The ABCs of Adenoids: Enlarged Adenoids in Children

What the adenoids do, how they cause trouble, and what to expect if they need to come out

Most parents first hear the word “adenoids” when a doctor mentions them as the reason for snoring, a constantly stuffy nose, or ear fluid that will not clear. Unlike the tonsils, the adenoids cannot be seen by looking in your child’s mouth, which makes them easy to misunderstand. As a fellowship-trained pediatric ENT in Frisco, I evaluate children with adenoid problems every week. This guide explains what the adenoids are, which problems they really cause (and which they do not), how they are evaluated, and what adenoid surgery involves, including its risks.

Key takeaways

• The adenoids are immune tissue at the back of the nose that grow through early childhood and then shrink.
• Enlarged adenoids can cause nasal blockage, snoring and sleep apnea, chronic sinus symptoms, and ear fluid.
• Removing the adenoids does not reduce ordinary colds, according to a randomized trial.
• A thin, flexible scope through the nose is the most accurate way to see the adenoids; a side-view X-ray is a fallback.
• For children under 4 getting their first ear tubes, national guidelines advise against routinely removing the adenoids unless there is a separate reason, such as nasal blockage or chronic adenoid infection.
• Adenoids grow back enough to need a second surgery in only about 2 percent of children.
• A child with a cleft palate, a hidden (submucous) cleft, or certain genetic syndromes needs extra caution, because removing the adenoids can occasionally affect speech.

What are the adenoids?

The adenoids sit high in the throat, behind the nose and above the soft palate. Along with the tonsils, they are lymphoid tissue: part of the immune system that samples germs coming in through the nose and mouth.

The adenoids change a great deal with age. An MRI study of children who did not snore found that adenoid size increases over roughly the first seven to eight years of life and then gradually decreases, while the airway behind the nose enlarges after about age 8. In children who snored, the adenoids and tonsils were large regardless of age. Large adenoids are common in young children and are a problem only when they cause symptoms.

How enlarged adenoids cause trouble

The adenoids are not responsible for the ordinary run of colds. In a randomized trial of 111 children ages 1 to 6 selected for adenoidectomy because of recurrent upper respiratory infections, children who had surgery right away had about the same number of infections over two years as children who waited. I do not recommend adenoid surgery simply because a child gets a lot of colds.

How adenoid problems are evaluated

1. History: nasal blockage between colds, snoring and pauses at night, ear infections, hearing, and speech. A short phone video of your child sleeping helps.
2. Examination of the ears, nose, mouth, and palate. I look specifically for signs of a hidden cleft in the palate, such as a split uvula (the small tissue that hangs at the back of the mouth), because that changes the surgical plan.
3. Flexible nasal endoscopy. After a numbing and decongesting spray, a thin, flexible camera passed through the nose shows the adenoids directly, along with how much of the back of the nose they block. It takes about a minute and is the reference standard for judging adenoid size.
4. A side-view X-ray of the neck when a child cannot cooperate with a scope. A 2025 meta-analysis of 50 studies comparing X-rays with endoscopy found that X-rays were only moderately accurate, and less accurate for moderate and severe enlargement, so endoscopy remains preferred when it is practical.
5. A hearing test if there is fluid behind the eardrums, and a sleep study when sleep apnea is suspected and the need for surgery is unclear.

Treatment options

Watching and medical treatment

Because the adenoids shrink with age, many children with mild symptoms improve with time. A nasal steroid spray is a reasonable first step for blockage: a Cochrane review found limited evidence that nasal steroids improve nasal blockage in children with moderate to severe adenoid enlargement, sometimes with a reduction in adenoid size, although the long-term effect is not known. Your child’s doctor will recommend a product and dose for your child’s age. Treating allergies, when present, also helps.

Adenoidectomy alone

Removing the adenoids alone is most often considered for:

• Nasal blockage and mouth breathing that persist despite medical treatment
• Sleep apnea in young children whose tonsils are small, including infants
• Chronic sinusitis. The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) consensus statement on pediatric chronic sinusitis supports adenoidectomy as a first surgery for children up to age 12.
• Chronic adenoid infection (adenoiditis), with constant thick drainage and bad breath

Adenoidectomy with tonsillectomy

When both the tonsils and adenoids are enlarged and causing sleep apnea, removing both (adenotonsillectomy) is the usual approach. My tonsillectomy page covers that procedure and its recovery, which is longer and more uncomfortable than recovery from adenoidectomy alone.

Adenoidectomy with ear tubes

Age matters here. The AAO-HNS guideline on ear fluid (otitis media with effusion) recommends ear tubes, not adenoidectomy, when surgery is needed for a child younger than 4, unless there is a distinct reason to remove the adenoids, such as nasal blockage or chronic adenoid infection. For children 4 and older, tubes, adenoidectomy, or both are reasonable. The 2022 AAO-HNS tympanostomy tube guideline update says surgeons may remove the adenoids at the time of tube placement for children with symptoms directly related to the adenoids, or for children 4 and older to potentially reduce future ear infections or the need for another set of tubes. See my ear tubes page for the tube procedure.

I perform these procedures at Stonebridge Surgery Center, and at Children’s Medical Center Plano or Texas Health Hospital Frisco when hospital care is the safer choice.

What to expect from adenoid surgery

The adenoids are removed through the mouth under general anesthesia, with no cuts on the face or neck. Most children go home the same day. Recovery is usually much easier than after tonsillectomy. Many children are back to normal activity within a few days. During recovery, parents commonly notice:

• Mild throat or neck discomfort, managed with acetaminophen or ibuprofen dosed by weight according to your surgeon’s instructions or the package label
• Bad breath and some nasal congestion for a week or two
• A change in voice. Some children sound more nasal for a while. A review of the research found this usually resolves within three to six months.

Can adenoids grow back?

Some adenoid tissue can regrow, but regrowth that needs a second operation is uncommon. A 2019 meta-analysis of 16 studies with nearly 96,000 children found a revision adenoidectomy rate of 1.9 percent, and the surgical technique used did not change that rate. A 2020 meta-analysis reported regrowth in about 8 percent of children across six studies, with revision surgery in about 2 percent. The studies disagree on whether a younger age at the first surgery raises the risk.

Risks, including effects on speech

Adenoidectomy is a common and generally safe operation. In a 2025 population study of more than 2,100 children in Germany, return to the operating room for bleeding after adenoidectomy alone occurred in 0.7 percent, and the main bleeding risk came from adding tonsil surgery.

The risk parents ask about most is velopharyngeal insufficiency (VPI). During speech, the soft palate lifts to seal the nose off from the mouth, and in some children large adenoids help make that seal. After they are removed, air can escape through the nose and speech sounds hypernasal. Mild, temporary changes are fairly common and usually resolve within months. Persistent VPI is rare: a 20-year review from a cleft team in Edinburgh estimated about 1 in 1,200 adenoidectomies.

Risk factors include a cleft palate or submucous cleft palate (a cleft hidden under the lining of the palate, sometimes signaled by a split uvula), poor palate movement, a deep throat, a family history of nasal-sounding speech, and earlier speech problems or food coming out of the nose. Children with 22q11.2 deletion syndrome (velocardiofacial syndrome) deserve particular care, because they are prone to VPI and some have carotid arteries that run in unusual positions in the throat. For children at risk, a surgeon may recommend a speech evaluation first, a partial adenoidectomy, or a different treatment. If persistent VPI occurs, speech therapy helps some children; others need corrective surgery.

A very rare complication, Grisel syndrome, is an inflammatory loosening of the top neck joint; its main sign is a painful, tilted neck soon after surgery, and early treatment usually works.

When to call or go to the emergency department after surgery

Go to the emergency department if your child has bright red bleeding from the nose or mouth, vomits blood, or has trouble breathing. Call your surgeon the same day for:

• A stiff or painful neck, a head held tilted to one side, or refusal to turn the head
• Fever above 102°F (38.9°C) that does not come down
• Not drinking enough, with few wet diapers or trips to the bathroom
• Speech that sounds very nasal or liquids coming out of the nose weeks after surgery

When to see a pediatric ENT

• Constant mouth breathing or nasal blockage that continues between colds
• Snoring most nights, with or without pauses in breathing
• Thick nasal drainage, daytime cough, or bad breath lasting more than a few months
• Repeated ear infections or fluid behind the eardrums, especially with nasal symptoms
• A nasal voice or noisy breathing that worries you

You can also read about tonsil and adenoid problems in children and my pediatric ENT care.

From my research and practice

A 2016 systematic review and meta-analysis I co-authored in the Journal of Laryngology & Otology (Reckley, Song, Chang, Cable, Certal, Camacho) pooled the studies of adenoidectomy alone for sleep apnea in children. Only three small studies qualified, but breathing events during sleep fell substantially, especially in infants under 12 months. My training at the University of Iowa included its cleft and craniofacial program, where I co-authored a retrospective review of children with submucous cleft palate and VPI, which found significant, stable improvement in nasal resonance with palatal surgery combined with speech therapy (Husein et al., 2004), and a review of long-term speech outcomes after pharyngeal flap surgery for VPI (2004). With Dr. Eric Mair, I also wrote a case-based review of velocardiofacial syndrome (2003) warning that failing to recognize the syndrome before head and neck surgery can lead to VPI or injury to abnormally placed carotid arteries. That work is why I check every child’s palate before recommending adenoid surgery. These papers are listed on my publications and research page.

Frequently asked questions

Do adenoids grow back after they are removed?

Some tissue can regrow, but it rarely causes problems again. Two meta-analyses put the rate of a second adenoid surgery at about 2 percent, and one found that the surgical technique used did not change that rate.

Will removing the adenoids weaken my child’s immune system?

The evidence is reassuring. A 2015 systematic review of 35 studies of tonsil surgery found no clinically significant negative effect on the immune system, and the adenoids are similar tissue that naturally shrinks as children grow.

How does the doctor know my child’s adenoids are enlarged?

The adenoids cannot be seen through the mouth. A thin, flexible scope passed through the nose after a numbing spray shows them directly and takes about a minute. A side-view X-ray is an alternative for children who cannot tolerate a scope, though it is less accurate.

Does my child need the adenoids out with ear tubes?

Not usually for a first set of tubes in a child under 4. Guidelines advise removing the adenoids at that age only when there is a separate reason, such as nasal blockage or chronic adenoid infection. For children 4 and older, adding adenoidectomy may reduce future ear problems and repeat tubes.

Will adenoid surgery change my child’s voice?

Many children sound less stuffy after surgery. Some sound more nasal for a few weeks to months, and this usually resolves. Persistent speech changes are rare and are more likely in children with cleft palate, a hidden cleft, or certain syndromes, which is why the palate is checked before surgery.

References

1. Papaioannou G, Kambas I, Tsaoussoglou M, et al. Age-dependent changes in the size of adenotonsillar tissue in childhood: implications for sleep-disordered breathing. J Pediatr. 2013;162(2):269–274. doi:10.1016/j.jpeds.2012.07.041
2. 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. doi:10.1136/bmj.d5154
3. Alqutub A, AlGhamdi RD, Maawadh LM, et al. Should we still consider lateral neck radiography in the evaluation of adenoid hypertrophy? A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. 2025;195:112389. doi:10.1016/j.ijporl.2025.112389
4. 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
5. Brietzke SE, Shin JJ, Choi S, et al. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014;151(4):542–553. doi:10.1177/0194599814549302
6. 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
7. Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical practice guideline: tympanostomy tubes in children (update). Otolaryngol Head Neck Surg. 2022;166(1 Suppl):S1–S55. doi:10.1177/01945998211065662
8. Lee CH, Hsu WC, Ko JY, Yeh TH, Lin MT, Kang KT. Revision adenoidectomy in children: a meta-analysis. Rhinology. 2019;57(6):411–419. doi:10.4193/Rhin19.101
9. Paramaesvaran S, Ahmadzada S, Eslick GD. Incidence and potential risk factors for adenoid regrowth and revision adenoidectomy: a meta-analysis. Int J Pediatr Otorhinolaryngol. 2020;137:110220. doi:10.1016/j.ijporl.2020.110220
10. Losgar H, Boeger D, Buentzel J, et al. Pediatric adenoidectomy is safe surgery with a low complication rate: a population-based study. Sci Rep. 2025;15(1):27967. doi:10.1038/s41598-025-13803-9
11. Lambert EM, You P, Kacmarynski DS, Rosenberg TL. Adenoidectomy and persistent velopharyngeal insufficiency: considerations, risk factors, and treatment. Int J Pediatr Otorhinolaryngol. 2021;149:110846. doi:10.1016/j.ijporl.2021.110846
12. Stewart KJ, Ahmad T, Razzell RE, Watson AC. Altered speech following adenoidectomy: a 20 year experience. Br J Plast Surg. 2002;55(6):469–473. doi:10.1054/bjps.2002.3886
13. Al-Driweesh T, Altheyab F, Alenezi M, et al. Grisel’s syndrome post otolaryngology procedures: a systematic review. Int J Pediatr Otorhinolaryngol. 2020;137:110225. doi:10.1016/j.ijporl.2020.110225
14. Bitar MA, Dowli A, Mourad M. The effect of tonsillectomy on the immune system: a systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. 2015;79(8):1184–1191. doi:10.1016/j.ijporl.2015.05.016
15. Reckley LK, Song SA, Chang ET, Cable BB, Certal V, Camacho M. Adenoidectomy can improve obstructive sleep apnoea in young children: systematic review and meta-analysis. J Laryngol Otol. 2016;130(11):990–994. doi:10.1017/S0022215116008938
16. Husein M, Chang E, Cable B, Karnell M, Karnell LH, Canady JW. Outcomes for children with submucous cleft palate and velopharyngeal insufficiency. J Otolaryngol. 2004;33(4):222–226. doi:10.2310/7070.2004.03082
17. Cable BB, Canady JW, Karnell MP, Karnell LH, Malick DN. Pharyngeal flap surgery: long-term outcomes at the University of Iowa. Plast Reconstr Surg. 2004;113(2):475–478. doi:10.1097/01.PRS.0000100806.45065.35
18. Cable BB, Mair EA. Avoiding perils and pitfalls in velocardiofacial syndrome: an otolaryngologist’s perspective. Ear Nose Throat J. 2003;82(1):56–60. doi:10.1177/014556130308200117

If your child breathes through the mouth, snores, or has ear or sinus problems that keep coming back, I’m happy to take a look. You can contact my office to schedule a visit in Frisco or at the McKinney office of ENT and Allergy Centers of Texas.