What are the indications and guidelines for adenoidectomy in adult patients?

Indications for Adenoidectomy in Adult Patients

Adenoidectomy is rarely indicated in adults and should be reserved for specific cases of chronic rhinosinusitis, postnasal obstruction, or chronic adenoiditis that have failed medical management. 1

Primary Indications for Adult Adenoidectomy

Adult adenoidectomy may be considered in the following conditions:

1. Chronic rhinosinusitis refractory to medical therapy

   • When persistent symptoms of nasal congestion, postnasal drainage, and facial pressure continue despite appropriate medical management
   • Particularly when adenoid tissue is confirmed as a source of bacterial biofilms contributing to chronic infection

2. Postnasal obstruction

   • When adenoid hypertrophy causes significant nasal airway obstruction
   • When obstruction creates disturbance of normal airflow resistance and turbulent flow patterns 1

3. Chronic adenoiditis

   • Persistent inflammation of adenoid tissue causing symptoms
   • Often associated with chronic sinusitis

Diagnostic Evaluation Before Considering Surgery

• Nasal endoscopy to visualize and assess adenoid tissue size and location
• CT imaging of sinuses to evaluate for concurrent sinusitis
• Allergy testing if allergic rhinitis is suspected as a contributing factor
• Trial of medical therapy including:
  • Intranasal corticosteroids
  • Saline irrigation
  • Appropriate antibiotic therapy for confirmed bacterial infection

Medical Management Before Surgery

A trial of medical management should be attempted before considering adenoidectomy:

• Intranasal corticosteroids should be the first-line treatment for adenoidal hypertrophy 1
• Saline irrigation to improve mucociliary clearance
• Appropriate antibiotic therapy for confirmed bacterial infections

Surgical Considerations

When adenoidectomy is indicated in adults:

• The procedure can typically be performed under local anesthesia
• Minimal bleeding is generally noted
• No nasal packing is typically required
• Postoperative crusting may occur

Important Caveats and Limitations

• Unlike in children, adenoidectomy in adults has limited evidence supporting its efficacy 2
• Adult adenoid tissue is typically atrophied compared to children, making the procedure less commonly indicated
• Nasal congestion in adults is more commonly due to other causes such as:
  • Septal deviation
  • Turbinate hypertrophy
  • Allergic rhinitis
  • Chronic rhinosinusitis with or without polyps

Potential Complications

• Bleeding (0.2-0.5% risk) 1
• Velopharyngeal insufficiency (rare in adults)
• Nasopharyngeal stenosis (rare complication)
• Persistent symptoms despite surgery (common when adenoid hypertrophy is not the primary cause of symptoms) 3

Follow-up Care

• Post-operative evaluation at 2-4 weeks
• Continued use of intranasal corticosteroids may be beneficial
• Allergy evaluation should be considered for patients with persistent symptoms 3

Differential Considerations

When adults present with symptoms suggesting adenoid hypertrophy, consider alternative diagnoses:

• Chronic rhinosinusitis with or without nasal polyps
• Allergic rhinitis
• Septal deviation
• Turbinate hypertrophy
• Nasopharyngeal malignancy (rare but important to exclude)

Remember that adenoidectomy in adults should be approached with caution and only after thorough evaluation and failed medical management, as the evidence base is significantly more limited than for pediatric adenoidectomy.