Adenoidectomy in children: Postoperative care and complications

INTRODUCTION — Adenoidectomy is a common pediatric surgical procedure that is performed alone or in conjunction with tonsillectomy.

This topic reviews postoperative care and complications following adenoidectomy in children.

Related topics include:

●(See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications".)

●(See "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care".)

●(See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications".)

●(See "Tonsillectomy in adults: Indications".)

●(See "Tonsillectomy in adults: Techniques and perioperative issues".)

GENERAL POSTOPERATIVE CARE

●Recovery – 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 severe obstructive sleep apnea (ie, apnea-hypopnea index >5 on polysomnogram), since these factors are associated with increased risk of perioperative respiratory compromise [1]. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'High-risk populations'.)

●Mild pain – 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 also have neck pain that can last for several days to a few weeks [2]. Occasionally, a child will complain of ear pain after surgery. This represents referred pain from the pharynx and can be treated with over-the-counter pain medications.

●Halitosis – Many children will have significant halitosis that can last up to two weeks after surgery. The bad breath is normal after surgery and resolves spontaneously.

●No dietary restrictions – There are no dietary restrictions following adenoidectomy, and most children consume a normal diet within a few days following surgery.

COMPLICATIONS

Postoperative hemorrhage — Bleeding is a rare complication of adenoidectomy. Nearly all cases of significant hemorrhage occur early (within 24 hours after surgery).

●Early (primary) hemorrhage – Primary hemorrhage (also called R1 hemorrhage) after adenoidectomy refers to bleeding from the nose within the first 24 hours following surgery. It is uncommon, with reported rates ranging from 0.1 to 0.8 percent [3-6]. These rates are slightly lower than reported rates of hemorrhage following tonsillectomy.

●Late (secondary) hemorrhage – Late or secondary hemorrhage (also called R2 hemorrhage) is exceedingly rare in children who have undergone adenoidectomy [3,6]; it is far less common than after tonsillectomy.

Postoperative hemorrhage following tonsillectomy (with or without adenoidectomy) is discussed separately. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Hemorrhage'.)

Velopharyngeal insufficiency — VPI is characterized by hypernasal speech and nasal air emission. In severe cases, nasal regurgitation of fluids can occur. VPI is a known complication of adenoidectomy with an estimated incidence of approximately 6 to 8 cases per 10,000 procedures [7,8].

VPI is 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 [9,10]. The poorly functioning palate is no longer able to achieve nasopharyngeal closure with the adenoid tissue removed. In children with a known cleft palate or submucous/occult cleft palate, performing 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 [10-16].

When VPI occurs after adenoidectomy surgery, it is often temporary and resolves within a few weeks [17,18]. Temporary hypernasality is more likely to occur in patients with larger preoperative adenoid size [19].

For patients with hypernasality that persists three months after adenoidectomy, management includes:

●Referral to a speech pathologist [20]. Some children improve with speech therapy alone, while others require additional surgery to enable the child to close his/her velopharyngeal inlet [8,21].

●Testing for DiGeorge (22q11 deletion) syndrome (also called velocardiofacial syndrome [VCFS]). VPI after adenoidectomy is common in children with VCFS, and genetic testing is suggested even if other clinical features of VCFS are absent [17,22]. (See "DiGeorge (22q11.2 deletion) syndrome: Clinical features and diagnosis", section on 'Diagnosis'.)

Temporomandibular joint dysfunction — A mouth gag is used to keep the mouth open during surgery. Rarely, this may cause dysfunction of the temporomandibular joint [23]. Reduced mouth opening is not a common problem following surgery [24].

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 [25-27].

Atlantoaxial rotary subluxation (Grisel syndrome) — Grisel syndrome is defined as nontraumatic subluxation of the atlantoaxial joint [28]. 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 [29-31]. (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 [32]. Children 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 [33]. (See "Necrotizing soft tissue infections" and "Vertebral osteomyelitis and discitis in adults".)

Regrowth of adenoids with recurrence of symptoms — Occasionally, the adenoids regrow due to incomplete removal. Repeat adenoidectomy may be warranted if regrowth is significant enough to cause recurrent symptoms.

The incidence of repeated adenoidectomy due to recurrent nasal or otologic symptoms following initial adenoidectomy is estimated to be 0.6 to 3 percent [34-37].

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 [35].

Risk factors for repeated adenoidectomy include [36,38-40]:

●Young age at the time of the original procedure. In one case-control study, children who underwent surgery at age <2 years were more than five times more likely to require repeated adenoidectomy compared with older children [34].

●An otologic indication for adenoidectomy (eg, otitis media with effusion [OME]).

●Original surgery consisted of adenoidectomy without tonsillectomy.

●Received multiple courses of antibiotics after the original surgery.

●Comorbid gastroesophageal reflux disease.

Tubal tonsil hyperplasia can also be the cause of recurrent nasal symptoms following adenoidectomy [37,41].

Other rare complications — Very rarely, meningitis, cervical osteomyelitis, or brainstem injury may complicate adenoidectomy. Retropharyngeal injection of local anesthetic agents have been implicated [33,42].

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 over-the-counter analgesics for pain relief. There are no dietary restrictions following adenoidectomy. (See 'General postoperative care' above.)

●Complications – Serious complications after adenoidectomy are rare. They may include the following (see 'Complications' above):

•Hemorrhage – Postoperative hemorrhage is uncommon, occurring in <1 percent of surgeries. When hemorrhage occurs, it almost always occurs within the first 24 hours following surgery. (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 recurrent symptoms. (See 'Regrowth of adenoids with recurrence of symptoms' above.)