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ABSTRACT
The initial part of the digestive tract between the oral cavity and the esophagus is represented by the pharynx, which
at the same time is a fragment of the respiratory tract, connecting the nasal cavity with the larynx. The pharynx
ensures the passage of food and conduction of air into the lower important parts of the div, participates in voice
formation and the formation of articulate speech, and performs a protective function. The important role of the
pharynx in protective mechanisms is largely due to the work of the pharyngeal lymphoepithelial structures, which
form the so- called eous Waldeyer
–
Pirogov ring. As part of the latter, paired palatine and tubal tonsils, unpaired
pharyngeal tonsils (PG) and lingual tonsils are differentiated line and granules of lymphoid tissue of the posterior
pharyngeal wall.
KEYWORDS
Adenoid vegetation, Waldeyer -Pirogov ring, palatine tonsils.
INTRODUCTION
Research Article
TREATMENT OF ADENOID VEGETATION UNDER ALLERGIC RHINITIS
(REVIEW)
Submission Date:
February 04, 2024,
Accepted Date:
February 09, 2024,
Published Date:
February 14, 2024
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume04Issue02-04
Mardonov Kh.
Tashkent Medical Academy, Uzbekistan
Djuraev J.A.
Tashkent Medical Academy, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
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Lymphoid tissue of the pharynx is part of the unified
human immune system and, unlike other peripheral
organs of immunity, is both an immune barrier and a
lymphocytopoietic organ that creates conditions for
constant transepithelial migration of macrophages and
other antigen-presenting cells. The immunological
reactivity of our div This is ensured due to the active
participation of the lymph epithelial ring in local
protective processes and the development of a
systemic response triggered by sensitization of
lymphocytes of the tonsils [1]. The functions of the
lymphoid tissue of the pharynx, in addition to
lymphopoiesis, are the formation of antibodies and
secretory immunoglobulins (Ig), regulation of the
processes of phagocyte migration, exocytosis and
phagocytosis, production of defensins, lactoferrin,
proteolytic enzymes, lysozyme and some others.
According to a number of authors, hypertrophy of the
structures of the Waldeyer
–
Pirogov ring indicates the
insufficiency of their function in providing conditions
for antigen presentation and is probably a sign of
immunodeficiency [2]. At birth, a person's tonsils are
underdeveloped and functionally inactive. Lima
formation foid structures occurs in response to
colonization of the child’s respiratory tract b
y
microorganisms.
Then,
during
life,
the
lymphoepithelial structures of the pharynx involute,
and the lymphoid tissue is replaced by connective
tissue. Typically, these changes begin in adolescence
and last for quite a long time. GM develops most
quickly in children. This process is especially intense at
the age of 1.5
–
3 years, which is due to the significant
frequency of contacts of the child with various
microorganisms, and physiological hyperplasia of the
brain is observed. According to various authors, the
“peak maturity” of the brain is observed at the age of
5
–
7 years, after which its age-related involution occurs
[3].
After contact with a particular pathogen, separate
clones of plasma cells are formed in the brain, which
then spread to the mucous membrane of the nasal
cavity and paranasal sinuses, where they synthesize
the corresponding secretory Ig A. When a new
pathogen appears, the above processes are repeated.
After removal of the GM, this complex mechanism
practically does not work, which can contribute to the
development of chronic respiratory tract pathology in
the child [2]. The GM is located in the area of the
posterior fornix of the nasopharynx, but can fill its
entire dome, and also spread to the side walls in the
area of the pharyngeal openings of the auditory tubes.
Normally, the GM does not reach the upper edge of the
vomer and choanae; its pathological hypertrophy
(proliferation) is determined divides like adenoids. In
Russia they use the classification tion of GM, proposed
by A.G. Likhachev. According to this classification,
depending on the degree of obstruction of the lumen
of the choanae, the following degrees of hypertrophy
are distinguished: fii adenoids:
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• 1st degree –
adenoid vegetations cover 1/3 of the
area Nika;
• 2nd degree –
adenoid vegetations cover 2/3 of the
area Nika;
• 3rd degree –
the choanae are completely closed [4].
Chronic adenoiditis (CA)
–
polyetiological care levy
with a duration of more than 12 weeks, which is based
on a violation of the physiological immune processes of
the brain. CA still retains one of the leading positions
among infectious and inflammatory diseases of the
upper respiratory tract in children under 10 years of
age. The etiological factors for the development of CA
are impaired nasopharyngeal aeration, antenatal and
perinatal factors, high antigen load, unfavorable
environmental conditions, immunodeficiency cytic
conditions and congenital diseases, accompanied
expected
decrease
in
nonspecific
immunity,
unfavorable allergic history [5, 6]. Morphological
changes in the lymphoid tissue of the nasopharynx are
formed due to disruption of regenerative processes
during prolonged antigenic viral and bacterial
exposure, which contribute to persistent microbial
colonization and lead to an increase in infiltration
tration by lymphocytes and macrophages of adenoid
vegeta tions with the formation of a transitional type
of surface epithelium. CA, accompanied by adenoid
hypertrophy, affects 70
–
75% of children aged 3 to 10
years [5, 7]. Chronic diseases of the upper respiratory
tract are often comorbid. Many patients have a
combination of CA and chronic rhinitis, including
allergic rhinitis [8]. Allergic rhinitis (AR) is quite
commonly known chronic disease of the respiratory
tract. According to the World Health Organization,
more than 40% of the world's population suffers from
AR. According to the data ARIA 2010 revision AR affects
10 to 20% of the population [1].
Symptoms of AR, according to the ISAAC study, were
observed on average in 31.7% of children 6
–
7 years old
and in 14.6% of children 13
–
14 years old. In Russia, the
prevalence of AR in children was 11.7%. There has been
an increase in the prevalence inadequacy of AR,
especially in developed countries [9]. AR in children
against the background of cerebral hypertrophy,
according to scientific research, occurs in children of
preschool and primary school age in 45
–
55% of cases
[10]. Scientific forecasts indicate a further continuing
trend towards an increase in the level of allergic
diseases in the human population, including in
childhood [11]. Allergic inflammation of the brain and
its subsequent hyperplasia significantly aggravate
nasal obstruction. Conducted research studies on the
study of microbiocenosis of the mucous membranes
data from the nasal cavity in patients with AR show
that when it is colonized by Staphylococcus aureus and
fungi of the genus Candida albicans increases the risk
of developing secondary immune deficiency and
complicated course of AR. Fungi of the genus Candida
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have a damaging effect on the nasal mucosa,
increasing the production of inflammatory mediators,
and supporting chronic allergic and infectious
inflammation [8, 12]. Questions of tactics for the
management of children with GM pathology against
the background of AR and determining indications for
surgical treatment niya remain open to this day. The
purpose of the review is to analyze the effectiveness of
conservative and complex (combination of surgical
and conservative) nogo) treatment of children with
GM and AR pathology. Materials and methods, We
analyzed 35 scientific publications published in the
PubMed and Scopus databases over the past 10 years.
Results Scientific research data show that a number of
external and internal factors can lead to various
disorders in the human immune system.
Excessive antigenic load leads to a compensatory
increase in the lymphoid tissue of the pharynx in
children with the subsequent development of
lymphadenopathy. This process is caused by the
inhibition of the mechanism of apoptosis of
lymphocytes by viruses that have tropism for them,
namely adenoviruses, res pyratoric syncytial, herpes
viruses type 4, Epstein
–
Barr virus, atypical
microorganisms and other pathogens, constitutional
predisposition susceptibility to lymphoproliferative
processes, which leads to inflammatory and
hyperplastic changes in the lymph nodes foid tissue of
the pharynx, in particular to CA [6]. According to recent
information, the role of fungal microflora in the
development of chronic pathology of the nasopharynx
has not been confirmed. Regular reflux of acidic chyme
into the pharynx during gastroesophageal Reflux
disease leads to disruption of the mechanisms of local
immunity (primarily the mucociliary system), which
creates favorable conditions for the colonization and
growth of pathogenic bacterial microflora. In children
with gastrointestinal tract esophageal reflux disease
sowing frequency S. aureus from the GM surface is at
the level of 70
–
75%. Most authors consider
Streptococcus to be the main pathogens responsible
for the pathological process in CA. Pneumoniae ,
Haemophilus influenzae , Moraxella Catarrhalis , S. _
aureus . However, the indicators differ significantly . S.
_ Torretta et al . (2019) in 50% of cases found fired up
Str . Pneumoniae , H. _ influenzae
–
in 66.7% [13], I.
Brook et al . (2000)
–
H . influenzae
–
in 64.4% , M.
catarrhalis
–
in 35.6% and S. aureus
–
in 33.3% of cases;
S. _ aureus
–
from 50 to 75% depending on concomitant
pathology, H. Influenza
–
3.3
–
66.7% , M. catarrhalis
–
6.7
–
35.6%, Str . Pneumoniae
–
3.3% of cases. According
to the authors, the most frequently detected
associations of microorganisms in the nasopharynx are
The following are available: H. influenzae + rhinovirus
–
in 8 (7.8%), S. pneumoniae + adenovirus
–
in 5 (4.9%), S
. pneumoniae + rhinovirus
–
in 3 (2.68%), S .
pneumoniae + parainfluenza virus type 1
–
in 3 (2.68%)
patients, in 8 (7.8%) patients S. pneumoniae was the
only causative agent of the disease tion , and in 13
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(12.7%) - in combination with various viruses:
adenovirus - 5 (4.9%), rhinovirus - 3 (2.68%),
parainfluenza virus type 1 - 3 (2.68 %) [14
–
16].
The most significant etiological factors of the form
Causes of CA are poor ecology, impaired aeration of
the nasopharynx, immunodeficiency states and
congenital diseases accompanied by impaired
immunity, and a negative allergic history [7, 15, 17]. AR
among all atopic diseases is the most significant risk
factor in the development of lymph hyperplasia id
fabric. AR is a chronic disease of the nasal mucosa,
which is based on IgE -mediated inflammation caused
by exposure to various allergens and manifested by a
complex of symptoms such as rhinorrhea , nasal
congestion , sneezing and itching in the nasal cavity. AR
often occurs with rhinosinusitis , adenoiditis , otitis
media and other diseases of the upper respiratory tract
and is combined with other allergic pathology [13, 18].
The presence of AR and CA in a child can be the leading
cause of the development of obstructive sleep apnea
syndrome and orthodontic changes [19]. According to
a number of otorhinolaryngologists , this problem in
case of GM hypertrophy , surgical treatment is the
solution
–
adenotomy [20].
Adenotomy is one of the most common surgical
interventions
performed
in
pediatric
otorhinolaryngology; This operation can quickly solve
the problem of nasal obstruction. breathing , as well as
restoring the drainage of natural anastomoses in the
rhinosinus-tubal
area,
helps
to
reduce
the
contamination of the brain. Indications for adenotomy
for hypertrophy of th
e brain are: • obstructive sleep
apnea syndrome; • the presence of anamnestic and
clinical signs of frequently recurring or regular
episodes of structural sleep disorders (snoring,
daytime sleepiness and lethargy of the child); •
persistent course of exudative otitis media (lack of
resolution of disease symptoms within 3 months ), not
amenable to conservative treatment research 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 the ineffectiveness
of drug prevention; • persistent difficulty in nasal
breathing ( without other causes of nasal obstruction
), resista
nce driven by a decrease in the child’s quality
of life (disturbance in sleep or educational activity in
adolescents) or leading to deformation of the facial
skeleton (according to a cephalometric study and
conclusion orthodontist or maxillofacial surgeon)
; •
chronic sinusitis, accompanied by severe clinical
manifestations and/or frequent exacerbations with a
significant decrease in the child’s quality of life when 1–
2 courses of conservative treatment are ineffective; •
expert opinion on the need to carry out nia adenotomy
as a stage in the treatment of concomitant pathology
(for example, the conclusion of cardiac surgeons on
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the need for adenotomy as a stage in preparing the
patient for cardiac surgery) [3].
According to the literature, relapses of adenoids are
observed occur in 9
–
65% of cases and develop under
the influence of the same factors that initially cause
hypertrophy of adenoid tissue. Some foreign scientists
have discovered unsuccessful results of adenotomy for
CA and RI nasinusitis in 55 children out of 121. Most
often these were children under 7 years of age and
with a history of bronchial asthma. P. _ Mattila
reported the effectiveness of elective adenotomy in
children [21]. Complex treatment , including local
antibacterial agents drugs and the use of nasal
steroids, in some cases, allows to achieve stable
remission in patients suffering from the concomitant
pathology of adenoid hypertrophy diseases /CA and
AR, as well as bronchial asthma [7, 22]. Research by
Russian scientists has shown the importance of GM for
the development of the child’s div; a number of
researchers have expressed an opinion in favor of
partial adenotomy and preservation of GM, arguing
their point of view by indicating that adenoid
vegetations are an immunocompetent organ for
inducing a mucosal and systemic immune response. In
addition, after adenotomy there is a risk of developing
vicarious hyperplasia of the lymphoid tissue of the
tubal tonsils , which leads to worsening exudative
symptoms nary , adhesive otitis. Relapses of adenoid
hypertrophy From 2
–
10 to 40
–
75% of children have
disabilities ; they develop under the influence of the
same factors that cause CA. Surgeon Clinical treatment
of adenoid vegetations, performed according to
indications, does not negatively affect the immune
defense mechanism and is highly effective in relation
to the quality of life of children [23, 24].
Conservative treatment includes drug and non-drug
methods of influencing CA. According to the clinical
guidelines “Adenoid hypertrophy. Hypertro
phy of the
palatine tonsils”, approved approved by the Russian
Ministry of Health dated September 1, 2021,
conservative treatment includes irrigation and
elimination tera pyu , topical antibacterial therapy,
mucolitis ical therapy, local glucocorticosteroid (GCS)
therapy [3]. These therapeutic directions are described
are also found in foreign literature [25]. Irrigation-
elimination therapy is aimed at reducing the severity of
symptoms of adenoiditis . Regular use of isotonic and
hypertonic solutions of sterile sea water does not allow
dysbiotic changes to progress and prevents prevents
the growth of pathogens, and also improves
mucociliary clearance and rheological properties of
nasal mucus. Hype rosmolar saline solutions reduce
nasal obstruction due to a pronounced anti-edematous
effect. Isotonic and hypertensive drugs have the same
effect. chemical solutions of sterile sea water in the
treatment of AR [9, 12, 26
–
28].
One of the possible causes of the pathology is
lymphoepititis lyal pharyngeal ring is a microbial obse
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changeability _ The microbiological picture against the
background of GM pathology is quite diverse, but
which specific pathogens are fundamental in the
development of GM/CA hypertrophy is not completely
clear. Microbial biofilms play an important role in the
formation of CA. Biofilms are communities formed by
related and unrelated microorganisms, delimited from
the external environment by additional membranes,
within which cells have specialization and contact with
each other . Bacterial films have been found in a large
number of patients with adenoid hypertrophy on the
surface of the removed tissue [29]. Against the
background of irrigation- elimination therapy in
children with adenoiditis , conditions are created for
the use of local antibacterial agents in order to
suppress
pathogenic
and
opportunistic
microorganisms [thirty, 31]. The use of nasal sprays
with etiotropic components tami allows achieving
eradication of infectious agents . The use of local
antibacterial therapy in the complex treatment of
adenoiditis in children increases the effectiveness and
compliance of treatment [32, 33]. In order to reduce
the severity of postnasal drip In the treatment of CA in
children, mucolytic drugs are used teacher rats with a
dominant mucoregulatory effect [33]. Intranasal
topical corticosteroids, namely mometasone furoate
are indicated in the treatment of CA/GA against the
background of AR according to the Clinical Guidelines
“Hypertrophy of the palatine tonsils ” , approved by
the Ministry of Health of Russia dated September 1,
2021. This drug is able to reduce the inflammatory
process, reduce the volume of tissue of adenoid
vegetations in children with AR, which is the main
indication for use values intranasal GCS [28]. In the
foreign literature there is clinical experience with the
endonasal use of mometasone furoate to reduce the
size of GM. After a course of treatment (1 month ), in
70.4% of patients the size of adenoid vegetations
decreased, which made it possible to avoid surgical
intervention [34].
CONCLUSIONS
Thus, the results of studies of recent decades, carried
out by Russian and foreign clinicians in the field of
pathogenesis, etiology, clinical picture and methods of
treatment of children with CA/HA, including against the
background of AR, leave questions of rational tactics
for managing such patients largely open. The need for
further study of the feasibility and effectiveness of
using this or that method and method of treating
children with GM pathology against the background of
AR is not raises doubts. In conclusion, we can conclude
that adequate weight The care of children with chronic
adenoiditis and AR is an urgent problem of modern
clinical otitis nolaringology and allergology. There is no
doubt that the treatment of such patients should be
comprehensive and individual. Further research into
this problem is needed in order to optimize treatment
tactics.
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