In the young, but when it is successful a smooth, greyish-white, spherical mass

will be seen in the choana early on, and later filling the nasopharynx. Once the

nasopharynx is filled the polypus may project below the soft palate, or may be

seen when the palate rises on phonation. It presents as a greyish convex mass on

examining the pharynx. Radiography will show a lack of air entry into the

affected maxillary sinus and cyst in this sinus, while a lateral projection will

demonstrate the polypoid swelling in the nasopharynx.

Treatment is surgical.

Part 7

DISEASES OF THE PHARYNX

Adenoid Hyperplasia

Symptoms. These include nasal obstruction leading to mouth breathing, difficulty

in feeding especially in small children, noisy respiration, snoring, typical

adenoid facies, i.e., dull facial expression, open mouth, dilated and flattened

nasolabial folds, indrawn nasal alae, protruding upper incisor teeth, enlarged

lymph nodes at the angle of the jaw or in the nuchal area, the adenoid habitus,

and rhinolalia clausa.

Obstruction of the nasopharynx may be responsible for:

1. Aural diseases, including obstruction of the eustachian tube, chronic tubal

and middle ear catarrh, serous effusion, recurrent acute otitis media, formation

of adhesions, also progression of chronic otitis media and conductive deafness.

2. Diseases of the nose and paranasal sinuses, including chronic purulent

rhinitis or sinusitis, and even pansinusitis

3. Disorders of the masticatory apparatus, including: maldevelopment of the

upper jaw, i.e., arched or "gothic" palate due to absence of the pressure of the

tongue on the hard palate, and absence of lateral pressure on the upper jaw and

alveolus by the tension of the buccinator muscle and the masticatory muscles

because of the open mouth. Also including anomalies of position of the teeth,

such as incorrect contact and orientation of the mandibular occlusion, and

gingivitis

4. Disorders of the lower respiratory system, i.e., chronic laryngitis,

tracheitis, and bronchitis

5. Other somatic effects, including a flat chest, round shoulders, loss of

appetite, poor general development, and sensitivity to attacks of infection

6. Effects on the intelligence and mental development due to chronic respiratory

obstruction and hypoxia during sleep; increased levels of CO2 in the blood

leading to restless, broken sleep causing tiredness during the day, apathy,

dullness, poor school performance, and "pseudodementia"

Pathogenesis. The disease is caused by above-average hypertrophy of the

lymphoepithelial tissue of the pharyngeal ring which is so immunobiologically

active during childhood. There is probably a hereditary disposition. Endocrine

and constitutional factors and the influence of diet, in particular

carbohydrates, are suggested. There are three degrees of adenoid hyperplasia.

Diagnosis. The main symptoms include chronic mouth breathing, snoring, and

proneness to infection. Examination by anterior and posterior rhinoscopy shows

the enlarged adenoid. Palpation may be needed.

Differential diagnosis. This includes choanal atresia, foreign bodies in the

nose, and other causes of nasal obstruction such as nasopharyngeal angiofibroma

and malignant tumors of the nasopharynx, possibly of mesenchymal origin

especially in children. Dental causes should be looked for to explain the

anomalies of position of the teeth and malocclusion.

Treatment. Conservative treatment by change of climate, diet, drugs, and so

forth is not satisfactory.

Operative treatment is by adenoidectomy.

The operation is carried out under local or general anesthesia. A Beckman's ring

adenotome is usually used to remove the adenoid. This instrument separates the

adenoid at its base.

Course and prognosis. The symptoms usually resolve rapidly after removal of the

mechanical obstruction. The child usually returns surprisingly rapidly to normal

physical, psychological, and intellectual health. The prognosis is very good;

recurrence after correctly performed adenoidectomy is unusual. Complications are

mainly postoperative bleeding and aspiration. These are only to be feared if

hemostasis is not achieved at operation or if tissue has been left behind.

Because a pathologic bleeding tendency may easily be overlooked, the following

investigations should be carried out before adenoidectomy:

1. History and family history relative to bleeding and coagulation disorders

should be taken.

2. The bleeding time should be determined.

3. The partial thromboplastin time (PTT) should be determined.

4. The thrombocyte count should be determined.

Tonsillar Hyperplasia.

Symptoms. This is usually combined with hypertrophy of the adenoid. In addition,

there is increased difficulty in swallowing and eating because of obstruction of

the faucial isthmus. Considerable respiratory obstruction may also occur when

only the tonsils are hyperplastic.There are three degree of tonsillar

hyperplasia.

Diagnosis. The local findings are obvious.

Differential diagnosis. This is similar to that for adenoid hypertrophy. It is

important to determine whether the tonsils alone are hypertrophic or whether

there is a coexisting adenoid hypertrophy.

Unilateral hyperplasia of the tonsil in an adult must always lead to suspicion

of malignancy. A rapid hyperplasia of the lymphatic pharyngeal ring points to a

disease of the entire lymphatic system.

Treatment. Tonsillectomy is performed, usually combined with adenoidectomy.

Not every enlargement of the tonsil or adenoid in a child is an indication for

removal. There must be considerable hyperplasia with obvious mechanical

obstruction of the naso- or oropharynx, and the appropriate clinical effects and

disorders must be present.