The Journal of International Medical Research

2008; 36: 157 – 162

Adenoid Hypertrophy in Adults: Clinical

and Morphological Characteristics
N YILDIRIM1, M ŞAHAN2 AND Y KARSLIOĞLU3
1
Department of Otolaryngology, Yuzuncuyil University Medical Faculty, Kazim Karabekir
Caddesi, Van, Turkey; 2Department of Otolaryngology, Ankara Military Hospital, Diskapi,
Ankara, Turkey; 3Department of Pathology, Gulhane Medical Faculty, Etlik, Ankara, Turkey

This study compared the aetiology and 25.0% of patients. Histopathological

pathological characteristics of adult and
childhood adenoid hypertrophy (AH).
Clinical and morphological features
and accompanying otolaryngological
pathologies were recorded in 40 adults and
23 children undergoing adenoidectomy
for obstructive AH. Both AH forms were
similar in terms of symptomatology and
associated inflammations. There were,
however, significant differences in otitis
media rate, with effusion and dullness,
and retraction in the eardrum both more
prevalent in childhood AH. Adult AH was
associated with nasal septum deviation in
features of adenoidal lymphoid tissue were
dissimilar in the two groups: numerous
lymph follicles with prominent germinal
centres was the chief finding in childhood
adenoids, whereas adult adenoids showed
chronic inflammatory cell infiltration and
secondary changes (e.g. squamous
metaplasia). These results underline the
importance of considering AH as a cause
or contributing factor in nasal obstruction
and related pathologies in adults and
supports the theory that it represents a
long-standing inflammatory process
rather than being a novel clinical entity.

KEY WORDS: ADENOID HYPERTROPHY; NASAL OBSTRUCTION; NASAL SEPTUM DEVIATION;

NASOPHARYNX; AETIOLOGY; PATHOLOGY; ADULTS

Introduction obstruction in childhood.3 Symptoms of AH

The adenoids (nasopharyngeal tonsils) are
part of Waldeyer’s ring of lymphoid tissue.
Located in the posterosuperior wall of
the nasopharynx, they hypertrophy
physiologically in children between the ages
of 6 and 10 years, then atrophy by the age of
16 years. The adenoids consist of
unencapsulated lymphoid tissue organized in
germinal centres.1,2 The term adenoid
hypertrophy (AH) indicates non-physiological
enlargement of the nasopharyngeal tonsils
and is the most prevalent cause of nasal
include open-mouth breathing, hyponasal
speech, snoring, obstructive sleep apnoea and
rhinorrhoea.2,3
Adenoidectomy with or without
tonsillectomy and ventilation-tube insertion
is one of the most frequently performed
operations.4 The main indications for
adenoidectomy are chronic and recurring
upper respiratory tract inflammation, such
as otitis media with effusion or sinusitis, and
obstructive AH.5,6
It has been demonstrated that AH is also

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Adenoid hypertrophy in adults

seen in the normal adult population7 and
may cause nasal obstruction.8,9 This study
aimed to investigate the aetiology and
pathological characteristics of adult AH
compared with childhood AH and assess its
clinical importance.
Patients and methods
PATIENTS
Adult patients with obstructive AH who
underwent adenoidectomy between 2002 and
2007 at Ankara Military Hospital, Ankara,
Turkey, were included in the study. The
diagnosis of AH was made on the basis of the
medical history, indirect nasopharyngoscopy
and/or endoscopy and imaging (direct films
and computed tomography) (Fig. 1); biopsy
was also performed in some cases. The group
for comparison consisted of children in whom
adenoidectomy for obstructive AH was carried
out, also at Ankara Military Hospital, during
2006; those undergoing adenoidectomy for
other indications were excluded.
SURGICAL PROCEDURE AND
ASSESSMENTS
In all the study participants, adenoidectomy
was performed under general anaesthesia
using adenotomes and curettes with the aid
of endoscopy. In some patients, additional
procedures for associated pathologies were
performed concurrently. Surgical specimens
were processed and stained with
haematoxylin and eosin, then assessed
using light microscopy.
Clinical and morphological features,
accompanying otolaryngological pathologies,
underlying upper respiratory inflammations
(e.g. allergic rhinitis, sinusitis), microscopic
properties of removed adenoidal tissue
samples and duration of nasal obstruction
were recorded for each study participant. In
cases of suspected nasal allergy, confirmation
was sought on the basis of medical history,
rhinological examination, immunoglobulin
E assessment and a ‘skin prick test’.
DATA AND STATISTICAL ANALYSIS
The prevalence rates of various clinical and
morphological features were compared in
the two groups using the Z test. A P-value
< 0.05 was considered to be statistically
significant. Parameters that belonged
exclusively to one or other of the groups,
such as smoking and nasal septum
deviation, were not included in the analysis.

A B

FIGURE 1: (A) Adult adenoid, endoscopic view. (B) Axial computed tomography view
in the same patient, showing the adenoid in contact with the inferior turbinate

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Adenoid hypertrophy in adults

Results almost all children nasal breathing

Forty consecutive adult patients (38 males
and two females) aged 20 – 39 years
undergoing adenoidectomy were included in
the study. The presenting symptom was
nasal obstruction in 38 patients, and tinnitus
and hearing loss in the remaining two cases.
In three cases the diagnosis of AH was
confirmed by biopsy. The comparison group
consisted of 23 consecutive children aged 4 –
11 years undergoing adenoidectomy for
obstructive AH.
Additional procedures were performed in
21 of the adults (septoplasty, ventilation tube
insertion, conchoplasty) and 16 of the
children (ventilation tube insertion and/or
tonsillectomy).
All patients in both groups complained of
difficulty in nasal breathing, with a duration
of > 10 years in seven (17.5%) and < 10 years
in 33 (82.5%) subjects in the adult group; in
difficulties had been present since infancy.
Six (15.0%) of the adult group had a history
of previous adenoidectomy in childhood.
Twenty-one (52.5%) of the adult group were
smokers.
Incidences of the related symptoms of
rhinolalia, snoring and obstructive sleep
apnoea are given in Table 1. The only
significant difference between the groups
was in the incidence of snoring (Table 1).
When the associated otolaryngological
pathologies and findings were compared in
the two groups, there were significant
differences in the rate of otitis media with
effusion (Table 2) and the rate of dullness
and retraction in the eardrum (Table 3): both
conditions were more prevalent in the
childhood group. Obstructive nasal septum
deviation was found in a noteworthy
proportion of the adult group (25.0%); the

TABLE 1:
Rhinopharyngological symptoms in adults and children undergoing adenoidectomy for
adenoid hypertrophy
Adults Children
Symptoms (n = 40) (n = 23) Z value
Difficulty with nasal breathing 40 (100%) 23 (100%) 0
Snoring 8 (20.0%) 12 (52.2%) 2.64a
Rhinolalia 3 (7.5%) 2 (8.7%) 0.17
Obstructive sleep apnoea 2 (2.5%) 1 (4.3%) 0.12
aP < 0.005.

TABLE 2:
Upper respiratory tract inflammation in adults and children undergoing adenoidectomy
for adenoid hypertrophy
Adults Children
Pathology (n = 40) (n = 23) Z value
Otitis media with effusion 5 (12.5%) 9 (39.1%) 1.93a
Otitis media sequelae 5 (12.5%) 1 (4.3%) 1.21
Sinusitis 3 (7.5%) 3 (13.0%) 0.68
Chronic tonsillitis 8 (20.0%) 5 (21.7%) 0.16
Allergic rhinitis 6 (15.0%) 4 (17.4%) 0.25
aP < 0.05.

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Adenoid hypertrophy in adults

TABLE 3:
Otological findings in adults and children undergoing adenoidectomy for adenoid
hypertrophy
Adults Children
Finding (n = 40) (n = 23) Z value
Dull and retracted tympanic membrane 4 (10.0%) 8 (34.8%) 1.52a
Myringosclerosis 2 (5.0%) 0 1.27
Atrophied tympanic membrane 2 (5.0%) 1 (4.3%) 0.97
Retraction sac 1 (2.5%) 0 1.1
Tympanic membrane perforation 1 (2.5%) 0 1.1
a
P < 0.05.

few cases of nasal septum deviation seen in
the childhood group did not impinge on the
nasal airway. Some otological symptoms
(tinnitus, hearing loss) and findings
(myringosclerosis, retraction sac, tympanic
membrane perforation or atrophy; Table 3)
were more prevalent in the adults studied
than in the children, but these differences
were not statistically significant.
On nasopharyngeal examination, the
lymphoid mass was mostly found to be
covered with a smooth epithelium in the
adult group. In three adults the mass was
irregular and asymmetrical; punch biopsies
were performed prior to surgery in these
patients. Mucosal thickening in a small
nasopharynx was seen in one adult patient.
In contrast, the lymphoid mass appeared
more or less cauliflower-like in all children
studied.
On histopathological examination, the
presence of numerous lymph follicles with
prominent germinal centres was the chief
finding in the adenoids removed from

FIGURE 2: (A1, A2) Histopathological view of a childhood adenoid, showing

prominent hyperplasia in the germinal centres. (B1, B2) In contrast to the childhood
adenoids, adult adenoid characteristics were fibrosis, chronic inflammatory cell
infiltration (B1) and squamous metaplasia (B2) (arrows). Haematoxylin and eosin stain

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 N Yildirim, M Şahan, Y Karslioğlu
Adenoid hypertrophy in adults
children. In contrast, adenoids removed from
adults showed intense chronic inflammatory
cell infiltration and secondary changes such
as squamous metaplasia in the surface
epithelium and fibrosis (Fig. 2).
Discussion
Obstructive AH is usually associated with
childhood. Less has been published on the
adult form, possibly due to its under-
diagnosis as a result of incomplete
nasopharyngeal examination, although it
has also been overshadowed by
accompanying rhinopharyngological
disorders.8,9 In a survey of 15 000 adults
(aged > 16 years), the adenoid was present in
2.5%.7 Various aetiopathogenetic
mechanisms have been proposed to explain
the presence of lymphoid hyperplasia in the
adult nasopharynx, including the
persistence of childhood adenoids due to
chronic inflammation9 or re-proliferation of
regressed adenoidal tissue in response to
irritants or infections.8 Finkelstein et al.10
reported the presence of obstructive adenoids
in 30% of heavy smokers. AH caused by
viruses in adults with compromised
immunity, especially those receiving organ
transplants and those with human
immunodeficiency virus (HIV), is a well-
known phenomenon.11 In the present study,
the percentage of smokers was not
significantly higher than in males of the
same age.12 In addition, the incidence of
allergic rhinitis in the adults and children
studied was not higher than that reported for
the country,13 in contrast to the findings of
some other published reports.10,14
It is noteworthy that a higher percentage
of children with AH were reported to suffer
from snoring compared with adults in the
present study. Snoring is highly prevalent in
childhood and is attributable to various
causes, among which AH is predominant.15
161
It is possible that snoring is more frequently
reported in children than in adults due to
close monitoring by the parents.
The histological features of childhood
adenoids in the present study are largely
consistent with hyperplasia, characterized by
an increase in the volume and number of
germinal centres,16,17 whereas the adult
adenoids displayed typical findings of
chronic inflammation. The presence of a
lymphoid mass in an adult nasopharynx is
suspicious, especially when accompanied by
unilateral middle-ear effusion, and
nasopharyngeal cancer should always be
ruled out in such cases. Ultrastructural
changes in lymphocytes in smoking-induced
AH and malignant transformation in HIV-
related AH have been demonstrated.12,18 In
the present study, malignancy was
considered in the differential diagnosis and
biopsies were performed in three patients;
these were all reported as negative.
The significant association between AH
and otitis media with effusion in the
childhood group is unsurprising: it is well
known that children are more susceptible to
middle-ear inflammation, owing to their
shorter and less tortuous Eustachian tubes.2
The co-existence of obstructive AH and
obstructive nasal septum deviation in 25.0%
of the adult group is noteworthy.
Developmental nasal septum deviation
usually manifests after adolescence,
affecting nasal physiology and predisposing
the person to chronic sinonasal
inflammation and post-nasal drip.19 Nasal
septum deviation may also indirectly cause
low-grade chronic inflammation of the
adenoids, interfering with their physiological
regression.
A considerable percentage (15.0%) of the
adult patients in the present study gave a
history of past adenoidectomy. This suggests
that there was inadequate removal of the
 N Yildirim, M Şahan, Y Karslioğlu
Adenoid hypertrophy in adults

adenoidal tissue at the previous operation,20 adult AH occurs secondary to chronic or

and also indicates that the pathological recurrent infections, or anatomical
processes leading to AH began in childhood. disturbances that cause chronic
In conclusion, the results of the present inflammation and persistence of the
study indicate that adult AH is associated nasopharyngeal tonsil.
with a history extending back to childhood,
chronic upper respiratory tract inflammations Conflicts of interest
and their consequences, and obstructive No conflicts of interest were declared in
nasal septum deviation. This suggests that relation to this article.

• Received for publication 13 August 2007 • Accepted subject to revision 17 August 2007
• Revised accepted 28 November 2007
Copyright © 2008 Field House Publishing LLP

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Author’s address for correspondence

Dr Nadir Yildirim
Department of Otolaryngology, Yuzuncuyil University Medical Faculty, Kazim Karabekir
Caddesi, 65200 Van, Turkey.
E-mail: nadir_yildirim@yahoo.com

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