Diagnosis and treatment
Adenoid Hypertrophy in Children
If your child snores every night, sleeps with their mouth open, and wakes up tired, it is probably not that they are a heavy sleeper: it is air that is not getting through the nose. We will explain why this happens and when treatment is necessary.
Almost every parent who arrives here with this question has already been told by someone that children snore because they sleep deeply. That is not it. Snoring that comes back almost every night, an open mouth to breathe through and restless sleep are signs that air is not getting through the nose properly, and in childhood the most common cause of this set of signs is enlarged adenoids.
This page explains what the adenoids are, which signs parents notice before any examination, how I confirm the diagnosis during the visit and what usually solves the problem. The decision about operating has a page of its own, and I point the way to it at the end.
What the adenoids are, and why they block the nose
The adenoids are defense tissue that sits behind the nose, in a space called the nasopharynx, right in the path the air takes on its way in. They grow along with the child in the first years, do their defense work and then usually shrink on their own. The problem shows up when they grow more than the space allows: air stops getting through, the child swaps the nose for the mouth, and the snoring begins.
Adenoids and tonsils are not the same thing, and this mix-up is common. You can see the tonsils by opening your child’s mouth; the adenoids sit behind the nose and cannot be seen at all without an examination. Both can be enlarged at the same time, which is why the two sometimes come up in the same conversation.
The signs parents notice first
Most of the time the person who notices is whoever walks past the bedroom door at night. It is worth bringing your child in for an evaluation when you observe:
- Snoring on most nights, noisy or heavy breathing during sleep.
- Breathing through an open mouth, asleep and sometimes awake, with dry lips in the morning.
- Restless sleep, a child who changes position all night, wakes up several times or gets up tired.
- Pauses in breathing during sleep, when the child seems to stop breathing for a few seconds and then starts again with a loud gasp.
- A nasal-sounding voice, as if the child always had a cold, and a blocked nose that does not get better.
- Bad breath in the morning that brushing does not fix.
- Ears: repeated pain, infections that keep coming back, or the impression that the child does not hear well and asks for the volume to be turned up.
- A complaint from school about attention, tiredness or irritability, which usually comes along with poorly slept nights.
- A remark from the dentist about the shape of the dental arch or of the bite in a child who has been mouth breathing for a long time.
You do not need all of them. Frequent snoring together with mouth breathing is already reason enough to investigate.
Why this matters beyond the snoring
A blocked nose charges its price in three places. In sleep, because a child who breathes badly sleeps badly, and poor sleep shows up during the day as tiredness, irritability or difficulty concentrating. When the pauses in breathing keep repeating, the picture moves into the territory of sleep apnea, and the evaluation takes on a different urgency.
In the ear, because the adenoids sit next to the opening of the channel that ventilates the middle ear. When they grow, that ventilation gets worse, and it is common for recurrent otitis media to appear, or fluid behind the eardrum, which muffles hearing without hurting and goes unnoticed.
And in the nose itself, because secretions that do not drain make repeated bouts of sinusitis more likely. Families often arrive telling me about the third or fourth course of antibiotics of the year, without anyone having looked behind the nose.
How I confirm it: the examination is done during your visit, at any age
The adenoids do not show up in a throat examination and cannot be assessed just by looking at the patient. To see them I perform flexible nasolaryngoscopy in my own office, with a thin, flexible instrument that goes in through the nose and shows the adenoids on a screen, with the degree of obstruction right there. There is no need to book somewhere else, there is no need for sedation, and the result comes out in the same visit, with me showing you the image.
I perform this examination at any age. That tends to be the first question from parents of a small child, and the answer is this one: there is no minimum age for me to assess.
In a very small child, or when the child does not cooperate with the instrument, I request a lateral neck radiograph (cavum). It also works as a screening step before the nasolaryngoscopy, when I already want an idea of the size of the adenoids before examining. The nasolaryngoscopy shows more, and that is why it is my examination of choice. The lateral neck radiograph comes in by my decision, in the two situations above, and not as a second option when something goes wrong.
When sleep becomes part of the assessment
If the history includes pauses in breathing, very fragmented sleep or sleepiness that does not match the age, the size of the adenoids on its own may not be enough. In those cases I request a sleep study, which measures what happens over the whole night and shows the real weight of the obstruction. It is what separates snoring that is merely bothersome from snoring associated with sleep disorders such as apnea.
If you would like more detail on how this shows up, I have written about the full picture on this page: sleep apnea in children.
What is done before surgery is considered
A good share of children improve without surgery, and medical treatment is the first path whenever the picture allows it. It starts with nasal rinsing with saline, which is simple and makes a real difference when it is done properly, and with controlling the allergy when there is one, because an allergic nose and large adenoids feed each other.
From there I usually use an intranasal corticosteroid spray, at the dose and for the length of time the case calls for, and I prescribe montelukast in some children, mainly in milder pictures of obstruction during sleep. Antibiotics only come in when there is a bacterial infection involved: they do not treat enlarged adenoids, and using them for that only postpones the solution.
What defines the next step is how the child responds to that treatment, together with what the examination showed and how much their sleep is being affected.
When surgery becomes indicated
Adenoid surgery, the adenoidectomy, comes in when the obstruction is significant and persists, when sleep remains compromised, when there is fluid in the ear that does not resolve or infections that keep coming back. It is not the first step, but it does start to make sense in persistent cases.
Two things families always ask, and that I answer right here. The adenoids can be operated on alone or together with the tonsils, and that depends on each child’s case, on what the examination shows and on what is causing the problem; there is no rule that holds for everyone. And the surgery is done on a day-hospital basis: the child goes in and comes out on the same day, and sleeps at home.
For more information about the surgical indication, for the tonsils as well as for the adenoids, go to the page on when to operate on adenoids and tonsils in children. If you want the step by step of the procedure, with preparation and recovery, it is on the adenotonsillectomy page.
What it is like to bring your child in for a consultation
The consultation starts with your story, and it is very important: what you hear at night, for how long, how many nights a week, how the child wakes up and how things are going at school. If you have a short video of the child sleeping, with the sound, bring it. It helps more than you would think.
Then I examine the child and perform the flexible nasolaryngoscopy in the same visit, at any age, showing you what appears on the screen. By the time you leave, you already know whether the adenoids are enlarged, how much they are obstructing, what to do now and what to watch for at home. When it is necessary to complete the picture with a radiograph or with a sleep study, I explain why I am making the request and we go over what changes in each case once the results are in hand.
I see children at three addresses in Greater São Paulo: Itaim Bibi, Morumbi and Alphaville. To book, message me on WhatsApp and tell me in one sentence what is happening with your child’s sleep.
Frequently asked questions about adenoid hypertrophy
My child is 2 years old. Is it already possible to do the examination?
It is. I perform flexible nasolaryngoscopy at any age, in the office, and there is no minimum age for assessing. When the child is very small or does not cooperate with the instrument on that day, I request a lateral neck radiograph (cavum), which I also use as a screening step when I want an idea of the size before examining.
Are adenoids and tonsils the same thing?
No. The tonsils are in the throat and show up when the child opens their mouth; the adenoids sit behind the nose and are only seen with an examination. Both can be enlarged at the same time, which explains why they are usually mentioned together.
Does a child who snores always have enlarged adenoids?
Not necessarily, and that is why the evaluation matters. Rhinitis, a deviated septum, large tonsils and obesity also obstruct breathing during sleep, sometimes alongside the adenoids. The examination is what tells one from the other.
Do the adenoids improve on their own with growth?
In many cases they shrink naturally over the course of growth. What cannot be done is to wait indefinitely when the child’s sleep is compromised, with repeated ear infections or with hearing affected, because during that time the problem keeps charging its price. The evaluation is exactly what serves to decide between observing and treating.
Will my child need surgery?
A good share of children improve with medical treatment, without surgery. The operation comes in when the obstruction is significant and persists, when sleep remains compromised or when there is fluid in the ear and infections that do not stop. The criteria for that decision are detailed on the page about when to operate on adenoids and tonsils in children.
Does the surgery require an overnight stay in hospital?
It is done on a day-hospital basis. The child goes in and comes out on the same day and sleeps at home.
Dr. José Eduardo Marcondes, physician, otolaryngologist (ENT), CRM-SP 107.711, RQE 43.840. This content is informational, does not replace a medical consultation, and does not supersede the plan of care defined by your own physician.
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