Indications for Adenoidectomy in Children — Clinical Criteria and Decision Guide

Epidemiology and clinical context

Adenoidectomy remains one of the most frequently performed surgical procedures in paediatric ENT. Adenoid hypertrophy reaches peak incidence between 3 and 7 years of age, corresponding to the period of maximum activity of the lymphoid tissue of the Waldeyer ring. The surgical decision must be based on clear clinical criteria, correlated with the functional impact on the patient.

This article summarises the current indications for adenoidectomy, in accordance with the guidelines of European and American paediatric ENT societies, adapted to current clinical practice.

Preoperative diagnostic evaluation

Clinical examination

Clinical evaluation includes a detailed history (duration and severity of symptoms, impact on quality of life, response to conservative treatment) and a complete ENT examination. The adenoid facies (chronic oral breathing, elongated face, lip incompetence, high-arched palate) suggests significant chronic obstruction.

Endoscopic evaluation

Flexible nasopharyngoscopy represents the gold standard in assessing adenoid size and the degree of obstruction. The endoscopic classification frequently used is the Parikh classification (modified):

• Grade I — the vegetations occupy less than 25% of the choana
• Grade II — 25-50% choanal obstruction
• Grade III — 50-75% choanal obstruction
• Grade IV — over 75% choanal obstruction, with vomero-adenoid contact

Endoscopy also allows assessment of the nasal mucosal condition, identification of any associated pathologies (septal deviation, turbinate hypertrophy, polyps), and visualisation of the tubal ostia.

Complementary investigations

• Polysomnography (PSG) — indicated when obstructive sleep apnoea syndrome (OSAS) is suspected. An apnoea-hypopnoea index (AHI) greater than 1 event/hour is considered abnormal in children.
• Lateral cephalometric radiograph — less precise than endoscopy, but useful when the latter is not available or tolerated
• Tympanometry — for evaluation of tubal function and the presence of any associated serous otitis
• Audiogram — in children with suspected conductive hearing loss

Absolute indications

The following clinical situations constitute absolute indications (broad consensus) for adenoidectomy:

1. Obstructive sleep apnoea syndrome (OSAS)

Adenoidectomy (with or without tonsillectomy) is the first-line treatment for paediatric OSAS. Clinical criteria include:

• AHI above 1/hour documented by polysomnography, or
• Suggestive clinical symptomatology: habitual snoring (more than 3 nights/week), breathing pauses observed by parents, daytime sleepiness, behavioural disturbances, attention deficit
• Endoscopically documented Grade III-IV adenoid hypertrophy correlated with symptoms

Untreated OSAS in children is associated with neurocognitive consequences (attention deficit, decreased school performance), cardiovascular complications (pulmonary hypertension), metabolic disturbances, and growth disorders.

2. Severe chronic nasal obstruction

Grade III-IV adenoid hypertrophy with significant nasal obstruction that does not respond to conservative treatment (nasal corticosteroids for a minimum of 4-6 weeks), with impact on quality of life: persistent daytime oral breathing, adenoid facies, feeding difficulties in infants.

3. Persistent serous otitis media (SOM)

Adenoidectomy is indicated in children with persistent bilateral serous otitis media (over 3 months) associated with audiometrically documented conductive hearing loss, especially at re-intervention after extrusion/obstruction of tympanic ventilation tubes. AAO-HNS guidelines recommend adenoidectomy as an adjunct procedure to ventilation tube insertion in children over 4 years with recurrent SOM.

Relative indications

Recurrent upper airway infections

Recurrent or chronic purulent adenoiditis with:

• Recurrent bacterial rhinosinusitis (more than 4-6 episodes/year) or chronic, refractory to adequate antibiotic treatment
• Recurrent acute otitis media (more than 3 episodes in 6 months or more than 4 in 12 months) in children with documented adenoid hypertrophy
• Chronic purulent postnasal drip with associated halitosis

Craniofacial developmental disorders

Chronic oral breathing secondary to adenoid hypertrophy can contribute to growth disorders of the mid-facial floor, dental malocclusions, and high-arched palate. Early adenoidectomy, combined with orthodontic treatment, can improve the prognosis.

Swallowing and voice disorders

Significant adenoid hypertrophy can cause hyponasality (nasal voice), swallowing difficulties, or poor feeding in older infants, constituting relative indications.

Contraindications

• Velopharyngeal insufficiency — adenoidectomy may worsen open rhinolalia (and nasal reflux) in children with cleft palate (including submucosal) or occult velopharyngeal insufficiency. Careful preoperative assessment of velopharyngeal function is mandatory.
• Uncontrolled coagulation disorders — require preoperative correction and multidisciplinary management
• Acute infection — the procedure is postponed until resolution of the acute episode (minimum 2-3 weeks)
• Age under 1 year — relative contraindication; adenoidectomy in infants requires individualised assessment and carries increased anaesthetic risk

Surgical considerations

Adenoidectomy is performed under general anaesthesia with orotracheal intubation. Available techniques include classic curettage (Beckmann adenotome), endoscopic-controlled adenoidectomy (direct visualisation — current gold standard), coblation, and microdebrider. Endoscopic control ensures complete resection and minimises the risk of recurrence or incomplete resection.

Adenoidectomy may be performed alone or in combination with tonsillectomy (adenotonsillectomy), myringotomy with ventilation tube insertion, or other procedures, depending on the clinical indication.

Conclusions

The decision for adenoidectomy must be individualised, based on the correlation between adenoid size (endoscopic evaluation), clinical symptomatology, functional impact, and response to conservative treatment. Objective documentation through endoscopy and, when indicated, polysomnography, supports the therapeutic decision and enables effective communication with the patient's family.