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The adenoids are a pad of lymphoid tissue at the back of the nose, above the roof of the mouth. They are largest in early childhood and usually shrink by the teenage years. When they are large they can block the nose, causing mouth breathing, snoring and sleep apnoea, and they can contribute to glue ear and repeated sinus infections. Removing them is a short operation with a recovery of a few days to a week. Most children breathe through the nose more easily afterwards, though some keep a mouth-breathing habit that takes practice to change.
The problem being fixed
Adenoid tissue grows through early childhood and usually regresses in adolescence. Enlarged or chronically infected adenoids cause problems in three ways.
- Nasal obstruction. Mouth breathing, snoring, a blocked-sounding (hyponasal) voice and, with enlarged tonsils, obstructive sleep apnoea (OSA). Intranasal corticosteroids reduce nasal obstruction in some children in the short term and are often tried first.1
- Eustachian tube dysfunction. The adenoids sit beside the openings of the eustachian tubes and act as a reservoir of bacteria, which links them to otitis media with effusion (glue ear) and recurrent acute otitis media.2
- Chronic rhinosinusitis. In children with persistent nasal discharge, nasal obstruction and cough, infected adenoid tissue can maintain the infection.3
What the operation involves
The adenoids are removed through the mouth under general anaesthetic, usually as day surgery, using a curette, suction diathermy, a microdebrider or coblation. The procedure is often combined with tonsillectomy for sleep apnoea (see Tonsillectomy) or with ventilation tubes (grommets) for glue ear.
Recovery is usually quick. A mild sore throat, blocked nose, bad breath and referred ear pain are common for a few days, and most children are back at school or childcare within a week. Pain relief is paracetamol and ibuprofen; codeine must not be given to children under 12.4
Who benefits — and what the evidence shows
Glue ear and ear infections
The otitis media with effusion guideline recommends adenoidectomy as an addition to surgery for glue ear in children aged 4 or older. Below that age it is recommended only when there is a separate reason, such as nasal obstruction or chronic adenoiditis.2 The Cochrane review found that adenoidectomy improved resolution of middle-ear effusion but gave little benefit for recurrent acute otitis media.5 Adding adenoidectomy to a first set of ventilation tubes reduced the need for further ear surgery.6
Recurrent colds
In a randomised trial of 111 children aged 1 to 6 with recurrent upper respiratory tract infections, adenoidectomy was no more effective than watchful waiting over two years.7 Frequent colds alone are not a reason for the operation.
Chronic rhinosinusitis
A meta-analysis found that about 69% of children with chronic rhinosinusitis improved after adenoidectomy, which is why it is usually the first surgical step before sinus surgery is considered. The evidence comes mainly from case series.3
Sleep apnoea
When both the tonsils and adenoids are enlarged, adenotonsillectomy is first-line treatment for OSA, and adenoidectomy alone is generally less effective. Adenoidectomy alone is used when the adenoids are the main obstruction and the tonsils are small.8
Rare complications worth knowing
Bleeding is less common than after tonsillectomy but can come from the nose or the mouth, and is managed the same way.
Velopharyngeal insufficiency. Removing the adenoid pad can leave a gap between the soft palate and the back of the throat, giving hypernasal speech and fluid coming out of the nose when drinking. It often settles over a few weeks; if it persists, the child needs speech pathology and ear, nose and throat (ENT) review. The risk is higher with a cleft or submucous cleft palate, so surgeons look for one before operating; a split (bifid) uvula is a clue.
Grisel syndrome. A rare, non-traumatic rotatory subluxation of the atlantoaxial joint after head and neck surgery or infection. It appears days after the operation as a painful, stiff neck held turned and tilted, often with fever. It needs urgent medical assessment and imaging; the neck must not be manipulated.
Down syndrome. Atlantoaxial instability is more common, so the neck is positioned carefully during surgery. Afterwards, new neck pain, head tilt, a change in walking, weakness, or a change in bladder or bowel control needs urgent assessment.9
- Call 000 now: more than a teaspoon of blood from the nose or mouth, vomiting blood, difficulty breathing, or, in a child with Down syndrome, new weakness in the arms or legs.
- Go to the emergency department today: any fresh bleeding from the nose or mouth, even if it stops; a new painful, stiff or twisted neck, especially with fever; or a child who is refusing to drink and passing little or no urine.
- See a doctor the same day: fever above 38.5 °C after the first day or two, foul-smelling nasal discharge after the first week, or ear pain that is getting worse rather than better.
Physiotherapy after adenoidectomy
The physiotherapist has little to do with the operation itself and more to do with what follows: the breathing pattern, sleep, and safe handling of the neck.
Assessment
- Breathing route. Observe resting breathing awake, ask about breathing during sleep (a short phone video from a parent helps), and check lip seal and whether nasal breathing is comfortable once healing is complete.
- Sleep symptoms. Snoring, witnessed pauses, restless sleep and daytime behaviour. A child whose symptoms continue after healing needs review; adenoid tissue can regrow, and the tonsils may be the remaining obstruction.
- The neck. In a child with Down syndrome, ask about symptoms of atlantoaxial instability before handling the neck. Any new torticollis after surgery is a medical referral, not a treatment target.
Treatment
- Practise nasal breathing once healed. Mouth breathing can persist as a habit after the obstruction is removed. Practise lip closure and nasal breathing during quiet activities first, then during play and exercise, and treat allergic rhinitis alongside — see Rhinitis and Sinusitis.
- Consider oropharyngeal (myofunctional) exercises as an adjunct for residual snoring or OSA. The evidence in children is limited to small studies.10
- Return to activity. Normal play within a day or two and school within about a week. Gentle nose blowing only for the first week, and swimming and contact sport when the surgeon advises.
- Airway clearance. Children with neuromuscular disease or cerebral palsy keep their usual routine. Avoid nasopharyngeal suction until the surgeon advises it is safe, and use oral suction for secretions in the meantime.
Role of the physiotherapist
Notice the complications that look like something else: a stiff neck after surgery is not a muscle problem, and a nasal voice is not a cold. Then help the child use the airway the operation opened, with nasal breathing practice and treatment of rhinitis, and follow up sleep symptoms that persist. See also Obstructive Sleep Apnoea.
Evidence summary
Framing. Adenoidectomy has the clearest evidence as an addition to ear surgery for glue ear in children aged 4 and over, moderate evidence in chronic rhinosinusitis, and no benefit for recurrent colds. For sleep apnoea it is usually combined with tonsillectomy. Its complications are rare, and the ones physiotherapists may meet first, velopharyngeal insufficiency and atlantoaxial problems, are easily mistaken for something minor.2,5,7,8
Evidence — ears and infectionGuideline and systematic review evidence supports adenoidectomy for persistent middle-ear effusion in children aged 4 or older, and adding it to first ventilation tubes reduces repeat surgery.2,5,6 A randomised trial found no benefit for recurrent upper respiratory tract infections.7 In chronic rhinosinusitis, most children improve, based mainly on case series.3
Evidence — obstruction and sleepIntranasal corticosteroids can reduce obstruction in the short term.1 Adenotonsillectomy is first-line for OSA with enlarged tonsils, and adenoidectomy alone is reserved for adenoid-dominant obstruction.8
Physiotherapy implicationsAssess the breathing route awake and asleep; retrain nasal breathing once healed and treat rhinitis; consider myofunctional exercises as an adjunct; screen for atlantoaxial symptoms in Down syndrome before handling the neck; refer new torticollis, hypernasal speech or nasal regurgitation promptly; and avoid nasopharyngeal suction early after surgery.9,10
Evidence gapsNo trial has tested breathing retraining after adenoidectomy. The links between mouth breathing and facial growth come from observational studies. Estimates of velopharyngeal insufficiency and Grisel syndrome come from case series, and the role of adenoidectomy alone in sleep apnoea has not been tested in a large randomised trial.
References & evidence base
- 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.
- 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.
- Brietzke SE, Brigger MT. Adenoidectomy outcomes in pediatric rhinosinusitis: a meta-analysis. Int J Pediatr Otorhinolaryngol 2008;72(10):1541–1545.
- Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg 2019;160(1 Suppl):S1–S42.
- van den Aardweg MT, Schilder AG, Herkert E, Boonacker CW, Rovers MM. Adenoidectomy for otitis media in children. Cochrane Database Syst Rev 2010;(1):CD007810.
- Mikals SJ, Brigger MT. Adenoidectomy as an adjuvant to primary tympanostomy tube placement: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg 2014;140(2):95–101.
- van den Aardweg MT, Boonacker CW, Rovers MM, Hoes AW, Schilder AG. Effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections: open randomised controlled trial. BMJ 2011;343:d5154.
- Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012;130(3):576–584.
- Bull MJ, Trotter T, Santoro SL, Christensen C, Grout RW; Council on Genetics. Health supervision for children and adolescents with Down syndrome. Pediatrics 2022;149(5):e2022057010.
- Camacho M, Certal V, Abdullatif J, et al. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep 2015;38(5):669–675.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
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