Adenoid Hypertrophy in Children — Symptoms, Diagnosis and Treatment

What are adenoid vegetations?

Adenoid vegetations (adenoids) are lymphoid tissue located on the posterior wall of the nasopharynx, behind the nose. They are part of Waldeyer's lymphatic ring, along with the palatine tonsils and the lingual tonsil. Their role is immune defense, being particularly active during the first years of life.

In some children, the adenoids enlarge excessively (adenoid hypertrophy), obstructing the nasal airway and the Eustachian tube orifices. This leads to chronic nasal obstruction, recurrent infections, and hearing problems.

Symptoms

Adenoid hypertrophy manifests through:

• Permanent mouth breathing — the child cannot breathe efficiently through the nose
• Intense nighttime snoring — sometimes with obstructive sleep apnea
• Nasal voice — closed rhinolalia ("stuffy" voice)
• Chronic rhinorrhea — persistent nasal discharge, mucous or purulent
• Chronic cough — predominantly nocturnal, caused by posterior nasal drip
• Recurrent middle ear infections — due to Eustachian tube obstruction
• Conductive hearing loss — due to associated serous otitis
• Adenoid facies — permanently open mouth, short upper lip, high-arched palate
• Restless sleep — frequent awakenings, nocturnal enuresis, daytime fatigue

Causes

Adenoid hypertrophy is favored by:

• Repeated upper respiratory tract infections — chronic immune stimulation leads to hyperplasia
• Constitutional predisposition — some children have a natural tendency toward lymphoid hypertrophy
• Allergic rhinitis — chronic inflammation stimulates adenoid tissue growth
• Gastroesophageal reflux — may contribute to chronic nasopharyngeal inflammation
• Exposure to cigarette smoke — an irritating factor that promotes hypertrophy

Adenoids grow physiologically during the first 3-7 years of life and usually involute after the age of 8-10 years.

Diagnosis

The diagnosis of adenoid hypertrophy is established through:

• Complete ENT clinical examination — assessment of nasal breathing, facial appearance, and ears
• Nasopharyngeal endoscopy — the gold standard method, allowing direct visualization of adenoid size and degree of obstruction
• Tympanometry — evaluates middle ear function and can reveal the presence of retrotympanic fluid
• Audiometry — in children with suspected hearing loss

Nasopharyngeal endoscopy is the most accurate examination for evaluating adenoid vegetations. It is performed quickly, without anesthesia, and provides essential information for therapeutic decision-making.

Treatment

Conservative treatment

In mild to moderate forms, the following can be attempted:

• Nasal lavage with saline solution — 2-3 times a day
• Nasal corticosteroids (mometasone, fluticasone) — 4-8 week courses, can reduce adenoid volume
• Treatment of associated allergic rhinitis — antihistamines and immunotherapy
• Antibiotic therapy — during episodes of acute adenoiditis

Surgical treatment — Adenoidectomy

Adenoidectomy is the surgical removal of adenoid vegetations, indicated in:

• Severe nasal obstruction with permanent mouth breathing
• Obstructive sleep apnea syndrome
• Recurrent middle ear infections (more than 4-6 episodes per year)
• Chronic serous otitis with hearing loss
• Recurrent adenoiditis unresponsive to medical treatment
• Associated chronic rhinosinusitis

The procedure is performed under general anesthesia, is quick (15-20 minutes), and recovery takes 5-7 days. It may be combined with tonsillectomy or with tympanostomy tube placement, depending on the associated pathology.

When to see a doctor

Schedule an ENT consultation if:

• The child constantly breathes through the mouth, day and night
• Nighttime snoring is loud and breathing pauses occur
• The child has frequent middle ear infections or does not hear well
• You notice changes in facial structure (mouth always open)
• The child is tired, irritable, and has difficulty concentrating

Complications

Untreated adenoid hypertrophy can lead to:

• Obstructive sleep apnea — with impact on neurocognitive and somatic development
• Conductive hearing loss — with delayed speech development
• Craniofacial changes — adenoid facies, high-arched palate, malocclusion
• Chronic sinusitis — due to obstruction of sinus drainage
• Growth retardation — due to deficiency of growth hormone secreted during deep sleep
• Nocturnal enuresis — sometimes resolved after adenoidectomy