132 THE PHARYNX AND NASOPHARYNX necessary. The differential diagnosis may be made by lateral radiography of the nasopharynx (Fig, 51), which will demonstrate a normal nasal airway in the resting phase, and by the cold spatula test. This consists in holding a cold metal spatula against the upper lip below the nose and estimating the nasal airway during normal respiration by the amount of steaming produced on the spatula. The other symptom arising from adenoid hypertrophy is deafness due to the adenoid mass obstructing the openings of the auditory tubes. This diminishes air entry to the middle ears. Symptoms due to infection are also referred to the nose and middle ears. Infection of the adenoids will cause an infection of the mucous membrane of the nose, and vice versa. This, in turn, may lead to an obstruction to the drainage of secretion from the paranasal sinuses and thus to infection of the sinuses. Removal of adenoids is usually sufficient to clear up most cases of sinus involvement in children. More serious is the effect of spread of infection Fig. 52. Adenoids as seen by posterior rhinoscopy. from the adenoids along the auditory tubes to give recurring attacks of acute otitis media, or to perpetuate a chronic otitis media. Enlarged infected adenoids are also a contributory factor in secretory otitis media. CLINICAL FEATURES. On posterior rhinoscopy a lobulated mass of the same colour as the mucous membrane is seen in the nasopharynx (Fig. 52). It may be so slight as to form only a moderate projection which does not encroach on the posterior nares, or it may hang down and obscure either part or the whole of the septum and choanae. The growths occasionally extend laterally to lie in close relation to the openings of the auditory tubes (the tubal tonsils). In rare instances the adenoids extend into the pharynx and project below the soft palate. Examination with a postnasal mirror can sometimes be carried out in young children. If not, it is never necessary to palpate the nasopharynx unless under general anaesthesia. Lateral radiographs of the nasopharynx will demonstrate the presence and size of adenoids (Fig. 53). DIAGNOSIS. The diagnosis is usually easy, but in the case of young infants it may not be possible to come to a definite conclusion prior to operation. In such cases it is wiser to give an anaesthetic and to palpate the postnasal space, and if adenoids are present they may then be removed. In all cases anterior rhinoscopy should be carried out to eliminate any other cause of nasal obstruction, The possibility of a coexistent infection of the paranasal sinuses must not be forgotten.