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 Otitis Media (Acute) Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever... read more 
), posterior choanae (causing sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more 
), or both.
Symptoms and Signs of Adenoid Disorders
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.
Diagnosis of Adenoid Disorders
Flexible nasopharyngoscopy
Adenoid hypertrophy is suspected in children and adolescents with characteristic symptoms, persistent middle ear effusions Otitis Media (Secretory) Secretory otitis media is an effusion in the middle ear resulting from incomplete resolution of acute otitis media or obstruction of the eustachian tube without infection. Symptoms include hearing... read more 
, or recurrent acute otitis media Otitis Media (Chronic Suppurative) Chronic suppurative otitis media is a persistent, chronically draining (> 6 weeks), suppurative perforation of the tympanic membrane. Symptoms include painless otorrhea with conductive hearing... read more 
or rhinosinusitis. Similar symptoms and signs in a male adolescent may result from an angiofibroma Juvenile Angiofibromas Juvenile angiofibromas are rare and benign growths that can develop in the nasopharynx. Diagnosis is with imaging. Treatment is excision. Juvenile angiofibromas are most common among adolescent... read more .
Children with velopharyngeal insufficiency Velopharyngeal Insufficiency Velopharyngeal insufficiency is incomplete closure of a sphincter between the oropharynx and nasopharynx, often resulting from anatomic abnormalities of the palate and causing hypernasal speech... read more , 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. CT or MRI may be considered in children when there is a high index of suspicion for angiofibroma or cancer.
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 Otitis Media (Secretory) Secretory otitis media is an effusion in the middle ear resulting from incomplete resolution of acute otitis media or obstruction of the eustachian tube without infection. Symptoms include hearing... read more or frequent otitis media Otitis Media (Chronic Suppurative) Chronic suppurative otitis media is a persistent, chronically draining (> 6 weeks), suppurative perforation of the tympanic membrane. Symptoms include painless otorrhea with conductive hearing... read more , 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 Epistaxis Epistaxis is nose bleeding. Bleeding can range from a trickle to a strong flow, and the consequences can range from a minor annoyance to life-threatening hemorrhage. Most nasal bleeding is anterior... read more 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 Velopharyngeal Insufficiency Velopharyngeal insufficiency is incomplete closure of a sphincter between the oropharynx and nasopharynx, often resulting from anatomic abnormalities of the palate and causing hypernasal speech... read more , often associated with submucosal cleft palate and bifid uvula, because it can precipitate or worsen hypernasal speech.
