今日の臨床サポート

アデノイド肥大・扁桃の異常(扁桃肥大含む)

著者: 林達哉 旭川医科大学 耳鼻咽喉科・頭頸部外科

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2021/02/10
参考ガイドライン:
  1. 米国小児科学会(AAP):Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome(2012)
  1. 米国耳鼻咽喉科・頭頸部外科学会(AAO-HNS):Clinical Practice Guideline: Tonsillectomy in children (Update) (2019)
  1. 米国睡眠医学会(AASM):The International classification of sleep disorders; 3rd ed, Academy of Sleep Medicine, Darien IL(2014)
患者向け説明資料

概要・推奨   

  1. 概要:
  1. 扁桃肥大(アデノイド肥大を含む)は小児の睡眠時無呼吸(OSA: obstructive sleep apnea)を含む閉塞性睡眠時呼吸障害(oSDB: obstructive sleep-disordered breathing)の最も一般的な原因であり、このような小児患者に口蓋扁桃摘出術±アデノイド切除術は非常に有効である。一方、術後出血などの術後合併症もみられることから、手術適応は慎重に評価しなければならない。成人の扁桃肥大では腫瘍性病変の可能性を念頭に置いて診断を進める必要がある。
  1. 推奨:
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
林達哉 : 特に申告事項無し[2021年]
監修:森山寛 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 扁桃肥大(アデノイド肥大を含む)による睡眠時呼吸障害(oSDB: obstructive sleep-disordered breathing)の有無の確定には終夜睡眠ポリグラフィ(PSG)がゴールドスタンダードである(American Academy of Sleep Medicine: The International classification of sleep disorders; 3rd ed, Academy of Sleep Medicine, Darien IL, 2014)。一方、実臨床において小児患者にPSGを適用することは必ずしも容易ではない。PSGの実施が難しい症例に対する対応が明記された米国のガイドライン(American Academy of Otolaryngology Head and Neck Surgery: Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary. Otolaryngology -- Head and Neck Surgery. 2019 Feb;160(2):187–205.)に基づき、手術適応の推奨を明確化した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 「アデノイド」は元来、「咽頭扁桃肥大に伴って何らかの障害を来した状態」を意味する言葉であるが、近年「咽頭扁桃」と同義に用いられる傾向にある。したがって、「アデノイド肥大」と「咽頭扁桃肥大」は同義語として扱われる。
  1. 扁桃とは咽頭を取り囲むように存在する咽頭扁桃、耳管扁桃、口蓋扁桃、舌扁桃からなるリンパ組織(ワルダイエル咽頭輪)の総称であるが、単に「扁桃肥大」といった場合には「口蓋扁桃肥大」を指すことが多い。
  1. 扁桃組織は幼児期に生理的に増大し、アデノイドは4~6歳で、口蓋扁桃は5~7歳で最大となる。
  1. アデノイドや口蓋扁桃が咽頭腔に占める相対的なサイズが大きいとさまざまな臨床症状を生じる。
  1. 閉塞性睡眠時無呼吸障害にアデノイド肥大や扁桃肥大が果たす役割は幼小児で大きく、成人では小さい。
  1. 成人のアデノイド肥大では上咽頭癌(<図表>)や悪性リンパ腫(<図表>)との鑑別、口蓋扁桃肥大(特に片側性の場合)では中咽頭癌(<図表>)や悪性リンパ腫(<図表>)との鑑別が重要である。
問診・診察のポイント  
 
  1. アデノイド肥大の症状は、①アデノイドが上咽頭を物理的に閉塞するために生じる症状、②耳管咽頭口への影響に起因する症状、の大きく2つに分けられる。この2つの病態を想起して病歴を聴取し、診断を進める。アデノイド肥大は経鼻的内視鏡で直接観察可能である(<図表>)。幼小児では施行が難しいことも多くこの場合、上咽頭X線側面像にて肥大の程度を確認する(<図表>)。①は口蓋扁桃肥大が加わると著明となるため、口蓋扁桃の観察も同時に行う。
 
 
 
 
  1. アデノイドが鼻腔を後方から閉塞することにより鼻呼吸障害が起こる。鼻呼吸障害は覚醒時の症状(鼻閉、口呼吸、閉鼻声)や睡眠時の症状(いびき、閉塞性睡眠時呼吸障害( 睡眠時無呼吸症候群 ))の原因となる。それぞれの症状の頻度や程度(無呼吸の回数、努力性呼吸の有無)を聴取する。

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文献 

著者: L Brodsky
雑誌名: Pediatr Clin North Am. 1989 Dec;36(6):1551-69. doi: 10.1016/s0031-3955(16)36806-7.
Abstract/Text Modern assessment of the tonsils and adenoids is based on an appreciation of new concepts pertaining to the pathogenesis of tonsil and adenoid disease. Recognition of the emergence of beta-lactamase-producing and encapsulated anaerobic bacteria in the tonsils and adenoids should lead to a reconsideration of present therapeutic recommendations for antibiotic therapy in infectious tonsil and adenoid disease. The performance of a precise history, use of a standardized physical examination, and judicious use of laboratory evaluation are all necessary for appropriate patient management and improved communication between the pediatrician and otolaryngologist. Thus, appropriate recommendation for tonsillectomy and adenoidectomy will enhance their benefits, and the result will be happier and healthier children.

PMID 2685730  Pediatr Clin North Am. 1989 Dec;36(6):1551-69. doi: 10.・・・
著者: Sanjay R Parikh, Mark Coronel, James J Lee, Seth M Brown
雑誌名: Otolaryngol Head Neck Surg. 2006 Nov;135(5):684-7. doi: 10.1016/j.otohns.2006.05.003.
Abstract/Text OBJECTIVE: To propose and validate a new subjective grading system of adenoid size with flexible fiberoptic evaluation.
STUDY DESIGN AND SETTING: Digital video clips of 24 flexible fiberoptic nasopharyngeal exams were presented to 24 examiners (otolaryngology resident and consultant physicians) at a tertiary care institution. Examiners were asked to use the proposed grading system to rate adenoid hypertrophy. Kappa statistical analysis was used to evaluate the degree of intergrader agreement or disagreement.
RESULTS: Statistical analysis of intergrader agreement demonstrated an overall Kappa score of 0.71 suggesting a "substantial" strength of agreement. The Kappa strength of agreement was found to be 0.83 (almost perfect) among consultant physicians and 0.62 (substantial) among resident physicians.
CONCLUSIONS: The proposed adenoid staging system is a reliable and consistent method of staging adenoid tissue size.
SIGNIFICANCE: This new validated grading system may be a useful standard for reporting adenoid size in future clinical outcome studies.

PMID 17071294  Otolaryngol Head Neck Surg. 2006 Nov;135(5):684-7. doi:・・・
著者: N A Black, C F Sanderson, A P Freeland, M P Vessey
雑誌名: BMJ. 1990 Jun 16;300(6739):1551-6.
Abstract/Text OBJECTIVE: To assess the effect of five different surgical treatments for glue ear (secretory otitis media) on improvement in hearing and, assuming one or more treatments to be effective, to identify the appropriate indications for surgery.
DESIGN: Randomised controlled trial of children receiving (a) adenoidectomy, bilateral myringotomy, and insertion of a unilateral grommet; (b) adenoidectomy, unilateral myringotomy, and insertion of a unilateral grommet; (c) bilateral myringotomy and insertion of a unilateral grommet; and (d) unilateral myringotomy and insertion of a grommet. Children were followed up at seven weeks, six months, 12 months, and 24 months by symptom history and clinical investigations.
SETTING: Otolaryngology department in an urban hospital.
PATIENTS: 149 Children aged 4-9 years who were admitted for surgery for glue ear and who had no history of previous operations on tonsils, adenoids, or ears and no evidence of sensorineural deafness. Inadequate follow up information on levels of hearing and on middle ear function was obtained from 22.
MAIN OUTCOME MEASURES: Mean hearing loss (dB) of the three worst heard frequencies between 250 and 4000 Hz, results of impedance tympanometry, and parental views on their child's progress.
RESULTS: In the 127 children for whom adequate information was available ears in which a grommet had been inserted performed better in the short term (for at least six months) than those in which no grommet had been inserted, irrespective of any accompanying procedure. Most of the benefit had disappeared by 12 months. Adenoidectomy produced a slight improvement that was not significant, though was sustained for at least two years. The ears of children who had had an adenoidectomy with myringotomy and grommet insertion, however, continued to improve so that two years after surgery about 50% had abnormal tympanometry compared with 83% of those who had had only myringotomy and grommet insertion, and 93% of the group that had had no treatment. Logistic regression analyses identified preoperative hearing level as the single best predictor of good outcome from surgery. Other variables contributed little additional predictive power.
CONCLUSIONS: If the principal objective of surgery for glue ear is to restore hearing then our study shows that insertion of grommets is the treatment of choice. The addition of an adenoidectomy will increase the likelihood of restoration of normal function of the middle ear but will not improve hearing. When deciding appropriate indications for surgery, a balance has to be made between performing unnecessary operations and failing to treat patients who might benefit from surgical intervention. Preoperative audiometry scores might be the best predictor in helping to make this decision.

PMID 2196954  BMJ. 1990 Jun 16;300(6739):1551-6.
著者: R Maw, R Bawden
雑誌名: BMJ. 1993 Mar 20;306(6880):756-60.
Abstract/Text OBJECTIVE: To measure the time to spontaneous resolution of severe chronic otitis media with effusion (glue ear) in children and study the effects of adenoidectomy, adenotonsillectomy, and ventilation tubes (grommets).
DESIGN: Randomised controlled study over 12 years.
SETTING: Paediatric otorhinolaryngology clinics and in-patient unit.
SUBJECTS: 228 children aged 2-9 years with pronounced hearing loss from glue ear and persistent bilateral middle ear effusions confirmed on three occasions over three months.
INTERVENTIONS: Children were randomly allocated to adenotonsillectomy, adenoidectomy, or neither procedure. In all groups a Shepard type ventilation tube was inserted in one randomly chosen ear. Follow up was annually for five years and then less often for up to seven years four months. For analysis the two operated groups were combined.
MAIN OUTCOME MEASURES: Otoscopic clearance of fluid, change in tympanogram, and improvement in mean audiometric hearing threshold.
RESULTS: Survival analysis showed appreciable otoscopic and tympanometric resolution of fluid with ventilation tubes alone and adenoidectomy alone compared with no surgery. Further improvement was seen after combination of both treatments. Mean audiometric hearing thresholds improved with fluid resolution. Resolution was delayed in younger children and in those whose parents smoked, irrespective of treatment. Whereas a single insertion of a Shepard tube resolved the glue for a mean (SD) period of 9.5 (5.2) months, the effect of adenoidectomy was sustained throughout follow up.
CONCLUSIONS: Treatment of glue ear considerably shortened the time to fluid resolution, combined adenoidectomy and tube insertion being better than either procedure alone. Resolution was longer in younger children and those whose parent(s) smoked, irrespective of treatment.

PMID 8490338  BMJ. 1993 Mar 20;306(6880):756-60.
著者: A R Maw, R Bawden
雑誌名: Acta Otorhinolaryngol Belg. 1994;48(4):317-24.
Abstract/Text Two hundred and twenty two children with bilateral secretory otitis media were allocated at random for adenoidectomy, adenotonsillectomy or for neither procedure. In all cases only a unilateral grommet was inserted. The contralateral unoperated ear was examined during a ten year period to show otoscopic clearance, change in tympanometric status and improvement in mean hearing threshold. Adenoidectomy or insertion of a grommet alone produces similar improvement but in combination are more effective than either procedure in isolation. The unoperated ear in cases not receiving either procedure reflects the natural history of the condition. It shows a steady improvement in all outcome measures as time passes.

PMID 7810300  Acta Otorhinolaryngol Belg. 1994;48(4):317-24.
著者: P L Ogra
雑誌名: N Engl J Med. 1971 Jan 14;284(2):59-64. doi: 10.1056/NEJM197101142840201.
Abstract/Text
PMID 4321186  N Engl J Med. 1971 Jan 14;284(2):59-64. doi: 10.1056/NE・・・
著者: A Böck, W Popp, K R Herkner
雑誌名: Eur Arch Otorhinolaryngol. 1994;251(7):423-7.
Abstract/Text Immunological functions of the tonsils and possible effects of their removal are still controversial. One reason for this is the lack of long-term follow-up investigations after tonsillectomy. In the present study selected parameters of the cellular and humoral immune systems of 160 children 0.5-11 years after tonsillectomy (mean 6.6 +/- 2.1 years) were compared to those of 302 age-matched non-tonsillectomized children. In tonsillectomized children the incidence of infections of the upper respiratory tract was not increased compared to the non-tonsillectomized control group. Slightly increased percentages of CD 21 + cells, raised counts of CD4+ cells, absolute and relative increases in DR+ cells and a raised CD4+ DR count was found mainly in tonsillectomized boys, while lymphocyte subpopulations of tonsillectomized girls remained unaffected. Tonsillectomized children had lower IgA levels, but the complement system was not altered in either sex. These findings show that while tonsillectomy may lead to certain changes in the cellular and humoral immune systems, these alterations are clinically insignificant and no increased frequency of immunomodulated diseases should be expected.

PMID 7857631  Eur Arch Otorhinolaryngol. 1994;251(7):423-7.
著者: Emma H van den Akker, Elisabeth A M Sanders, Birgit K van Staaij, Ger T Rijkers, Maroeska M Rovers, Arno W Hoes, Anne G M Schilder
雑誌名: Ann Allergy Asthma Immunol. 2006 Aug;97(2):251-6. doi: 10.1016/S1081-1206(10)60022-1.
Abstract/Text BACKGROUND: It remains controversial whether pediatric adenotonsillectomy ultimately results in decreased serum immunoglobulin levels and if so whether such a decrease is associated with increased susceptibility to upper respiratory tract infections (URIs).
OBJECTIVE: To evaluate changes in serum immunoglobulin levels in relation to occurrence of URIs in children participating in a randomized controlled trial on the effectiveness of adenotonsillectomy.
METHODS: A total of 300 children aged 2 to 8 years, with symptoms of recurrent throat infections or tonsillar hypertrophy, were randomly assigned to either adenotonsillectomy or watchful waiting (WW). Serum samples were collected at baseline and at 1-year follow-up. Occurrence of throat infections and other URIs during first-year follow-up was recorded in a diary by the child's parents.
RESULTS: Paired serum samples were available for 123 children (63 in the adenotonsillectomy group and 60 in the WW group). IgG1 and IgG2 levels decreased but remained within the reference range for age in both study arms. IgM and IgA levels decreased as well but remained elevated. The IgA level in the adenotonsillectomy group decreased in significantly greater degree compared with the WW group, but this difference disappeared in cases where children experienced frequent URIs. In general, no relation between immunoglobulin levels and the number of throat infections or URIs at 1-year follow-up was found.
CONCLUSIONS: Immunoglobulin levels of children undergoing adenotonsillectomy decreased from elevated to slightly elevated or reference values for age during 1-year follow-up irrespective of treatment (adenotonsillectomy or WW). IgA showed a greater decrease in the adenotonsillectomy group but rose to levels comparable with the WW group in cases of frequent URIs. This finding indicates that the remaining mucosa-associated lymphoid tissue can compensate for the loss of tonsil and adenoid tissue.

PMID 16937760  Ann Allergy Asthma Immunol. 2006 Aug;97(2):251-6. doi: ・・・
著者: M Sainz, F Gutierrez, P M Moreno, C Muñoz, M Ciges
雑誌名: Clin Otolaryngol Allied Sci. 1992 Oct;17(5):376-9.
Abstract/Text The possible immunoregulatory role of the tonsils was studied by determining immunoglobulins IgG, A, M, E and factors C'3, C'4 and PFB of the complement system before and after tonsillectomy. The synthesis in vitro of IgG and IgM by lymphocytes stimulated with pokeweed mitogen was also measured. There were statistically significant differences between pre and post-operative levels of serum IgG, IgA and IgM, which decreased after surgery. Practically no change in the mean values of IgE and no significant differences in the levels of serum C'3, C'4, and PFB, were found. The in-vitro synthesis of both immunoglobulins (IgG, IgM) by lymphocytes increased significantly after tonsillectomy. Our results suggest that not only does tonsillectomy have no counterproductive effect on the immune system, but that, on the contrary, it seems to improve the immune response, since it appears to unblock the suppression to which the immune system was subject.

PMID 1458616  Clin Otolaryngol Allied Sci. 1992 Oct;17(5):376-9.
著者: L Sennaroglu, M Onerci, G Hascelik
雑誌名: Laryngoscope. 1993 Dec;103(12):1349-51. doi: 10.1288/00005537-199312000-00005.
Abstract/Text Although tonsillectomy and adenoidectomy are common surgical procedures, the effects of these operations on the immune system have not been thoroughly determined. Our data on neutrophil chemotaxic functions in a group of 17 patients with chronic tonsillitis and adenoid hypertrophy show that chronic tonsillitis and adenoid hypertrophy impair neutrophil chemotaxic functions and that there is a subsequent normalization of these values following tonsillectomy and adenoidectomy.

PMID 8246653  Laryngoscope. 1993 Dec;103(12):1349-51. doi: 10.1288/00・・・
著者: R T Brouillette, S K Fernbach, C E Hunt
雑誌名: J Pediatr. 1982 Jan;100(1):31-40.
Abstract/Text Twenty-two infants and children were found to have clinically significant obstructive sleep apnea. A history suggesting complete or partial airway obstruction during sleep was obtained on all patients, and physical examination of the sleeping patient revealed snoring, retractions, or OSA in 21 patients. Nevertheless, the mean delay in referral for 20 patients first seen after the neonatal period was 23 +15 (+ SD) months. Sixteen of 22 patients (73%) developed serious sequelae: cor pulmonale in 12 (55%), failure to thrive in six (27%), permanent neurologic damage in two (9%), and behavioral disturbances, hypersomnolence, or developmental delays in five (23%). Clinical and radiologic evaluations revealed anatomic abnormalities which narrowed the upper airway in 21 patients; enlarged tonsils and/or adenoids in 14, micrognathia in three,generalized facial abnormalities in three, and cleft palate repair/tonsillar hypertrophy in one. In five patients, upper airway fluoroscopy was performed and was helpful in establishing the site and mechanism of obstruction. Polygraphic monitoring was utilized to quantify the frequency and duration of OSA. Prolonged partial airway obstruction during sleep resulted in significant hypercarbia in 11 patients and hypoxemia in five. Twenty patients improved after surgery which relieved or bypassed the pharyngeal airway obstruction; two cases are pending. Increased awareness of OSA and examination of the sleeping patient should result in earlier treatment and less morbidity for infants and children with OSA.

PMID 7057314  J Pediatr. 1982 Jan;100(1):31-40.
著者: J Leach, J Olson, J Hermann, S Manning
雑誌名: Arch Otolaryngol Head Neck Surg. 1992 Jul;118(7):741-4.
Abstract/Text A retrospective study was conducted to determine which types of children might have polysomnographic findings that are most compatible with obstructive sleep apnea (OSA). The charts of 93 patients who were aged 18 months to 12 years were examined. All 93 patients had symptoms that were initially suggestive of OSA, and they underwent polysomnography. The types of presenting symptoms and associated illnesses were noted. Physical findings, including height, weight, and tonsil size, were examined. Of 93 patients with symptoms that were suggestive of OSA, 34 met sleep study criteria for OSA. In 44 patients, OSA was not demonstrated, and 15 patients had other results. On the basis of age, sex, and symptoms, no significant differences could be found between the group with OSA and the group with normal polysomnographic findings. Cor pulmonale, tonsil hypertrophy, and failure to thrive were associated with OSA. Surprisingly, obesity was not significantly associated with OSA.

PMID 1627296  Arch Otolaryngol Head Neck Surg. 1992 Jul;118(7):741-4.・・・
著者: M A Richardson, A B Seid, R T Cotton, C Benton, M Kramer
雑誌名: Laryngoscope. 1980 Jul;90(7 Pt 1):1106-10.
Abstract/Text Peripheral Sleep Apnea syndrome has been associated with enlarged tonsils and adenoids as well as other abnormalities which may cause upper airway obstruction in children. A multidisciplinary approach is used at the Step Disorder Center of Cincinnati General Hospital to evaluate the role of tonsils and adenoids in sleep apnea. Polysomnographic techniques combined with cine sleep studies of the upper airway document the degree, site and type of obstruction. This presentation highlights the entity of obstructive sleep apnea and provides a rational clinical approach in the management of these patients.

PMID 7392747  Laryngoscope. 1980 Jul;90(7 Pt 1):1106-10.

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契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから