After the multifactorial causes of rhinosinusitis have been addressed and adequate medical management has continually failed to yield effective responses, the clinician may then consider a more interventional approach to therapy. Adenoidectomy offers promise as a simple, effective, and relatively safe procedure that may affect the sinuses indirectly.75 Clinical trials have shown adenoidectomy to be effective in alleviating symptoms in some patients,76'77 although definite conclusions cannot be drawn, owing to the limited size of these studies. Different theories have been described to explain the relationship between adenoids and the symptoms of chronic rhinosinusitis. One theory is that adenoid hypertrophy with chronic nasal obstruction and stasis may merely mimic signs and symptoms of rhinosinusitis; with adenoidectomy, the effective relief of symptoms may be so great that further aggressive intervention is unneccessary.7,78 Another theory asserts that an adenoidal bed of any size may act as a bacterial reservoir that serves as a nidus for chronic infection.79 Studies have been conducted in which adenoidectomy produced a positive response in pediatric rhinosinusitis patients, in both the presence and absence of adenoid hypertrophy.75,79 To establish a causal relationship, more investigations are needed. Although there is no consensus on the timing of adenoidectomy, it appears to be a reasonable first surgical step before performing functional endoscopic sinus surgery (FESS) in children with chronic rhinosinusitis, regardless of adenoid size75 (see Endoscopic Sinus Surgery, below). Children with overt or submucous cleft palate, however, would not be candidates for adenoidectomy.

Endoscopy may also be performed while the child is anesthetized for adenoidectomy. This allows for assessment of the nasal cavities with particular attention directed to anatomic abnormalities and the patency of the maxillary ostium. Also during thus evaluation, middle meatal cultures may be obtained, although their correlation with sinus bacteriology is still under debate.

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