TIPS The adenoid and snoring M Klein Respiratory Unit, Department of Paed/atrlcs and Child Hea/th, University of Cape Town mk/eln@;ch.uct.ac.za Thus, radiology has almost nothing to say about the severity of airway ob- struction in children who snore. How- ever, radiology can define the anatomi- cal size of the airways and the degree to which the adenoid encroaches on the airway. The absolute size of the adenoid has little importance. If the adenoid can be identified by radiogra- phy it is resectable, and if the history is that the child snores, then the child suffers from airway obstruction when it sleeps - whether the airway appears to be patent when it is awake or not. Radiology can also be helpful in those children in whom adenoidec- tomy has failed to cure the snoring or in whom snoring has recurred after adenoidectomy. Because adenoidec- tomy is often done "blind", some ad- enoid may be left behind. So, what should a radiologist say when reporting on the adenoid? Before reading on, try to formulate your own opinion on Figures 1 to 4. Reports The radiograph in Figure 1 was taken with the child awake. The nose Background The adenoid is of particular inter- est in childhood because adenoidec- tomy - with or without tonsillectomy - cures snoring in over 95% of infants and children, even when the adenoid appears to be normal in size by radiog- raphy or by endoscopy. Snoring is of concern because it means that the airway is obstructed during sleep. Why and how this oc- curs is beyond the scope of this brief presentation. The sleep-associated air- way obstruction disrupts the ar- chitecture of normal sleep and may cause asphyxia. Snoring al- most every night can have se- vere effects, including death. The most easily recognised ad- verse effects include failure to thrive, cor pulmonale and sys- temic hypertension. But more common and more difficult to recognise are neurodevelop- mental delay, behaviour disor- ders and school problems. Of cardinal importance in the investigation of infants and children who snore is the fact that snoring occurs during sleep, whereas investigations are gen- Figure 1: Soft tissue lateral neck radiograph. erally done in awake infants. Elght-year-old boy. Snoring a/most every night. 81 SA JOURNAL OF RADIOLOGY. February 2001 to page 52 mailto:mk/eln@;ch.uct.ac.za The adenoid and snoring from page 51 and paranasal sinusesare patent. A well- defined adenoid (pharyngeal tonsil) is visible between the palate and the base of the skull. The adenoid occupies about 70% of the potential airway lu- men in the area of the hard palate. Even though the airway appears to be patent, removal of the adenoi- dal tissue can be expected to cure this child's snoring. The radiograph in Figure 2 was also taken with the child awake. The nose, paranasal sinuses and pharyngeal remnant is sufficient to explain the recurrence of snoring following pre- vious adenoidectomies in this child. [Note: Permanent curing of the snoring followed endoscopic removal of the adenoidal remnant: fourth time luckyl] Figure 3 shows a double-contrast barium study of the nasopharynx. The previous adenoidectomy (presumably blind curettage) has failed to remove the superior pole of the adenoid. In this view it appears to occlude the air- way completely. This re- sidual adenoidal tissue is sufficient to account for the failure of adenoidec- tomy to cure the snoring. [Note: A cure fol- lowed endoscopic removal. Adenoids are often said to have re- grown, but organs do not regrow after re- moval. "Regrowth" of an adenoid signifies incom- plete prior removal.] The CT in Figure 4 shows homogeneous soft tissue mass (adenoid) be- tween the base of the skull and the posterior margin of the nasal septum - the internal nares. Occlusion of the internal nares by this re- sidual adenoidal tissue Figure 2: Soft tissue lateral neck radiograph. Eleven- year-old girl. Three previous adenoidectomies for snoring. Relief of snoring after each procedure, but snoring recurred within months of each procedure. airway are patent. The adenoid has been removed incompletely by previ- ous surgery (almost certainly blind cu- rettage) and there is a small pea-sized piece of adenoidal remnant at the su- perior pole of the adenoid - at the point of the internal nares. Because of the critical position at the internal nares (see example, Figure 4), regrowth of this small adenoidal almost certainly accounts for the fail- ure of the adenoidectomy (blind cu- rettage) to cure this child's symptoms. [Note: CTs are rarely required to confirm the presence of adenoidal tis- sue] In this instance the surgeon was reluctant to consider that a "small piece" of adenoid could account for the failure of the operation. The CT was supplied courtesy of Prof SO 82 SAJOURNAL OF RADIOLOGY. February 2001 Figure 3: Soft tissue lateral neck radiograph after instillation of di/uta barium to outline airway. Figure 4: CT of nasopharynx. Approxi- mately five-year-old chi/d. Previous adenoidectomy failed to cure snoring. Conventional radiograph similar to Figure 2. Delport, University of Pretoria. The case was reported in the South Afri- can Medical Journal.] Reference: Delport SO, Mulder AA. Obstructive sleep apnoea persisting after adenoidectomy. SAfr Med J. 1987;71: 194-5.