What is the appropriate evaluation and management for a 5‑year‑old boy with adenoid hypertrophy?

Evaluation and Management of Adenoid Hypertrophy in a 5-Year-Old Boy

The appropriate management depends on the presenting symptoms: if the child has obstructive sleep apnea or significant nasal obstruction, adenotonsillectomy is the first-line treatment; if presenting with otitis media with effusion, tympanostomy tubes are preferred initially with adenoidectomy reserved for specific indications or repeat surgery. 1

Initial Clinical Assessment

Determine the primary clinical presentation, as this dictates management:

• Obstructive symptoms: Document presence of mouth breathing, snoring, witnessed apneas, sleep disturbance, hyponasal speech, and daytime behavioral problems 1, 2
• Otologic symptoms: Assess for recurrent acute otitis media, chronic otitis media with effusion, hearing loss, and duration of middle ear effusion 1, 3
• Nasal obstruction: Evaluate severity of nasal airway obstruction and its impact on quality of life 2, 4

Diagnostic Evaluation

• Physical examination: Flexible nasal endoscopy allows direct visualization of adenoid size and percentage of nasopharyngeal airway obstruction 5
• Hearing assessment: Audiometry or tympanometry is essential when otitis media with effusion is present 1
• Sleep evaluation: For suspected obstructive sleep apnea syndrome, polysomnography is the gold standard, though alternative objective testing may be used if unavailable 1

Management Algorithm by Primary Indication

For Obstructive Sleep Apnea or Significant Nasal Obstruction

Adenotonsillectomy is recommended as first-line treatment when adenotonsillar hypertrophy is present on examination. 1

• This approach results in improvements in symptoms and sequelae of obstructive sleep apnea, with major decreases in obstructive events 1
• At age 5 years, this child is in the optimal age range for surgical benefit 3
• Postoperative monitoring should be performed to determine if further treatment is needed 1

Medical management alternative: Intranasal corticosteroids (fluticasone or mometasone) can be considered for mild cases or when surgery is contraindicated 1, 2, 6

• Fluticasone propionate nasal drops 400 mcg/day for 8 weeks reduced adenoid/choana ratio from 87% to 56% and eliminated surgery need in 76% of patients 2
• Mometasone significantly improved nasal obstruction, snoring, and adenoid size compared to control 6
• Critical caveat: Allergic rhinitis is the most common cause of reactive adenoid hypertrophy (80% of cases), and failure to identify and treat underlying allergy will result in persistent or recurrent hypertrophy despite any intervention 7

For Otitis Media with Effusion

Tympanostomy tube insertion is the preferred initial surgical procedure; adenoidectomy should NOT be performed unless a distinct indication exists such as nasal obstruction or chronic adenoiditis. 1, 3

• This recommendation is based on randomized controlled trials showing tubes provide a 62% relative decrease in effusion prevalence with less surgical risk than adenoidectomy 1
• The added risk of adenoidectomy outweighs limited short-term benefit for initial surgery in this age group 1

When adenoidectomy IS indicated:

• For repeat surgery after tube extrusion with recurrent otitis media with effusion, adenoidectomy is recommended as it confers a 50% reduction in need for future operations 1, 3
• At age 5 years, the benefit of adenoidectomy is in the optimal range (greatest for children ≥3 years old) 3
• When middle ear effusion persists ≥4 months with hearing loss or other significant symptoms 1

For Recurrent Acute Otitis Media

• Bilateral tympanostomy tubes with consideration of adenoidectomy is recommended when middle ear effusion is present at assessment 3
• The benefit of adding adenoidectomy depends on presence of effusion and frequency of episodes 1, 3

Important Clinical Pitfalls to Avoid

• Do not assume infectious etiology: Allergic inflammation is the predominant cause of adenoid hypertrophy and requires different management with intranasal corticosteroids and allergen control 7
• Contraindication: Never perform adenoidectomy in children with overt or submucous cleft palate due to risk of velopharyngeal insufficiency 3
• Avoid inappropriate procedures: Tonsillectomy alone or myringotomy alone should not be used to treat otitis media with effusion 1, 3

Risk Factors Requiring Postoperative Inpatient Monitoring

If surgery is performed, admit for observation if the child has: 1

• Severe obstructive sleep apnea (oxygen saturation <80% or apnea-hypopnea index ≥24/hour)
• Age younger than 3 years
• Obesity
• Cardiac complications of obstructive sleep apnea
• Failure to thrive