Adenoidectomy

Updated: Jul 21, 2015
  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Overview

Background

Adenoidectomy is the surgical procedure in which the adenoids are removed. Adenoids are lymphoid tissue located in the back of the nose. They are often not understood by the lay public or by physicians who are not otolaryngologists because they are not observed during routine physical examinations because of their location. Although the tissue composition of adenoids is the same as that of the tonsils, the diseases associated with infected adenoids differ from the diseases associated with infected tonsils, based on their location. This causes additional confusion because the adenoids are often simultaneously grouped with the tonsils when reporting outcomes in scientific journals.

An adenoidectomy is often associated with other surgical procedures (eg, tonsillectomy, placement of tympanostomy tubes). In fact, throughout most of the 20th century, tonsillectomies were usually performed in conjunction with adenoidectomies. Despite more than 50 years of research, some controversy is still associated with the indications for adenoidectomy. Most often, an adenoidectomy is performed in pediatric patients. The focus of this article is pediatric adenoidectomy.

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History of the Procedure

Adenoidectomy was probably first performed in the late 1800s when Willhelm Meyer of Copenhagen, Denmark, proposed that adenoid vegetations were responsible for nasal symptoms and impaired hearing. However, tonsillectomy has been performed for at least 2000 years; Celsus first described the procedure as early as 50 BC. The hidden location of the adenoid certainly had an impact on the historical timing of discovery.

The 2 operations (tonsillectomy and adenoidectomy) were routinely performed together beginning in the early part of the 1900s, when the tonsils and adenoids were considered reservoirs of infection that caused many different types of diseases. Tonsillectomy and adenoidectomy (T&A) was considered a treatment for anorexia, mental retardation, and enuresis or was performed simply to promote good health.

As odd as those indications sound, they actually can be explained. Children with failure to thrive have improved appetites and gain weight after tonsillectomy and adenoidectomy (T&A) because their throats are typically no longer chronically sore and they can breathe better. Children who have persistent middle ear effusions often have hearing loss and associated speech delay and may be classified as mentally challenged. Adenoidectomies help resolve ear fluid problems, speech delays, and perceptions of low intelligence. Enuresis has actually been studied and listed as an indication for tonsillectomy and adenoidectomy (T&A) because large tonsils and adenoids block normal breathing through the nose and mouth, which interrupts sleep architecture and decreases normal brain and brainstem control of urinary function.

Additionally, almost every child experiences improved health and more energy following tonsillectomy and adenoidectomy (T&A). Based on the broad range of indications for surgery, tonsillectomy and adenoidectomy (T&A) became almost universal for school-aged children in the early 1900s.

In the 1930s and 1940s, the widespread use of tonsillectomy and adenoidectomy (T&A) became controversial because (1) antimicrobial agents were developed to help treat tonsillitis and adenoiditis, (2) the fact that a natural decline in the incidence of upper respiratory infections in older school-aged children became evident, (3) some studies were published showing that tonsillectomy and adenoidectomy (T&A) was ineffective, and (4) an increased risk of developing poliomyelitis following tonsillectomy and adenoidectomy (prior to the vaccine) was recognized. Once the opinion pendulum began to swing towards avoidance of surgery, good prospective clinical trials, which have been performed over the last two decades, were required to prove to the medical and lay community that good indications for tonsillectomy and adenoidectomy (T&A), tonsillectomy alone, and adenoidectomy alone, exist.

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Epidemiology

Frequency

Obtaining current information is difficult because adenoidectomy is usually performed in outpatient settings, for which data are not well regulated or recorded. Good information was recorded during the 1970s and 1980s when the procedure was mainly performed in inpatient settings. In the United States in 1971, more than 1 million tonsillectomy and adenoidectomy procedures, tonsillectomies alone, or adenoidectomies alone were performed, with 50,000 of these procedures consisting of adenoidectomy alone.

In comparison, in 1987, 250,000 combined or single procedures were performed, with 15,000 consisting of adenoidectomy alone. However, starting in this time period, outpatient tonsillectomy and adenoidectomy (T&As) and adenoidectomies were being performed more often, which may account for a possible underestimation of the total number of surgeries performed. In current practice, almost all adenoidectomies alone are performed in outpatient settings unless other issues or medical problems require hospital admission or an overnight stay. Additionally, tonsillectomy and adenoidectomy (T&A) is also usually performed in an outpatient setting, unless the child is young or other issues or medical problems require hospital admission or an overnight stay.

Probably the best source to obtain the true incidence and frequency of the procedures is data from all the managed health care companies throughout the United States. Tonsillectomy and adenoidectomy (T&A) is considered the most common major surgical procedure in the United States.

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Etiology

Adenoids, shown in the images below, are on the posterior nasopharyngeal wall posterior to the nasal cavity, shown below. They develop from a subepithelial infiltration of lymphocytes in the 16th week of gestation. They are a component of the Waldeyer ring of lymphoid tissue, which is a ring of lymphoid tissue in the oropharynx and nasopharynx that consists mainly of the adenoids, the palatine tonsils, and the lingual tonsils.

Adenoids immediately following removal. This speci Adenoids immediately following removal. This specimen is approximately 2 cm wide and 1 cm high.
Picture of the tonsils superiorly and adenoids inf Picture of the tonsils superiorly and adenoids inferiorly immediately following removal. Note the centimeter scale on the pen.
Drawing of a sagittal section of the nasal cavity, Drawing of a sagittal section of the nasal cavity, nasopharynx, oral cavity, palate, and oropharynx and of the location of the tonsils and adenoids.
A rigid rhinoscopy photograph of the posterior nas A rigid rhinoscopy photograph of the posterior nasal cavity, nasopharynx, and adenoids. The photograph shows the posterior portion of the left inferior turbinate in the right corner, the posterior portion of the left middle turbinate in the superior mid area, and the septum on the left-hand side. The adenoids are in the center, completely blocking the choanae. The floor of the nose is shown inferior to the adenoid bed.

Adenoids are present at birth and then begin to enlarge. They, along with the tonsils, continue to grow until individuals are aged 5-7 years. The adenoids usually become symptomatic, with snoring, nasal airway obstruction, and obstructed breathing during sleep, when children are aged approximately 18-24 months. By the time children reach school age, the adenoids normally begin to shrink, and, by the time children reach preteen or teenage years, the adenoids are usually small enough for the child to become asymptomatic.

At birth, the nasopharynx and, thus, the adenoids, are accessible to many organisms. The establishment of the upper respiratory tract is initiated at birth. By the time children are aged 6 months, lactobacilli, anaerobic streptococci, actinomycosis, Fusobacterium species, and Nocardia species are present. Normal flora found in the adenoid consists of alpha-hemolytic streptococci and enterococci, Corynebacterium species, coagulase-negative staphylococci, Neisseria species, Haemophilus species, Micrococcus species, and Stomatococcus species. The adenoids can become infected and harbor pathogenic bacteria, which may lead to the development of disease of the ears, nose, and sinuses.

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Pathophysiology

Based on the current literature, adenoids can contribute to recurrent sinusitis and chronic persistent or recurrent ear disease because they can harbor a chronic infection. The type and amount of pathogenic bacteria seem to vary based on the disease present and the age of the child. [1]

Overall, the most commonly cultured bacteria have been Haemophilus influenzae, group A beta-hemolytic Streptococcus, Staphylococcus aureus, Moraxella catarrhalis, and Streptococcus pneumoniae, usually in that order. The author has found resistant bacteria of the 3 most common pathogens of otitis media and rhinosinusitis (ie, H influenzae, M catarrhalis, S pneumoniae) in children with those diseases.

Adenoidectomy, regardless of size of the adenoids, has improved the signs and symptoms of rhinosinusitis and has reduced the recurrence of persistent middle ear effusions or infections in studies evaluating children older than 3 years.

Recurrent or persistent middle ear effusion

Recurrent or persistent otitis media is multifactorial and age-dependent. The 2 main features accounting for disease in the middle ear are immune function and the function of the eustachian tube. Infants have a natural lack of immune function and poorer eustachian tube function, both of which improve over time. Many children outgrow their ear infections because of this maturity. Persistent ear infections or fluid problems in children are usually related to persistent immature eustachian tube function, dysfunction related to chronic adenoid infection, or dysfunction of the eustachian tube related to congestion from allergic rhinitis. Several studies indicate that eustachian tube function is improved and fluid collection is prevented following adenoidectomy, independent of the size of the adenoids.

The studies over the last 2 decades that evaluated the pathophysiology of the adenoids' role in causing ear infections are confusing. Initially, the confusion regarded the mechanism of eustachian tube dysfunction; the debate was about whether eustachian tube dysfunction was related to a physical obstruction or the harboring of a chronic infection. Several authors compared the amount of bacteria in the adenoids of children with disease (eg, recurrent ear infections, persistent ear infections, nasal airway obstruction). Often, the control subjects for the children with middle ear effusions were different, consisting of either children with adenoid hypertrophy alone without ear infections or, occasionally, children without any head and neck pathology or infection.

Pillsbury et al demonstrated more pathogenic bacteria in the adenoid beds of patients with recurrent otitis media than in the adenoid beds of patients cultured for persistent serous otitis media or hypertrophy. [2] Additionally, Brodsky and Koch cultured more bacteria from the adenoids of patients with either recurrent otitis media or persistent otitis media than from the adenoids of patients without infections in the head and neck. [3]

However, Brodsky et al found the same amount of pathogenic bacteria in the adenoids of patients with otitis media and rhinosinusitis, regardless of size, as in the adenoids of patients with only adenoid hyperplasia causing nasal airway obstruction. Even more confusing is the fact that Maw and Speller found the same amount of pathogenic bacteria in the adenoids and tonsils of patients with otitis media with effusion as was found in patients without any head and neck disease. [4]

Regardless of the mechanism, adenoidectomy, independent of the size of the adenoid, has been shown to be effective for resolving chronic persistent otitis media with effusion and possibly recurrent otitis media in children older than 4 years. Adenoidectomy in children younger than 3 years has been shown to be safe, but its effectiveness for treating recurrent otitis media or rhinosinusitis is not proven.

Whether the bacteria that are harbored in the adenoids cause irritation of the eustachian tube lining, resulting in dysfunction, or the harbored bacteria cause a chronic low-grade infection in the middle ear space, resulting in persistent fluid or recurrent infections, remains unclear.

Chronic sinusitis

For patients with chronic sinusitis, the adenoid appears to act as a reservoir of infection. This is based on the improvement observed following adenoidectomy independent of the weight of the adenoids in children with symptoms of chronic sinusitis as shown by Lee and Rosenfeld in 1997. [5] Additionally, Brodsky et al showed that the same pathogenic bacteria in the adenoids were cultured from the middle meatus near the anterior sinus drainage site. [6] McClay also showed that resistant bacteria were found in the adenoid bed. [7]

Nasal airway obstruction

Enlarged adenoids can also cause nasal airway obstruction, with clinical symptoms of nasal congestion, snoring, and breathing through the mouth, by physically blocking the back of the nose. Symptoms of nasal airway obstruction may overlap with chronic sinusitis symptoms, and the physical obstruction may add to sinusitis itself by blocking normal nasal flow posteriorly, resulting in a stasis of secretions and an obstruction in the sinus outflow tract.

Often, enlarged adenoids (with the tonsils) can obstruct breathing patterns in children and can cause obstructive breathing, including apneas, at night. Obstruction is based on their size alone. However, when enlarged, the adenoids may have a chronic infection.

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Presentation

Children who benefit from adenoidectomy can have several different clinical presentations. Children who have recurrent or persistent otitis media may benefit from adenoidectomy independent of the size of the adenoid pad. Hence, these children may or may not present with nasal airway obstructive symptoms (eg, nasal congestion, snoring, sleeping with open mouths) because their adenoids may not be enlarged. However, often these children do have some form of nasal congestion or snoring. The respected prospective studies to date only include children aged 3-4 years and older. The effectiveness of adenoidectomy for resolving otitis media in children younger than 3-4 years who have small- or moderate-sized adenoids has not been addressed.

Children can also present with symptoms of chronic or recurrent sinusitis. These clinical symptoms may include postnasal drainage or purulent anterior rhinorrhea, cough, fever, facial pain, and nasal congestion.

Additionally, children may have nasal airway obstructive symptoms without signs of acute or chronic infections. The symptoms include nasal airway obstruction, snoring, and mouth breathing. When enlarged, the adenoid blocks normal nasal cavity airflow and causes chronic mouth breathing, which can lead to palatal and dental abnormalities.

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Indications

Indications for adenoidectomy are as follows:

  • Enlargement causing nasal airway obstruction, which can result in obstructive breathing, obstructive sleep apnea symptoms, and chronic mouth breathing (could result in palatal and dental abnormalities)
  • Recurrent or persistent otitis media in children aged 3-4 years and older
  • Recurrent and/or chronic sinusitis

Lee and Rosenfeld demonstrated that signs and symptoms in children with recurrent sinusitis are improved by adenoidectomy, independent of the weight of the adenoid. [5] The fact that children with enlarged adenoid pads blocking the choana have improved signs and symptoms of chronic sinusitis following adenoidectomy is not in doubt. However, pediatric rhinologists have some concern that a school-aged child with a small adenoid pad and CT scan evidence of chronic sinusitis may not improve if only adenoidectomy is performed. In 1999, a presentation at the American Academy of Pediatrics confirmed this concern by finding that adenoidectomy usually controlled symptoms and infections in children with large adenoids; however, if the adenoid was small and CT scan evidence of chronic sinusitis was present, not as many children improved, leading the authors to believe these children would benefit from initial procedures of adenoidectomy and endoscopic sinus surgery.

Van den Aardweg et al evaluated the effect of adenoidectomy in decreasing the number of upper respiratory infections (URIs) for 2 years following the procedure in children aged one to six years. Of 111 children at 13 hospitals, both the surgery and no surgery groups each had 8 episodes of URIs in the study period. Results suggest adenoidectomy is not an effective treatment for recurrent respiratory infections in children. However, the study did find the prevalence of upper respiratory tract infections decreased over time in both groups. [8]

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Relevant Anatomy

The adenoid is on the posterior wall of the nasopharynx, which lies posterior to the nasal cavity. The adenoid lies over the base of the skull and clivus area, shown below.

Drawing of a sagittal section of the nasal cavity, Drawing of a sagittal section of the nasal cavity, nasopharynx, oral cavity, palate, and oropharynx and of the location of the tonsils and adenoids.

The adenoid overlies mucosa that overlies the superior constrictor muscle in this area. The adenoid can be large enough to encroach on the posterior oropharyngeal wall. Lateral to the adenoid is the torus tubarius, shown below, which is the medial orifice of the eustachian tube. The superior wall of the nasopharynx abuts the choanae (ie, the posterior portion of the nasal cavity). The adenoid can be enlarged enough to obstruct the choanae. The percentage of obstruction of the choanae is often used to size the adenoids.

A rigid rhinoscopy photograph taken all the way ba A rigid rhinoscopy photograph taken all the way back into the choanae of the left nasal cavity. The photograph shows the septum on the left, the small adenoids on the posterior superior wall of the nasopharynx in the center, and the eustachian tube orifice on the right. This photograph is of the rigid rhinoscopy pathway down the nasal cavity of an infant aged 6 weeks.

Attached to the floor of the nose and choanae is the soft palate, depicted above. The soft palate is the anterior inferior wall of the nasopharynx. The soft palate is responsible for regulating the amount of airflow into the nasal cavity and nasopharynx from the oral cavity and oropharynx by opening and closing the posterior and lateral nasopharyngeal wall, where the adenoid is housed. This sphincter of muscles is called the velopharynx. The amount of airflow into the nasal cavity regulates the resonance of the voice. Too much airflow through the nose results in hypernasal speech, and too little airflow results in hyponasal speech (see Velopharyngeal Insufficiency).

If the adenoid changes in size or is removed, the muscles of the palate must accommodate to a new gap size to close off the nasopharynx. An inability of the velopharyngeal muscles to accommodate results in velopharyngeal insufficiency (VPI).

For more information about the relevant anatomy, see Tonsil and Adenoid Anatomy.

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Contraindications

No absolute contraindications exist, except for conditions in which general anesthesia cannot be performed.

Relative contraindications for total adenoidectomy

See the list below:

  • A severe bleeding disorder, which could be overcome by preoperative, intraoperative, and postoperative coagulation medicines and techniques, is a relative contraindication to adenoidectomy.
  • A child at risk of developing VPI, which might be associated with a short palate, submucous cleft palate, true cleft palate, muscle weakness or hypotonia associated with a neurological disorder, velocardiofacial syndrome, or Kabuki syndrome, is another relative contraindication. These conditions may be overcome with partial adenoidectomy or preoperative planning for muscular speech therapy following adenoidectomy (see Velopharyngeal Insufficiency).
  • Atlantoaxial joint laxity is observed in 10% of children with Down syndrome. Surgery in the neutral position or following stabilization by neurosurgery may make it possible to perform the surgery without injury to the patient.
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