Removal of adenoids for treatment of glue ear
Best practice guidance
Summary
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 EBI guidance published in November 2018 – ‘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 18 years and under.
Recommendation
Adjuvant adenoidectomy should not be routinely performed in children undergoing grommet insertion for the treatment of otitis media with effusion.
Adjuvant adenoidectomy for the treatment of glue ear should only be offered when one or more of the following clinical criteria are met:
- The child has persistent and / or frequent nasal obstruction which is contributed to by adenoidal hypertrophy (enlargement)
- The child is undergoing surgery for re-insertion of grommets due to recurrence of previously surgically treated otitis media with effusion
- The child is undergoing grommet surgery for treatment of recurrent acute otitis media.
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.
Rationale for recommendation
NICE guidance recommends that adjuvant adenoidectomy should not be performed for the treatment of glue ear in the absence of persistent and / or frequent upper respiratory tract symptoms. A recent systemic review demonstrated that whilst adjuvant adenoidectomy resulted in an improvement in resolution of the glue ear at 6 and 12 months compared to grommets alone, the benefit in hearing compared to grommets alone was very limited.
Adjuvant adenoidectomy is considered a low risk procedure but does increase the length of surgery compared to inserting grommets alone. Risks include 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.
If there is a history of cleft palate or palpable palate abnormality such as submucous cleft palate or a history of speech problems before the operation; full multidisciplinary assessment should be carried out before adenoidectomy.
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. However, for most children, removing their adenoids during the glue ear operation may cause more harm than good.
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. If a child has certain other persistent symptoms as well as glue ear, then it may benefit them to remove their adenoids during the same operation as inserting the grommets.
What are the BENEFITS of the procedure?
Most children do not need their adenoids removed when grommets are inserted. However, in a few cases, removing the adenoids may help to improve certain symptoms.
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.
Coding
Code script
WHEN apcs.der_procedure_all like '%E20[1489]%’
AND apcs.der_procedure_all like '%D151%’
AND der.Spell_Primary_Diagnosis like 'H65[2349]%'
AND not (apcs.der_diagnosis_all like '%G473%’
OR apcs.der_diagnosis_all like '%J32[0123489]%’
OR apcs.der_diagnosis_all like '%J352%’
OR apcs.der_diagnosis_all like '%Q35[13579]%’
OR apcs.der_diagnosis_all like '%Q37[01234589]%’)
AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date)<=18
AND APCS.Admission_Method not like ('2%’)
THEN '2D_adenoid_removal'
Code Definitions
Procedure codes (OPCS)
Main
E201 Total adenoidectomy
E204 Suction diathermy adenoidectomy
E208 Other specified operations on adenoid
E209 Unspecified operations on adenoid
D151 Myringotomy with insertion of ventilation tube through tympanic membrane (coded in addition to E20-)
Diagnosis codes (ICD)
Inclusion
H652 Chronic serous otitis media
H653 Chronic mucoid otitis media
H654 Other chronic nonsuppurative otitis media
H659 Nonsuppurative otitis media, unspecified
Exclusion
G473 Sleep apnoea
J320 Chronic maxillary sinusitis
J321 Chronic frontal sinusitis
J322 Chronic ethmoidal sinusitis
J323 Chronic sphenoidal sinusitis
J324 Chronic pansinusitis
J328 Other chronic sinusitis
J329 Chronic sinusitis, unspecified
J352 Hypertrophy of adenoids
Q351 Cleft hard palate
Q353 Cleft soft palate
Q355 Cleft hard palate with cleft soft palate
Q357 Cleft uvula
Q359 Cleft palate, unspecified
Q370 Cleft hard palate with bilateral cleft lip
Q371 Cleft hard palate with unilateral cleft lip
Q372 Cleft soft palate with bilateral cleft lip
Q373 Cleft soft palate with unilateral cleft lip
Q374 Cleft hard and soft palate with bilateral cleft lip
Q375 Cleft hard and soft palate with unilateral cleft lip
Q378 Unspecified cleft palate with bilateral cleft lip
Q379 Unspecified cleft palate with unilateral cleft lip
Potential
H661 Chronic tubotympanic suppurative otitis media
H662 Chronic atticoantral suppurative otitis media
H663 Other chronic suppurative otitis media
H664 Suppurative otitis media, unspecified
H669 Otitis media, unspecified
H670 Otitis media in bacterial diseases classified elsewhere
H671 Otitis media in viral diseases classified elsewhere
H678 Otitis media in other diseases classified elsewhere
H681 Obstruction of Eustachian tube
H698 Other specified disorders of Eustachian tube
H699 Eustachian tube disorder, unspecified
Additional Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3[789]%' and apcs.der_diagnosis_all not like '%D4[012345678]%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’
References
- NICE Clinical guidance (2008) Otitis media with effusion in under 12s [CG60].
- 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.
- Schilder AG, Marom T, Bhutta MF, et al. Panel 7: Otitis media: Treatment and complications. Otolaryngol Head Neck Surg. 2017;156(4_suppl):S88-S105. doi: 10.1177/0194599816633697.
- Van dA, Schilder A, Herkert E, Boonacker C, Rovers MM. Adenoidectomy for otitis media in children. Cochrane Database of Systematic Reviews. 2010(1). doi: 10.1002/14651858. CD007810.pub2.
How up to date is this information?
Last revised December 2023
Changes
December 2023 - Coding updated August 2022 – Coding updated
Review Date
