Adenoid Hypertrophy (Enlarged Adenoids)

What the adenoids are

The adenoids sit high in the back of the nose, where the nasal passages meet the throat (the nasopharynx). Together with the tonsils, they form a ring of lymphoid tissue that samples germs entering through the nose and mouth and helps train the immune system in early childhood. They grow during the first years of life, are largest around ages 3 to 7, and usually shrink by adolescence. Adults rarely have noticeable adenoids.

Because they sit right next to the openings of the Eustachian tubes (which drain the middle ears), enlarged adenoids can affect the ears as well as breathing.

Symptoms of enlarged adenoids

Blocked nose

• breathing through the mouth, especially at night
• dry, cracked lips and bad breath
• a nasal "blocked" voice (hyponasal speech), like having a cold all the time
• persistent runny nose or nasal discharge

Sleep problems

• loud snoring most nights
• pauses in breathing, gasping or snorting during sleep (sleep apnea)
• restless sleep, unusual sleeping positions with the neck extended
• bedwetting
• daytime sleepiness, irritability, hyperactivity or poor concentration

Ear problems

• repeated middle ear infections (acute otitis media)
• fluid behind the eardrum (glue ear), causing muffled hearing and sometimes speech delay

Long-term effects

Children who mouth-breathe for years may develop a long, narrow face, an open-mouth posture and dental crowding ("adenoid face"), though how much adenoids cause this is debated.

Causes

• Normal growth: adenoids are naturally large in young children.
• Repeated infections: colds, tonsillitis and sinus infections make adenoids swell.
• Allergies: allergic rhinitis contributes to adenoid enlargement and nasal blockage.
• Reflux and exposure to smoke may play a role.
• In adults: enlargement is unusual and may be caused by infection, HIV, smoking, or rarely lymphoma or nasopharyngeal cancer, so it is always investigated.

Diagnosis

A doctor will ask about snoring, breathing pauses, mouth breathing, ear infections and hearing. They will examine the nose, ears and throat. The adenoids cannot be seen through the mouth, so assessment may involve:

• Nasal endoscopy: a thin, flexible camera passed through the nose, the most accurate method
• Lateral neck X-ray: a side view showing adenoid size relative to the airway
• Hearing test and tympanometry: for glue ear
• Sleep study (polysomnography): to confirm and grade obstructive sleep apnea when the diagnosis is unclear

Treatment

Watchful waiting

If symptoms are mild, many children improve as adenoids shrink with age.

Medicines

• Steroid nasal sprays (such as mometasone or fluticasone) for 6 to 12 weeks can shrink adenoids and improve nasal blockage and mild sleep-disordered breathing in some children.
• Allergy treatment with antihistamines, steroid sprays and trigger avoidance.
• Antibiotics for bacterial ear or sinus infections, not for adenoid enlargement itself.
• Montelukast is sometimes used for mild sleep apnea, but it carries a warning about mood and behavior side effects.

Adenoidectomy

Surgical removal of the adenoids is recommended for:

• obstructive sleep apnea (usually with removal of the tonsils as well, as adenotonsillectomy)
• persistent nasal obstruction affecting breathing, sleep or eating
• recurrent or persistent glue ear needing a second set of ear tubes, typically in children over about 4
• chronic adenoiditis or sinusitis not responding to medical treatment

The operation is done under general anesthesia through the mouth with no external cuts, takes about 20 to 30 minutes, and most children go home the same day. Recovery usually takes about a week, with a sore throat, blocked nose, bad breath and mild ear pain. Adenoids can occasionally regrow, especially when removed in very young children.

Outlook

Most children with adenoid hypertrophy do well. Symptoms usually improve as adenoids shrink with age or after adenoidectomy. Treating sleep apnea improves sleep, behavior, attention and growth.

Frequently asked questions

What are the symptoms of enlarged adenoids?

Common symptoms are mouth breathing, snoring, a blocked or runny nose, a nasal-sounding voice, restless sleep with breathing pauses, bad breath and repeated ear infections or glue ear. Children may be tired, irritable or inattentive during the day.

Do enlarged adenoids go away on their own?

Often, yes. Adenoids are largest in early childhood and usually shrink between ages 7 and 12, nearly disappearing by the teens. Children with mild symptoms may simply be monitored. Severe symptoms such as sleep apnea need treatment.

When should adenoids be removed?

Removal is usually recommended for obstructive sleep apnea, persistent nasal blockage that affects sleep or daily life, recurrent glue ear needing repeat ear tubes, or chronic adenoid and sinus infections that do not respond to treatment.

Can adults have enlarged adenoids?

It is uncommon because adenoids shrink with age. In adults, enlargement can be caused by infection, smoking, allergies or HIV, and rarely by lymphoma or nasopharyngeal cancer. An adult with enlarged adenoids should have an ENT examination.

Is adenoid surgery safe?

Adenoidectomy is a common, low-risk operation. Possible complications include bleeding, which is uncommon, temporary nasal voice, and rarely regrowth. Most children recover within a week.