List of Abbreviations
AH – adenoid hypertrophy
PTH – palatine tonsil hypertrophy
CT – computed tomography
ICD-10 – International Classification of Diseases, 10th Revision
NSAIDs – Nonsteroidal anti-inflammatory and antirheumatic drugs (ATX code: M01A) (nonsteroidal anti-inflammatory drugs)
Terms and Definitions
Adenoid hypertrophy (AH) is an enlargement of the pharyngeal tonsil accompanied by persistent nasal breathing difficulty and/or other complications (various forms of obstructive sleep disorders, secretory otitis media, facial skeletal deformity, etc.).
Palatine tonsil hypertrophy (PTH) – is an enlargement of one or both palatine tonsils, which may be asymptomatic or accompanied by symptoms such as snoring, apneas during sleep, swallowing disorders, articulation disorders, facial skeletal deformity, etc.
Adenoiditis is a reactive inflammatory change of the pharyngeal tonsil as an organ of regional mucosal immunity, occurring when antigens affect the mucosa of the nasal cavity and pharynx. In the absence of a significant impact on the child's quality of life and other associated complications (otitis media) in children under 7–9 years of age, this condition is not regarded as a pathology.
Recurrent acute sinusitis – the diagnosis is valid if the patient has had 4 or more episodes of acute sinusitis over the past year according to anamnesis and/or medical documentation.
Recurrent acute otitis media – the presence of three or more distinct episodes of AOM within 6 months or 4 or more episodes over a 12-month period.
Obstructive sleep apnea syndrome (OSAS) is a manifestation of the spectrum of obstructive sleep disorders, characterized by repeated episodes of complete (apnea) or partial (hypopnea) upper airway obstruction during sleep.
Chronic sinusitis in children is inflammation of the paranasal sinus mucosa and nasal cavity lasting more than 12 weeks (without complete resolution of symptoms), accompanied by two or more symptoms, including nasal breathing difficulty (nasal congestion), nasal discharge, and cough ± endoscopic signs in the nasal cavity ± changes in the paranasal sinuses according to computed tomography.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Adenoid hypertrophy (AH) is an enlargement of the pharyngeal tonsil accompanied by persistent nasal breathing difficulty and/or other complications (various forms of obstructive sleep disorders, secretory otitis media, facial skeletal deformity, etc.).
Palatine tonsil hypertrophy (PTH) is an enlargement of one or both palatine tonsils, which may be asymptomatic or accompanied by symptoms such as snoring, sleep apneas, swallowing disorders, articulation disorders, facial skeletal deformity, etc.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Viral infection, genetic predisposition, and environmental exposure are cited as the most likely factors in the etiology of AH and PTH. There is more controversial evidence regarding the role of bacterial infection, gastroesophageal reflux, and allergy.
The pathogenesis of viral effects on the pharyngeal tonsil is partly the same as in the nasal cavity: the virus damages the ciliated epithelium on the surface of the pharyngeal tonsil, creating areas of "baldness" that are more vulnerable to virus and bacteria adhesion factors. With isolated exposures, these changes are reversible. The structure of the ciliated epithelium is gradually and completely restored. Frequent exposure to viral agents leads to a disruption of the regenerative processes of the mucosa with the formation of a transitional type of epithelium, and increased infiltration of the mucosa by phagocytes and lymphocytes. In some areas of the pharyngeal tonsil, the degree of infiltration is so great that the boundaries between the epithelium and the tonsil parenchyma are blurred. The basement membrane and the lamina propria of the mucosa damaged in the process provoke fibroblasts to release transforming growth factor beta, which leads to tonsillar tissue hyperplasia. The result of the action of certain viruses with a tropism for lymphoid tissue (adenoviruses, herpes viruses) is the suppression of the lymphocyte apoptosis mechanism. This results in pronounced hypertrophy of the tonsils and lymph nodes. Special attention is paid to human herpesvirus type IV. Herpetic infection is one of the frequent causes of marked hypertrophy of the pharyngeal tonsil, followed by the development of persistent nasopharyngeal obstruction. Some studies note the significance of the persistence of herpes viruses type IV and VI, adenovirus, and human bokavirus in the tissue of the lymphopharyngeal ring organs as a factor leading to hypertrophy and chronization of the inflammatory process in the pharyngeal tonsil tissue. However, according to some data, it has been established that persistence of other viruses, including RNA viruses, also occurs in the tissue of the lymphopharyngeal ring organs in the absence of any clinical manifestations of the disease.
Despite the apparent obviousness of the role of the genetic factor in the development of adenoid and palatine tonsil hypertrophy, to date there are only isolated data demonstrating the significance of single nucleotide polymorphisms of the SCGB1D4 (IIS) and Ugrp2 genes in increasing the risk of adenoid hypertrophy in children and the association of a mutation in the DEFB1 gene with the risk of AH and PTH development.
A negative role in the formation of the lymphopharyngeal ring is played by tobacco smoke and an unfavorable environmental state, which is confirmed by the difference in the prevalence rate of the pathology in children living in large cities and industrial centers compared to children in suburbs and rural areas. Publications also note the negative effect of tobacco smoke on adenoids in children.
The role of bacteria in the etiology of adenoid hypertrophy and palatine tonsil hypertrophy is debatable. According to some researchers, the leading pathogen determining the development of pathological changes in the adenoids is Streptococcus pneumoniae, while others point to Staphylococcus aureus. There are only isolated studies on the role of atypical bacteria in the etiology of AH and PTH, and their results are extremely contradictory, requiring further study. The emergence of new data on the human and respiratory tract microbiome, in particular, raises major questions about the validity of the "traditional" assessment of bacteria as a key etiological factor in the development of chronic respiratory pathology. With a high degree of probability, it can be stated that the isolation of individual bacteria from the pharynx in healthy patients does not make it possible to assess risks or make any prognostic predictions regarding the likelihood of disease development and its clinical course.
The presence of regular episodes of gastroesophageal reflux in a patient may increase the risk of both AH and PTH formation and chronic inflammatory otorhinolaryngological pathology in general. The results of most studies devoted to this issue have shown that in tissue samples taken from patients during adenoidectomy and tonsillectomy, markers indicating the impact of the refluxate are reliably identified more often compared to tissue biopsies obtained from healthy individuals.
To date, allergy is not considered the primary etiological factor in the development of AH. Nevertheless, some studies report a fairly frequent association between adenoid hypertrophy and atopy in children. The accumulated results of numerous studies on the relationship between AH and allergic rhinitis were analyzed in one of the latest international consensus documents on allergic rhinitis. Thus, the authors of the document note that signs of AH are found more frequently in children with allergic rhinitis than in the group of children without allergies. However, in the group of patients with AH, the incidence of allergic rhinitis does not differ from that in the general population. An age-dependent relationship between these diseases was also noted: the peak incidence of AH occurs at an earlier age compared to the peak incidence of allergic rhinitis (the correlation is negative in preschool children and positive in older age groups). According to some studies, there is a relationship between atopy and the risk of developing PTH.
Thus, the etiology of AH and PTH is multifactorial. In an individual patient, several etiological factors may simultaneously play a role in the onset of AH and/or PTH, which in most cases makes it impossible to single out a primary one.
1.3 Epidemiology of the Disease or Condition
Data on the prevalence of AH in children are highly variable. According to a recent meta-analysis of foreign studies, on average about 35% of children have adenoid hypertrophy, while the results in individual studies reached 70% [1]. Data on the prevalence of PTH are scarce. In Denmark, an examination of 50,000 children established that the incidence of PTH is about 25 per 1,000 child population [2].
There are no large-scale studies reflecting the prevalence of AH and PTH in Russia. According to the state statistical reporting form No. 12 "Report on the number of diseases registered in patients living in the service area of a medical institution" and data on population visits to outpatient clinics in the Mytishchi District of the Moscow Region, the prevalence of AH ranged from 50.9±3.6 to 62.5±3.9 per 100 visitors [3]. Based on the analysis of data from an otorhinolaryngological examination of 1,685 students from 6 secondary schools in Arkhangelsk, the first place among individual nosologies overall and in primary and middle school children belonged to the pathological prevalence of PTH (116.3±15.6‰) and AH (128.2±16.3‰), while the prevalence of grade III adenoid hypertrophy was 13.1±5.5‰ [4].
Studies in the adult population note that the prevalence of adenoid hypertrophy in adults ranges from 2.5% to 18.8%. The detection rate of adenoids in adults reliably decreased with age. This pathology is more common in men [54]. There are currently no exact data on the epidemiology of PTH in the adult population. However, it is known that PTH in adults, as in children, is an important cause of obstructive sleep apnea [55].
1.4 Features of Coding the Disease or Condition
J31.1 - Chronic nasopharyngitis (as a possible coding option for chronic adenoiditis in children)
J35.1 – Hypertrophy of palatine tonsils
J35.2 – Hypertrophy of adenoids
J35.3 – Hypertrophy of adenoids with hypertrophy of palatine tonsils
J35.8 – Other chronic diseases of adenoids and palatine tonsils (e.g., adenoiditis)
1.5 Classification of the disease or condition
In Russia, the classification of AH proposed by A.G. Likhachev [5] is most commonly used. According to this classification, there are 3 degrees of adenoid hypertrophy depending on the degree of choanal lumen obstruction by the nasopharyngeal tonsil tissue:
Grade I – the pharyngeal tonsil tissue covers no more than 1/3 of the upper part of the vomer;
Grade II – the pharyngeal tonsil tissue covers from 1/3 to 2/3 of the vomer;
Grade III – the pharyngeal tonsil tissue covers more than 2/3 of the vomer.
To assess the degree of palatine tonsil hypertrophy, the classification by B.S. Preobrazhensky [6] is most frequently used. According to this classification, the reference landmarks for determining the degree of tonsil hypertrophy are a horizontal line drawn through the edge of the palatoglossal (anterior) arch and a vertical line through the middle of the uvula; the distance between them is divided into three parts:
Grade I – enlargement of the tonsil by 1/3 of this distance;
Grade II – the tonsil occupies 2/3 of the gap;
Grade III – the tonsils reach the uvula and touch each other.
1.6 Clinical presentation of the disease or condition
Patient complaints and clinical symptoms are most commonly observed in patients with grade III AH and grade III PTH. In grade I and II AH and PTH, patients usually (but not always) do not present any complaints, and symptoms of the disease are absent.
In PTH, the parents' sole complaint is usually the "presence of snoring" in the child. Unlike inflammatory problems, in PTH, snoring during sleep is constant and often independent of the child's sleeping position. In some cases, in addition to snoring and difficulty breathing during sleep, parents may also note "classic" symptoms of OSA: daytime sleepiness and decreased academic performance in educational institutions. Much less frequently, patients with PTH exhibit bite changes and minimal dysphonic manifestations.
Symptoms and complaints of patients with AH (including AH with PTH) are more diverse. In addition to breathing problems during sleep, complaints are most often noted regarding persistent difficulty in nasal breathing and conditions associated with persistent nasal obstruction: a constantly open mouth, hyponasality, and a sensation of "dry mouth." Frequently, patients with AH complain of hearing loss as a manifestation of secretory otitis media and/or recurrent episodes of acute otitis media in the anamnesis. Even with grade II AH, parents of patients often complain of prolonged (up to several weeks) persistence of rhinological symptoms (nasal congestion, post-nasal discharge, cough in the child) after a cold. When analyzing anamnestic data in school-age patients with AH, diagnosed episodes of acute sinusitis (including recurrent forms) are frequently noted.
In the presence of adenoiditis, the main complaint of the patient and/or their legal representatives is episodes of cough (usually productive, nocturnal and morning), which are a manifestation of post-nasal drip syndrome (discharge flowing down the posterior pharyngeal wall). Symptoms of adenoiditis can also be observed with a small size of the nasopharyngeal tonsil. In adenoiditis, patients with grade II and III AH typically report simultaneous complaints of nasal congestion and cough.
Reactive inflammatory changes in the pharyngeal tonsil resulting from a cold or in the setting of allergic rhinitis are physiological for children under 7–9 years of age and, in the absence of clinical signs of complications (otitis media, acute sinusitis) and a significant impact of symptoms on the child's quality of life (sleep disturbance and/or impaired daytime activity due to cough and/or difficulty in nasal breathing), should not be regarded as a pathological condition.
Symptoms of adenoid hypertrophy (AH) and adenoiditis are not pathognomonic and require differential diagnosis with such conditions as acute rhinosinusitis, chronic rhinosinusitis, allergic rhinitis, vasomotor rhinitis, nasal septal deviation, hypertrophic rhinitis, foreign bodies of the nasal cavity and nasopharynx, and neoplasms of the nasal cavity and nasopharynx. AH is frequently identified as a comorbid condition in patients with acute sinusitis, chronic sinusitis, and allergic rhinitis.
Symptoms of AH and palatine tonsil hypertrophy (PTH) in adults do not differ from those in pediatric practice.
2. Diagnostics, medical indications and contraindications for diagnostic methods
The presence of pharyngeal and palatine tonsils in a child is not a pathology. The justification for diagnostic evaluation and establishing a diagnosis includes the patient's (or legal representative's) complaints of corresponding symptoms, clinical manifestations of the disease, and/or the presence of a comorbid condition whose course may be affected by adenoiditis, AH, and/or PTH.
Criteria for diagnosing PTH:
the diagnosis is established based on complaints, medical history, and physical examination data (pharyngoscopy with mandatory assessment of the lower pole of the palatine tonsils).
Criteria for diagnosing AH:
the diagnosis is established based on complaints, medical history, physical examination data, and instrumental examination data (nasopharyngeal rhinoendoscopy, lateral nasopharyngeal radiography, or computed tomography).
2.1 Complaints and Anamnesis
Complaints and medical history: the duration of the disease, what the patient believes triggered the onset of the disease, and the dynamics of symptoms and clinical manifestations (including their impact on the child's sleep and daily activities), ongoing treatment and its efficacy (including adverse events likely associated with the treatment) are clarified from the medical history. It is important to clarify the presence of disease symptoms and their severity outside of acute respiratory infection episodes. The severity of clinical symptoms at the time of examination is noted separately in comparison with the severity of previous symptoms.
The history of life clarifies the presence of concomitant diseases in patients (primarily allergies). If comorbid diseases are present, it is determined whether the child is under the care of a specialist for them, what treatment they are receiving, and whether surgical stages of treatment are planned. Data on previously performed rhinosurgical interventions and manipulations on the nasal cavity (nasotracheal intubation and placement of any nasal tubes) are of great importance.
2.2 Physical Examination
An appointment (examination, consultation) with an otolaryngologist is recommended for all patients with AH and PTH to assess the patient's general condition, the severity of clinical signs of the disease, and comorbid pathology [6, 7].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: a general examination is performed for all patients upon presentation to the otorhinolaryngologist at the outpatient stage, as well as upon admission of the patient to the inpatient otorhinolaryngology department.
It is not recommended to perform digital palpation of the nasopharynx in children for the diagnosis of AH in outpatient practice [7].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the results of this procedure in terms of diagnostic value are extremely subjective, while the procedure causes unpleasant sensations for the child and carries a risk of trauma to the pharyngeal structures.
2.3 Laboratory Diagnostics
Laboratory diagnostic methods are not used for diagnosing AH and PTH, but are only necessary in diagnosing comorbid conditions.
2.4 Instrumental Diagnostics
Required only in the diagnosis of AH.
Lateral nasopharyngeal radiography is recommended for patients with clinical manifestations characteristic of AH to assess the size of the pharyngeal tonsil [8].
GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)
Comments: a relatively inexpensive and, in most cases, accessible and painless method for the child to assess the size of the pharyngeal tonsil. Disadvantages of nasopharyngeal radiography include a minor radiation dose, the need to maintain correct patient positioning during the study (the child's mouth must be open), and the inability to interpret the results for differential diagnosis with other space-occupying lesions of the nasopharynx. In some cases, this study may not correlate with symptom severity.
Nasopharyngeal radiography has low diagnostic significance for patients who have previously undergone adenoidectomy, due to the impossibility of differential diagnosis between AH and compensatory hypertrophy of the torus tubarius, and the assessment of cicatricial changes in the nasopharynx.
Endoscopic endonasal revision of the nasal cavity and nasopharynx is recommended for patients with clinical manifestations characteristic of AH to visualize the nasopharyngeal cavity and pharyngeal tonsil [9].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: provided that flexible optics are used and there is technical capability to capture and save photo and/or video images of the examination, this is the most preferred diagnostic method for AH. Endoscopic examination of the nasopharynx is the method of first choice for the differential diagnosis of AH with other diseases and for assessing the state of the nasopharynx after surgery, including in the long-term follow-up. Disadvantages of the method include the need to comply with proper optics disinfection protocols after the examination. Certain difficulties may also arise when performing nasopharyngeal endoscopy in emotionally labile children in outpatient and consultative settings.
The use of rigid endoscopes for the examination increases the child's negative perception (especially at preschool age) of this procedure.
Performing an endoscopic examination without saving the imaging data significantly reduces the objectivity of the information provided to the patient, taking into account possible subsequent consultations with other doctors.
Computed tomography (CT) of the upper respiratory tract and neck is recommended for patients with clinical manifestations characteristic of AH, based on special indications, to assess the size of the pharyngeal tonsil and perform differential diagnosis with other rhinological pathologies having similar symptoms [10, 11].
Level of Evidence AGrade of Evidence 3Level of Recommendations A (Grade of Evidence – 3)
Comments: this study should not be performed on all patients for the diagnosis of AH. CT is advisable in complex cases for differential or simultaneous diagnosis with other rhinological pathologies.
Tympanometry is recommended for patients with AH to objectively assess the state of the middle ear structures [12].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
2.5 Other Procedures
It is not recommended to perform microbiological swab-impression cultures of pharyngeal structures in children for the diagnosis of AH and PTH [13].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: taking into account the limited capabilities of cultural microbiological studies in assessing the microbiota of the pharyngeal and palatine tonsils and the high carriage rate of opportunistic bacteria on the pharyngeal mucosa in healthy individuals, it can be stated with a high degree of probability that the absence of bacterial pathogen growth or the isolation of individual bacteria from the pharynx in patients without clinical signs of bacterial infection does not allow for risk assessment or any prognostic conclusions regarding the likely risk of disease development and its clinical course.
A consultation with an allergist-immunologist is recommended for patients with AH and/or PTH based on special indications to confirm/exclude comorbid allergic pathology and coordinate management tactics [14].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: due to the high probability of comorbid allergic diseases (allergic rhinitis, atopic bronchial asthma, atopic dermatitis), for their diagnosis and coordination of management tactics in patients with AH and/or PTH presenting with clinical and anamnestically confirmed signs of allergic diseases, an otolaryngologist should recommend a planned consultation with an allergist-immunologist. A consultation with an allergist-immunologist is primarily indicated for patients with the following history and/or clinical examination findings:
ocular symptoms and/or recurrent episodes of sneezing (nasal pruritus);
episodes of rhinological symptoms whose onset patients associate with plant pollination, contact with animals, and/or any other specific situations;
recurrent attacks of cough, wheezing, dyspnea, or chest tightness triggered by various factors (such as respiratory infection, tobacco smoke, contact with animals or pollen, etc.; physical exertion, stress) and manifesting mainly at night or early in the morning;
various multiple skin lesions characteristic of atopic dermatitis, urticaria, and other dermatological diseases of allergic etiology;
recurrent forms of acute otitis media or acute recurrent rhinosinusitis.
A consultation with a specialist in sleep disorders prevention and treatment is recommended for patients with AH and/or PTH based on special indications to diagnose obstructive sleep disorders [15].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: all patients with clinical andamnestic signs of recurrent episodes of obstructive sleep disorders are recommended, whenever possible, a scheduled consultation with a specialist in the prevention and treatment of sleep disorders for objective diagnosis and coordination of treatment tactics.
It is recommended to consult an orthodontist for patients with adenoid hypertrophy and/or palatine tonsil hypertrophy based on special indications for the purpose of objective diagnosis of facial skeleton pathology and coordination of treatment tactics [16].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: all patients with clinical signs of congenital and acquired changes in the maxillofacial region are scheduled for a routine orthodontic consultation for diagnosis and coordination of treatment tactics.
It is recommended to consult an infectious disease specialist for patients with adenoid hypertrophy and/or palatine tonsil hypertrophy based on special indications for the purpose of diagnosing persistent forms of viral infections and coordinating treatment tactics [17].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: due to the significance of the influence of herpesvirus infection on the course of pathology of the lymphopharyngeal ring organs, patients with adenoid hypertrophy and/or palatine tonsil hypertrophy are shown a consultation with an infectious disease specialist if one of the following signs is present and persists for the last 3 months or more:
lymphadenopathy in 3 or more groups (at least 3 enlarged lymph nodes in each group);
hepatomegaly and/or splenomegaly;
in the clinical blood test, a decrease in the absolute neutrophil count below the age norm and/or the total neutrophil count below 5×109/L.
In order to minimize the number of unjustified laboratory tests, the otorhinolaryngologist only conducts a clinical assessment of the patient's symptoms and the dynamics of their severity, forming groups of patients who require a consultation with an infectious disease specialist. The decision to perform actual laboratory diagnostics aimed at identifying suspected viral agents must be made by the infectious disease specialist.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Patients with adenoid hypertrophy and palatine tonsil hypertrophy undergo elective surgical treatment if indications are present. In the absence of indications or the presence of absolute contraindications to surgical treatment, patients with adenoid hypertrophy and palatine tonsil hypertrophy are under the dynamic observation of an otorhinolaryngologist.
Surgical treatment in patients with concomitant chronic or congenital pathology is carried out only in agreement with the relevant specialist.
Absolute contraindications to surgical treatment include: state of shock, acute stage of myocardial infarction, acute stage of cerebrovascular accident, "late" stages of severe infectious and oncological diseases, severe/extremely severe and terminal general condition of the patient determined by concomitant pathology. Relative contraindications to surgical treatment are uncontrolled or poorly controlled comorbid somatic pathology, structural anomalies of the nasal structures that significantly increase the risks of developing "major" intraoperative complications.
Conservative treatment is justified only for patients with clinical andamnestic signs of inflammatory changes in the pharyngeal tonsil tissue (adenoiditis) or palatine tonsils (tonsillitis) in the presence of corresponding complaints or complications.
1. Surgical treatment
It is recommended to perform tonsillotomy in children with palatine tonsil hypertrophy based on special indications in order to reduce the size of the palatine tonsils [18].
GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)
Comments: tonsillotomy in patients with palatine tonsil hypertrophy is performed only in the presence of indications and the absence of contraindications. The main indication for tonsillotomy in children is the presence ofamnestic and clinical signs of frequently recurring or regular episodes of obstructive sleep disorders (snoring ± daytime sleepiness and lethargy in the child).
If objective diagnosis of obstructive sleep disorders is possible, it is advisable to focus on the apnea-hypopnea index: moderate form – apnea-hypopnea index from 5 to 15, severe form – apnea-hypopnea index greater than 15.
If a patient simultaneously has indications for both tonsillotomy and tonsillectomy, it is advisable to perform tonsillectomy.
Preference should be given to performing tonsillotomy in children under general anesthesia in an otorhinolaryngological department of a hospital or short-stay hospital.
It is recommended to perform tonsillectomy in adult patients with palatine tonsil hypertrophy and obstructive sleep apnea syndrome to reduce the severity of obstructive sleep apnea syndrome symptoms in the absence of contraindications [55,56]
It is recommended to perform adenoidectomy in patients with adenoid hypertrophy based on special indications in order to restore nasopharyngeal aeration [19-23].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: adenoidectomy in patients with adenoid hypertrophy is performed only in the presence of indications and the absence of contraindications. Indications for adenoidectomy in children with adenoid hypertrophy include:
the presence of amnestic and clinical signs of frequently recurring or regular episodes of obstructive sleep disorders (snoring ± daytime sleepiness and lethargy in the child). If objective diagnosis of obstructive sleep disorders is possible, it is advisable to focus on the apnea-hypopnea index: moderate form – apnea-hypopnea index from 5 to 15, severe form – apnea-hypopnea index greater than 15;
persistent secretory otitis media (lack of resolution of symptoms for 3 months), refractory to conservative treatment and confirmed by tympanometry data;
recurrent course (3 or more episodes in the last 6 months or 4 or more in the last 12 months) of acute otitis media and/or acute sinusitis with the exclusion of other causes (primarily immunodeficiencies) and ineffectiveness of drug prevention;
chronic sinusitis accompanied by pronounced clinical manifestations and/or frequent exacerbations with a significant decrease in the child's quality of life in case of ineffectiveness of 1-2 courses of conservative treatment;
persistent difficulty in nasal breathing (in the absence of other causes of nasal obstruction) accompanied by a decrease in the child's quality of life (sleep disturbance or academic performance in adolescents), or leading to facial skeleton deformity (according to cephalometric research and the conclusion of an orthodontist or maxillofacial surgeon);
conclusion of specialists on the necessity of performing adenoidectomy as a stage of treatment of concomitant pathology (for example, the conclusion of cardiac surgeons on the necessity of adenoidectomy as a stage of preparing the patient for cardiac surgery).
Taking into account the specifics of childhood, preference should be given to performing adenoidectomy in children under general anesthesia in an otorhinolaryngological department of a hospital or short-stay hospital.
It is recommended to perform adenoidectomy together with tonsillotomy if the patient has both adenoid hypertrophy and palatine tonsil hypertrophy based on special indications in order to restore nasopharyngeal aeration [20-23].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: this surgical treatment is performed in children with adenoid hypertrophy and palatine tonsil hypertrophy only in the presence of indications and the absence of contraindications. Indications for simultaneous adenoidectomy and tonsillotomy are the same as for adenoidectomy.
Adenoidectomy with tonsillotomy should be performed under general anesthesia with mandatory visual control of the surgical field followed by observation in the early postoperative period in the otorhinolaryngological department of a hospital.
2. Conservative treatment
Conservative treatment of children with adenoid hypertrophy is advisable only if patients have amnestic and clinical signs of adenoiditis: productive cough (as a consequence of postnasal drip), nasal discharge, periodic difficulty in nasal breathing. If there is no significant impact of symptoms on the child's quality of life (sleep disturbance, eating and daily activity disorders) and other associated complications (otitis media) in children under 7-9 years of age, this condition is not regarded as pathology, and patient management is limited to dynamic observation.
It is recommended to prescribe irrigation and elimination therapy to all patients with adenoiditis to optimize nasal cavity hygiene [24-26].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: irrigation of the nasal cavity 1-2 times a day with isotonic or hypertonic saline solutions (salt concentration 1.5-3%) based on seawater (ATC code: R01AX Other nasal preparations) allows optimizing the nasal hygiene procedure, reducing the severity of nasal symptoms and creating optimal conditions for the subsequent local administration of drugs containing an active substance (e.g., antibacterial drugs).
In preschool children, it is recommended to refrain from washing the nasal cavity with large volumes of solutions due to the high risk of developing otitis media as a consequence of these procedures.
It is recommended to prescribe topical antibacterial therapy to patients with clinical signs of adenoiditis based on special indications in order to suppress opportunistic bacterial microflora of the nasopharynx [27–29].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comments: local application of antibacterial drugs (both single-ingredient and combination drugs) in the form of nasal sprays containing framycetin (ATX code: R01AX Other nasal preparations) or, for children older than 2.5 years, a combination drug of Dexamethasone + Neomycin + Polymyxin B + Phenylephrine (ATX code: R01AX Other nasal preparations) [28, 29] or thiamphenicol glycinate acetylcysteinate inhalation solution (ATX code: J01B Amphenicols) [27] can be used in short courses (up to 7 days) in the treatment of patients with clinical manifestations of adenoiditis when signs of bacterial infection involvement appear (mucopurulent discharge from the nose and along the posterior pharyngeal wall throughout the day, lack of positive dynamics in the severity of disease symptoms within 7–10 days against the background of anti-inflammatory therapy). Local use of antibacterial drugs makes it possible to achieve a bactericidal effect on planktonic forms of opportunistic bacteria while avoiding the toxic effect of a systemic drug. However, the practice of administering solutions of antibacterial drugs intended for parenteral, intraconjunctival, or endaural administration into the nasal cavity should be excluded. Due to their pharmacokinetics, they are not adapted for use in the nasal cavity and nasopharynx, which can lead to impaired mucociliary clearance in this area.
It is recommended to prescribe expectorant mucolytic drugs to patients older than 2 years with clinical signs of adenoiditis in order to reduce the severity of post-nasal drip [30, 31].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: to reduce post-nasal drip in the treatment of adenoiditis in children, it is possible to use only expectorant mucolytic drugs with a dominant mucoregulatory effect. Among the currently available expectorant mucolytic drugs, carbocisteine (ATX code: R05CB03) has optimal pharmacodynamic properties to achieve this effect. In children with clinical signs of adenoiditis, course administration (from 1 to 3 months) of carbocisteine in the form of syrups (including those containing carbocisteine lysine monohydrate as the main active substance) reduces the severity of post-nasal drip symptoms and increases the likelihood of resolution of the clinical picture of secretory otitis media as a comorbid condition. The clinical effect of these drugs is probably due to their mucoregulatory and anti-inflammatory action. There is evidence of synergism in the anti-inflammatory effect on the mucous membrane with simultaneous use with glucocorticosteroids (for endonasal use (ATX code: R01AD09 #Mometasone**)), which may be important for increasing the rate of symptom relief. With carbocisteine monotherapy (syrup formulation containing carbocisteine lysine monohydrate as the main active substance), a significant difference in the severity of clinical manifestations of post-nasal drip compared to a watchful waiting strategy is achieved only by the 2nd–3rd week of treatment [30].
When using carbocisteine in the treatment of a patient with adenoiditis, simultaneous administration of other expectorant mucolytic drugs (including topical ones) should be avoided to prevent an increase in post-nasal drip.
It is recommended to prescribe local glucocorticosteroid therapy to patients with adenoiditis older than 2 years who have allergic rhinitis as a concomitant disease in order to reduce the severity of disease symptoms [32].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comments: despite available data on the use of #mometasone** nasal spray (ATX code: R01AD09) in children, as of the end of 2020, neither "adenoid hypertrophy" nor "adenoiditis" nor even "nasopharyngitis" is registered as an indication for use in any single-ingredient topical glucocorticosteroid drug in Russia.
#Mometasone** (ATX code: R01AD09) in the form of a nasal spray is used in patients with adenoiditis who have allergic rhinitis as a concomitant disease, at a dose of 1 actuation (50 mcg) into each nasal nostril once daily (100 mcg/day) for a course of 1 to 3 months [32].
It is not recommended to use oils, primarily thuja oil, in patients with adenoid hypertrophy and adenoiditis [33].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: oils have no evidence base for efficacy in the treatment of nasopharyngeal pathology. There is also evidence that nasal application of oils has a pronounced cilioinhibitory effect on the ciliated epithelium of the nasal cavity and nasopharynx, leading to impaired mucus clearance and increasing the risk of bacterial infection.
It is not recommended to perform daily nasal cavity irrigation with antiseptics and disinfectants (ATX code: D08) in patients with adenoid hypertrophy and adenoiditis in order to minimize the impact on the normal microbiota of the nasal cavity and nasopharynx and the state of mucociliary transport [34, 35].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: prolonged uncontrolled nasal irrigation with solutions of antiseptics and disinfectants (ATX code: D08) has no evidence base for efficacy, disrupts mucociliary transport in the nasal cavity and nasopharynx, and can lead to local dysbiotic changes.
3. Pharmacotherapy after adenoidectomy and/or tonsillotomy
Drug therapy in children in the early postoperative period is aimed at reducing the severity of pain syndrome.
It is recommended to prescribe non-steroidal anti-inflammatory and antirheumatic drugs (ATX code: M01A) (NSAIDs) or aniline derivatives (ATX code: N02BE) to patients with pain syndrome after adenoidectomy and/or tonsillotomy for pain relief [36, 37].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: symptomatic analgesia is administered to patients after adenoidectomy and/or tonsillotomy when they complain of pain or other manifestations of pain syndrome (refusal of fluid and food intake, repeated vomiting, and nausea). Among non-steroidal anti-inflammatory and antirheumatic drugs (ATX code: M01A), ibuprofen** (ATX code: M01AE01) is traditionally used in pediatric practice at a dose of 8–10 mg/kg/dose (up to 30 mg/kg/day) in oral dosage forms considering the child's age (film-coated tablets from 6 years of age) and rectal suppositories (in younger children under 2 years of age). In children aged 6 years and older, ketoprofen (ATX code: M01AE03) in the form of granules for oral solution (active substance: ketoprofen lysine salt) may be used at 40 mg per dose up to 3 times a day. Paracetamol** (ATX code: N02BE anilines) is prescribed in any dosage form considering the child's age at 10–15 mg/kg/dose (up to 60 mg/kg/day). If oral administration is impossible and the rectal suppository form is unavailable, parenteral administration of paracetamol** solution at a single dose calculated as 15 mg/kg is possible to achieve analgesia.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended that a general examination by an otorhinolaryngologist, including a standard otorhinolaryngological examination, be performed on all patients after adenoidectomy and/or tonsillotomy before discharge from the hospital and at the outpatient stage 7–14 days after discharge from the hospital in order to assess the patient's general condition and rule out late postoperative complications [38].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to maintain a protective regimen for patients after adenoidectomy and/or tonsillotomy for 5–7 days after surgery in order to reduce the likelihood of postoperative complications [7].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: to reduce the risk of postoperative complications, patients are advised to:
reduce the number of patient contacts (exclude visits to organized children's groups and crowded places);
limit physical activity;
avoid overheating (primarily local overheating in the head and neck area), including by excluding hot food and drinks from the diet.
It is recommended to consult a specialist dealing with dysphonia disorders (a speech-language pathologist/defectologist) for patients after adenoidectomy and/or tonsillotomy if dysphonia symptoms persist for more than 1 month after surgery in order to conduct diagnostics and determine further treatment tactics [39].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to consult a specialist dealing with the prevention and treatment of sleep disorders for patients after adenoidectomy and/or tonsillotomy if symptoms of obstructive sleep disorders persist for more than 6–8 weeks after surgery in order to conduct objective diagnostics and determine further treatment tactics [40].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
5. Prevention and Dispensary Observation
Specific prevention of adenoid hypertrophy and nasopharyngeal tonsil hypertrophy in children is absent. Given the significant role of respiratory viruses in the etiopathogenesis of these conditions, it is advisable to follow general rules for the prevention of acute respiratory viral infections (see Clinical Guidelines No. 25).
There are therapeutic treatment methods that can be considered as routine and emergency prophylactic measures for adenoiditis in children.
It is recommended to perform herbal medicine using standardized oral preparations from the antiseptic drugs group (ATC code: R02AA Other antiseptics) in children older than 1 year who are at risk for respiratory infections, for the prevention of potential acute respiratory viral infection (ARVI) episodes and to reduce the duration and severity of subsequent episodes of adenoiditis, in the absence of contraindications [44-46].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: Medicinal products containing marshmallow root, chamomile flowers, horsetail, walnut leaves, yarrow, oak bark, and dandelion root (ATC code: R02AA20) are prescribed for the treatment of adenoiditis in children against the background of emerging ARVI symptoms, both as monotherapy and as part of combination therapy.
It is recommended to use combination preparations of Lysozyme + Pyridoxine (R02AA20 Other antiseptics) in children older than 3 years upon the onset of symptoms of acute nasopharyngitis, in order to reduce the duration and severity of subsequent episodes of adenoiditis, in the absence of contraindications [47].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: combination preparations of Lysozyme + Pyridoxine (ATC code: R02AA20) are prescribed as a "preventive" treatment for adenoiditis in children against the background of emerging ARVI symptoms, both as monotherapy and as part of combination therapy.
It is recommended to use drugs from the other immunostimulants group (ATC code: L03AX) (from the bacterial lysates group) in children at risk for respiratory infections to reduce the duration and severity of subsequent episodes of adenoiditis and its complications, in the absence of contraindications [48-50].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comments: drugs from the other immunostimulants group (ATC code: L03AX) (from the bacterial lysates group) are usually used as a routine preventive measure in courses according to the instructions for use 2–3 times a year. For the prevention of adenoiditis, both oral forms and topical preparations can be used.
It is recommended for children, in order to prevent potential episodes of adenoiditis and its complications, to consider the use of topical probiotics based on bacteria that make up the normal pharyngeal microbiota, in the absence of contraindications [51-53].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
6. Organization of Medical Care
Indications for hospital admission to a medical organization:
1) patients are hospitalized for elective surgical treatment (adenoidectomy and/or tonsillotomy) if there are indications and no contraindications to surgery;
2) patients with anamnestic and clinical signs of adenoiditis receive treatment on an outpatient basis and/or in consultative and diagnostic departments.
Indications for discharging a patient from a medical organization:
1) after adenoidectomy and/or tonsillotomy, provided the patient's general condition is satisfactory and there are no complications.
7. Additional Information
Performing adenoidectomy and/or tonsillotomy in a patient with concomitant chronic somatic pathology carries a risk of exacerbation of the comorbid disease in the early postoperative period [38].
The presence of allergic rhinitis as a comorbid pathology in a patient increases the likelihood of persistence/incomplete resolution of nasal symptoms (anterior and posterior rhinorrhea, to a lesser extent nasal congestion) due to persisting inflammatory changes in the nasal mucosa as a manifestation of allergic rhinitis [41].
The presence of obesity as a comorbid pathology in a patient increases the likelihood of persistent symptoms of sleep-disordered breathing after surgery [42].
The presence of gastroesophageal reflux disease as a comorbid pathology in a patient increases the likelihood of persistent nasal symptoms (anterior and posterior rhinorrhea, to a lesser extent nasal congestion) after surgery and increases the risk of infectious complications in the early postoperative period [43].
Medical therapy for adenoiditis in patients with adenoidal hypertrophy has an extremely limited effect on the resolution of symptoms of sleep-disordered breathing [32].
Patients and/or their parents/legal representatives, if the child has a comorbid pathology that could affect the outcome of adenoidectomy and/or tonsillotomy, must be informed by the physician about this situation prior to surgery.
Criteria for Evaluating the Quality of Medical Care
Quality assessment criteria for primary health care in children with adenoid hypertrophy, palatine tonsil hypertrophy
No. | Quality assessment criteria | Evaluation of compliance |
|---|---|---|
1. | Initial appointment (examination, consultation) by anotorhinolaryngologist was completed. | Yes/No |
2. | Nasopharyngeal radiography (lateral projection) and/or endoscopic endonasal revision (diagnostic endoscopy) of the nasal cavity and nasopharynx were performed (upon diagnosis establishment) | Yes/No |
3. | Follow-up appointment (examination, consultation) by an otorhinolaryngologist | Yes/No |
3.10.10.2. Quality assessment criteria for specialized medical care in children with adenoid hypertrophy, palatine tonsil hypertrophy
No. | Quality assessment criteria | Evaluation of compliance |
|---|---|---|
1. | A daily examination by an otorhinolaryngologist was performed, with monitoring and care provided by nursing staff in the inpatient department | Yes/No |
2. | Adenoidectomy or video-assisted adenoidectomy and/or tonsillotomy or tonsillectomy was performed | Yes/No |
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Sundman J, Nerfeldt P, Fehrm J, Bring J, Browaldh N, Friberg D. Effectiveness of Tonsillectomy vs Modified Uvulopalatopharyngoplasty in Patients With Tonsillar Hypertrophy and Obstructive Sleep Apnea: The TEAMUP Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. 2022 Dec 1;148(12):1173-1181. doi: 10.1001/jamaoto.2022.3432.
Appendix A1. Working Group Composition
Karpova E.P., D.Sc. (Med.), Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Yunusov A.S., D.Sc. (Med.), Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest
Tulupov D.A., Ph.D. (Med.), Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.
Karneeva O.V., D.Sc. (Med.), Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest
Zyabkin I.V., D.Sc. (Med.), Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest
Polunin M.M., D.Sc. (Med.), Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest
Geppe N.A., D.Sc. (Med.), Professor, no conflict of interest
Polyakov D.P., Cand. of Med. Sci., is a member of the National Medical Association of Otorhinolaryngologists; there is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
The methodology for developing clinical guidelines is based on a comprehensive analysis of the current state of the problem, review of literature data and regulatory legal acts, followed by professional discussion and introduction of changes based on conference and national congress resolutions, provided they are approved by the Ministry of Health.
These clinical guidelines summarize the authors' experience in diagnosing and treating patients with adenoid hypertrophy and palatine tonsil hypertrophy. They contain information necessary for the diagnosis, differential diagnosis, and selection of treatment methods for patients with adenoid hypertrophy and palatine tonsil hypertrophy.
Target audience for these clinical guidelines:
otorhinolaryngologists;
otorhinolaryngologist-audiologists;
city (district) pediatricians;
district pediatricians;
adolescent general practitioners;
general practitioners (family physicians).
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | There is only a rationale for the mechanism of action or expert opinion |
Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | There is only a rationale for the mechanism of action of the intervention (preclinical studies) or expert opinion |
Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The update mechanism for clinical guidelines provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific conditions, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Order of the Ministry of Health of the Russian Federation No. 606n dated November 7, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile 'Allergology and Immunology'" Registered with the Ministry of Justice of the Russian Federation on January 28, 2013. Registration No. 26732
Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, "On approval of the procedure and timelines for the development and revision of clinical guidelines, the standard form of clinical guidelines, and requirements for their structure, composition, and the scientific validity of the information included therein." Registered with the Ministry of Justice of the Russian Federation on May 8, 2019. Registration No. 54588
Guidelines for the development of physician action algorithms. Ministry of Health of the Russian Federation, 2016.
Appendix B. Physician Action Algorithms
Patient management algorithm
Appendix C. Patient Information
The pharyngeal and palatine tonsils are not neoplasms, and their presence is not a pathology. The pharyngeal and palatine tonsils belong to regional immune system organs that all children should have. Enlargement of the pharyngeal and palatine tonsils in preschool-aged children is a physiological process associated with the developmental stages of the child's immune system. The enlargement of the pharyngeal and palatine tonsils may be either asymptomatic or accompanied by specific patient complaints.
Reactive inflammatory changes in the pharyngeal tonsil (adenoiditis) resulting from a cold or occurring against the background of allergic rhinitis are physiological in children under 7–9 years of age. In the absence of clinical signs of complications (otitis media, acute sinusitis) and a significant impact of symptoms on the child's quality of life (impaired sleep and/or daytime activity due to cough and/or nasal breathing difficulty), they should not be regarded as a pathological condition.
The primary causes leading to changes in the pharyngeal and palatine tonsils are respiratory viruses and genetic predisposition.
Patient complaints and clinical symptoms are most commonly observed in patients with grade III AH and grade III PTH. In grade I and II AH and PTH, patients usually (but not always) do not present any complaints, and symptoms of the disease are absent.
In pharyngeal tonsil hypertrophy (PTH), the sole complaint from parents is typically the child's snoring. Unlike inflammatory conditions, snoring in PTH is constant during sleep and often independent of the child's sleeping position. Symptoms and complaints in patients with adenoid hypertrophy (AH) (including AH with PTH) are more diverse. Besides breathing difficulties during sleep, the most common complaints include persistent nasal breathing difficulty and conditions associated with chronic nasal obstruction: constantly open mouth, hyponasality, and a sensation of dry mouth. Patients with AH frequently present with hearing loss as a manifestation of secretory otitis media, and/or a history of recurrent acute otitis media episodes. When adenoiditis is present, the primary complaint of the patient and/or their representatives is coughing (usually productive nighttime and morning cough), resulting from post-nasal drip syndrome (mucus running down the posterior pharyngeal wall). Symptoms of adenoiditis can occur even with a small nasopharyngeal tonsil size.
The justification for examining the patient and utilizing specific instrumental diagnostic methods includes the patient's (or their legal representatives') complaints regarding corresponding symptoms, clinical manifestations of the disease, and/or the presence of a comorbid condition whose course could be affected by adenoiditis, AH, and/or PTH. The choice of diagnostic methods is determined by the otorhinolaryngologist based on general physical examination findings and medical history.
When a patient presents with specific clinical symptoms and complaints, the otorhinolaryngologist prescribes treatment. Surgical treatment for patients with AH and PTH is performed on an elective basis only when indications are present and contraindications are absent. Surgical treatment in patients with concurrent chronic or congenital pathology is performed only in consultation with the relevant specialist. Conservative treatment is justified exclusively for patients who exhibit clinical and anamnestic signs of inflammatory changes in the pharyngeal tonsil tissue (adenoiditis) or palatine tonsils (tonsillitis) accompanied by relevant complaints or complications.
How to prevent the development of pathology of the pharyngeal and palatine tonsils: there are currently no specific preventive measures that guarantee the prevention of lymphopharyngeal ring pathology. Existing preventive measures for acute respiratory viral infections (ARVI) only slightly reduce the frequency of physician visits regarding problems with the pharyngeal and palatine tonsils.
Consult a specialist if: following a cold-related illness, the child develops symptoms such as nasal congestion, snoring, hearing loss, or a cough (with lower respiratory tract pathology ruled out) that persist without a tendency to resolve within 2 weeks.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
To date, no scales or questionnaires are used in the diagnosis of AH or PTH. The assessment of symptom severity and their impact on the patient's quality of life is generally binary: the symptom is present but does not affect the child's sleep and daily activities, or the symptom is present and impairs the patient's quality of life (sleep, daily activities).
The obstructive sleep-disordered breathing severity index, including the apnea-hypopnea index, is assessed by a specialist focused on the prevention and treatment of sleep disorders.