Enlarged Adenoids in Children: Symptoms and Treatment Options

The adenoid (often called "the adenoids") is a single pad of tissue at the very back of the nose, where it meets the throat. Along with the tonsils, it helps the body fight off infections during early childhood. In some children, the adenoid becomes enlarged, and this can lead to a range of symptoms that affect breathing, sleep, and ear health.

At Capital ENT & Sinus Center, our board-certified ENT specialists regularly evaluate and treat children with adenoid problems. Understanding what to look for can help parents know when it may be time to seek care.

What Is the Adenoid and Why Does It Enlarge?

The adenoid is part of the immune system. It is small at birth, grows quickly in the toddler years, and is usually at its largest between about ages 3 and 7. After that it gradually shrinks, and by the teenage years most children have little adenoid tissue left (MedlinePlus). In young children, the adenoid helps trap germs that enter through the nose and mouth.

The adenoid is not equally large in every child. Frequent colds and other upper respiratory infections, allergies, and exposure to tobacco smoke can all make it larger. An enlarged adenoid often goes along with enlarged tonsils, and symptoms tend to be worse when both are large. When the adenoid is big enough, it can block airflow through the back of the nose and the openings of the tubes that connect the middle ear to the throat (the eustachian tubes), leading to noticeable symptoms.

Common Symptoms of an Enlarged Adenoid

Children with an enlarged adenoid often show signs related to nasal obstruction and breathing difficulty. Parents may notice that their child breathes through the mouth most of the time, especially during sleep. Other symptoms can include:

• Persistent nasal congestion or a "stuffy," nasal-sounding voice
• Noisy breathing during the day
• Snoring at night
• Restless sleep or pauses in breathing during sleep
• Dry lips and bad breath from mouth breathing
• A runny nose or postnasal drip that keeps coming back
• Frequent ear infections or fluid buildup in the middle ear, sometimes with muffled hearing

Over time, constant mouth breathing may also affect how the teeth and face develop, which is one more reason not to ignore it (Dykewicz et al., 2020).

In some cases, an enlarged adenoid contributes to sleep-disordered breathing, including obstructive sleep apnea. Children with sleep apnea may snore loudly, gasp or choke during sleep, wet the bed, or seem tired, irritable, or hyperactive during the day. The American Academy of Pediatrics recommends that children who snore regularly and have signs of sleep apnea be evaluated, and a sleep study may be recommended (Marcus et al., Pediatrics, 2012). For children, this is usually an overnight study in a sleep lab. Our article Do I Need a Sleep Study? explains more.

How Is an Enlarged Adenoid Diagnosed?

Allergies, nasal polyps, and a deviated septum can cause symptoms that look a lot like an enlarged adenoid, and the adenoid cannot be seen just by looking in the mouth. Our ENT specialists start with a physical examination and a review of your child's symptoms. In many cases, a small flexible camera (nasal endoscope) is used to look at the adenoid directly. This quick procedure is performed in the office and shows how large the adenoid is and how much it is blocking the back of the nose. We also often order an X-ray of the side of the neck, which shows the size of the adenoid without a scope.

If ear problems are present, a hearing test and examination of the eardrums may also be recommended. Children who have recurrent ear infections or persistent fluid behind the eardrum may benefit from ear tubes in addition to adenoid treatment.

Treatment Options for an Enlarged Adenoid

Treatment depends on how much the adenoid is affecting your child's breathing, sleep, ears, and overall health. Because the adenoid shrinks on its own with age, mild symptoms can sometimes be watched.

Nasal steroid spray. For a blocked nose without significant sleep apnea, a daily nasal steroid spray is usually the first treatment. Studies show it can improve nasal blockage and, in many children, shrink the adenoid (Zhang et al., Cochrane Review, 2008). It takes regular daily use, often for several weeks to a few months, to judge whether it is working. Side effects at the usual children's doses are generally mild. Treating underlying allergies with medications or allergy shots may also help in certain children.

Adenoidectomy. Surgical removal of the adenoid may be recommended when:

• Nasal blockage, mouth breathing, or snoring continue despite a fair trial of nasal spray
• An enlarged adenoid contributes to sleep apnea
• A child has repeated bouts of thick nasal drainage or chronic sinus infections. In children, adenoid removal is usually the first surgery considered for chronic sinusitis.
• Fluid behind the eardrum lasts 3 months or longer, or ear infections keep coming back. For ear fluid, adenoid removal is most helpful in children 4 and older, usually together with ear tubes; in younger children it is generally added only when there is another reason, such as nasal blockage or chronic adenoid infection (AAO-HNS Otitis Media With Effusion Guideline, 2016).

When a child has sleep apnea along with enlarged tonsils and an enlarged adenoid, removing both is usually the first treatment (American Academy of Pediatrics). In these children, a tonsillectomy may be performed at the same time.

Adenoidectomy is performed under general anesthesia, takes no stitches, and most children go home the same day. Recovery from adenoid removal alone is usually quicker than after tonsillectomy: most children can return to daycare or school about 48 hours after surgery and feel close to normal within about a week. Snoring and a stuffy nose can last up to 2 weeks while the swelling goes down, and a mild, temporary change in the voice is common. Bleeding is not common, but call us right away for any bleeding from the nose or mouth. Our guides Getting Ready for Adenoidectomy and Adenoidectomy Recovery cover the details.

When Should You See a Specialist?

Parents should consider scheduling an appointment with an ENT specialist if their child has ongoing mouth breathing, frequent snoring, repeated ear infections, fluid in the ears, or signs of poor sleep quality. If a child seems unusually tired during the day, has trouble concentrating at school, or shows pauses in breathing at night, these may be signs of sleep-disordered breathing that warrants evaluation.

Early assessment can help identify whether an enlarged adenoid is the cause of these symptoms and what steps may improve your child's comfort and health. Our team at Capital ENT & Sinus Center is experienced in evaluating and treating pediatric airway and ear problems, and we work with families to determine the most appropriate care for each child. Learn more about our pediatric ENT care.

Sources

• MedlinePlus. Adenoid removal. National Library of Medicine.
• American Academy of Otolaryngology-Head and Neck Surgery. Tonsils and Adenoids. ENTHealth.org.
• Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):576-584. doi:10.1542/peds.2012-1671
• Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41. doi:10.1177/0194599815623467
• Zhang L, Mendoza-Sassi RA, César JA, Chadha NK. Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database Syst Rev. 2008;(3):CD006286. doi:10.1002/14651858.CD006286.pub2
• Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767. doi:10.1016/j.jaci.2020.07.007