The tonsils are located in the back of the mouth on each side. The adenoid is in the back of the nose. The tonsils can be seen by looking in the mouth, but the adenoids usually cannot be seen on routine exam. Evaluating the adenoid usually requires passing an endoscope through the nose, using a mirror in the back of the mouth or obtaining an x-ray.
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The tonsils and adenoid are lymphoid tissue and part of the immune system, but their role is limited. Removing them does not weaken the immune system. Instead, their removal may actually reduce the frequency of illnesses in some children.
Removal is considered when they are excessively enlarged or frequently infected. They do not need to be infected to get enlarged. In fact, children often have obstructive problems from enlarged tonsils and adenoids without ever having had sore throats or "strep throat."
Tonsillitis refers to an infection of the tonsil but does not specify the cause of the infection. One type of bacteria that causes tonsillitis is called strep. As such, strep throat is just one type of tonsillitis.
Since the tonsils are located in the back of the mouth, the main symptom is sore throat. Sometimes the pain is severe enough that children will only eat food that is easy to swallow. Fever, headache, and stomach ache are additional symptoms that may be present. The tonsils tend to become swollen and inflamed while the lymph nodes in the neck become enlarged and tender. White spots may also appear on the tonsils. An important factor in diagnosing tonsillitis is that nasal drainage, cough, and hoarseness are not present. These symptoms are more consistent with a cold or upper respiratory infection, not tonsillitis.
Tonsillitis is diagnosed based on the child’s symptoms and exam. The rapid strep test or strep culture may indicate that this bout of tonsillitis is being caused by the bacteria strep. Determining whether the tonsillitis is caused by strep is important in deciding whether your child needs a penicillin shot or other antibiotic. On the other hand, a specific diagnosis of strep tonsillitis (i.e. strep throat) is not necessary when determining the potential benefit of tonsil surgery. Instead, consideration for tonsillectomy is based on the frequency and severity of each tonsillitis episode, regardless the strep results.
An exact number cannot be specified as it must be determined on an individual basis. One study did show a benefit of tonsil removal when children had had seven episodes of tonsillitis in one year, five episodes a year for two years, or three episodes a year for three years. In addition to the frequency of infections, the severity of symptoms with each episode should be considered. If a child is having moderate to severe symptoms that respond slowly to antibiotics and cause an excessive number of missed school days, then surgery may be offered with even fewer episodes than specified above.
The adenoids are similar to tonsils, just in a different location. They may become infected as frequently as the tonsils. As such, removal of the adenoids is sometimes performed at the same time as tonsillectomy.
Problems may include:
Snoring is one sign because it results from breathing through a passageway that is too small. On the other hand, snoring alone does not require tonsil and adenoid surgery. The additional signs of worrisome obstructive sleep include:
Overall, children with significant obstructive sleep problems have a restless sleep during which they appear to struggle to breathe.
A sleep study can be performed in the hospital or a sleep lab which records numerous aspects of sleep including breathing pattern, oxygen level, heart rhythm and brain waves. By measuring these parameters, the presence and severity of obstructive sleep apnea can be determined. A formal sleep study is a reasonable consideration if uncertainty exists regarding the degree of a child’s obstructive sleep problems. On the other hand, if a parent describes a sleeping pattern consistent with significant obstruction, most physicians will proceed directly with tonsillectomy and adenoidectomy based solely on parental observations without a sleep study.
Children with obstructive sleep may experience excessive daytime sleepiness including fatigue and may fall asleep at inappropriate times. In actuality, the more common daytime consequence of children’s poor sleep quality is irritability and poor concentration, not tiredness. They tend to be cranky. They can have difficulty concentrating resulting in poor school performance. Admittedly, to determine whether poor behavior and school performance is more due to sleep issues or other factors is difficult.
Children may be slow eaters and refuse certain foods due to the difficulty in chewing and breathing at the same time. They may have difficulty swallowing and occasional choking. In addition, they may have a poor appetite due to diminished senses of smell and taste resulting from poor airflow through the nose.
Delayed growth can be caused by associated eating problems. Delayed growth can also result from disrupted sleep because growth hormone is predominantly produced during deep sleep. In addition to these growth issues, severe obstructive sleep apnea can, on rare occasions, lead to heart and lung problems.
Enlarged adenoids, allergies, sinus infections and colds can all cause nasal obstruction. Determining which one is the cause of the obstruction can be difficult. In general, enlarged adenoids cause constant nasal obstruction without significant discharge. In contrast, nasal obstruction from allergies may fluctuate based on different seasons, locations and activities. Allergies often cause other symptoms in addition to nasal obstruction including clear discharge and itchy nose and eyes. Nasal obstruction from sinus infections and colds occurs when the child is sick and is associated with infected secretions.
Their enlargement leads to chronic mouth-breathing which may result in abnormal facial development, misalignment of the teeth, and tooth discoloration. Admittedly, not all children with these enlarged tissues develop a poor bite requiring orthodontic work. Orthodontists have differing opinions on the need for tonsil and adenoid removal to prevent or assist with dental braces.
Prior to surgery, there is no routine need for blood test and no starting of IV's. The child is given a relaxing medication before going back to the operating room which minimizes separation anxiety from the parents. Once in the operation room, the child goes off to sleep by breathing an anesthetic gas and then the IV is inserted.
Both are removed through the mouth without any external incisions. The instruments used to remove them vary between surgeons because none has been proven to be consistently safer, less painful and more cost-effective than another. Bleeding is usually minimal and easily controlled with electrocautery, not sutures. The time in the operating room is typically less than one hour.
A parent is allowed to go back to the recovery room once the child is becoming more alert. The child is initially upset and disoriented but soon settles down. He/she remains at the surgical facility for at least a few hours after surgery to ensure that there are no problems with pain, nausea, bleeding or breathing. If a child is having any such difficulties, or if the child is under three years old, then he/she may be admitted to a hospital overnight for observation.
Tonsillectomy and adenoidectomy has an excellent chance of eliminating obstructive sleep problems. If a child has fatigue, irritability, or concentration problems due to poor sleep quality, then these problems can also be improved. A child may eat better and gain weight after tonsillectomy and adenoidectomy. In addition, the surgery often allows a child to breathe better through the nose which potentially can help with normal facial and dental development. Although removal has multiple potential benefits, these benefits cannot be guaranteed in every case.
The main risk associated with tonsillectomy is bleeding. Scabs form where the tonsils are removed. These scabs fall off after approximately one week and can lead to bleeding. Stopping the bleeding may require going back to the operating room. Even in the cases of rebleeding, needing a transfusion or choking on the blood is extremely rare. Other uncommon risks of tonsillectomy include teeth injury, taste disturbance, and cautery burns.
The main risk associated with adenoidectomy is a change in voice quality. Adenoidectomy opens more space behind the nose which allows more air into the nose while talking, possibly resulting in a high-pitched, squeaky voice. While a temporary nasal voice is common, a permanent voice problem is rare. Another uncommon risk of adenoidectomy is troublesome scarring.
Dehydration can occur during recovery due to poor pain control. The duration and severity of pain varies among children. In general, the pain lasts approximately one week and can be controlled with medications. On rare occasions, the discomfort prevents adequate fluid intake, requiring a return to the hospital for intravenous (IV) fluids. Dehydration requiring intravenous fluids can also result from persisting nausea and/or vomiting.
The risks of general anesthesia are often parents’ main concern. While life-threatening problems can occur, the chance is exceptionally low. In a healthy child, the risk involved with general anesthesia is equivalent to the risk associated with a long distance car trip.
Since the surgery is performed in an operating room, costs include fees from the surgeon, anesthesiologist and surgical facility. Fortunately, these charges are usually covered by insurance. We will assist you in trying to obtain insurance approval. Even with insurance approval, you will be responsible for any deductibles, co-insurance, or co-payments.
Antibiotics are unlikely to permanently reduce the size of these tissues. Daily use of a nasal steroid spray may reduce the size of adenoids, but not tonsils. Medical treatment of any associated allergies or chronic sinus infections may improve nasal breathing and sleep quality, but probably will not affect their size.
Watchful waiting may be a reasonable alternative, as they typically get smaller as the child gets older. They usually are at maximum size around six years of age and have substantially reduced in size by around 12 years. Adult snoring and sleep apnea are seldom due to enlarged tonsils and adenoids. The issue usually is not whether the child will outgrow the problem. Instead, the issue is the impact on the child’s quality of life while waiting for conditions to improve. The other concern is any long-term consequences on the heart, lung, or facial development.
The decision to proceed with surgery always involves weighing the potential benefits against the possible complications, postoperative recovery issues, and financial costs. We will only recommend tonsillectomy and adenoidectomy if we feel the potential advantages outweigh the disadvantages. Regardless, only you can determine if your child’s obstruction and associated symptoms are bothersome enough to warrant the risks, discomfort, and costs of surgery. Clinical studies do substantiate that the vast majority of parents are pleased with the results from their child’s surgery and would do it again.
Ear, nose, and throat doctors who specialize in tonsil and adenoid care are available in CEENTA's offices in both North and South Carolina.