Do you know why some children breathe through their mouths even when their noses aren’t blocked? Adenoids grow larger during early childhood to fight infections, then typically shrink after age 5. When adenoids remain enlarged or become chronically infected, they block the nasopharynx—the area behind the nose where air passes to reach the lungs. This blockage creates distinct symptoms that differ from typical cold or allergy issues:
- Mouth breathing becomes constant rather than occasional
- Snoring occurs every night regardless of sleep position
- The voice develops a permanently nasal quality as if the child has a perpetual cold
The adenoidectomy surgery procedure removes these lymphoid tissues through the mouth using instruments, taking approximately 20-30 minutes under general anesthesia. Unlike tonsils, which sit visibly in the throat, adenoids hide behind the soft palate where only an ENT doctor can visualize them using mirrors or endoscopes. The decision between surgery and conservative management depends on specific symptom patterns, examination findings, and the impact on the child’s development and quality of life.
Identifying Problematic Adenoid Enlargement
Enlarged adenoids create a characteristic pattern of symptoms that worsen at night. Children breathe through their mouths continuously, leading to dry lips, bad breath, and dental problems from altered jaw positioning. Sleep becomes fragmented with frequent snoring, gasping, and brief breathing pauses. These disruptions prevent deep sleep phases, causing daytime fatigue, difficulty concentrating at school, and behavioral changes.
The facial structure begins changing when mouth breathing persists beyond several months. The upper jaw narrows, creating a high-arched palate and crowded teeth. The face elongates, developing what orthodontists call “adenoid facies”—a long face with an open mouth posture, flattened cheekbones, and dark circles under the eyes from poor sleep quality. These skeletal changes become permanent if mouth breathing continues past childhood.
Ear problems develop when enlarged adenoids block the Eustachian tubes connecting the middle ear to the nasopharynx. Fluid accumulates behind the eardrum, causing hearing loss that fluctuates with head position. Children may turn up television volumes, frequently ask for repetition, or appear inattentive during conversations. Recurrent ear infections occur and may require evaluation by a healthcare professional for appropriate treatment.
Surgical Criteria and Medical Evaluation
ENT specialists may recommend adenoidectomy when specific clinical criteria are met. Obstructive sleep symptoms with documented apnea episodes on sleep studies may indicate surgical intervention. Hearing loss persisting beyond three months despite medical treatment, especially when audiometry shows conductive hearing loss greater than 20 decibels, may warrant adenoid removal. Children experiencing recurrent ear infections or requiring ventilation tube insertion may be considered for concurrent adenoidectomy.
Physical examination reveals adenoids occupying more than two-thirds of the nasopharyngeal airway on endoscopic assessment. X-rays show the adenoid-nasopharyngeal ratio exceeding 0.8, though endoscopy provides more accurate evaluation. Tympanometry demonstrates flat curves indicating middle ear fluid, while flexible nasopharyngoscopy allows direct visualization of adenoid size and any concurrent sinus drainage issues.
The timing of surgery considers developmental factors. Operating between ages 3-7 may yield favorable outcomes, as facial growth remains active and can normalize after airway obstruction resolves. Delaying surgery past age 10 may result in permanent facial changes requiring orthodontic correction. However, surgery before age 2 carries higher anesthesia risks and potential for adenoid regrowth.
Non-Surgical Management Options
Conservative treatment may be considered when adenoid enlargement remains mild without sleep disruption or ear complications. Intranasal corticosteroid sprays like mometasone or fluticasone may reduce adenoid tissue volume when used consistently for 8-12 weeks. The medication should reach the nasopharynx, requiring proper spray technique with the head tilted forward and nozzle aimed toward the ear on the same side.
Saline nasal irrigation removes thick secretions and allergens that may contribute to adenoid inflammation. Using isotonic saline solution twice daily through squeeze bottles or neti pots clears the nasal passages. Adding xylitol to the rinse solution may provide additional antimicrobial benefits. Children typically learn the technique by age 4-5 with parental guidance.
Allergy management may help reduce adenoid hypertrophy triggered by environmental allergens. Identifying specific triggers through skin prick testing or specific IgE blood tests guides avoidance strategies. Encasing mattresses and pillows in dust-mite proof covers, using HEPA air filters, and maintaining indoor humidity between 30-50% minimizes allergen exposure. Oral antihistamines provide symptom relief but don’t reduce adenoid size directly.
⚠️ Important Note
Antibiotics only treat bacterial infections of the adenoids, not enlargement itself. Repeated antibiotic courses without addressing underlying obstruction may lead to resistant organisms and persistent symptoms.
The Adenoidectomy Surgery Procedure
Pre-operative preparation begins with fasting from midnight before morning surgery or six hours for afternoon procedures. Blood tests checking hemoglobin levels and coagulation parameters ensure safe surgery. The anesthetist reviews the child’s medical history, focusing on previous anesthetic reactions, loose teeth, and recent respiratory infections that might necessitate postponement.
The surgical technique involves accessing adenoids through the open mouth without external incisions. The surgeon uses a mirror or 70-degree endoscope to visualize the nasopharynx while removing adenoid tissue with curettes, microdebriders, or coblation devices. Coblation technology uses radiofrequency energy at 40-70°C to dissolve tissue with minimal thermal damage to surrounding structures. Bleeding points undergo cauterization with suction electrocautery.
Endoscopic-assisted techniques can improve surgical precision. The surgeon confirms complete adenoid removal while preserving the torus tubarius—the opening of the Eustachian tube. Leaving residual adenoid tissue near the Eustachian tubes prevents post-operative middle ear problems. The entire procedure typically completes within 20-30 minutes.
Recovery Timeline and Expectations
Immediate post-operative recovery occurs in the recovery room over 30-60 minutes as anesthesia wears off. Children experience throat discomfort similar to a sore throat, which can be managed with paracetamol or ibuprofen as recommended by a healthcare professional. Some blood-tinged saliva appears normal during the first 24 hours. Nausea from swallowed blood during surgery may be addressed with anti-emetic medications as prescribed.
The first week involves gradually improving symptoms. Days 1-3 bring peak discomfort with referred ear pain from shared nerve pathways. Soft foods like yogurt, smoothies, and soup may help prevent irritation to the surgical site. Bad breath develops from healing tissue slough, resolving by day 10. Children typically return to school after 5-7 days, avoiding physical education for two weeks.
Long-term improvements become apparent within 2-4 weeks. Snoring ceases immediately in many cases, though some children continue mild snoring for several weeks as swelling resolves. Nasal breathing returns naturally without conscious effort. Speech clarity improves as the nasal quality disappears. Appetite increases with better sleep quality, often leading to catch-up growth in previously underweight children.
💡 Did You Know?
Adenoid tissue lacks a capsule like tonsils, making complete removal challenging. Small remnants may persist but rarely cause problems if the main obstructing mass is removed.
Potential Complications and Risk Management
Primary bleeding occurs in a small percentage of cases within 24 hours of surgery. Warning signs include frequent swallowing, restlessness, and increasing pulse rate before visible bleeding appears. Management involves returning to the operating room for cauterization of bleeding vessels. Secondary bleeding between days 5-10 results from premature scab separation, usually managed conservatively with rest and hydration.
Velopharyngeal insufficiency causes temporary nasal regurgitation of liquids and hypernasal speech. The soft palate requires 2-4 weeks to adapt to the enlarged nasopharyngeal space. Speech therapy may become necessary if symptoms persist beyond six weeks. Using straws and taking smaller sips may help minimize liquid regurgitation during recovery.
Nasopharyngeal stenosis represents a rare but serious complication from excessive scarring. Risk factors include concurrent tonsillectomy, aggressive cauterization, and previous cleft palate repair. Prevention involves careful surgical technique and appropriate post-operative care. Treatment of established stenosis may require surgical revision or dilation procedures.
What an ENT Specialist Says
The decision for adenoidectomy involves balancing current symptoms against natural adenoid regression with age. Adenoids represent only a small portion of the lymphoid system. The tonsils, lymph nodes, and remaining lymphoid tissue provide adequate immune function after adenoidectomy.
Children with allergic rhinitis or chronic sinusitis may experience symptom recurrence despite successful adenoidectomy if underlying conditions remain untreated. Comprehensive evaluation includes allergy testing and sinus imaging when indicated. Concurrent management of all contributing factors optimizes surgical outcomes.
Post-operative bleeding risk increases with aspirin or traditional Chinese medicines containing blood-thinning herbs. The timing for stopping these medications and avoiding them during recovery should be determined by a healthcare professional. Parents should provide complete medication lists including supplements during pre-operative consultation.
Putting This Into Practice
- Monitor your child’s breathing patterns during sleep by observing for mouth breathing, snoring frequency, and breathing pauses. Record videos of problematic breathing to show the ENT specialist, as symptoms may not occur during brief clinic examinations.
- Document ear infection frequency, antibiotic courses, and hearing concerns in a symptom diary. Include dates, prescribed medications, and response to treatment. This information helps determine if adenoid problems contribute to recurrent infections.
- Assess daytime symptoms including mouth breathing during quiet activities, nasal voice quality, and concentration difficulties at school. Teachers often provide observations about classroom attention and academic performance changes.
- Practice nasal breathing exercises if pursuing conservative management. Teach children to consciously close their mouths during quiet activities, gradually building nasal breathing habits. Use nasal strips at night to encourage nasal airflow while retraining breathing patterns.
- Prepare children for surgery through age-appropriate explanation and hospital orientation programs. Reading books about hospital experiences and allowing children to bring comfort items reduces anxiety and improves cooperation.
When to Seek Professional Help
- Snoring occurs every night with observed breathing pauses
- Mouth breathing persists during daytime activities
- More than four ear infections within six months
- Hearing difficulties affecting school performance
- Speech remains unclear with persistent nasal quality
- Behavioral changes including hyperactivity or daytime sleepiness
- Poor weight gain despite adequate food intake
- Chronic nasal discharge lasting beyond three weeks
- Recurrent sinusitis requiring multiple antibiotic courses
Next Steps
Children with obstructive sleep symptoms and breathing pauses require surgical evaluation. Document symptoms, monitor sleep disruption, and consider intranasal corticosteroids for mild cases before surgery.
If your child experiences persistent mouth breathing, nightly snoring with breathing pauses, or recurrent ear infections, an ENT specialist can provide evaluation and treatment options.
