Adenoids in children: when and how to treat, and when to watch

Adenoid hypertrophy is one of the most common causes of upper airway obstruction in children. Management depends on the degree of obstruction, the presence of complications and the child’s age: mild and moderate symptoms call for conservative treatment and observation, while marked obstruction, obstructive sleep apnea (OSA) and recurrent ear infections call for surgery.

Natural course

Adenoid tissue grows actively in the first years of life, reaches its maximum size by age 6–8 and then starts to shrink naturally. Some children with mild sleep-disordered breathing improve spontaneously: in one study (children aged 5–9 with mild/moderate OSA), 46% of children in the observation group normalized on polysomnography without surgery. However, most of them still had clinical symptoms (snoring, obstructive episodes). ^{[1][2][3][4][5]}

When observation and conservative treatment are appropriate

• Mild and moderate hypertrophy without significant airway obstruction, without OSA and without recurrent ear infections
• Children under 4 — adenoidectomy is not recommended unless there is marked nasal obstruction or chronic adenoiditis ^[6][7]
• Situations in which symptoms may resolve on their own as the child grows

Medical therapy:

• Intranasal corticosteroids — mometasone, fluticasone, budesonide — the basis of conservative treatment. A meta-analysis of 30 studies (2,301 children) showed a significant reduction in adenoid size, improvement in clinical symptoms and a lower need for adenoidectomy (RR 0.30; 95% CI 0.17–0.54). A course of treatment usually lasts 6–8 weeks ^[8][9]
• Montelukast — a leukotriene receptor antagonist that reduces inflammation of the adenoid tissue. Combining montelukast with intranasal corticosteroids may work better than either alone, especially with concomitant allergic rhinitis and the “edematous” type of adenoids. However, the FDA boxed warning about possible serious neuropsychiatric side effects of montelukast should be taken into account ^{[10][11][12][13]}
• Saline nasal irrigation — in the MIST+ study it led to resolution of obstructive sleep-disordered breathing symptoms in 41% of children, comparable to the effect of intranasal steroids (44%) ^[14]

When adenoidectomy is indicated

According to the AAO-HNS recommendations: ^[7][15]

• Obstructive sleep apnea (OSA) — the main indication. Adenotonsillectomy is first-line therapy for OSA in children. Hospital admission is recommended for children under 3, for severe OSA (AHI >10/hour or SpO₂ <80%) and for children with comorbidities ^[15]
• Recurrent throat infections (Paradise criteria) — 7 or more episodes in 1 year, 5 or more episodes a year for 2 years, or 3 or more episodes a year for 3 years, with documented clinical signs (temperature >38.3°C, cervical lymphadenopathy, tonsillar exudate, positive GAS test) ^[16]
• Otitis media with effusion (OME) — adenoidectomy is recommended as an addition to ventilation tube placement in children aged 4 and older, as well as for repeat tube placement ^[6]
• Chronic nasal obstruction — with mouth breathing, hyponasal speech, disturbed sleep, exercise intolerance ^[7][17]
• Chronic adenoiditis/rhinosinusitis — that does not respond to conservative therapy ^[7]
• Development of “adenoid face” — a narrow upper jaw, open bite, retrognathia — an indication for early intervention to prevent irreversible dentofacial deformities ^[18]

Practical algorithm

It is important to note that even when the Paradise criteria are met, the benefit of tonsillectomy is greatest in the first year after surgery, after which the rate of infections also falls in the observation group. This underlines the need for an individual approach that takes into account the severity of symptoms, the effect on quality of life and the family’s preferences. ^[15][16]