What is the treatment for adenoid hypertrophy?

Treatment of Adenoid Hypertrophy

A trial of intranasal corticosteroids should be initiated before considering surgical intervention for adenoid hypertrophy, with adenoidectomy reserved for cases with documented obstructive sleep apnea, chronic adenoiditis, or failure of medical management. 1, 2

Medical Management: First-Line Approach

Intranasal Corticosteroids

• Intranasal corticosteroids are the primary medical treatment for adenoid hypertrophy, with evidence showing significant reduction in adenoid size and improvement in nasal obstruction symptoms 1, 2
• Treatment duration should be at least 4-8 weeks to assess efficacy before considering surgical options 3, 4
• Multiple formulations have demonstrated effectiveness:
  • Fluticasone propionate nasal drops (400 mcg/day) reduced adenoid/choana ratio from 87% to 56% over 8 weeks, eliminating surgery in 76% of patients 5
  • Mometasone (100 mcg/day) for 40 days allowed 77.7% of patients to avoid adenoidectomy 4
  • Beclomethasone (336-400 mcg/day) showed significant improvement in symptom scores and adenoid size reduction 4
  • Azelastine-fluticasone combination (137 mcg/50 mcg twice daily) reduced adenoid/choana ratio from 3.57 to 1.74 and removed 96% of patients from surgery lists 6

Evidence Supporting Medical Management

• A Cochrane review demonstrated that intranasal corticosteroids significantly improve nasal obstruction symptoms and reduce adenoid size in children with moderate to severe adenoidal hypertrophy 4
• The European Respiratory Society found that intranasal steroids improved apnea-hypopnea index (AHI) from 3.7-11 to 0.3-6 in children with mild to moderate OSA and adenoid hypertrophy 1
• This approach is particularly effective when allergic rhinitis coexists, as inflammation contributes to adenoid enlargement 1

Surgical Management: Indications

Clear Indications for Adenoidectomy

Adenoidectomy is indicated when patients have: 1, 2

• Obstructive sleep apnea with documented adenotonsillar hypertrophy (excessive daytime sleepiness, witnessed apnea episodes, polysomnography confirmation)
• Chronic adenoiditis unresponsive to medical therapy
• Chronic sinusitis related to adenoid obstruction
• Failure of medical management after appropriate trial of intranasal corticosteroids (minimum 4-8 weeks)

Additional Surgical Considerations

• For otitis media with effusion, adenoidectomy is typically recommended after first tympanostomy tube extrusion with recurrent effusion, or when coexisting adenoiditis, postnasal obstruction, or chronic sinusitis is present 1
• The European Respiratory Society recommends adenoidectomy for childhood obstructive sleep apnea in the presence of adenoid hypertrophy (Evidence Level C) 2
• Surgery may be considered for severe nasal obstruction from adenoid hypertrophy when medical management fails 1

Treatment Algorithm

Step 1: Initial Assessment

• Document specific symptoms: nasal obstruction, mouth breathing, snoring, sleep disturbance, witnessed apneas, daytime sleepiness 2
• Perform nasal endoscopy to assess adenoid size and adenoid/choana ratio 7, 5
• Evaluate for allergic rhinitis as a contributing factor 1
• Do NOT proceed to surgery without documented sleep apnea or failure of medical management 2, 3

Step 2: Medical Trial (4-8 weeks minimum)

• Initiate intranasal corticosteroids at appropriate dosing for age 1, 2, 4
• Add saline irrigations as adjunctive therapy 1
• Treat underlying allergic rhinitis if present 1
• Reassess symptoms and adenoid size at 4-week intervals 5

Step 3: Reassessment

• If symptoms improve and adenoid size decreases significantly, continue medical management 4, 5
• If no improvement after 8 weeks AND patient has documented OSA or severe symptoms, proceed to surgical consultation 2, 3
• Consider polysomnography if sleep-disordered breathing is suspected but not documented 2

Critical Pitfalls to Avoid

• Do not perform adenoidectomy based solely on adenoid size without documented functional impairment or failure of medical therapy 2, 3
• Approximately 80% of the population has anatomic variations that may appear significant but are not clinically relevant without symptoms 3
• Surgical risks must be weighed against modest benefits in cases without documented sleep apnea 2
• Inadequate duration of medical therapy (less than 4 weeks) before declaring treatment failure 3, 4
• Failing to address underlying allergic rhinitis, which perpetuates adenoid inflammation 1, 8

Special Populations

Children with Mild OSA

• CPAP and mandibular advancement devices should be considered before surgery for mild OSA 3
• Weight management is crucial when BMI contributes to OSA 3
• Intranasal steroids alone improved sleep parameters in children with mild to moderate OSA and adenoid hypertrophy 1

Children with Allergic Rhinitis

• Intranasal corticosteroids address both adenoid hypertrophy and underlying allergic inflammation 1
• Treatment of allergic rhinitis may improve sleep quality and reduce adenoid size without surgery 1, 8
• Consider leukotriene receptor antagonists as adjunctive therapy in allergic patients 1