When should children undergo an adenoidectomy (removal of adenoids)?

When Should Children Have an Adenoidectomy?

Children should undergo adenoidectomy primarily for obstructive sleep apnea with adenoid hypertrophy, as an adjunct to tympanostomy tubes in children ≥4 years old with recurrent otitis media and middle ear effusion, for chronic nasal obstruction causing significant symptoms, or for chronic adenoiditis—but not as initial treatment for otitis media alone in children under 4 years. 1, 2, 3

Primary Indications for Adenoidectomy

Obstructive Sleep Apnea and Sleep-Disordered Breathing

• Adenoidectomy is indicated for children with obstructive sleep apnea caused by adenoid hypertrophy, particularly when accompanied by significant snoring, daytime somnolence, mouth breathing, and witnessed apnea episodes 2, 3
• Children with moderate OSA, small tonsils, and significant adenoid hypertrophy may benefit from adenoidectomy alone rather than adenotonsillectomy, with comparable outcomes and fewer complications 3
• Documented sleep apnea (not just snoring) should be present, ideally with excessive daytime sleepiness and witnessed apnea episodes 2
• Before proceeding to surgery, a trial of intranasal corticosteroids should be considered for adenoidal hypertrophy 2

Otitis Media Indications (Age-Dependent)

For children ≥4 years old:

• Adenoidectomy should be performed as an adjunct to tympanostomy tube insertion in children with recurrent acute otitis media who have middle ear effusion at assessment 1
• For children 4 years or older requiring surgery for otitis media with effusion, clinicians should recommend tympanostomy tubes, adenoidectomy, or both 1
• The benefit of adenoidectomy is greatest for children aged 3 years or older and is independent of adenoid size 1

For children <4 years old:

• Adenoidectomy should NOT be performed as the initial surgical intervention for otitis media with effusion unless a distinct indication exists, such as nasal obstruction or chronic adenoiditis 1, 3
• In children aged 10-24 months with recurrent acute otitis media, adenoidectomy as first-line treatment is not effective in preventing further episodes 4

Repeat Surgery Considerations

• When a child needs repeat surgery for otitis media with effusion, adenoidectomy is recommended as it confers a 50% reduction in the need for future operations 1
• The benefit for reducing future surgeries is apparent from age 2 years but greatest for children aged 3 years or older 1

Chronic Nasal Obstruction and Adenoiditis

• Adenoidectomy is indicated for significant nasal airway obstruction causing mouth breathing, noisy breathing, and difficulty breathing during physical activity 2, 3
• Chronic adenoiditis represents a distinct indication for adenoidectomy 1, 3
• Chronic rhinosinusitis may benefit from adenoidectomy in selected cases 3

Critical Contraindications and Cautions

Absolute Contraindications

• Adenoidectomy should NOT be performed in children with overt or submucous cleft palate due to risk of velopharyngeal insufficiency 1

Important Clinical Pitfalls

• Do not perform adenoidectomy solely for recurrent throat infections—this is an indication for tonsillectomy, not adenoidectomy 5
• Tonsillectomy alone is not recommended for treating otitis media with effusion as it has limited efficacy and carries higher risks 1
• Myringotomy alone is ineffective for chronic otitis media with effusion 1
• The revision adenoidectomy rate is approximately 1.3%, with mean interval between procedures of 1.8 years 6

Risk Factors Supporting Earlier Intervention

• Daycare attendance increases risk for recurrent infections 7
• Multiple antibiotic allergies or intolerance may favor earlier surgical intervention 5
• Documented hearing loss with persistent middle ear effusion warrants more aggressive management 7

Potential Complications

• Hemorrhage (rare but serious) 1
• Transient velopharyngeal insufficiency 1
• Persistence of symptoms requiring revision surgery in 1.3% of cases 6