What is the recommended stepwise management for a child with adenoid hypertrophy, including first‑line medical therapy and criteria for adenoidectomy?

Management of Adenoid Hypertrophy in Pediatrics

Initial Clinical Assessment

Begin by determining whether the child presents with obstructive symptoms (mouth-breathing, snoring, witnessed apneas, sleep disturbance, hyponasal speech, daytime behavioral problems) or otologic symptoms (recurrent acute otitis media, chronic otitis media with effusion, hearing loss). 1

• Perform audiometric testing (audiometry or tympanometry) when otitis media with effusion is suspected to document hearing status before proceeding with treatment decisions. 1
• Obtain polysomnography when obstructive sleep apnea (OSA) is suspected, as this is the gold-standard diagnostic test; alternative objective testing may be used only when polysomnography is unavailable. 2, 1

First-Line Medical Therapy

Intranasal corticosteroids (fluticasone or mometasone) should be tried first for mild obstructive disease or when surgery is contraindicated. 1, 3

• Fluticasone propionate nasal drops at 400 mcg/day for 8 weeks can reduce the adenoid/choana ratio by approximately 35% and eliminate the need for surgery in 76% of patients. 4
• Combined maximal medical treatment (intranasal mometasone furoate, oral desloratadine, nasal saline irrigation, and bacteriotherapy with intermittent decongestion drops) for 9-12 months results in clinical improvement in 72% of preschool children, with an average 8.4% decrease in adenoid/choana ratio. 5
• Medical therapy is particularly appropriate when adenoid hypertrophy is associated with IgE-mediated inflammation or allergic rhinitis. 6

Surgical Management: Obstructive Sleep Apnea

When a child has confirmed OSA with adenotonsillar hypertrophy and no surgical contraindications, adenotonsillectomy is the recommended first-line surgical treatment. 2

• Adenotonsillectomy is superior to adenoidectomy or tonsillectomy alone because residual lymphoid tissue may contribute to persistent obstruction. 2
• The procedure results in major decreases in obstructive events and improvements in symptoms, quality of life, and behavioral outcomes. 2
• Adenoidectomy alone may be considered in non-obese patients with moderate OSA and small tonsils, as this approach provides comparable benefits with fewer complications. 7

High-Risk Patients Requiring Postoperative Monitoring

Children with the following characteristics require inpatient observation after adenotonsillectomy: 2, 1

• Age younger than 3 years
• Severe OSA on polysomnography (oxygen saturation <80% or apnea-hypopnea index ≥24 events/hour)
• Cardiac complications of OSA
• Failure to thrive
• Obesity
• Craniofacial anomalies or neuromuscular disorders

Surgical Management: Otitis Media with Effusion

For initial surgical management of otitis media with effusion (OME), tympanostomy tube insertion is the preferred procedure—not adenoidectomy. 1, 8

• Randomized controlled trials demonstrate a 62% relative reduction in effusion prevalence with tubes compared with adenoidectomy, with lower surgical risk. 1
• Adenoidectomy should not be performed as first-line surgery for OME unless a distinct indication exists such as nasal obstruction or chronic adenoiditis. 1, 8

Age-Specific Criteria for Adenoidectomy in OME

• For children <4 years old, tympanostomy tubes alone are preferred, as the added surgical and anesthetic risks of adenoidectomy outweigh the limited short-term benefit. 8
• For children ≥4 years old with OME, adenoidectomy becomes appropriate either as a standalone procedure or as an adjunct to tympanostomy tubes. 8
• When repeat surgery is needed after tube extrusion with recurrent OME, adenoidectomy is recommended as it confers a 50% reduction in the need for future operations. 1, 3

Surgical Management: Recurrent Acute Otitis Media

Adenoidectomy is recommended as an adjunct to tympanostomy tube insertion in children with recurrent acute otitis media who have middle ear effusion present at assessment. 1, 3

• The benefit is greatest for children aged 3 years or older and is independent of adenoid size. 1, 3
• The number needed to treat is 9 to prevent future recurrent acute otitis media in children <2 years of age when middle ear effusion is present. 8

Critical Contraindications

Do not perform adenoidectomy in children with overt or submucous cleft palate due to the risk of velopharyngeal insufficiency. 1, 3

Common Pitfalls to Avoid

• Do not perform tonsillectomy alone or myringotomy alone for OME—these procedures lack efficacy for effusion resolution. 1
• Do not delay surgery waiting for polysomnography in a child with severe clinical obstruction and significant tonsillar hypertrophy (grade 3+ tonsils). 3
• Do not perform adenoidectomy solely for recurrent throat infections—this is an indication for tonsillectomy, not adenoidectomy. 8
• Recognize that complete resolution of OSA occurs in only 25% of children with severe preoperative disease, so postoperative follow-up with reassessment is essential. 3

Surgical Risks

Potential complications include pain, anxiety, dehydration, anesthetic complications (mortality risk approximately 1:50,000), hemorrhage (approximately 2%), infection, postoperative respiratory difficulties, velopharyngeal incompetence, and nasopharyngeal stenosis. 2, 8