What is the treatment for enlarged adenoids in children?

Treatment of Enlarged Adenoids in Children

Adenoidectomy is indicated for specific conditions—obstructive sleep apnea, chronic adenoiditis, or significant nasal obstruction—but should be reserved for children ≥4 years old when performed for otitis media with effusion, with a trial of intranasal corticosteroids recommended before surgery in most cases. 1, 2

Initial Management Approach

Medical Management First-Line

• Trial intranasal corticosteroids before considering surgery for adenoidal hypertrophy causing nasal obstruction without other complications 3, 2, 4
• Medical therapy addresses the allergic and inflammatory component of adenoid enlargement, as adenoids harbor increased mast cells and allergic mediators 5, 6
• This approach avoids surgical and anesthetic risks (anesthesia mortality ~1:50,000, hemorrhage risk ~2%) 1

When to Proceed Directly to Surgery

Surgery is appropriate without a trial of medical therapy in these specific scenarios:

• Obstructive sleep apnea with documented symptoms (snoring, witnessed apnea, daytime somnolence, mouth breathing, neck extension during sleep) 2, 4
• Chronic adenoiditis with recurrent infections despite appropriate antibiotic therapy 3, 2
• Severe nasal obstruction causing sleep-disordered breathing 4

Age-Specific Surgical Recommendations

Children <4 Years Old

• Tympanostomy tubes alone are preferred for otitis media with effusion (OME) 1
• Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction or chronic adenoiditis) 3, 1
• The added surgical and anesthetic risks outweigh limited short-term benefit in this age group 1
• Exception: Adenoidectomy is most beneficial for recurrent acute otitis media (AOM) in children <2 years old when middle ear effusion is present at assessment (number needed to treat = 9) 1, 2

Children ≥4 Years Old

• Adenoidectomy becomes appropriate as standalone procedure or adjunct to tympanostomy tubes for OME 1, 4
• Reduces need for future tube re-insertions by approximately 10% 3, 1
• For repeat surgery after tube extrusion with recurrent effusion, adenoidectomy reduces need for future operations by 50% 4
• Adenoidectomy confers significant benefit for recurrent AOM in this age group 1

Specific Clinical Indications

Primary Indications (Any Age if Criteria Met)

Obstructive Sleep Apnea:

• Adenotonsillectomy is indicated for documented sleep-disordered breathing with adenotonsillar hypertrophy 2, 4
• Clinical documentation (snoring, restless sleep, witnessed apnea) sufficient even without polysomnography when history is well-documented 4
• Note: Complete OSA resolution occurs in only 25% of children with severe preoperative disease, requiring postoperative reassessment 4

Chronic Adenoiditis:

• Indicated when recurrent infections persist despite appropriate antibiotics 3, 2
• Adenoids harbor pathogenic bacteria (Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus) resistant to penicillin but sensitive to co-amoxiclav and ciprofloxacin 7

Significant Nasal Obstruction:

• Must be associated with sleep-disordered breathing, chronic sinusitis, or chronic adenoiditis 4
• Mouth breathing alone is not sufficient indication for surgery 4

Secondary Indications (Age-Dependent)

Otitis Media with Effusion:

• Children ≥4 years: Adenoidectomy appropriate after 3-month watchful waiting period with persistent effusion and documented hearing difficulties 3, 1
• Adenoidectomy as adjunct to tympanostomy tubes or for repeat surgery 3, 1
• Must document middle ear effusion present at time of assessment for tube candidacy 1, 2

Recurrent Acute Otitis Media:

• Most beneficial in children <2 years with middle ear effusion present 1, 2
• Children ≥4 years: Adenoidectomy as adjunct to tympanostomy tubes 2, 4

Absolute Contraindications

• Overt or submucous cleft palate due to risk of velopharyngeal insufficiency 1, 2, 4
• Adenoidectomy should never be performed solely for recurrent throat infections (this is an indication for tonsillectomy, not adenoidectomy) 1, 2

Key Clinical Pitfalls to Avoid

• Do not perform adenoidectomy for OME in children <4 years unless distinct indication (nasal obstruction, chronic adenoiditis) exists 3, 1
• Do not delay surgery waiting for polysomnography in children with clear clinical obstruction and significant tonsillar hypertrophy 4
• Do not use adenoidectomy to treat recurrent throat infections 1, 2
• The benefit of adenoidectomy for otitis media is unrelated to adenoid size but relates to adenoid serving as bacterial reservoir 1
• Recognize that adenoidectomy alone is not appropriate for OME without other indications in young children 3, 1

Factors Favoring Earlier Surgical Intervention

• Multiple antibiotic allergies or intolerance 2
• Documented hearing loss with persistent middle ear effusion 2
• Daycare attendance (increases infection risk) 2
• Growth retardation, poor school performance, enuresis, behavioral problems associated with sleep-disordered breathing 4