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ADENOIDS & JUVENILE NASOPHARYNGEAL ANGIOFIBROMA (JNA)

ENT - MBBS 4th Year

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PART 1: ADENOIDS

Embryology

• Adenoids develop at 16 weeks as subepithelial infiltration of lymphocytes in the nasopharynx
• They form part of Waldeyer's ring (along with palatine tonsils, lingual tonsil, tubal tonsils)

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Anatomy

• Located on the posterior wall of the nasopharynx (roof and posterior wall)
• Covered by ciliated pseudostratified columnar epithelium (respiratory type); luminal aspect has multiciliated and secretory cells
• Unlike palatine tonsils, adenoids have no crypts - they have surface folds/rugae
• They are not encapsulated and have no afferent lymphatics

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Physiology / Role

• Part of the mucosal immune system; produce secretory IgA (sIgA)
• Act as first-line defense against inhaled antigens
• Adenoid size peaks at 4-10 years, then undergoes spontaneous involution at puberty
• In children with CRS (chronic rhinosinusitis):
  • Adenoids serve as a bacterial reservoir - bacteria from middle meatal swabs and adenoidal core cultures are near-identical (S. pneumoniae, Group A strep, H. influenzae, S. aureus, coagulase-negative staphylococci)
  • Positive predictive value of adenoid core culture for predicting middle meatal culture: 91.5%
  • Biofilms cover 88-99% of adenoid surface in CRS children vs 0-6.5% in simple obstructive adenoid hypertrophy
  • Lower IgA expression in CRS adenoids; higher TGF-β1, MMP-2, MMP-9

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Adenoid Hypertrophy - Clinical Features

• Lateral soft tissue X-ray of nasopharynx - shows pad of adenoid tissue in postnasal space (arrow visible on soft tissue radiograph)

• Flexible nasendoscopy (gold standard)
• Note: adenoid size alone does not correlate with severity of CRS on CT

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Adenoid and Otitis Media with Effusion (OME / Glue Ear)

• Adenoid hypertrophy causes Eustachian tube dysfunction → OME
• Adenoidectomy alone improves OME/recurrent AOM (due to both mechanical obstruction relief and elimination of bacterial reservoir)
• Added for children ≥4 years when distinct indications exist

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Medical Treatment

• Intranasal corticosteroids may significantly improve nasal obstruction symptoms in moderate-to-severe adenoid hypertrophy and may reduce adenoid size (Cochrane evidence - limited but supportive)

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Indications for Adenoidectomy

1. OSA associated with postnasal obstruction
2. Recurrent acute otitis media or prolonged serous otitis media (>3 months duration)
3. Recurrent rhinosinusitis
4. Postnasal discharge / chronic adenoiditis
5. Failure to thrive due to airway obstruction

• 6-7 episodes of acute tonsillitis in 1 year
• 5 episodes/year for 2 years
• 3 episodes/year for 3 years (Paradise criteria)
• Peritonsillar abscess

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Adenoidectomy - Operative Technique

• Patient supine, oropharynx exposed with Boyle-Davis mouth gag + Doughty's tongue plate
• Nasopharynx palpated; adenoid curette (St. Clair Thompson) used to scrape adenoid pad
• Haemostasis with post-nasal pack or suction cautery
• Important: Avoid sedative premedications and postoperative opiates in OSA patients (risk of respiratory depression)

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PART 2: JUVENILE NASOPHARYNGEAL ANGIOFIBROMA (JNA)

Definition

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Epidemiology

• Age: typically 10-25 years, predominantly males
• Extremely rare in females (some cases in maxillary sinus site)
• Androgen-dependent: androgen receptors (esp. estrogen receptors) present in tumour tissue - explains male predominance and puberty-related onset

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Site of Origin

• Arises from the sphenopalatine foramen at the root of the pterygoid process on the lateral nasal wall
• This is the most important fact - the tumour originates here

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Pathology

• Sessile, lobulated, rubbery, dark red to tan-gray
• Unencapsulated, sessile, wide-based attachment to nasopharynx
• No mucosal ulceration

• Admixture of vascular tissue + fibrous stroma
• Vessel walls lack elastic fibres and have incomplete or absent smooth muscle → accounts for profuse bleeding
• Vascular cavities with endothelial layer but no muscle layer (unlike normal arteries)
• Similarities between nasal mucosal cells, genital erectile tissue, and vascular spaces

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Growth Pattern

• Locally infiltrative, slow-growing
• Expands laterally via pterygopalatine fossa → infratemporal fossa
• Extends into nasopharynx and choanal space → anterior nasal cavity and sinuses
• Can expand to: maxillary/ethmoid sinuses, orbit, cheek, cavernous sinus
• Intracranial extension (middle/anterior cranial fossa) - uncommon but serious

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Clinical Features

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Diagnosis

• Enhancing soft tissue mass from nasopharynx/lateral nasal wall
• Widening of pterygopalatine fossa
• No bone erosion generally
• Holman-Miller sign (classical): anterior bowing of posterior wall of maxillary sinus

• Vascular tumour with flow voids within the mass
• Enhancement on gadolinium imaging
• Best for delineating intracranial extension and follow-up

• Shows feeding vessels arising from branches of the external carotid artery (mainly internal maxillary artery)
• If intracranial spread: internal carotid artery also feeds the tumour
• DSA shows enlarged intratumoral vessels + intense inhomogeneous blush in venous phase

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Chandler Staging (1984)

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Management

• Well-established adjunct to induce tumour shrinkage, improve surgical access, reduce intra-operative blood loss
• Done transarterially with particles (PVA) or liquids (NBCA/Onyx)
• For tumours supplied by branches of external carotid - relatively straightforward
• Intracranial supply (internal carotid) increases risk of neurological deficit
• Direct tumour puncture technique with Onyx injection - improves devascularization

• Traditional: Open approaches (transpalatal, lateral rhinotomy, midfacial degloving)
• Modern: Endoscopic surgical resection - now preferred for smaller tumours (Stage I-II) without spread; some consider preoperative embolization unnecessary for smaller endoscopic cases
• Large/intracranial tumours: Combined skull base approach (head and neck surgeon + neurosurgeon)

• Used when surgery is contraindicated or for recurrence
• Primary radiation therapy has been reported
• Gamma knife used in some cases

• Flutamide (androgen antagonist) - shown to reduce tumour size, may have role as pre-operative adjunct

• Spontaneous regression reported after cessation of androgen stimulation (post-puberty)
• Rare malignant transformation reported

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Key Exam Points - JNA

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Comparison Table: Adenoids vs JNA

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