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n/a

Document type

Clinical policy

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Hertfordshire and West Essex ICB

Output type

Clinical Policies & Evidence-based Interventions

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Removal of adenoids for treatment of glue ear

v1.0

Policy:

This is a national Evidence Based Intervention policy formally adopted by Hertfordshire and West Essex Integrated Care Board. Please see https://ebi.aomrc.org.uk/

Adenoids are lymphatic tissue that reside in the post-nasal space and arise from the roof of the nasopharynx. Adenoids are only usually present in children and tend to grow from birth, reaching the largest size when a child is between 3 and 5 years of age, before slowly shrinking away by adulthood. When the adenoids are enlarged or inflamed, they may contribute to glue ear (otitis media with effusion), which can affect hearing. They can also cause symptoms of nasal blockage, mouth breathing, obstructive sleep and other upper respiratory tract symptoms (e.g. persistent runny nose).

When children have persistent glue ear that affects hearing, one option for treatment of the hearing loss is with grommet insertions (ventilation tubes) and guidance for this intervention is already set out in the guidance – Grommets for glue ear in children.

In some circumstances, when a child is undergoing surgery to insert grommets, the adenoids may also be partially resected at the same time. This is a short procedure performed via the mouth to remove excessive adenoidal tissue (adenoidectomy) and is most commonly performed either by electrocautery (monopolar suction diathermy), cold steel dissection (curettage), or coblation. The aim of adenoidectomy is to improve eustachian tube function and therefore reduce the recurrence of glue ear after grommets fall out.

This guidance applies to children aged under 12 years of age.

This policy should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Criteria:

When planning grommet surgery for the management of glue ear, consider adjuvant adenoidectomy unless assessment indicates an abnormality with the palate.

Adjuvant adenoidectomy for the treatment of glue ear can be considered if:

• The child is undergoing grommet surgery for treatment of hearing loss due to glue ear.
  
  
• The child is undergoing surgery for re-insertion of grommets due to recurrence of previously surgically treated glue ear.
  
  
• The benefits and risks of adenoidectomy has been discussed with the child and their family or carers, and a shared decision has been made on whether to have the procedure. Including that there is a risk of haemorrhage, and velopharyngeal insufficiency. 
  
  

This guidance only refers to children undergoing adenoidectomy for the treatment of glue ear and should not be applied to other conditions where adenoidectomy should continue to be routinely funded:

 

• As part of treatment for obstructive sleep apnoea or sleep disordered breathing in children (e.g. as part of adenotonsillectomy).
  
  
• As part of the treatment of chronic rhinosinusitis in children.

• For persistent nasal obstruction in children and adults with adenoidal hypertrophy.
  
  
• In preparation for speech surgery in conjunction with the cleft surgery team.
   

Please see the accompanying guidance: Grommets for glue ear in children.

Rationale for Recommendation

NICE guidance recommends that adjuvant adenoidectomy can be considered when planning grommet surgery. The most important outcome in children with glue ear for measuring the effectiveness of an intervention is the improvement in hearing. There is some evidence that adenoidectomy with or without unilateral or bilateral grommets reduced the presence or persistence of glue ear. Experts agree that if adenoidectomy improves the glue ear, it may also have beneficial effects on hearing.

Adjuvant adenoidectomy is considered a low-risk procedure and if someone is already having general anaesthesia for grommets, the added risk of doing adenoidectomy at the same time is likely to be very small.

Risks include the increased length of surgery, damage to teeth, lips or gums, bleeding (usually only minor and self-resolving), and rarely (around 1%) velopharyngeal insufficiency (VPI). VPI can result in speech problems such as hypernasal speech or audible escape of air out of the nose when talking and in some cases can cause nasal regurgitation.

In those with an abnormality of the palate, adenoidectomy is likely to lead to velopharyngeal insufficiency or nasal regurgitation, and so this procedure is not likely to be appropriate for this group.

Patient Information

Information for Patients
Adenoids are lumps of tissue at the back of a child’s throat. They may occasionally need to be removed at the same time as an operation to help relieve a condition called glue ear, where the middle ear becomes filled with sticky fluid. In this operation, tubes to drain fluid from the middle ear (grommets) are inserted into the ear.

About the condition
Adenoids are usually only present in children. They reach their largest size between the ages of 3-5 years old and then they slowly shrink away. Sometimes adenoids become large and inflamed and this may contribute to glue ear. Glue ear can affect a child’s hearing. Adenoids may also cause other symptoms such as frequent congestion in the nose. A child with glue ear may benefit from their adenoids being removed during the same operation as inserting the grommets.

What are the BENEFITS of the intervention?
Removing the adenoids may help to improve hearing in children with glue ear.  

What are the RISKS?
Removing adenoids is generally considered to be a low–risk procedure. However, risks include damage to teeth, lips or gums, bleeding or very rarely changes in speech. There are also risks because of the slightly increased time it takes to remove the adenoids during the operation to insert the grommets.  

What are the ALTERNATIVES?
Grommets can be inserted without removing a child’s adenoids. There is no long-term difference in the hearing ability of children who do not have their adenoids removed compared to those who have them removed while grommets are inserted. You can discuss any questions you may have with your child’s doctor to help you make a decision.  

What if you do NOTHING?
Adenoids tend to shrink after the ages of 3-5 years old. Any contribution of the adenoids to a child’s glue ear or hearing should resolve naturally as they grow up.

Further information can be found at https://ebi.aomrc.org.uk/interventions/removal-of-adenoids-for-treatment-of-glue-ear/ This weblink was correct as of 31/12/2024.

References

1. NICE guidance [NG233] (2023) Otitis media with effusion in under 12s. https://www.nice.org.uk/guidance/ng233 . 
2. NICE guideline NG233 Evidence Review [F] (2023) Otitis media with effusion in under 12s [F] Evidence reviews for adenoidectomy for children with otitis media with effusion (OME). https://www.nice.org.uk/guidance/ng233/evidence/f-adenoidectomy-for-children-with-ome-pdf-13133198707
3. MacKeith S, Mulvaney CA, Galbraith K, Webster KE, Paing A, Connolly R, Marom T, Daniel M, Venekamp RP, Schilder AGM. Adenoidectomy for otitis media with effusion (OME) in children. Cochrane Database of Systematic Reviews 2023, Issue 10. Art. No.: CD015252. DOI: 10.1002/14651858.CD015252.pub2 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015252.pub2/full
4. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: Otitis media with effusion executive summary (update). Otolaryngol Head Neck Surg. 2016;154(2):201-214. doi: 10.1177/0194599815624407.