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EN4.23 | Adenoids — SDL Guide (Part 2)

Diagnosis and Differential Diagnosis

The diagnosis of adenoid hypertrophy in a child is clinically straightforward when the characteristic combination is present: a child aged 3–10 years with chronic mouth breathing, snoring, hyponasal voice, recurrent ear infections, and a normal anterior nasal cavity on rhinoscopy. However, several other conditions can produce a similar presentation in childhood, and the differential diagnosis must be considered to avoid missing serious pathology. The most dangerous error is to attribute a nasopharyngeal mass in an adolescent male to residual adenoid tissue when it is actually a juvenile nasopharyngeal angiofibroma — a vascular tumour that will bleed catastrophically if blindly biopsied. Clinical vigilance, especially for age-atypical presentations and unilateral features, is the safeguard against this error.

The differential diagnosis for nasal obstruction in children includes:
- Choanal atresia: congenital bony or membranous obstruction of the posterior choanae; bilateral choanal atresia presents at birth as a neonatal respiratory emergency (newborns are obligate nasal breathers); unilateral choanal atresia may not be diagnosed until childhood as a cause of unilateral nasal obstruction. Diagnosed by failure to pass a catheter through the nasal cavity to the nasopharynx, or on CT scan.
- Nasal foreign body: almost always unilateral; foul-smelling purulent unilateral discharge; visible or palpable on endoscopy.
- Allergic rhinitis: bilateral, intermittent, associated with sneezing and watery discharge; turbinate enlargement; no nasopharyngeal mass; allergen-positive.
- Nasal polyps: uncommon in children without cystic fibrosis; bilateral, pale grey masses; anosmia.
- Nasopharyngeal tumour: the most important mimic to exclude in a child or adolescent. Nasopharyngeal carcinoma (relatively rare in young children but commoner in South-East Asia) and, critically, juvenile nasopharyngeal angiofibroma (JNA) in adolescent males presenting with a nasopharyngeal mass and recurrent epistaxis. Any nasopharyngeal mass in a child that is unusual in appearance, irregular, bleeding, or in an older teenage male must be evaluated with contrast CT — NOT biopsied blindly (JNA: DO NOT BIOPSY — catastrophic haemorrhage).

Important distinction: adenoids regress at puberty. A 'nasopharyngeal mass' noted in a teenager (>12–13 years) that is NOT regressing should raise concern about JNA or another tumour, not be attributed to adenoids.

Management: Adenoidectomy and Indications

The management of adenoid hypertrophy is guided by the severity of symptoms, the age of the child, and the presence of complications. Not all adenoid hypertrophy requires surgery — mild cases in children under 3 years may be managed with watchful waiting or a trial of medical therapy, as physiological regression may reduce symptoms over time. However, when adenoids are causing significant obstruction, recurrent ear disease with hearing loss, or sleep-disordered breathing, surgery is the most effective treatment. The key principle is that the threshold for surgery should be proportional to the functional impact: a child with mild snoring and occasional mouth breathing does not require the same urgency as one with confirmed OSA and 35 dB bilateral conductive hearing loss from glue ear during the critical language-acquisition years. Shared decision-making with the parents — explaining the natural history of adenoids, the modest evidence for medical therapy, and the realistic outcomes of surgery — is the foundation of good adenoid management.

Medical management:
- Intranasal corticosteroids (INCS): small studies support a modest reduction in adenoid size with intranasal mometasone or fluticasone; appropriate as a first-line trial in mild-to-moderate hypertrophy without complications.
- Treatment of acute adenoiditis: oral amoxicillin-clavulanate for acute bacterial episodes; antibiotics do not reduce adenoid size but control acute infection.
- Nasal saline irrigation: aids drainage and mucociliary clearance; safe adjunct.

Surgical management — adenoidectomy:

Indications for adenoidectomy:
- Significant nasal obstruction with mouth breathing, snoring, and sleep-disordered breathing (most compelling indication).
- Obstructive sleep apnea with apnoeic episodes confirmed clinically or on sleep study.
- Recurrent ASOM (≥4 episodes per year) or chronic OME with conductive hearing loss (≥25 dB for ≥3 months in both ears) — often combined with grommets (tympanostomy tube insertion) to ventilate the middle ear.
- Recurrent adenoiditis (≥4–6 episodes per year).
- Adenoid facies with progressive facial growth impairment before skeletal maturation.

The procedure: Adenoidectomy is performed under general anaesthesia with the child supine and the neck extended (Rose position). The nasopharynx is exposed by retracting the soft palate. Adenoid tissue is removed by curettage (using an adenoid curette — the classical method) or by suction diathermy (coblation or monopolar suction diathermy — increasingly preferred for bloodless technique). Unlike tonsillectomy, there is no capsular plane for dissection — all adenoid tissue is removed by abrading the surface.

Combined adenotonsillectomy: When both adenoid hypertrophy and palatine tonsillar hypertrophy coexist (common in children with OSA), both are removed in the same procedure.

Complications of adenoidectomy:
- Haemorrhage (most important): primary (within 24 hours) or secondary (5–7 days post-op); requires return to theatre if significant.
- Post-nasal space stenosis: rare — over-aggressive curettage removing the posterior choanal mucosa can cause stenosis.
- Velopharyngeal incompetence (VPI): transient nasal regurgitation and hypernasal speech occur if the adenoids were contributing to soft palate closure during swallowing; usually resolves spontaneously. The pre-operative exclusion of a submucous cleft palate is critical — adenoidectomy in a child with an unrecognised submucous cleft can unmask permanent VPI.
- Recurrence: adenoid tissue can regrow if surgery is performed at a very young age or if only partial removal is achieved.

Self-Assessment

Consider this scenario before the quiz. Use it to test whether you can apply the full clinical reasoning chain from this module:

A 7-year-old boy has a 3-year history of mouth breathing, loud snoring with observed nocturnal pauses, and inattentiveness at school. His general practitioner has given him four courses of antibiotics this year for ear infections. Audiogram shows 35 dB conductive hearing loss bilaterally. Tympanometry shows type B curves bilaterally. On examination: open mouth, elongated face, narrow maxilla, anterior rhinoscopy normal. Nasal endoscopy shows a large adenoid pad filling the nasopharynx and encroaching on both Eustachian tube ostia.

List all the indications for surgery in this child. What procedure(s) would you recommend? What pre-operative examination is non-negotiable? What is the most important complication to counsel the parents about?