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, gastroesophageal reflux. Other risk factors include ongoing exposure to bacterial or viral infection (eg, to multiple children at a child care center). Severe hypertrophy can obstruct the eustachian tubes (causing otitis media), posterior choanae (causing sinusitis), or both.
Although patients with adenoid hypertrophy may not complain of symptoms, they usually have chronic mouth breathing, snoring, sleep disturbance, 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, halitosis, and cough.
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 an angiofibroma.
Children with velopharyngeal insufficiency, eg, due to velocardiofacial syndrome, may produce a 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.
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 does not provide sufficient or accurate evidence of adenoid size and is not routinely recommended for evaluation. Lateral x-ray imaging may be considered in children when there is a high index of suspicion for angiofibroma or cancer.
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. Children > 4 years who require tympanostomy tubes often undergo adenoidectomy when tubes are placed. Surgery is also recommended for younger children with recurrent epistaxis or significant nasal obstruction (eg, sleep disturbance, 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 velopharyngeal insufficiency, often associated with submucosal cleft palate and bifid uvula, because it can precipitate or worsen hypernasal speech.