Adenoid tissue typically regresses around puberty. Therefore, the typical patient with adenoiditis is a prepubescent child with a recent history of URI. The patient may also have a history of recurrent acute otitis media, chronic nasal obstruction with mouth-breathing, chronic otitis media, sleep-disordered breathing/obstructive sleep apnea, or GERD/LPR.

Physical findings include purulent rhinorrhea, post-nasal drip, nasal obstruction, snoring, fever, mouth breathing, and halitosis. Indirect mirror exam may allow the practitioner to observe enlarged adenoids with exudates, though this can be a very challenging exam to perform in children. A flexible nasal and laryngeal endoscopic exam can allow for better evaluation of the adenoids but can require advanced training to use as well as the cooperation of the child and parents.

Long-standing adenoiditis with subsequent adenoid hypertrophy in early childhood can lead to the development of what is known as adenoid facies, or long face syndrome. Enlarged adenoids block the nasopharynx and result in obligate mouth breathing, which can lead to craniofacial abnormalities including a high-arched palate and retrognathic mandible.[9] 

Clinical Evaluation

The diagnosis of acute adenoiditis is made clinically based on the findings of:

Possible concurrent acute otitis mediaFeverPurulent rhinorrheaPost-nasal dripNasal obstruction Throat painHalitosis

Visual inspection of the adenoids may be attempted using a laryngeal mirror or nasal endoscope.

Laboratory TestingRapid strep testCulturesAllergy testing

If it presents in the context of pharyngitis, the clinician may want to perform a rapid strep test. The purpose of doing so is two-fold. First, this will give a definitive diagnosis of the patient’s condition and help guide antibiotic therapy. Second, the doctor’s office will have a record of positive and negative strep tests which will play an important role when deciding whether an adenoidectomy, plus or minus tonsillectomy, is indicated. It is important to remember that adenoiditis remains a clinical diagnosis, so if the strep test is negative the physician can presume it is due to a different causative organism.

In cases of persistent infection despite antibiotic therapy, the clinician may choose to perform throat cultures to help identify the causative agent and guide therapy as direct cultures of adenoids may be difficult in the office setting. 

If the adenoiditis is believed to be the result of seasonal or environmental allergies, allergy skin testing may be useful in directing therapy. 

Radiology Testing

Lateral neck X-ray

Computed tomography (CT) of the sinuses

Sinus X-rays or sinus CTs may be obtained to look for a source of infection in the sinuses if this is suspected clinically. This is rarely required in routine cases. Lateral neck X-rays are an effective way to evaluate specifically for adenoid hypertrophy. In a patient with adenoid hypertrophy who snores a sleep study can be obtained to rule out obstructive sleep apnea.

Adenoiditis is often seen clinically as a component of rhinosinusitis or pharyngitis. Due to this fact, practitioners often use clinical management guidelines for rhinosinusitis and pharyngitis when approaching the treatment of adenoiditis. 

Medical Management

Watch and waitIf the clinician believes the cause of adenoiditis is by the common cold or other common viral infection they should refrain from using antibiotics. Typically, uncomplicated upper respiratory viral infections will resolve within five to seven days.[8]

Antibiotic treatment

If symptoms continue or clinical presentation is suggestive of bacterial etiology, such as a high fever or purulent discharge from the nose or throat, the first-line management is antibiotics covering the most common pathogens. Amoxicillin is a commonly used first-line agent due to its good coverage and tolerability. Alternatively, cefdinir or cefuroxime may be used, particularly if the patient has not responded to amoxicillin. If the patient has a penicillin allergy, alternatives include clarithromycin or azithromycin. Effective antibiotic treatment should yield an improvement of symptoms in 48-72 hours. Treatment duration should be ten days, as treating for a shorter duration yields significant relapse rates and breeds antibiotic resistance. If the condition fails to improve after a course of amoxicillin or other first-line agents, amoxicillin-clavulanate should be prescribed to eliminate potential beta-lactamase producing organisms.[8]

Allergy treatment

If the adenoiditis is believed to be secondary to environmental allergies, the patient can be given a trial of nasal steroid sprays, oral steroids, oral antihistamines, or some combination thereof to see if this produces any relief in symptoms. If this is effective, the patient may benefit from formal allergy testing followed by immune-modulating therapy to provide definitive relief.

Reflux treatment

If the adenoiditis is believed to be secondary to LPR/GERD, treatment of this condition using lifestyle and diet modification with or without the use of H2 blockers or proton-pump inhibitors may provide sufficient relief of symptoms.[6]

Surgical Management

Adenoidectomy

In the absence of symptomatic improvement after treatment with amoxicillin-clavulanate or if the patient has multiple episodes of adenoiditis requiring antibiotic treatment, referral to an otolaryngologist is warranted for further evaluation and potential surgical intervention. Depending on the individual circumstances, surgical procedures may include adenoidectomy with or without tonsillectomy or myringotomy with tympanostomy tube placement, or endoscopic sinus surgery. If the patient meets the Paradise criteria for tonsillectomy, most otolaryngologists will remove the adenoids at the same time to remove another possible source of recurrent infections.[10]

Differential diagnosis includes:

• Viral URTI
• Sinusitis
• Rhinosinusitis
• Nasal polyposis
• Pharyngitis
• Tonsillitis
• Seasonal/environmental Allergies
• Nasopharyngeal neoplasm
• Laryngopharyngeal reflux

The medical treatment available for treating adenoiditis is successful in most instances. For those with recurrent disease, adenoidectomy provides a definitive solution by removing the hypertrophic or infected adenoid tissue.

If adenoiditis is left untreated, the patient may develop a chronic infection of the adenoids which in some cases can lead to the development of a biofilm. The adenoids may then serve as a nidus of infection for other closely related structures and lead to rhinosinusitis, pharyngitis, tonsillitis, and otitis media.[4][11]

Adenoid Hypertrophy

Adenoid hypertrophy is responsible for some of the more common complications related to disease of the adenoids. As they enlarge the tissues can create a significant obstacle to the flow of air through the nasopharynx. This enlargement can cause mouth breathing, snoring, and OSA. OSA can be a life-threatening disease if left untreated. Removing the adenoids can increase the flow of air through the nasopharynx, decreasing obstructive episodes, and leading to better CPAP compliance or resolution of the condition altogether.

Enlarged adenoids may also obstruct the opening of the Eustachian tubes in the nasopharynx. Without proper function of the Eustachian tube, negative pressure can build in the middle ear. This negative pressure can lead to the formation of an effusion which can cause conductive hearing loss and speech problems, as well as serve as a nidus for bacterial infections.

Long-standing adenoiditis with subsequent adenoid hypertrophy can lead to the development of what is known as adenoid facies or long-face syndrome. Enlarged adenoids can block the nasopharynx and result in obligate mouth breathing, which can lead to craniofacial abnormalities including a high-arched palate and retrognathic mandible.[9]

Patients with recurrent adenoiditis or the complications of adenoid hypertrophy should obtain a referral to an otolaryngologist for further evaluation and treatment. Other disciplines that may need to be involved in the care of the patient include sleep medicine, allergy specialists, and gastroenterology depending on the individual’s needs.

Adenoiditis is a common issue in children and may be unavoidable since they are frequently in contact with the common pathogens and allergens that cause the inflammation. However, it is essential to seek treatment before chronic adenoiditis, and adenoid hypertrophy develop, as these can lead to serious complications and decreased quality of life.

• Adenoiditis is a condition of childhood as most adenoid tissue atrophies by adulthood.
• Adenoiditis is seldom a solitary issue. It is usually discussed as being part of or indistinguishable from adenotonsillitis, rhinosinusitis, or pharyngitis.
• Adenoid hypertrophy is responsible for the most common health issues associated with the adenoids.
• Obstructive sleep apnea (OSA) is the most serious complication of adenoid disease.
• Adenoidectomy is the definitive treatment for adenoid disease.

Because causes of adenoiditis can include a number of different factors including recurrent bacterial infections, allergies, and GERD,  treatment of adenoiditis and its complications may require the care of multiple specialists. These specialists should work in close coordination to maximize patient outcomes. It is important to find the root cause/s and treat them, or the problem may never fully resolve and lead to further complications. Healthcare team members should pay close attention to the signs and symptoms of OSA as this is the most serious complication of adenoid disease.