DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.

ADENOID AND TUBAL TONSIL HYPERTROPHY : UNDER

ESTIMATED ENTITY IN ADULTS
*Kalpana Dasgupta, **Arfath Mustafa, ***Seema Patel, ****Prafulla Sakhare, *****Md. Izhar Khan
Date of receipt of article -23-02-2016
Date of acceptance -2-5-2016
DOI- 10.21176/ojolhns.2016.10.1.9
ABSTRACT
Background: Traditionally it is believed that there is involution of adenoid after the age of puberty. A study was
undertaken to find out occurrence of adenoid and tubal tonsil hypertrophy in adults
Aim: To find out occurrence of adenoid & tubal tonsil hypertrophy in adults.
Setting design : A prospective study in a tertiary care centre.
Materials & Methods : Study done on 50 subjects of chronic mucosal disease of ear, fifty subjects of retracted
tympanic membrane and 50 subjects having normal ear, nose, throat examination. Nasal endoscopy was done in
all the patients after relevant investigations to know presence of Adenoid & tubal tonsil hypertrophy.
Results - In chronic mucosal disease subjects adenoid hypertrophy (AH), tubal tonsil hypertrophy (TTH) and
both AH & TTH was found in 12 %, 14 %, & 8 % respectively. In subjects having retracted drum adenoid
hypertrophy was present in 14 %, TTH in 2% & both AH & TTH in 8%.
In control group one subject (0.5%) had adenoid hypertrophy, none had tubal tonsil hypertrophy.(p<0.005)
Conclusion:- AH & TTH is observed in adult patients suffering from ENT disease & AH was seen in only one
adult having no ENT complaints.
Key Words:- Adult patients, Adenoid hypertrophy, Tubal Tonsil hypertrophy.

Traditionally it is believed that there is involution

of adenoid after the age of puberty. Adenoid
hypertrophy (AH) is not common in adults. Tubal
tonsil hypertrophy(TTH) is not a common occurrence.
Few studies (1, 2, 3) have shown occurrence of tubal tonsil
hypertrophy with or without adenoid enlargement
after adenoidectomy surgery. Clear literature is not
available on incidence of tubal tonsil hypertrophy. Few
articles are available mentioning adenoid hypertrophy
in adults. Studies were undertaken to find out
occurrence of adenoid and tubal tonsil hypertrophy in
adults4, 5, 6,7.
Adenoid & Tubal tonsil hypertrophy can present
with nasal and / or aural symptoms.Nasopharyngeal
pathology (e.g-AH & TTH) can lead to middle ear
inflammation and we have selected patients suffering
from middle ear inflammation for the study. 100 adult

patients suffering from chronic mucosal disease of

middle ear (tubotympanic chronic suppurative otitis
media) and retracted tympanic membrane were
subjected for study. Nasal endoscopy was done in all
the patients to note the occurrence of tubal tonsil and
adenoid hypertrophy.
MATERIAL METHODSThis is a prospective study done at tertiary care
centre from August 2015 to January 2016. Approval
Affiliations:
*,**,***,****,*****, Department of ENT Govt Medical College &
Hospital. Nagpur
Address of Correspondence:
Dr. K S Dasgupta. Prof & HOD Dept of ENT
Department of ENT Govt Medical College & Hospital.
Nagpur, G-11. Bhakti Prayag Apt.,LaxmiNagar. Nagpur -22
mobile no- 09822229496
Email -drkalpanadasgupta@gmail.com

45

Vol.-10, Issue-I, Jan-June - 2016

INTRODUCTION

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

from college ethical committee and informed consent

from all the patients was obtained.100 patients suffering
from chronic mucosal disease and retraction of
tympanic membrane were selected for study. 50 normal
patients were taken for study for control group. 44%
patients were male and 56 % were female aged between
20-50 years.50 patients had chronic mucosal disease and
50 were having retraction of tympanic membrane. 50
patients having no complaints of ear, nose and throat
having normal tympanic membrane were also included
as control group.
Inclusion criteria:1.

Adult patients having chronic mucosal disease

(tubotympanic chronic suppurative otitis media).

2.

Adult patients having retracted tympanic

membrane.

Vol.-10, Issue-I, Jan-June - 2016

Exclusion criteria1.

HIV positive patients.

2.

Patients having aural cholesteatoma.

3.

Patients having nasopharyngeal pathology other

than adenoid or tubal tonsil hypertrophy.

Thorough history regarding ear, nose and throat

complaints was taken and so also personal history
about smoking and any allergy was asked. Past history
of any ear, nose, throat operation was noted. Detail
general examination, systemic examination and ear,
nose, throat, neck examination was done.
Lymphadenopathy (cervical and other) if any was noted.
Otomicroscopy, pure tone audiometry, x- ray
nasopharynx soft tissue lateral view was done. Nasal
endoscopy was performed in all the patients.
Nasopharyngeal examination with particular attention
to presence of enlarged adenoid and tubal tonsil was
done. Patients were divided into three groups: 1) having
adenoid hypertrophy 2)tubal tonsil hypertrophy and
3)both adenoid and tubal tonsil hypertrophy.
Statistical analysis- done by unpaired t- test.
RESULTS:50 Cases of chronic mucosal disease(having central
perforation),50 cases of retracted drum and 50 cases
(control group) having normal tympanic membrane
were studied. Nasal endoscopy was done in all the
subjects. Nasal endoscopy showed following findings
in respect of symptomatology,clinical,endoscopic
findings and surgery performed are depicted in Table
46

I. In Chronic mucosal disease:Adenoid hypertrophy was present in 12% (6/50),

Tubal tonsil hypertrophy in 14%(7/50) and both
Adenoid hypertrophy and Tubal tonsil was present in
8% (4/50).AH & TTH was seen in 34%(17/50) subjects.
Out of these 17 patients 11 patients(64.70%) were
between the age 20 to 25 years and 6 patients (35.29%)
were between the age of 26-50 years. 9(52.94%) were
male and 8( 47%) were females, 5 (29.41%) out of 17
patients gave history of smoking . 3(17.64%) patients
had allergic rhinitis
In Retracted Drum: Adenoid hypertrophy was
present in 14%(7/50),Tubal tonsil hypertrophy in
02%(1/50) and both Adenoid and Tubal tonsil
hypertrophy was present in 08%(4/50) subjects. Out
of 12 patients 4(33.33%) patients were between the age
20-25yrs,8(66.66%) were between 26-50yrs and
5(41.66%) were male and 7(58.33%) were female. 2
(16.66%) were smokers,4(33.33%) were suffering from
allergic rhinitis.
In Control group: Adenoid hypertrophy was
present in 1(0.5%) male patient aged 26yrs,who was non
smoker. He was not suffering from allergic Rhinitis.
So out 0f 100 patients of Ear diseases 29% (29/
100) showed Adenoid and Tubal tonsil hypertrophy.
In all these patients steroid nasal spray and oral
antihistaminic was started for 3 months. 3 months
follow up was completed in 12 patients. Out of these
12 patients 6 patients had persistent adenoid
hypertrophy and adenoidectomy was performed in
these patients. Specimen was sent for histopathological
examination to confirm the diagnosis. Remaining 17
patients had undergone medical line of management.
DISCUSSION:Adenoid and tubal tonsils are collection of
lymphoid tissue in nasopharynx. Adenoid hypertrophy
occurs physiologically in children between the age of 6
to 10 years, then atrophy at the age of 16 years 8.
Adenoid hypertrophy is not common in adults, tubal
tonsil hypertrophy is also uncommon and it may be
missed in routine clinical examination . In out patient
department initially nasopharyngeal examination is
done by posterior rhinoscopy. Detail and proper view
is not obtained many a times and thus posterior
rhinoscopy examination is inadequate to comment
about structures visualized. With the advent of flexible

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

In present study in patients having chronic mucosal

disease of ear and retraction of drum, adenoid
enlargement was seen 13% cases, tubal tonsil
enlargement in 8% and both in 8% cases. In control
group adenoid hypertrophy was observed in 0.5% cases
(p<0.005)
Manas Ranjan Rout et al4 studied 200 cases in their
paper entitled Adenoid hypertrophy in adult: a case
series. They found 15% adults having adenoid
hypertrophy. They subjected all the patients for
adenoidectomy after histopathological examination.
N Yildirim et al5 performed adenoidectomy in
forty adult patients, 38 patients had history of nasal
obstruction & 2 patients had hearing loss & tinnitus.
In this series coexistance of obstructive AH &
obstructive nasal septum deviation in 25% of adult
group was noteworthy. According to them DNS may
also indirectly cause low grade chronic inflammation
of adenoids, interfering with their physiological
regression.
In present study nasal obstruction was present in
34% (17/50) patients of chronic mucosal disease of ear.
50% patients(25/50) had deviated nasal septum and
44%(11/25) needed septal correction. Out of these 25
patients 8% had associated adenoid or tubal tonsil
hypertrophy. In 50 patients of retracted drum, nasal
obstruction was present in 54%(27/50) cases. 60%(30/
50) patients had deviated nasal septum and septal
Table I: Symptomatology, clinical & endoscopic
findings with surgery performed.

correction was done in 66.66%(20/30). Associated

adenoid hypertrophy and tubal tonsil hypertrophy was
seen in 10%(3/30) subjects. So findings of present series
are not comparable with Yildirim series as far as coexistance of AH and DNS is concerned. This could be
because most of their patient had nasal obstruction (38/
40) while in present series patient selected were basically
of ear disease. In Yildirim et al study 20% (8/40) patients
of AH had associated ear disease.
In N Yildirim series 15% adults had history of
adenoidectomy suggesting inadequate removal of
adenoid tissue at the previous operation indicating
pathological process leading to AH began in childhood.
In present series previous history of adenoidectomy
was absent.
In their study incidence of allergic rhinitis and
smoking was not high. Similar observations were made
in present study also. However Finkelstein Y et al. 8
found high incidence of nasopharyngeal lymphoid
hyperplasia in smokers.
R.H Kamel et al 6 did adenoidectomy in 35 adults
by endoscopic approach. They observed secretory otitis
media in 5 cases (14.25%). They have not mentioned
about how many cases were screened to get these 35
cases of adenoid hypertrophy.
Karodpati N et al 7 in their study Adenoid
hypertrophy in Adults- A myth or reality studied 13
cases of adenoid hypertrophy in adults between 18 to
35 years. However, they have not mentioned about
how many patients they had screened to get these 13
patients. They have done adenoidectomy in all the
patients.
To our knowledge, the tubal tonsil hypertrophy
in adults and its clinical relevance is not addressed in
any prior publication. In present series tubal tonsil
hypertrophy alone was seen in14% of cases in chronic
mucosal disease of ear and 02% in cases of retraction of
drum. Tubal tonsils hypetrophy and adenoid
hyperytrophy together were seen in 8% cases of
chronic mucosal disease and 8 % cases of retracted
drum.
Many authors have described hypertrophy of
tubal tonsil in children as a cause of recurrent symptoms
after prior adenoidectomy. In present series no history
of prior adenoidectomy was found.

CP = Central Perforation, RT = Retraction

Kevin S Emerick et al1 identified 42 patients having

47

Vol.-10, Issue-I, Jan-June - 2016

nasopharyngoscope and nasal endoscopes

nasopharyngeal visualization is easier and adequate.

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

tubal tonsil hypertrophy (TTH) after adenoidectomy

at an interval of 4 years 2 months. The average age of
presentation was 7years 2 months. All their patients
presented with nasal symptoms, only 4 of the 10
patients had otitis media or otitis media with effusion.
The location of tubal tonsil logically suggests that a
potential inflammatory obstruction of the eustachian
tube predisposes the patient to recurrent otitis media
or otitis media with effusion.
Keiji Honda et al 3 examined 177 ears 18 to 24
months after adenoidectomy; among 30 ears found to
have otitis media with effusion, 50% demonstrated
marked ipsilateral TTH.
Various aetiopathogenetic mechanism proposed to
explain the presence of lymphoid hyperplasia in adult
nasophaynx are5
1.

persistence of childhood adenoid due to chronic

inflammation.

2.

reproliferation of regressed adenoidal tissue in

response to irritants or infection.

3.

inadequate removal of the adenoidal tissue at

previous operation.

4.

heavy smoking.

5.

allergic rhinitis.

Removal of adenoid may place a greater burden

on the remaining lymphoid tissue in the nasopharynx,
leading to progressive hypertrophy over a prolonged
period of time.
The location of the tubal tonsil logically suggest
that a potential inflammatory obstruction of the
eustachian tube predisposes the patients to recurrent
otitis media or otitis media with effusion,

Vol.-10, Issue-I, Jan-June - 2016

CONCLUSION:In present series we could not identify aetiological

factors or could not give definite suggestions about
specific treatment modalities in cases of AH & TTH in
adults. We can definitely conclude that adenoid
hypertrophy and tubal tonsil hypertrophy can be seen
in adults. This hypertrophy can be present independent
of previous adenoidectomy. AH & TTH can present
with nasal symptoms and aural symptoms. Nasal
endoscopy to rule our AH & TTH should be
performed in the patients having nasal & aural
symptoms.

48

DISCLOSURES
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None,
(c) Funding - None
(d) No financial disclosures
REFERENCES1.

Kevin S Emerick MD, Michael J. Cunningham

MD. Tubal tonsil hypertrophy- A cause of
recurrent symptoms after adenoidectomy. Arch
otolaryngol Head Neck Surgery, 2006; 132(2): 153156

2.

Hazem Saeed, Khalid Abdel Shakour, Atef

Hamed, Wail Fayez. Tubal tonsil hypertrophy:
A cause of recurrent otitis media with effusion.
Egypt J. otolaryngol 06/2010; vol26. June (No.2)

3.

Keiji Honda, Masahito Tankea, Tadami

Kumazawaa. Otitis Media with Effusion and
Tubal Tonsil. Acta otolaryngol Suppl. 1998
454218-221. Published online: 8 Jul 2009

4.

Manas Ranjan Rout, Diganta Mohanty, Y.

Vijaylaxmi et al. Adenoid Hypertrophy in Adults:
A case Series. Indian J Otolaryngol Head Neck
Surgery. Jul- sept 2013; 65(3): 269274.

5.

N Yildirim, M Sahan and Y Karslioglu. Adenoid

hypertrophy in adults: clinical & morphological
characteristics The journal of international medical
research 2008; 36:157-162.

6.

Reda H Kamel, M.D., Elia A.Ishak PHD.

Enlarged adenoid and adenoidectomy in adults:
endoscopic approach and histopathological
study.The Journal Laryngology and Otology.
Dec 1990; vol 104, pp965-967.

7.

Karodpati N, Shinde V, Deogawkar S, Ghate G.

Adenoid hypertrophy in Adults- A myth or
reality. Downloaded from
http://
www.webmedcentral.com on 05 mar-2013.Pg26
{WebmedCentralotorhinolaryngology
2013;4(3):WMC004079 doi: 10.9754/journal.wmc.
2013.004079}

8.

Finkelstein Y, Malik Z, Kopolovic J et al (1997).

Characterization
of smoking-induced
nasopharyngeal lymphoid hyperplasia.
Laryngoscope 107:1635-1642.