Reviewed on : 12 Nov 2024

Reviewed by : GP Gateway Editor

Expires : 12 Nov 2026

1. Category: Threshold

Threshold procedures and therapies are those in which a clinical threshold has been set which needs to be met before funding will be made available for treatment

For patients who DO NOT meet the eligibility criteria, the ICB will only consider funding the treatment if an Individual Funding Request (IFR) detailing the patient’s clinical presentation is submitted to the ICB

2. Background

This policy is based on NHS England’s Evidence-Based Interventions (EBI) recommendations see link to programme below – accurate at the point of publication: https://ebi.aomrc.org.uk/interventions/removal-of-adenoids-for-treatment-of-glue-ear/

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’. ICB policy can be found here Document Library – Happy Healthy Lives

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 policy applies to children aged 18 years and under

3. Indication

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

4. Eligibility Criteria/ Commissioning position

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) OR
• The child is undergoing surgery for re-insertion of grommets due to recurrence of previously surgically treated otitis media with effusion OR
• The child is undergoing grommet surgery for treatment of recurrent acute otitis media.

This policy 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

For patients who DO NOT meet the eligibility criteria, the ICB will only consider funding the treatment if an Individual Funding Request (IFR) detailing the patient’s clinical presentationis submitted to the ICB

5. Guidance/References

https://ebi.aomrc.org.uk/interventions/removal-of-adenoids-for-treatment-of-glue-ear/NICE Clinical guidance (2008)

Otitis media with effusion in under 12s [CG60]surgery:https://www.nice.org.uk/Guidance/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.

Myringotomy with or without Grommets

Prior approval from the CCG is be required before any treatment proceeds in secondary care. 

Refer to Secondary Care provider via RSS using the appropriate Prior Approval Referral Form.

Surgical treatment will only be supported in accordance with the care pathway for children with suspected otitis media with effusion (OME) in NICE Clinical Guideline CG60 (February 2008) on “Surgical Management of Otitis media with effusion in Children” Ref: http://guidance.nice.org.uk/CG60.

Referral Criteria

Section a

• The child has had a specialist audiology and ENT assessment AND
• The child has had persistent bilateral OME documented over a period of 3 months
• AND one of the following:

1) The child has a hearing level in the better ear of 25-30 or worse averaged at 0.5, 1, 2 & 4kHz OR

2) The child has persistent bilateral OME with hearing loss less than 25-30dbHL where the impact of hearing loss on a child’s developmental, social or educational status is judged to be significant OR

3) The child’s worse ear averaged at 0.5, 1,2 and 4 kHz (or equivalent dBA where dNHL not available)

Section b

The child cannot undergo standard assessment of hearing thresholds where there is clinical and tympanographic evidence of persistent glue ear and where the impact of the hearing loss on a child’s development, social or educational status is judged to be significant.

Section c

The child has Down’s Syndrome or Cleft Palate and has had a specialist MDT assessment in line with NICE guidance.