Review

Journal of International Medical Research

48(11) 1–8
Chronic adenoiditis ! The Author(s) 2020
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DOI: 10.1177/0300060520971458
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Hai Wang

Abstract
In addition to acute adenoiditis and adenoid hypertrophy/vegetation, chronic adenoiditis is anoth-
er disease of the adenoids. However, most physicians overlook chronic adenoiditis or confuse it
with adenoid hypertrophy/vegetation. The incidence of chronic adenoiditis has increased in
recent years as a result of higher rates of chronic nasopharyngeal or upper airway infections.
The clinical characteristics of chronic adenoiditis can include but are not restricted to the fol-
lowing: long-term infection (especially bacterial infection); obstruction of the upper airway;
infections of adjacent regions, such as the nose, nasal sinus, pharyngeal space, middle ear, and
atlantoaxial joint; induced upper airway cough syndrome; and the presence of several “infectious-
immune” diseases, including rheumatic fever, autoimmune nephropathy, and anaphylactoid pur-
pura. To date, no consensus on the treatment of chronic adenoiditis is available. However,
adenoidectomy can address the local obstruction, and some patients benefit from systemic or
local anti-bacterial therapy. Physicians in the Departments of Otolaryngology, Respiration, and
Pediatrics should be familiar with the clinical manifestations of chronic adenoiditis and try to
develop effective treatment methods for this disease.

Keywords
Adenoids, adenoid hypertrophy, adenoidectomy, chronic adenoiditis, infection, upper airway
obstruction
Date received: 18 March 2020; accepted: 13 October 2020

Introduction
Although chronic adenoiditis is listed in the
International Classification of Diseases-10- Pediatrics, First Affiliated Hospital of Heilongjiang
Clinical Modification (ICD-10-CM) as University of Chinese Medicine, Harbin, China
J35.02 (http://www.icd10data.com), most Corresponding author:
Hai Wang, Pediatrics, First Affiliated Hospital of
clinicians, including some otolaryngolo- Heilongjiang University of Chinese Medicine, Harbin,
gists, are unfamiliar with this diagnostic ter- China.
minology. In recent years, an increasing Email: 782955547@qq.com

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2 Journal of International Medical Research

number of patients with chronic inflamma- diagnosis is not difficult if physicians are
tion of the adenoids and complicated nasal, familiar with these manifestations.
pharyngeal, and auricular diseases have
been admitted to the Respiratory, Adenoid hypertrophy/vegetation
Ophthalmology, Otorhinolaryngology, and Adenoid hypertrophy/vegetation is the
Pediatrics Departments.1 Therefore, chron- most common condition reported. It is
ic adenoiditis has become a common clini- described in three sections in the ICD-10
cal disease. The aim of this review was to as follows: J35.2 (hypertrophy of adenoids),
summarize the recent progress in the J35.3 (hypertrophy of tonsils with hypertro-
research on chronic adenoiditis and associ- phy of adenoids), and J35.8 (other chronic
ated diseases and improve the awareness of diseases of tonsils and adenoids: . . .;
this condition among clinicians. Adenoid vegetations; . . .). The manifesta-
tions of simple adenoid hypertrophy
Diseases of adenoids include mouth breathing, snoring (which is
more severe in the supine position and can
According to the descriptions in most text-
progress to obstructive sleep apnea-
books, there are only two types of adenoid
hypopnea syndrome [OSAHS] in severe
diseases, acute adenoiditis and adenoid
cases), and adenoid-face.
hypertrophy/vegetation. However, the diag-
nosis of “chronic adenoiditis” is described
Chronic adenoiditis
in some published articles and ICD codes.
The use of the term “chronic adenoiditis”
Acute adenoiditis was rare in earlier studies. As a description
of a clinical manifestation but not a specific
The clinical manifestations of acute adenoi- term for the diagnosis of a particular disease,
ditis include sudden high fever, severe nasal no exact definition or diagnostic criteria
obstruction, mouth breathing, and yellow were available for “chronic adenoiditis”.
snot dripping from the posterior pharyn- As of August 2020, less than 100 studies
geal wall. Nasal obstruction in infants can on chronic adenoiditis have been published,
lead to dystithia, increased neutrophils, and the first authors of more than half of
high C-reactive protein (CRP) levels in the these studies were from Russia. The first
peripheral blood, and enlarged adenoids on study on chronic adenoiditis, which was
the lateral image of the pharynx.2,3 Because also authored by a Russian investigator,
the adenoids are located behind the nose was published in 1967.4 However, eight stud-
and cannot be directly observed through ies on chronic adenoiditis have been pub-
the mouth, misdiagnosis and missed diag- lished since January 2019, suggesting that
nosis are relatively common in clinical prac- this disease has received increasing attention.
tice. Nasal endoscopy has important value
in diagnosing acute adenoiditis. However,
Clinical characteristics of
this disease is generally overlooked by
physicians in the Respiratory and chronic adenoiditis
Pediatric Departments of primary and gen-
Manifestations of upper
eral hospitals. Additionally, diagnostic
devices are limited in these hospitals. The
airway obstruction
clinical manifestations of acute adenoiditis Chronic adenoiditis involves an increase in
are relatively specific, and thus the the size of adenoids, which induces
Wang 3

continuous or intermittent snoring, mouth and anti-immune capacities of bacteria.

breathing, and dry mouth. These symptoms Antibiotics and immune mechanisms of
are identical to the manifestations of ade- the body only kill free bacteria or bacteria
noid hypertrophy and can easily lead to on the surface of BFs. However, in the pres-
confusion between the two conditions. ence of relatively low antibiotic concentra-
Adenoid inflammation with concomitant tions or a weak immune system, bacteria
obstructive hypertrophy, but not adenoid that survived in BFs can become free and
hypertrophy, is more commonly found in consequently cause infection.12 Therefore,
clinical practice. However, not all cases adenoids may act as reservoirs for patho-
of chronic adenoiditis are accompanied genic bacteria in patients with upper respi-
by evident manifestations of postnasal ratory diseases.13
obstruction.
Continuous glandular secretion
Long-term inflammation
Wei et al.14 performed nasal endoscopy in
Adenoids are located at the center and are
patients with chronic adenoiditis and found
the pivot point of the upper respiratory
the presence of mucosal edema at the sur-
tract. Adenoids have many folds or crypts
face of adenoids, which was accompanied
with limited blood flow, and thus bacteria
by different degrees of mucus or pus adhe-
can easily aggregate in them. Rajeshwary
sion. The adhesion of sticky or sticky puru-
et al.5 performed bacterial culture with
100 specimens from resected adenoids and lent discharge, known as postnasal drip
found that only 7% of the specimens syndrome, was identified by looking
showed no bacterial growth. Similarly, through the mouth in about half of the
Badran et al.6 found that only four out of patients.
35 specimens of resected adenoids exhibited
no bacterial growth. Ren T et al.7 con- Non-severe systemic infection
ducted 16S rRNA sequencing by PCR for and intoxication
67 specimens of adenoids and detected
Because the blood flow to adenoids is lim-
3,121 strains of different bacteria.
ited, the manifestations of systemic intoxi-
Rajeshwary et al.5 found that the most
cation, such as fever, increased leucocytes/
common bacteria included Streptococcus
granulocytes, and elevated CRP levels, are
pneumoniae, Haemophilus influenzae,
Staphylococcus aureus, and Moraxella not typically observed when chronic inflam-
catarrhalis. Bacteria in adenoids generally mation is not severe.
include all of the bacteria found in the
nasal cavity, nasal sinus, tonsils, and Complications and comorbidities
middle ear effusion.5,8–10 Emaneini et al.11 of chronic adenoiditis
found that S. aureus present in adenoids
formed extracellular biofilms (BFs). A bac- Adenoids are located at the center of the
terial BF is a membrane-like substance region between the nose, pharynx, and
formed by the polysaccharide matrix, ears and play a central role in upper respi-
fibrous proteins, and proteolipid proteins ratory infection and the spread of infection
secreted by bacteria attached to the surfaces from adenoids to other locations. In addi-
of tissues. BFs contain various types of bac- tion, inadequate immunity against infection
teria and even DNA and RNA. In addition, can lead to the development of other
BFs can enhance the antibiotic resistance diseases.
4 Journal of International Medical Research

Rhinitis and rhinosinusitis lead to increased tympanic pressure and

earache or induce secretory otitis media.17
Marseglia GL et al.15 assessed 287 children
with the manifestation of upper respiratory
infection for more than 10 days. The find-
Ozostomia
ings of nasal endoscopy confirmed nasosi- Previously, ozostomia in children was
nusitis in 256 children (89.2%), isolated thought to be primarily caused by gastroin-
rhinosinusitis in 207 children (80.85%), testinal function disorders, such as gastro-
nasosinusitis accompanied by adenoiditis esophageal reflux and laryngopharyngeal
in 49 children (19.15%), and simple adenoi- reflux. Recent studies have demonstrated
ditis in 20 children (7%). that chronic tonsillitis and tonsillar calculus
are the major causes of ozostomia in
Chronic pharyngeal inflammation adults.18 Tulupov DA et al.19 examined 37
children aged 5 to 18 years and found that
Adenoids are important components of
ozostomia was caused by chronic tonsillitis,
Waldeyer’s ring. Pathogens, inflammatory
chronic adenoiditis, chronic rhinosinusitis,
cells, and their products can spread along
and sub-atrophic rhinitis in 31, three, two,
the anatomical spaces and consequently
and one child, respectively. Dinc ME
induce acute or chronic infections of the
et al.20 used portable gas chromatography
pharynx and adjacent tissues, such as
to measure the levels of volatile sulfur com-
chronic pharyngitis, cobblestone throat,
pounds, hydrogen sulfide, methyl mercap-
soft palatitis, abscesses of the posterior pha-
tan, and dimethyl sulfide in 40 children
ryngeal wall, and abscesses of the periphar-
with adenoid hypertrophy and found signif-
yngeal space.
icant differences compared with the con-
trols. However, the levels between the two
Lymphadenitis groups were comparable at three months
Infection, especially chronic infection, of after adenoidectomy.
the nose and pharynx can lead to hyperpla-
sia and the enlargement of the correspond- Upper airway cough syndrome (UACS)
ing lymph nodes. This is the major cause of
UACS, also known as post-nasal drip syn-
enlarged cervical lymph nodes and intra-
drome, is a common cause of chronic cough
glandular parotid lymph nodes in children.
in adults and children and the first leading
cause of chronic cough among Europeans
Suppurative/secretory otitis media and Americans. UACS was previously
The pharyngeal opening of the auditory thought to be mainly caused by rhinitis,
tube is located at the adenoids of the lateral nasosinusitis, and allergic rhinitis.
nasopharyngeal wall and adjacent lym- However, recent evidence indicated that
phoid tissues. The auditory tube mucosa is adenoid diseases are the major cause of
connected to the mucosa of the nasophar- UACS.21–23 As patients with chronic
ynx and tympanum and has a secretory cough are mainly admitted to the depart-
function. Infections in adenoids can ments of Pediatrics or Respiration for treat-
spread along the auditory tube to the ment, and the anatomical locations of
middle ear and consequently induce suppu- adenoids are hidden, the misdiagnosis and
rative otitis media16 and even mastoiditis. missed diagnosis of chronic adenoiditis are
Hyperplastic adenoids can also block the common. The features of cough caused by
auditory tube, which can subsequently chronic adenoiditis are as follows: (1) cough
Wang 5

occurring or worsening upon postural The diagnosis of chronic adenoiditis mainly

change and (2) cough mainly occurring depends on long-term local infection as fol-
after falling asleep or when waking up in lows: 1) reporting foreign body sensations at
the morning. the pharynx, adhesion of the sputum, and
postnasal dripping, along with long-term
Other infection-induced diseases manifestations of throat clearing, nasopha-
ryngeal inhalation, and expectoration; 2)
Other infection-induced diseases include tic
can be accompanied with other symptoms,
disorders, rheumatic fever, glomerulonephri-
including nasal obstruction, running nose,
tis, nephrotic syndrome, and anaphylactoid
sneezing, rhinocnesmus, dry throat, and
purpura. Murphy TK et al.24 reported that
headache; 3) physical examination can
the manifestations of tic disorder in a child
show evident retropharyngeal folliculitis
with severe OSAHS evidently improved
and cobblestone-like changes, the adhesion
after adenoidectomy. Motta G et al.25 of mucinous, or purulent secretion; 4) nasal
found that the titer of anti-streptolysin O endoscopy shows mucosal edema on the
increased significantly in children with surface of adenoids accompanied with dif-
repeated tonsillitis/otitis media. Palatine ton- ferent degrees of mucus or pus adhesion;
sillitis is closely associated with the develop- and 5) lateral X-ray imaging, local comput-
ment and recurrence of glomerulonephritis ed tomography scanning, or nasal endosco-
and nephrotic syndrome. Because the loca- py of the nasopharynx shows the
tions and functions of adenoids are similar enlargement of adenoids and obstruction
to palatine tonsils, it is possible that adenoi- of the upper airway, which suggests the con-
ditis also triggers these diseases. comitant presence of adenoid hypertrophy/
vegetation.
Upper cervical spine syndrome/cervical
spine dysfunction/atlantoaxial subluxation Treatments for chronic
in children adenoiditis
The cervical spine in children is not
Owing to the limited understanding of the
completely developed, and the functions of
clinical characteristics and diagnosis of
support, movement, and protection are not
chronic adenoiditis, especially the confusion
fully established. Atlantoaxial joint instabil-
with adenoid hypertrophy, very limited
ity is very common in children,26 and pha-
treatment strategies and measurements
ryngeal inflammation is a common cause of
are currently available for this chronic
atlantoaxial subluxation in children.27 The
infection.
pharynx and adenoids are adjacent to the
atlantoaxial joint, with shared venous and
Adenoidectomy
lymphatic circulation. Inflammation can
cause atlantoaxial joint effusion, transverse Surgical or medical treatments are available
ligament hyperemia, and laxity, thereby for simple adenoidal hypertrophy, especial-
resulting in spontaneous luxation or ly in patients with induced OSAHS. For
subluxation. patients with adenoidal hypertrophy
accompanied by chronic infection, the sur-
gical indications should be re-assessed after
Diagnosis of chronic adenoiditis effective treatment with antibiotics. As
To date, no universally accepted diagnostic described above, the infection of adenoids
criteria for chronic adenoiditis are available. can trigger chronic diseases, including
6 Journal of International Medical Research

nephritis, nephrotic syndrome, and rheu- Montelukast and glucocorticoids

matic fever, and even lead to the recurrence for nasal inhalation
and refractory of the diseases. The com-
Both montelukast and glucocorticoids for
bined resection of palatine tonsils and
nasal inhalation have good efficacies in
adenoids may provide additional benefit
treating adenoidal hypertrophy in some
for these patients compared with the
patients. However, because both chronic
simple resection of palatine tonsils.
infection and hyperplasia co-exist in chron-
However, recurrence was found in some
ic adenoiditis, the treatment mechanisms of
patients who received adenoidectomy, as these two drugs for chronic adenoiditis need
the local infection was not completely to be further investigated and validated.
cleared.28 In summary, chronic adenoiditis is a
common disease that is easily overlooked
in children. Infected adenoids may serve as
Anti-bacterial treatment a “bacteria pool” in the upper airway and
Karpova et al. found that systemic or local are an important issue in chronic nasophar-
anti-bacterial treatments are effective for yngitis and otitis media. Chronic adenoiditis
chronic adenoiditis induced by bacterial has unique clinical manifestations and is
infection and that some patients benefited accompanied by various complications and
from these treatments.3 Nesterova et al.29 comorbidities that are substantially differ-
divided 170 patients with chronic adenoidi- ent than those associated with adenoidal
tis into three groups who were administered hypertrophy. Adenoidectomy may benefit
low-frequency ultrasound for nasopharyn- some patients. More studies and investiga-
geal disinfection, oral amoxicillin/clavu- tions are needed to further the understand-
lanic acid, or oral broncho-vaxom for ing of this disease, and pediatricians should
treatment. The findings showed that the pay particular attention to this condition.
effectiveness of oral broncho-vaxom was
higher than that of the other two treat- Declaration of conflicting interest
ments. Some researchers, especially those The authors declare that there is no conflict of
interest.
from Russia,30 topically administer hyal-
uronic acid for the treatment of otolaryngo-
Funding
logical disorders, which has shown
This research received research fund of
moderate or high effectiveness. This disease
Heilongjiang University of traditional Chinese
is mainly caused by bacterial infection;
medicine (2019XY05).
however, because of the accompanying
issues, including poor local blood circula- ORCID iD
tion, the presence of BFs, and bacterial
Hai Wang https://orcid.org/0000-0002-2516-
drug resistance, no agreements have been 4613
reached regarding the indications, selection,
and duration of antibiotic treatments.
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