Early childhood asthma and adenotonsillectomy: From upper airway microbiota to type 2 biomarkers and clinical outcomes.

Abstract

Early childhood asthma is one of the most common chronic diseases in children, and its course may be modified by coexisting upper airway obstruction. It remains uncertain whether adenoidectomy or adenotonsillectomy can improve asthma control or reduce exacerbations in children with asthma and obstructive symptoms. Emerging evidence links asthma phenotype, type 2 inflammatory biomarkers (fractional exhaled nitric oxide, blood eosinophilia, periostin, chitinase) and changes in upper airway microbiota with variable clinical responses to surgery. This narrative review summarises studies evaluating the impact of adenoidectomy and adenotonsillectomy on asthma outcomes in paediatric populations, including secondary analyses of major randomised controlled trials (CHAT, PATS). Across heterogeneous cohort and database studies, surgery is associated with improved symptom control and reductions in hospitalisations and emergency visits in selected children, particularly younger patients with severe obstruction and poorly controlled disease despite pharmacotherapy. A post-hoc analysis of the CHAT trial demonstrated a significant reduction in wheezing after adenotonsillectomy, and a secondary analysis of the PATS trial showed a trend toward improved asthma symptom burden, although neither trial was designed with asthma as a primary endpoint. Conversely, some large population-based analyses suggest a neutral effect or even an increased long-term risk of asthma in specific subgroups, underscoring substantial uncertainty. Critically, no randomised controlled trial has evaluated asthma control or exacerbation rate as a primary outcome after adenotonsillectomy, and overall evidence quality is low to very low. Adenotonsillectomy should therefore be considered a targeted option for a carefully selected subgroup of young children with documented upper airway obstruction and poorly controlled asthma, rather than a routine intervention. Well-designed multicentre prospective studies with standardised asthma endpoints, detailed phenotyping and microbiome and biomarker assessment are needed to clarify which patients derive durable benefit and to define the role of surgery within personalised asthma management.