Hypertrophy or inflammation of the adenoids is common among children. Symptoms include nasal obstruction, sleep disturbances, and middle ear effusions with hearing loss. Diagnosis is enhanced by flexible fiberoptic nasopharyngoscopy. Treatment often includes intranasal corticosteroids, antibiotics, and, for significant nasal obstruction or persistent recurrent acute otitis media or middle ear effusion, adenoidectomy.
The adenoids are a rectangular mass of lymphatic tissue in the posterior nasopharynx. They are largest in children age 2 to 6 years. Enlargement may be physiologic or secondary to viral or bacterial infection, allergy, irritants, and, possibly inflammation such as that caused by gastroesophageal reflux. Other risk factors include ongoing exposure to people with bacterial or viral infection (eg, to multiple children at a child care center). Severe hypertrophy can obstruct the eustachian tubes (causing otitis media) and/or posterior choanae (causing sinusitis or obstructive sleep apnea).
Symptoms and Signs of Adenoid Disorders
Although patients with adenoid hypertrophy may not complain of symptoms, they typically have chronic mouth breathing, snoring, sleep disturbances, halitosis, recurrent acute otitis media, conductive hearing loss (secondary to recurrent otitis media or persistent middle ear effusions), and a hyponasal voice quality. Chronic adenoiditis can also cause chronic or recurrent nasopharyngitis, rhinosinusitis, epistaxis, and cough.
Diagnosis of Adenoid Disorders
Flexible nasopharyngoscopy
Adenoid hypertrophy is suspected in children and adolescents with characteristic symptoms, persistent middle ear effusions, or recurrent acute otitis media or rhinosinusitis. Similar symptoms and signs in a male adolescent may result from a juvenile nasopharyngeal angiofibroma.
Children with velopharyngeal insufficiency (eg, due to velocardiofacial syndrome) may have hypernasal speech (ie, sounding as if too much air escapes through the nose) that must be differentiated from the hyponasal speech (ie, as with a congested nose) of adenoid hypertrophy.
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The standard for office assessment of the nasopharynx is flexible nasopharyngoscopy. Sleep tape recording, often used to document snoring, is not as accurate or specific. A sleep study may help define the severity of any sleep disturbance due to chronic obstruction.
Lateral x-ray imaging is a useful alternative to assess adenoid size, especially when a child cannot tolerate an endoscopic examination. CT or MRI may be considered in children when the index of suspicion for angiofibroma or cancer is high.
Treatment of Adenoid Disorders
Treatment of cause
Sometimes adenoidectomy
Underlying allergy is treated with intranasal corticosteroids, and underlying bacterial infection is treated with antibiotics.
In children with persistent middle ear effusions or frequent otitis media, adenoidectomy often limits recurrence (1). If children are > 4 years and require tympanostomy tubes, adenoidectomy is often done when tubes are placed. Adenoidectomy is also recommended for younger children with recurrent epistaxis or other significant complications of nasal obstruction (eg, sleep disturbances, voice change). Although it requires general anesthesia, adenoidectomy usually can be done on an outpatient basis with recovery in 48 to 72 hours.
Adenoidectomy is contraindicated in patients with velopharyngeal insufficiency, which can be associated with submucosal cleft palate and bifid uvula because adenoidectomy can precipitate or worsen hypernasal speech.
Treatment reference
1. Mitchell RB, Archer SM, Ishman SL, et al: Clinical practice guideline: Tonsillectomy in children (update)-Executive Summary. Otolaryngol Head Neck Surg 160 (2):187–205, 2019, doi: 10.1177/0194599818807917
