INTRODUCTION — Adenoidectomy is a common pediatric surgical procedure that is performed alone or in conjunction with tonsillectomy [1]. This topic reviews the postoperative care and complications in children who have undergone adenoidectomy alone. Postoperative issues in children who have undergone tonsillectomy with or without adenoidectomy are discussed in greater detail separately. The indications, contraindications, and preoperative and intraoperative care for both procedures in children are also reviewed elsewhere. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications" and "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications" and "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care".)
Tonsillectomy in adults is discussed in detail separately. (See "Tonsillectomy in adults: Indications" and "Tonsillectomy in adults".)
POSTOPERATIVE CARE — The recovery following adenoidectomy is remarkably easy compared with the recovery following tonsillectomy alone or tonsillectomy with adenoidectomy. Patients who undergo adenoidectomy alone are typically discharged home the same day as surgery. Exceptions include infants <18 months old, children with underlying comorbid conditions, and those with significant obstructive sleep apnea (ie, apnea-hypopnea index >5 on polysomnogram), since these factors are associated with increased risk of perioperative respiratory compromise [2,3]. (See "Management of obstructive sleep apnea in children", section on 'Surgical therapy'.)
Pharyngeal pain from the surgical site and endotracheal intubation typically only requires nonnarcotic analgesics, such as acetaminophen or ibuprofen, on an as-needed basis. A minority of patients may also have neck pain that may last for several days to a few weeks [4]. Occasionally, a child will complain of ear pain after surgery. The ear pain is referred from the pharynx and is treated with over-the-counter pain medications.
Many children will have significant halitosis that can last up to two weeks after surgery. The bad breath is normal after of the surgery and resolves spontaneously.
There are no dietary restrictions following adenoidectomy, and most children consume a normal diet within a few days following surgery.
COMPLICATIONS — Significant complications after adenoidectomy are uncommon in children. Postoperative hemorrhage almost always occurs in the first 24 hours following surgery rather than later. Velopharyngeal insufficiency (VPI), nasopharyngeal stenosis, and atlantoaxial rotary subluxation are other rare potential complications of the surgery. Occasionally, the adenoids regrow due to incomplete removal. Repeat adenoidectomy may be warranted if regrowth is significant enough to cause recurrence of symptoms. Very rarely, meningitis, cervical osteomyelitis, or brainstem injury may complicate adenoidectomy. Retropharyngeal injection of local anesthetic agents have been implicated [5,6].
Postoperative hemorrhage — Bleeding from the nose after adenoidectomy mostly occurs within the first 24 hours following surgery (called primary, early, or R1 hemorrhage), with rates similar to the lower end of that seen with tonsillectomy (around 0.5 to 0.8 percent) [7-9]. Late or secondary hemorrhage is rare in children who have undergone adenoidectomy and is much less common than after tonsillectomy. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Hemorrhage'.)
Velopharyngeal insufficiency — VPI is characterized by hypernasal speech, nasal air emission, and nasal regurgitation of fluids in severe cases. It is a known complication of adenoidectomy with an estimated incidence of approximately 1 in 1200 to 1 in 1500 procedures [10-12]. VPI is most commonly thought to occur due to the unmasking of a preexisting palatal problem, such as a submucous or occult cleft palate. Removal of the adenoids increases the size of the nasopharyngeal airway [13,14]. The poorly functioning palate is no longer able to achieve nasopharyngeal closure with the adenoid tissue removed.
Often, VPI is temporary and resolves within a few weeks of adenoidectomy surgery [15,16]. If hypernasality persists three months after adenoidectomy, further evaluation by a speech pathologist is indicated. VPI after adenoidectomy is associated with chromosome 22q11 deletion syndrome [17]. Testing for this genetic anomaly is suggested even if other clinical features of velocardiofacial syndrome are not present [15]. Some children improve with speech therapy alone, while others require additional surgery to enable the child to close his/her velopharyngeal inlet [11,18]. In children with a known cleft palate or submucous/occult cleft palate, performance of a partial superior adenoidectomy, in which a small amount of adenoidal tissue is left inferiorly to ensure adequate velopharyngeal closure, can reduce the chance of developing VPI [14,19-24]. (See "DiGeorge (22q11.2 deletion) syndrome: Clinical features and diagnosis".)
Temporomandibular joint dysfunction — A mouth gag is used to keep the mouth open during the tonsillectomy/adenoidectomy. Rarely, this may cause dysfunction of the temporomandibular joint [25]. Reduced mouth opening is not a common problem following surgery [26].
Nasopharyngeal stenosis — A rare complication after pharyngeal surgery is nasopharyngeal stenosis. This entity is characterized by significant narrowing or obliteration of the normal passage between the oropharynx and nasopharynx. Patients present with difficulty breathing through their nose, difficulty blowing air out their nose, hyponasal speech, and dysphagia. Obstructive sleep apnea, chronic rhinorrhea, and anosmia may occur if the stenosis is severe. Surgical correction is required for severe stenosis [27,28].
Atlantoaxial rotary subluxation (Grisel syndrome) — Grisel syndrome is defined as nontraumatic subluxation of the atlantoaxial joint [29]. It is a rare complication that can occur after adenoidectomy (image 1) or other otolaryngologic procedures (tonsillectomy, mastoidectomy). Key features include severe neck pain accompanied by torticollis and pain upon head rotation [30-32]. (See "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation'.)
Hematogenous spread of infection from the posterior-superior pharynx to the cervical spine is thought to initiate the subluxation process. The use of monopolar suction cautery during the adenoidectomy procedure is also a risk factor for Grisel syndrome [33]. Children, particularly those with Down syndrome, have increased laxity of their cervical ligaments, making them more susceptible to this disorder. (See "Down syndrome: Clinical features and diagnosis", section on 'Atlantoaxial instability'.)
Early identification is important to prevent progressive neurologic sequelae from spinal cord injury. Radiologic evaluation is indicated for any patient presenting with severe neck pain and torticollis following surgery. Diagnosis and management of atlantoaxial rotary subluxation are discussed in greater detail separately. (See "Acquired torticollis in children", section on 'Atlantoaxial rotary subluxation'.)
Other causes of neck pain and torticollis — Cervical fasciitis, cervical osteomyelitis, and cervical emphysema are other rare causes of prolonged neck pain and torticollis in children following adenoidectomy [5]. (See "Necrotizing soft tissue infections" and "Vertebral osteomyelitis and discitis in adults".)
Regrowth of adenoids with recurrence of symptoms — The border of the adenoid pad is indistinct, and complete removal is not always obtained, particularly with older techniques, such as curettage without visualization of the nasopharynx [34]. Regrowth of the adenoids may occur, although it is often not of a significant enough degree to warrant repeat surgery [35]. The incidence of repeated adenoidectomy due to recurrent nasal or otologic symptoms following initial adenoidectomy is estimated to be 0.55 to 3 percent [1,34,36,37].
Risk factors for repeated adenoidectomy include young age at the time of the original procedure, an otologic indication for adenoidectomy, presence of gastroesophageal reflux disease, adenoidectomy without tonsillectomy, and need for multiple courses of antibiotics after the original surgery [36,38,39]. In one case-control study, children younger than two years were 5.6 times more likely and children younger than five years were 3.2 times more likely than children older than five years to require repeated adenoidectomy compared with older children [1]. Tubal tonsil hyperplasia can also be the cause of recurrent nasal symptoms following adenoidectomy [37,40].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Tonsillectomy and adenoidectomy in children".)
SUMMARY AND RECOMMENDATIONS
●Recovery and routine postoperative care – The recovery following adenoidectomy is relatively easy compared with the recovery following tonsillectomy alone or tonsillectomy with adenoidectomy. Patients usually go home the day of surgery and only require as-needed, nonnarcotic analgesics for pain relief. There are no dietary restrictions following adenoidectomy. (See 'Postoperative care' above.)
●Complications – Significant complications after adenoidectomy are rare. They may include the following (see 'Complications' above):
•Hemorrhage – Postoperative hemorrhage almost always occurs in the first 24 hours following surgery rather than later. (See 'Postoperative hemorrhage' above.)
•Velopharyngeal insufficiency (VPI). (See 'Velopharyngeal insufficiency' above.)
•Temporomandibular joint dysfunction. (See 'Temporomandibular joint dysfunction' above.)
•Nasopharyngeal stenosis. (See 'Nasopharyngeal stenosis' above.)
•Atlantoaxial rotary subluxation. (See 'Atlantoaxial rotary subluxation (Grisel syndrome)' above.)
•Occasionally, the adenoids regrow due to incomplete removal. Repeat adenoidectomy may be warranted if regrowth is significant enough to cause recurrence of symptoms. (See 'Regrowth of adenoids with recurrence of symptoms' above.)
