What is the recommended approach to evaluate and manage adenoid hypertrophy in children, including criteria for medical therapy versus adenoidectomy?

Management of Adenoid Hypertrophy in Children

For children with adenoid hypertrophy, the management approach depends critically on the primary presentation: adenotonsillectomy is first-line for obstructive sleep apnea with adenotonsillar hypertrophy, while tympanostomy tubes alone (not adenoidectomy) are preferred for initial treatment of otitis media with effusion unless a separate indication exists. 1

Clinical Assessment

Identify the Primary Presentation

The evaluation must distinguish between two distinct clinical scenarios that drive different treatment pathways 1:

Obstructive symptoms:

• Mouth breathing, snoring, witnessed apneas during sleep 1
• Sleep disturbance, daytime behavioral problems 1
• Hyponasal speech, difficulty breathing during physical activity 2
• Noisy breathing, nasal congestion 2

Otologic symptoms:

• Recurrent acute otitis media (≥3 episodes in 6 months or ≥4 in 12 months) 1
• Chronic otitis media with effusion (≥3 months duration) 1
• Hearing loss documented by audiometry 1

Essential Diagnostic Testing

• Polysomnography is the gold-standard test when obstructive sleep apnea is suspected and should be obtained before surgical intervention 1, 2
• Audiometric testing (audiometry or tympanometry) is mandatory when otitis media with effusion is present to document hearing status and guide treatment decisions 1
• Lateral nasopharyngeal radiography can objectively measure adenoid size (adenoid/choana ratio) and correlates well with symptom severity, though it is not required for diagnosis 3, 4

---

Medical (Non-Surgical) Management

First-Line Medical Therapy

Intranasal corticosteroids should be trialed before surgical intervention for adenoid hypertrophy, particularly in mild-to-moderate obstructive disease or when surgery is contraindicated. 1, 2

Specific regimens with evidence:

• Fluticasone propionate nasal drops 400 mcg/day for 8 weeks reduced adenoid/choana ratio by 35.6% and eliminated surgery in 76% of children 5
• Mometasone furoate combined with oral desloratadine, nasal saline irrigation, and bacteriotherapy for 12 months achieved clinical improvement in 72% of preschool children 6

Expected outcomes:

• Significant reduction in adenoid/choana ratio and improved nasal obstruction symptoms 1, 6, 5
• Improved apnea-hypopnea index in children with mild-to-moderate OSA 2
• Better tympanometry and audiometry outcomes in children with otitis media with effusion 7

Important caveat: Medical therapy is appropriate for mild disease or as a temporizing measure, but documented obstructive sleep apnea with significant adenotonsillar hypertrophy requires surgical intervention 1, 2

---

Surgical Management

For Obstructive Sleep Apnea

Adenotonsillectomy (not adenoidectomy alone) is the recommended first-line surgical treatment for children with confirmed OSA and adenotonsillar hypertrophy. 1

Rationale:

• Adenotonsillectomy produces marked reductions in obstructive respiratory events and clinically important improvements in sleep symptoms, quality of life, and behavioral performance 1
• Residual tonsillar tissue after adenoidectomy alone can maintain airway obstruction 1
• Randomized controlled trials demonstrate superior symptom improvement and event reduction (Level I evidence) 1

Exception: Adenoidectomy alone is appropriate when tonsils are minimally enlarged but adenoid hypertrophy is significant 2, 8

For Otitis Media with Effusion

The surgical algorithm for OME differs fundamentally from OSA management:

Initial surgery:

• Tympanostomy tubes alone are the preferred first surgical procedure 1
• Adenoidectomy should NOT be performed as initial surgery for OME unless a separate indication exists (nasal obstruction, chronic adenoiditis) 1
• Rationale: RCTs show 62% relative reduction in effusion with tubes compared to adenoidectomy, with lower surgical risk 1

Repeat surgery after tube extrusion:

• Adenoidectomy is recommended when repeat surgery is needed for recurrent OME, conferring a 50% reduction in future operations 1
• This benefit is greatest for children ≥3 years of age and is independent of adenoid size 1

For children ≥4 years requiring surgery:

• Consider tympanostomy tubes, adenoidectomy, or both based on clinical context 1

For Recurrent Acute Otitis Media

Adenoidectomy is indicated as an adjunct to tympanostomy tubes when middle ear effusion is present at the time of assessment. 1

Meta-analysis data show adenoidectomy reduces AOM frequency and recurrence when effusion is present, though the benefit for total time with AOM is less clear 7

---

Surgical Risk Stratification and Post-Operative Monitoring

High-Risk Patients Requiring Inpatient Observation

The following children require inpatient monitoring after adenotonsillectomy 1:

• Severe OSA: oxygen saturation <80% or apnea-hypopnea index ≥24 events/hour
• Obesity
• Cardiac complications of OSA
• Failure to thrive
• Craniofacial anomalies or neuromuscular disorders 1

Surgical Complications

• Mortality risk: approximately 1 in 50,000 1
• Hemorrhage: ~2% of cases 1
• Velopharyngeal insufficiency (transient or permanent) 1, 9
• Nasopharyngeal stenosis 1
• Grisel's syndrome (rare atlantoaxial subluxation) 9

Absolute Contraindication

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

---

Common Pitfalls to Avoid

• Do not perform tonsillectomy alone for OME—it lacks efficacy for effusion resolution 1
• Do not perform myringotomy alone for chronic OME—it is ineffective 1
• Do not perform adenoidectomy as first-line surgery for OME in the absence of nasal obstruction or chronic adenoiditis—tubes alone are safer and more effective 1
• Do not assume adenoidectomy alone is adequate for OSA when significant tonsillar hypertrophy is present—adenotonsillectomy is superior 1
• Do not proceed to surgery without objective documentation (polysomnography for OSA, audiometry for OME) 1, 2