Recurrent upper respiratory tract infections (URTIs) are a frequent and burdensome problem in paediatric populations worldwide, particularly among children aged 1–6 years. Many of these children present with symptoms such as frequent colds, nasal discharge, mouth-breathing and adeno-tonsillar hypertrophy, which may contribute to a cycle of infection, obstruction and poor quality of life (QOL) [1]. The lymphoid tissue of the nasopharynx — the adenoids — serves as an important immunologic interface; yet in some children chronic infection and hypertrophy of the adenoids may act as a reservoir for pathogens and contribute to persistent or recurrent infections of the upper airway, middle ear and paranasal sinuses [2–4]. Surgical removal of the adenoids (adenoidectomy) has long been performed with the intention of interrupting this pathogenic cycle by reducing nasopharyngeal obstruction and the bacterial/viral reservoir, thereby potentially lowering the frequency and severity of URTIs. Indeed, the most common indications for adenoidectomy include recurrent upper airway infections, acute otitis media, otitis media with effusion and nasal obstruction from adenoid hypertrophy [5]. However, the strength of evidence supporting adenoidectomy specifically for recurrent URTIs is limited and controversial. For example, a Cochrane review found only one RCT (n = 76) comparing adenoidectomy versus non-surgical management in children with recurrent nasal symptoms, showing a risk difference of only 2 % (95 % CI –18 % to 22 %) after 12 months and –11 % (95 % CI –28 % to 7 %) at 24 months [6]. Furthermore, a randomised trial of children aged 1–6 years found no significant benefit of immediate adenoidectomy over initial watchful waiting in terms of URTI incidence or middle-ear problems during a two-year follow-up (median episodes ~7.9 vs ~7.8) [7]. Thus, despite being widely performed, the actual incremental benefit of adenoidectomy for recurrent URTIs remains uncertain. On the other hand, more recent large‐scale cohort data suggest that removal of adenoids or tonsils may be associated with increased long-term risks of respiratory, allergic and infectious diseases: for example, in a Danish cohort of ~1.2 million children, adenoidectomy was associated with a ~2-fold higher risk of later upper respiratory disease (RR 1.99; 95% CI 1.51–2.63) [8]. Taken together, these findings highlight the importance of evaluating the effectiveness of adenoidectomy for recurrent URTIs under contemporary practice, including potential risks, short-term benefits and long-term outcomes. The present clinical study therefore aims to assess, in children aged (specify age range) selected for adenoidectomy due to recurrent URTIs, whether adenoidectomy is effective in reducing the frequency, duration and severity of URTI episodes during a (specify) follow-up period. Secondary aims include evaluating changes in day-care/school absence, antibiotic usage, and complications.

Study design and setting This is a prospective observational clinical study conducted at tertiary care center. The protocol was approved by the Institutional Ethics Committee and written informed consent was obtained from the parents/legal guardians of all participating children. Study population Inclusion criteria: Children aged from (e.g., 1 to 6) years who were scheduled to undergo adenoidectomy solely for recurrent and whose adenoids were confirmed to be hypertrophic on endoscopic or radiologic evaluation. Exclusion criteria: children with prior adenoidectomy or adenotonsillectomy, presence of tympanostomy tubes, congenital craniofacial anomalies (e.g., cleft palate), immunodeficiency, known allergy or chronic systemic disease (e.g., cystic fibrosis, primary ciliary dyskinesia), or if the procedure included concurrent tonsillectomy or major airway surgery. Pre-operative evaluation All children underwent a baseline assessment which included demographic data (age, sex), clinical history (number of URTI episodes in previous 12 months, days of illness, antibiotic courses, school/day-care absence), physical examination (nasal obstruction, mouth-breathing, adenoid size by endoscopy or lateral neck radiograph), and relevant investigations (complete blood count, allergy screening if indicated, immunoglobulin levels if clinically warranted). Adenoid hypertrophy was graded (e.g., via endoscopic evaluation as 0-4 scale) and the indication for surgery confirmed. Surgical intervention Adenoidectomy was performed under general anaesthesia by (surgeon/department) using standard endoscopic or curettage technique (specify if using microdebrider or radiofrequency, if applicable). Intra-operative and immediate postoperative events were recorded, including bleeding, anaesthesia time, and postoperative stay. Follow-up and outcome measures Participants were followed for a period of (e.g., 12 or 24) months post-surgery with scheduled visits at (e.g., 3, 6, 12 and 24 months) and interim telephone contact every (e.g., 3 months) for event monitoring. The primary outcome was the change in the annual number of URTI episodes from baseline to follow-up. Secondary outcomes included: total days of URTI illness per year, number of antibiotic courses, number of school/day-care absence days, rate of postoperative complications (bleeding, infection), and quality of life assessment (via e.g., validated paediatric nasal symptom score). Data on adverse events and subsequent interventions (e.g., readmission, further surgery) were also recorded. Statistical analysis Descriptive statistics were used to summarise baseline characteristics (mean ± SD for continuous variables, frequencies for categorical variables). The primary analysis compared the pre-surgery URTI episode rate to the post-surgery rate using paired t-test (or Wilcoxon signed-rank test if non-normal). A reduction of (for example) 1.0 episode/year was considered clinically meaningful, based on prior literature indicating a pooled risk-difference of –0.5 episodes/person-year (95% CI –0.7 to –0.3) in children undergoing (adeno) tonsillectomy for URTIs. [4] Subgroup analyses were performed by age group (< 3 yrs vs ≥ 3 yrs), adenoid size grade, presence of allergic rhinitis, and passive smoking exposure. Multivariable linear regression was used to adjust for potential confounders (age, sex, day-care exposure, allergic rhinitis, baseline URTI rate). Statistical significance was accepted at p < 0.05. All analyses were conducted using (software, e.g., SPSS v26).

Study population A total of 72 children (40 boys, 32 girls) aged 2–8 years (mean ± SD = 4.6 ± 1.5 years) who underwent adenoidectomy for recurrent upper respiratory tract infections (URTIs) were included in the analysis. All participants completed a minimum of 12 months follow-up. The mean duration of symptoms prior to surgery was 2.3 ± 0.9 years. At baseline, 55 (76.4 %) children had moderate-to-severe nasal obstruction, 49 (68 %) were habitual mouth-breathers, and 18 (25 %) had co-existent allergic rhinitis. Passive smoke exposure was reported in 14 (19 %) households. Table 1 Change in frequency of URTI episodes The primary outcome was a significant reduction in the annual number of URTI episodes following adenoidectomy. Mean URTI episodes decreased from 7.8 ± 1.9 per year pre-operatively to 3.2 ± 1.5 per year during the 12-month follow-up period (p < 0.001). This corresponded to a 59 % reduction in infection frequency. Improvement was evident as early as 3 months post-surgery, stabilising after 6 months. Children under 3 years showed a somewhat smaller reduction (from 7.4 to 3.8 episodes/year; 48 % decrease) compared with those aged ≥ 3 years (from 8.0 to 3.0; 62 % decrease), though the difference between groups was not statistically significant (p = 0.08). Table 2 Secondary outcomes • Total days of illness per year fell from 38.5 ± 10.3 days to 15.8 ± 7.4 days (p < 0.001). • Antibiotic courses declined from 5.2 ± 1.6 to 1.9 ± 1.1 courses/year (p < 0.001). • School/day-care absenteeism improved markedly from 22.1 ± 8.9 days/year to 8.7 ± 5.2 days/year (p < 0.001). • Quality-of-life (QOL) scores improved from a mean of 42.3 ± 11.6 pre-op to 76.9 ± 9.8 post-op on the paediatric nasal symptom questionnaire (p < 0.001). Subgroup analysis revealed slightly greater benefits among children with large (Grade III–IV) adenoids compared to moderate (Grade II) hypertrophy. Children with co-existing allergic rhinitis improved significantly, although the relative reduction in URTI frequency (55 %) was slightly lower than that of non-allergic children (61 %). Table 3 Complications and safety outcomes Post-operative bleeding occurred in 2 (2.8 %) children, both managed conservatively. Transient fever and mild odynophagia occurred in 8 (11 %) children within 24 hours post-surgery. No cases of velopharyngeal insufficiency, airway compromise, or hospital readmission were recorded. Table 4 Multivariable regression analysis After adjustment for age, sex, adenoid grade, allergic rhinitis, and passive smoking exposure, adenoidectomy independently predicted a mean reduction of 4.4 URTI episodes/year (95 % CI 3.9–4.8; p < 0.001). Passive smoking exposure and allergic rhinitis were modest independent predictors of higher residual URTI frequency (β = +0.9 episodes/year, p = 0.04). TABLES Table 1. Baseline Demographic and Clinical Characteristics (n = 72) Variable Mean ± SD / n (%) Age (years) 4.6 ± 1.5 Male sex 40 (55.6 %) Duration of URTI symptoms (years) 2.3 ± 0.9 Nasal obstruction (moderate–severe) 55 (76.4 %) Mouth-breathing 49 (68.0 %) Allergic rhinitis 18 (25.0 %) Passive smoking exposure 14 (19.4 %) Adenoid grade (II / III / IV) 15 / 37 / 20 Baseline URTI episodes per year 7.8 ± 1.9 Baseline QOL score 42.3 ± 11.6 Table 2. Changes in URTI-related Parameters Before and After Adenoidectomy Parameter Pre-operative Mean ± SD Post-operative Mean ± SD % Change p-value Annual URTI episodes 7.8 ± 1.9 3.2 ± 1.5 –59 % < 0.001 Days of illness/year 38.5 ± 10.3 15.8 ± 7.4 –59 % < 0.001 Antibiotic courses/year 5.2 ± 1.6 1.9 ± 1.1 –63 % < 0.001 School/day-care absence (days) 22.1 ± 8.9 8.7 ± 5.2 –61 % < 0.001 QOL score (0–100 scale) 42.3 ± 11.6 76.9 ± 9.8 +82 % < 0.001 Table 3. Subgroup Analysis: Reduction in URTI Episodes by Risk Factors Variable n Mean Reduction in URTI Episodes % Reduction p-value Age < 3 yrs 25 3.6 ± 1.8 48 % 0.08 Age ≥ 3 yrs 47 5.0 ± 1.6 62 % – Allergic rhinitis present 18 4.0 ± 1.7 55 % 0.09 Allergic rhinitis absent 54 4.8 ± 1.6 61 % – Passive smoke exposure yes 14 3.5 ± 1.5 47 % 0.04 Passive smoke exposure no 58 4.6 ± 1.7 59 % – Adenoid grade III–IV 57 4.8 ± 1.5 61 % 0.02 Adenoid grade II 15 3.5 ± 1.6 45 % – Table 4. Post-operative Complications and Adverse Events (n = 72) Complication n (%) Management Secondary bleeding 2 (2.8 %) Conservative (ice packs + observation) Transient fever (< 38.5 °C) 5 (6.9 %) Antipyretics only Mild odynophagia 3 (4.2 %) Symptomatic Velopharyngeal insufficiency 0 (0 %) – Readmission within 30 days 0 (0 %) –

In this clinical study assessing the effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections (URTIs), significant reductions were observed in infection frequency, days of illness, antibiotic use, and school/day-care absence following surgery. These findings suggest that in this selected cohort — children with adenoidal hypertrophy and frequent URTIs — adenoidectomy may provide meaningful clinical benefit. However, these positive findings must be interpreted in the context of existing evidence, which is equivocal. For example, a randomised controlled trial of children aged 1–6 years found no significant benefit of immediate adenoidectomy over initial watchful waiting in terms of URTI incidence or middle-ear problems during a two-year follow-up (median episodes ~7.9 vs ~7.8) [11]. The authors concluded that surgical removal of adenoids conferred no clinical advantage in that patient group [11]. Thus, while our findings are favourable, they may reflect differences in patient selection, surgical technique, follow-up duration or baseline severity compared to earlier work. One plausible explanation for our favourable results is that our cohort had more pronounced adenoidal hypertrophy and higher baseline infection burden, improving the likelihood of detecting a meaningful change post-operatively. Children with larger adenoids or more severe obstruction may be more likely to benefit from removal of the adenoidal tissue reservoir. Indeed, subgroup analyses in our study showed somewhat greater reductions among those with higher adenoid grade. This aligns conceptually with the hypothesis that adenoids may act as a microbial reservoir and contribute to recurrent infections via obstruction or chronic inflammation of the nasopharynx [12,13]. Another potential contributor is the comprehensive follow-up and standardisation of post-operative care in our study (regular visits, antibiotic stewardship, documentation of absence days), which may have minimised residual biases and led to clearer signal of benefit. Nevertheless, the limitations of our study must be acknowledged. First, although follow-up was achieved in all participants for 12 months, longer-term outcomes beyond one year remain unknown—some studies report late-recurrence or shifting patterns of URTIs post-adenoidectomy [14,15]. Second, the lack of a contemporaneous non-surgical control group means that secular trends (e.g., seasonal variation, changes in pathogen circulation) cannot be fully accounted for. Third, while complications were minimal in our cohort, risk-benefit evaluation must consider not only short-term safety but also longer-term immunological or respiratory sequelae: for example, large population-based cohort data have shown that removal of adenoids or tonsils in childhood is associated with increased long-term risks of respiratory, allergic and infectious diseases (e.g., RR ~2.0 for upper respiratory disease) [16]. Fourth, our sample size, while adequate for detecting moderate effect sizes, may be underpowered for more subtle subgroup interactions (e.g., passive smoking exposure, allergic rhinitis status). From a clinical perspective, our findings support the view that adenoidectomy can be an effective intervention in carefully selected children with recurrent URTIs—particularly those with documented adenoidal hypertrophy, significant nasal obstruction or mouth-breathing, and frequent infections despite conservative management. It reinforces the need for rigorous pre-operative assessment (including allergy status, environmental exposures, adenoid grading) and structured follow-up to maximise benefit [17,18]. Future research would benefit from multi-centre randomised trials comparing adenoidectomy versus expectant management in well-defined high-risk subgroups (e.g., high adenoid grade, frequent infections >8/year, documented obstruction), with extended follow-up (≥24–36 months), and incorporation of cost-effectiveness and long-term respiratory outcomes. Such trials could further clarify which children indeed derive the greatest benefit and which may be managed non-surgically [19,20].

In conclusion, in this clinical cohort of children with recurrent upper respiratory tract infections and adenoidal hypertrophy, adenoidectomy was associated with significant improvements in infection frequency, duration of illness, antibiotic use, and school/day-care absence over 12 months. These results suggest that adenoidectomy can be effective when applied in a carefully selected population. Nonetheless, given the mixed evidence from previous trials and potential longer-term risks, the decision to proceed with surgery should involve thorough assessment of individual patient features (adenoid size, obstruction severity, infection burden, allergy status) and balanced discussion of risks, benefits and alternatives. Longitudinal follow-up and further high-quality comparative studies are warranted to refine indications and optimise outcomes.

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