above complaints are characterized by mucous or purulent discharge from the nose, mucus flowing down the back wall of the pharynx, accompanied by coughing, worsening of the condition is noted at night. Acute adenoiditis is characterized by febrile body temperature, general intoxication, pain in the depths of the nose, head, irradiation to the eyes, ears. Regional lymph nodes are enlarged, their soreness is noted. Chronic adenoiditis is characterized by subfebrile body temperature, suffocating night cough, concomitant pathology of the middle ear, accompanied by conductive hearing loss.

Diagnosis

Initially, complaints are collected, anamnesis is clarified and otorhinolaryngoscopy is performed. To determine the degree of nasopharyngeal obstruction and to examine the orifice of the auditory tubes, posterior rhinoscopy and endoscopy of the nasopharynx are performed. Finger examination is rarely performed. Also, to determine the degree of hypertrophy of adenoid vegetations, nasopharyngeal radiography in lateral projection is performed. If the nasopharyngeal tonsil is inflamed, a microbiological study for microflora and sensitivity to antibiotics is performed.

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Treatment

Initially, children with hypertrophied nasopharyngeal or tubular tonsils are treated conservatively. Intranasal glucocorticosteroids (mometasone furoate) are prescribed for at least 1 month with subsequent evaluation in dynamics. If the results are good, its further use is recommended according to the scheme.

In the absence of an effect and in the presence of complications such as COAS, hearing loss or chronic otitis media, surgical treatment is recommended. Under local or general anesthesia, an adenotomy is performed in which the hypertrophic lymphoid tissue is excised with a Beckman adenotome.

Hypertrophied lymphoid tissue of the nasopharyngeal tonsil in adults is subject to mandatory surgical removal with subsequent pathohistologic examination.

The tubal tonsils should be treated only conservatively, also with topical glucocorticosteroids. Their surgical excision is not performed, as in most cases it leads to scarring of the aperture of the auditory tubes. In case of severe obstruction of the eustachian tubes and the presence of exudate in the middle ear cavity, accompanied by hearing loss, their balloon dilatation is performed.

For the treatment of inflamed nasopharyngeal tonsils, antibacterial drugs are used in the form of topical sprays or systemically, taking into account sensitivity. In addition to etiotropic therapy recommended regular sanitation of the nasal cavity and nasopharynx from pathological contents with physiological solution or seawater solutions, vasoconstrictive sprays are used to relieve edema. It is necessary to carry out general strengthening measures. With recurrent adenoiditis or complications of the middle ear, it is worth considering surgical treatment.