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Adenoiditis is inflammation of the adenoid tissue, most commonly caused by infection, allergies, or irritation from stomach acid. This condition rarely occurs in isolation and is typically part of a broader regional pathology, such as adenotonsillitis, pharyngitis, rhinosinusitis, or laryngopharyngeal reflux. Persistent inflammation or irritation can lead to adenoid hypertrophy, contributing to complications such as nasal obstruction, mouth breathing, snoring, recurrent ear infections, and sleep-disordered breathing. Acute adenoiditis typically presents with fever, purulent nasal discharge, nasal congestion, postnasal drip, sore throat, and swollen cervical lymph nodes. Chronic adenoiditis may involve milder but persistent symptoms, including nasal obstruction and recurrent upper respiratory infections. Diagnosis is often clinical but may be supported by nasal endoscopy, imaging, or nasopharyngoscopy. Treatment options include analgesics, antibiotics, nasal corticosteroids, and adenoidectomy for recurrent or chronic cases. An interprofessional approach is essential to ensure comprehensive care and improved long-term outcomes, particularly in pediatric populations. This activity aims to enhance understanding of adenoiditis and promote collaborative management strategies to optimize patient outcomes. Objectives: Implement evidence-based diagnostic strategies, including clinical evaluation, nasal endoscopy, and imaging when appropriate. Apply appropriate medical and surgical management strategies for patients with adenoiditis. Identify potential complications associated with adenoiditis, including obstructive sleep apnea, recurrent otitis media, nasal obstruction, mouth breathing, and speech or developmental delays. Collaborate with interprofessional team members, including otolaryngologists, pediatricians, and family physicians, to provide coordinated, comprehensive care for patients with adenoiditis. Access free multiple choice questions on this topic.

The pharyngeal tonsil, commonly referred to as the adenoids or adenoid pad, is a collection of lymphoid tissue covered by mucous membrane located on the posterior wall of the nasopharynx, just above the level of the soft palate (see Image. Sagittal Section of Nose, Mouth, Pharynx, and Larynx with Adenoid Hypertrophy). The adenoids, along with the faucial tonsils, lingual tonsils, and tubal tonsils of Gerlach, form Waldeyer's ring, a circumferential collection of lymphoid tissue that surrounds the upper aerodigestive tract. This structure is named after Heinrich Wilhelm Gottfried von Waldeyer-Hartz, a German anatomist from the turn of the 20th century.[1] The tissues of Waldeyer's ring play a critical role in immune function early in life. Antigens introduced through the oral and nasal cavities come into contact with the immune cells of Waldeyer's ring; these cells then produce immunoglobulin A antibodies and contribute to immunologic memory. This process is thought to prime the immune system during infancy.[2] The adenoids are present at birth and enlarge throughout childhood, reaching peak size by 7 years of age. In most individuals, adenoid tissue regresses in size during puberty and may be nearly absent by adulthood. Consequently, adenoiditis predominantly affects children and adolescents. Adenoiditis occurs when the adenoid tissue is inflamed due to infection, allergies, or irritation from stomach acid as a component of laryngopharyngeal reflux (LPR). Adenoiditis rarely occurs independently and is typically a component of a more extensive disease process such as adenotonsillitis, pharyngitis, or rhinosinusitis. Continual irritation may lead to adenoid hypertrophy, which is responsible for many of the complications of adenoid disease, including Eustachian tube dysfunction and recurrent acute otitis media, obstructive sleep apnea (OSA), and voice changes. Clinical Anatomy The adenoids receive their blood supply from the ascending pharyngeal, maxillary, and facial arteries. Venous drainage occurs through the pharyngeal veins. The vagus and glossopharyngeal nerves supply innervation. Adenoid size is clinically graded on a scale from 0 to 4 based on the degree of nasopharyngeal obstruction: Grade 0: Absent Grade 1+: <25% obstruction of the nasopharynx Grade 2+: 25%-50% obstruction Grade 3+: 50%-75% obstruction Grade 4+: >75% obstruction [3]

Many agents and pathogens can cause inflammation of the adenoid tissue. A viral upper respiratory tract infection (URTI) often precedes acute adenoiditis. In this state, bacteria can proliferate on the irregular, convoluted surface of the adenoid pad. The most common organisms cultured from adenoid specimens include: Haemophilus influenzae Streptococcus pneumoniae Streptococcus pyogenes Staphylococcus aureus  [4] Chronic adenoiditis is most often a polymicrobial infection and may include anaerobic pathogens. The condition frequently results from biofilm development and may contribute to recurrent URTIs in children. In most cases of pediatric rhinosinusitis, adenoiditis is also involved.[5] Allergies are believed to play a role in adenoiditis and subsequent adenoid hypertrophy. Allergens inhaled through the nose come in contact with the adenoid tissue; the adenoid then proliferates to respond to the allergens and produce immunoglobulin A.[6] Chronic stomach acid irritation in the setting of gastroesophageal reflux disease (GERD) may also exacerbate adenoiditis and adenoid hypertrophy, particularly in infants and young children.[7]

The exact incidence and prevalence of adenoiditis alone are unknown, as adenoiditis is typically considered part of a regional disease process, such as rhinosinusitis or adenotonsillar disease. Since adenoid tissue atrophies during puberty, adenoiditis is a condition predominantly found in children. Current literature does not suggest a predilection for gender, race, region, or socioeconomic class in this disease, although parental smoking has been positively correlated.[8] Adenoiditis can be difficult to differentiate from bacterial sinusitis in children; therefore, statistics on sinusitis in children may provide some insight into the frequency of adenoiditis. Most children experience 6 to 8 viral URTIs annually, with approximately 5% to 13% progressing to bacterial superinfection, leading to sinusitis with adenoiditis as a potential component of the illness.[9]

Acute adenoiditis often occurs after a viral URTI. Bacteria subsequently proliferate and infect the adenoids and surrounding tissue, resulting in inflammation and increased exudate production. Symptoms include rhinorrhea, postnasal drip with or without a cough, nasal obstruction, snoring, fever, and halitosis. Chronic adenoiditis results in many of the same symptoms but lasts at least 90 days and is often caused by polymicrobial infections and biofilm formation. Notably, exudates are frequently absent in chronic adenoiditis.[5] Other causes of adenoiditis include environmental allergens and chemical irritation from stomach acid in the presence of GERD/LPR.[7] Chronic inflammation may lead to lymphoid tissue proliferation and subsequent adenoid hypertrophy. Please see StatPearls' companion resource "Adenoid Hypertrophy, for further information. Adenoid tissue may also contribute to pediatric chronic rhinosinusitis by causing nasal obstruction and serving as a bacterial reservoir. A 2001 study by Bernstein et al found identical bacterial strains in both the adenoids and the sinuses. In contrast, Coticchia et al found a significantly higher incidence of biofilms in patients with chronic rhinosinusitis compared to those with OSA syndrome.[10][11] These biofilms support bacterial persistence and impede the local immune response, promoting chronic inflammation.[12] Although both adenoid and tonsillar hypertrophy involve enlargement of lymphoid tissue in children, they differ in immunologic composition. Adenoid hypertrophy is characterized by increased naïve B cells and regulatory T cells, weaker antigen presentation, and decreased cytotoxic CD8+ T-cell activity as the condition progresses. These immune differences help explain variations in the immune response between adenoiditis and tonsillitis, and may inform future treatment approaches.[13] Adenoid hypertrophy can cause upper airway and Eustachian tube obstruction, resulting in complications such as OSA and otitis media.[4] Prolonged symptoms can also affect a child's development and contribute to speech and language delays.[14] Other causes of adenoid hypertrophy, though not necessarily adenoid inflammation, include primary sinonasal malignancies, lymphoma, and HIV infection.[15]

Adenoid tissue typically regresses around puberty; therefore, the quintessential patient with acute adenoiditis is a prepubescent child who has a recent history of URTI. Patients with chronic adenoiditis may also have a history of recurrent acute otitis media, chronic nasal obstruction with mouth-breathing, chronic otitis media, sleep-disordered breathing/OSA, or GERD/LPR. Chronic adenoiditis is characterized by persistent symptoms, including a foreign body sensation in the pharynx, postnasal drip, sputum adhesion, frequent throat clearing, and recurrent expectoration. Patients may also experience nasal obstruction, rhinorrhea, sneezing, nasal itching (rhinocnesmus), dry throat, and headache.[16] Physical findings include purulent rhinorrhea, postnasal drip, nasal obstruction, snoring, fever, mouth breathing, and halitosis. An indirect mirror examination may allow the clinician to observe enlarged adenoids with exudate, although it can be challenging to perform in children. Flexible nasal and laryngeal endoscopy provides a more comprehensive assessment of the adenoids. In rare cases, the adenoid pad may be large enough to protrude downward and be visible beneath the edge of the soft palate (see Image. Adenoiditis). When the adenoid is large enough to displace the soft palate or obstruct the choanae, it can affect the quality of the patient's speech.[17] 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, leading to craniofacial abnormalities, including a high-arched palate and retrognathic mandible.[18]

Laboratory Testing Rapid Strep test Cultures Allergy testing When adenoiditis presents in association with pharyngitis, a rapid streptococcal antigen test may be performed. The purpose of doing so is twofold. First, this informs the choice of antibiotic therapy. Second, documenting a history of streptococcal infection is important when deciding whether an adenoidectomy, with or without tonsillectomy, is indicated. Adenoiditis remains a clinical diagnosis; therefore, if the Strep test is negative, the clinician can presume that symptoms are 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 treatment, as direct cultures of the adenoids may be challenging to obtain in the office setting. Other tests to consider include a complete blood count and HIV testing. If the adenoiditis is believed to result from seasonal or environmental allergies, allergy skin testing may help direct therapy. Radiology Lateral neck x-ray Computed tomography of the sinuses Imaging is not routinely required in uncomplicated cases. However, sinus radiographs or computed tomography scans may be obtained when sinus disease is suspected clinically. A lateral neck radiograph is a useful modality for assessing adenoid hypertrophy, particularly when fiberoptic examination is not tolerated. In patients with adenoid hypertrophy and symptoms such as snoring, a sleep study can be obtained to rule out OSA.

Adenoiditis is most often encountered clinically as a component of rhinosinusitis or pharyngitis. Consequently, clinicians generally follow management guidelines for rhinosinusitis and pharyngitis when treating adenoiditis.[19][20] Medical Management Observation: If adenoiditis is thought to be due to a viral URTI, antibiotics are not ordinarily prescribed. Typically, uncomplicated URTIs resolve within 5 to 7 days.[9] Antibiotic treatment: If symptoms persist for longer than 1 week or the clinical presentation suggests a bacterial etiology, such as a high fever or purulent discharge from the nose or throat, the first-line management is antibiotic therapy targeting the most common pathogens. Amoxicillin is a commonly used first-line agent due to its broad coverage and minimal adverse effect profile. Alternatively, cefdinir or cefuroxime may be used, particularly if patients have not responded to amoxicillin. If there is a penicillin allergy, alternatives include clarithromycin or azithromycin. Effective antibiotic treatment should begin to improve symptoms within 48 to 72 hours. Treatment duration should be 10 days, as shorter durations lead to high relapse rates and promote antibiotic resistance. If the condition fails to improve after a course of amoxicillin or other first-line agent, amoxicillin-clavulanate should be prescribed to address potential beta-lactamase–producing organisms.[9] Saline sprays and nasal rinses may also shorten the duration of symptoms by irrigating out the causative microorganisms and the stagnant mucous secretions that may harbor them. Allergy treatment: If the etiology of the adenoiditis is more likely allergic and there are no clinical signs or symptoms of infection, a trial of nasal or oral steroids and antihistamines should be provided to assess symptom improvement. Common options include fluticasone or mometasone nasal sprays, azelastine or olopatadine nasal sprays, and oral fexofenadine, cetirizine, or loratidine. If this is effective, patients may benefit from formal allergy testing followed by immunotherapy, such as allergy shots or sublingual drops. Saline sprays and nasal rinses may also play a role in these cases. Reflux treatment: If patients have LPR/GERD, dietary modification and elevating the head of the bed, with or without oral H2 blockers or proton-pump inhibitors, may reduce adenoid inflammation.[7] Surgical Management

Allergy treatment: If the etiology of the adenoiditis is more likely allergic and there are no clinical signs or symptoms of infection, a trial of nasal or oral steroids and antihistamines should be provided to assess symptom improvement. Common options include fluticasone or mometasone nasal sprays, azelastine or olopatadine nasal sprays, and oral fexofenadine, cetirizine, or loratidine. If this is effective, patients may benefit from formal allergy testing followed by immunotherapy, such as allergy shots or sublingual drops. Saline sprays and nasal rinses may also play a role in these cases. Reflux treatment: If patients have LPR/GERD, dietary modification and elevating the head of the bed, with or without oral H2 blockers or proton-pump inhibitors, may reduce adenoid inflammation.[7] 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 circumstances, surgical procedures may include adenoidectomy with or without tonsillectomy, myringotomy with tympanostomy tube placement, or endoscopic sinus surgery. When patients meet the Paradise criteria for tonsillectomy, most otolaryngologists perform adenoidectomy concurrently to eliminate another possible source of recurrent infections.[21] Similarly, adenoidectomy is often recommended in patients who require repeat tympanostomy, as adenoid hypertrophy is a potential cause of chronic Eustachian tube dysfunction.[22]

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 circumstances, surgical procedures may include adenoidectomy with or without tonsillectomy, myringotomy with tympanostomy tube placement, or endoscopic sinus surgery. When patients meet the Paradise criteria for tonsillectomy, most otolaryngologists perform adenoidectomy concurrently to eliminate another possible source of recurrent infections.[21] Similarly, adenoidectomy is often recommended in patients who require repeat tympanostomy, as adenoid hypertrophy is a potential cause of chronic Eustachian tube dysfunction.[22] Adenoidectomy is performed under general anesthesia using an orotracheal tube or laryngeal mask airway, with the patient positioned supine. A shoulder roll is often used to extend the patient's neck, and a Crowe-Davis or McIvor mouth gag provides surgical exposure, as for a tonsillectomy. A red rubber catheter is often passed through 1 nostril and retrieved through the mouth; its ends can be clamped below the nose to retract the soft palate and improve nasopharyngeal visualization. If this retraction method is selected, a rolled-up piece of gauze should be placed under the catheter, between the clamp and the patient's face, to protect the skin. A laryngeal mirror is then used to visualize the adenoid pad via the mouth, which is a maneuver that requires some practice to avoid disorientation. If the mirror fogs, its surface can be wiped on the buccal mucosa to warm it and remove condensation. The adenoid is then removed en bloc with a sharp adenoid curette or excised piecemeal with various powered instruments, such as monopolar suction cautery, coblation, or microdebrider. Bleeding from the adenoid pad is common intraoperatively and is best managed with a combination of cautery, pressure with tonsil packs, and hemostatic or vasoconstrictive agents, such as oxymetazoline. Fortunately, significant postoperative bleeding is rare. If tonsil packs are used, they must be removed before the procedure ends. During removal of the adenoid, the surgeon must take care to avoid any injury to the Eustachian tube orifices (the tori tubarii). Mild trauma to the nasal surface of the soft palate or the posterior nasal septum should be avoided as well, but it is not necessarily problematic if it occurs.

Adenoidectomy is performed under general anesthesia using an orotracheal tube or laryngeal mask airway, with the patient positioned supine. A shoulder roll is often used to extend the patient's neck, and a Crowe-Davis or McIvor mouth gag provides surgical exposure, as for a tonsillectomy. A red rubber catheter is often passed through 1 nostril and retrieved through the mouth; its ends can be clamped below the nose to retract the soft palate and improve nasopharyngeal visualization. If this retraction method is selected, a rolled-up piece of gauze should be placed under the catheter, between the clamp and the patient's face, to protect the skin. A laryngeal mirror is then used to visualize the adenoid pad via the mouth, which is a maneuver that requires some practice to avoid disorientation. If the mirror fogs, its surface can be wiped on the buccal mucosa to warm it and remove condensation. The adenoid is then removed en bloc with a sharp adenoid curette or excised piecemeal with various powered instruments, such as monopolar suction cautery, coblation, or microdebrider. Bleeding from the adenoid pad is common intraoperatively and is best managed with a combination of cautery, pressure with tonsil packs, and hemostatic or vasoconstrictive agents, such as oxymetazoline. Fortunately, significant postoperative bleeding is rare. If tonsil packs are used, they must be removed before the procedure ends. During removal of the adenoid, the surgeon must take care to avoid any injury to the Eustachian tube orifices (the tori tubarii). Mild trauma to the nasal surface of the soft palate or the posterior nasal septum should be avoided as well, but it is not necessarily problematic if it occurs. Surgery typically improves airflow through the nasopharynx, decrease the frequency of infections and obstructive episodes, improve compliance with continuous positive airway pressure devices and oral appliances, or even resolve the OSA altogether; however, adenoidectomy comes with risks, which include damage to the torus tubarius and subsequent transient or persistent Eustachian tube dysfunction, Grisel syndrome (atraumatic subluxation of the atlantoaxial joint accompanied by inflammation), velopharyngeal dysfunction that may be transient or persistent (chronic dysfunction is more common in patients with palatal clefting), and regrowth of adenoid tissue.

Differential diagnosis for adenoiditis includes the following: Viral URTIs Rhinosinusitis Nasal polyposis Pharyngitis Tonsillitis Environmental allergies Nasopharyngeal neoplasm (Tornwaldt cyst, nasopharyngeal angiofibroma, nasopharyngeal carcinoma, and lymphoma) LPR HIV

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

If left untreated, adenoiditis may progress to chronic infection, which in some cases can lead to biofilm formation. The adenoids may then serve as a nidus of infection for nearby structures, leading to rhinosinusitis, pharyngitis, tonsillitis, and otitis media.[5][23] Adenoid Hypertrophy As the adenoids enlarge, airflow through the nasopharynx can become obstructed (see Image. Anatomical Differences in Pediatric Airway Related to Sleep Apnea). This enlargement can cause mouth breathing, snoring, and OSA. OSA can affect cardiopulmonary health if left untreated and may interfere with cognitive, emotional, and behavioral development in children.[24][25][26] Enlarged adenoids may also obstruct the opening of the Eustachian tubes in the nasopharynx. Impaired Eustachian tube function can lead to negative middle-ear pressure, tympanic membrane retraction, and middle-ear effusion, potentially resulting in conductive hearing loss, delayed speech development, and increased susceptibility to bacterial infections. Long-standing adenoiditis with subsequent adenoid hypertrophy can cause the clinical finding known as adenoid facies or long-face syndrome. Enlarged adenoids often obstruct the nasopharynx and result in obligate mouth breathing, which may then lead to craniofacial abnormalities, including a high-arched palate and retrognathic mandible.[18]

Patients with recurrent adenoiditis or complications of adenoid hypertrophy should be referred to an otolaryngologist for further evaluation and treatment. Depending on the individual's needs, other specialties that may need to be involved include sleep medicine, allergy and immunology, and gastroenterology.

Adenoiditis is a common issue in children and often occurs due to their frequent exposure to pathogens and allergens that cause inflammation of the upper aerodigestive tract. However, it is important to seek treatment before chronic adenoiditis and adenoid hypertrophy develop, as these conditions can lead to complications that may decrease quality of life.

Key facts to keep in mind about adenoiditis include: Adenoiditis is primarily a childhood condition, as most adenoid tissue undergoes atrophy by adulthood. Adenoiditis is seldom a solitary issue. This condition is typically part of or indistinguishable from adenotonsillitis, rhinosinusitis, or pharyngitis. Adenoid hypertrophy is responsible for the most common health issues associated with the adenoids. OSA and recurrent acute otitis media are two of the most common complications of adenoid inflammation and hypertrophy. Surgical adenoidectomy is the definitive treatment for adenoid disease.

Managing adenoiditis, especially when complicated by recurrent infections, allergies, GERD, or OSA, requires a team-based approach. Family physicians, midlevel healthcare providers, pediatricians, and otolaryngologists work together to find and treat the root cause using evidence-based methods and avoiding unnecessary interventions. Nurses support the care team by monitoring patient status, coordinating follow-up care, and reinforcing treatment plans. Pharmacists help ensure medications are used safely and effectively, particularly antibiotics. Each team member brings important skills and plays a specific role in delivering patient-centered care.