The adenoids are a small pad of tissue at the back of the nose, where it meets the throat, and part of the immune system. They usually start to shrink at around the age of four and have largely gone by early adulthood. In some children, though, they grow large enough to block the back of the nose, and they can affect both breathing and the ears. This article covers the signs parents notice, why doctors often wait first, and what to expect if surgery is needed.
Signs parents notice
The most typical sign of enlarged adenoids is mouth breathing. Your child may sound blocked up, snore at night, and sometimes stop breathing for a few seconds during sleep. Frequent ear infections can also go with large adenoids.
The second picture involves the ear: fluid collecting behind the eardrum, in the middle ear, known as glue ear or otitis media with effusion. Its main sign is usually temporary hearing loss, often in both ears. If your child speaks loudly, asks you to repeat things, turns the television up, does not hear you from across a room, is easily distracted, or seems tired and irritable, their hearing should be checked. Earache and balance problems can also occur. Glue ear that lasts a long time can affect speech development and progress at school.
Watching first: the three-month wait
In most children the fluid clears on its own, usually within three months. So the guideline recommends watchful waiting for three months, counted from when the fluid started (if known) or from the diagnosis, for a child who is not in a risk group. It also recommends against steroids, antibiotics, antihistamines or decongestants to treat the fluid; there is no effective medicine for it.
If the fluid lasts three months or longer, an age-appropriate hearing test is done. Children who keep the fluid and do not have tubes are checked again every three to six months until it has gone or significant hearing loss appears.
Children with Down syndrome, a cleft palate, existing hearing loss or delayed speech are in a risk group. In them the fluid is less likely to clear by itself and poor hearing can matter more, so they are assessed earlier and more closely.
With enlarged adenoids, too, the doctor may suggest waiting to see whether the problems settle on their own, depending on how serious they are.
When tubes or adenoid removal are considered
An ear tube, also called a grommet or tympanostomy tube, is a tiny tube placed in the eardrum. It lets the fluid drain and keeps the eardrum open. The current guideline recommends offering tubes to children who have had fluid in both ears for three months or longer together with documented hearing difficulty. Tubes may also be considered when fluid has lasted three months and is likely causing problems such as poor balance, difficulty at school, behaviour problems or ear discomfort.
With repeated ear infections, the decision depends on whether there is fluid in the ears at the time of assessment. If both ears are clear at that point, tubes are not recommended; if fluid is present in one or both ears, they may be offered.
Adenoid removal (adenoidectomy) can be done on its own for problems caused by the adenoids, such as a blocked nose, snoring or sleep apnoea. Removing the adenoids at the same time as inserting tubes is considered in two situations: when the child has symptoms from the adenoids themselves, such as nasal blockage or adenoid infection, or when the child is four or older, to reduce the chance of further infections or of needing tubes again. In children under four, the adenoids are not removed for ear fluid alone unless there is a separate reason. For some children, a temporary hearing aid is also an option.
The day of surgery
Both procedures are done under general anaesthetic, so your child is asleep, and most are day cases: your child goes home the same day once well enough. They will need to stop eating and drinking for a set time beforehand, and you will be told when.
For a tube, a small opening is made in the eardrum, the fluid is drained and the tube is placed in the opening; it takes only a short time. The adenoids are removed through the mouth, with no cuts on the outside, usually in about half an hour. If both are needed, they can be done under the same anaesthetic.
After waking up your child may feel sick. After adenoid removal a blocked nose, a sore throat and sore ears, a temporarily nasal-sounding voice and bad breath are common. These are a normal part of healing.
The following weeks
Recovery from adenoid removal usually takes about a week. Keep your child off school or nursery during that time and away from crowds to lower the chance of an infection. For pain, give the recommended painkiller, such as paracetamol or ibuprofen, at the recommended dose; never give aspirin to children under 16 unless a doctor has prescribed it. Get your child back to their usual food as soon as possible and give plenty to drink, since eating helps the throat heal. Any change in the voice usually settles within a few weeks.
After tubes, children are usually back to normal quickly. The guideline advises against routine earplugs or keeping most children out of swimming; your doctor will tell you if your child is an exception. If the ear discharges while the tube is in place, see your doctor: this is usually treated with antibiotic ear drops rather than medicine by mouth. The first check is within three months of the operation, followed by regular checks until the tube falls out on its own, usually within six to twelve months.
After adenoid removal, call the practice the same day if your child has pain that painkillers do not ease or that is getting worse, a high temperature, a painful or stiff neck, or is not drinking. Any bleeding from the throat or nose, blood in vomit, or black or brown vomit is an emergency: call 112 or go to the nearest emergency department straight away.