Indications for surgery (adenoidectomy, tonsillectomy)

The main criteria that determine whether a child needs adenoidectomy can be divided into obstructive, infectious and otological indications, each with clear clinical benchmarks.

1. Obstructive sleep apnea (OSA) / sleep-disordered breathing

This is the most common indication for adenotonsillectomy. According to the American Academy of Pediatrics (AAP), if a child has OSA with adenotonsillar hypertrophy and no contraindications to surgery, adenotonsillectomy is recommended as first-line therapy. Key criteria: ^[1]

• Clinical signs of sleep-disordered breathing — loud snoring (audible through a closed door, 3 or more nights a week), observed apneas, restless sleep, daytime sleepiness, ADHD-like behavioral problems ^[2]
• Polysomnography (PSG) — the gold standard for diagnosing OSA, although in practice fewer than 10% of children have PSG before surgery. The AAP recommends PSG for all children with suspected OSA, whereas the AAO-HNS does not require routine PSG in healthy children with enlarged tonsils and clinical signs of obstruction ^[3][4]
• PSG is especially indicated — for children under 2, with complex comorbidities (Down syndrome, craniofacial anomalies), and when tonsil size does not match the severity of symptoms ^[2]
• Severe OSA — AHI >10/hour or SpO₂ <80% requires postoperative inpatient monitoring ^[3][4]

2. Recurrent throat infections (Paradise criteria)

Tonsillectomy (often with adenoidectomy) is indicated for severe recurrent infections that meet the Paradise criteria: ^[3][5]

• 7 or more episodes in the past year, or
• 5 or more episodes a year for the past 2 years, or
• 3 or more episodes a year for the past 3 years

Each episode must be documented and accompanied by at least one of the following: temperature >38.3°C, cervical lymphadenopathy, tonsillar exudate, positive GAS test. ^[5]

Important: the benefit of tonsillectomy is greatest in the first year after surgery; after that the rate of infections falls even without surgery. In children who do not meet the Paradise criteria, tonsillectomy is not cost-effective and does not bring clinically meaningful improvement. ^[5]

3. Otitis media with effusion (OME)

Adenoidectomy is recommended as an addition to tympanostomy for OME in the following situations: ^[6][7][8]

• Child aged 4 or older — systematic reviews confirm the benefit of adenoidectomy in this age group: fewer OME recurrences, less time with middle ear effusion and twice as long an effect from tympanostomy tubes (from 12 to 24 months) ^[8]
• Repeat ventilation tube placement — regardless of age ^[8]
• In children under 4 — adenoidectomy for OME is not recommended, except for marked nasal obstruction or chronic adenoiditis ^[6][8]

4. Chronic nasal obstruction and other indications

Adenoidectomy is indicated for chronic symptoms related to adenoid hypertrophy: ^[8][9]

• Persistent mouth breathing, hyponasal speech
• Exercise intolerance
• Chronic adenoiditis/rhinosinusitis that does not respond to medical therapy
• Abnormal development of the facial skeleton (“adenoid face”)

5. Contraindications to adenoidectomy

If there are risk factors for velopharyngeal insufficiency, the operation can be performed leaving part of the adenoid tissue in the area of Passavant’s ridge to ensure closure of the nasopharynx. ^[3]