For over 17 years now, parents and primary caretakers of children of all ages have come to see me to discuss whether their child needs to have his/her tonsils/adenoid tissue removed.
These families are either referred by their friends, neighbors, pediatricians, family physicians, or self-referred after reading information on the internet on why their kid snores, and when to consider having their child’s tonsils and adenoid removed. Here are the most common questions I am asked:
WHAT ARE TONSILS AND ADENOID TISSUE?
Adenoid tissue is a single bed of lymphoid tissue, and just like the tonsils, they are considered a part of our immune system. Research suggests that the adenoid serves to “protect” against bacteria and viruses that human bodies are exposed to through breathing, and this process is especially active in the first few years of life when a toddler may experience frequent colds. In fact, once children reach the age of approximately 10 years this bed of tissue generally shrinks and doesn’t seem to do much. There are ways to predict which child will have an enlarged adenoid, even though families often tell me that a big adenoid “runs” in their family, meaning the parents or someone in the family had it removed during their childhood.
Our immune system is perfectly functional without adenoid or tonsil tissue, and children are not going to get “sick” more often because we remove these tissues.
The adenoid pad is often removed at the same time as tonsil removal surgery, but not necessarily the other way around. Your child should not have anything removed unless it’s clearly indicated. As I tell parents daily, “My job as a surgeon is not to take something out because I can, but because I have to and we have failed all other less invasive options.”
WHERE IS THE ADENOID?
The adenoid pad is located in the very back of the nasal passage, in the center of the head. Adenoid tissue generally can’t be seen by looking into the nostrils, but can be seen using a flexible fiberoptic endoscope (noodle looking camera ENTs use), when it is passed through the nostril straight into the back of the nasal passages.
Newborns do not have enlarged tonsil or adenoid tissues. After the first year of life, as babies are exposed to many viral infections or “colds,” then the adenoid and tonsils can enlarge as a response to such infections.
While not proven, enlargement of adenoid tissue may be due to severe gastroesophageal reflux (GER) or laryngopharyngeal reflux (LPR), or chronic exposure to irritants like nicotine smoke. There may in fact be a genetic predisposition to adenoid tissue becoming enlarged in some children, but currently this is not proven.
HOW WOULD I KNOW IF MY CHILD HAS ENLARGED ADENOID?
Here are some signs and symptoms:
Chronic mouth breathing
If your child always has his/her mouth open, and can’t seem to close their mouth, both when awake and asleep, then it is possible he/she is doing so because they can’t breathe through their nose.
Your child sounds like “Darth Vader”
It is easy to know where your child is because you and everyone else can always hear him/her breathing, and even during awake states he/she may sound like they are breathing heavy or asleep.
He/she eats and chews with their mouth open all the time
Despite your best efforts to teach the good manners of chewing with the mouth closed, your child chews with their mouth open. Your poor kid may not be able to ever close his/her mouth because then he/she would not be able to breathe while eating.
Your child snores terribly!
Significant snoring and/or always mouth-breathing during sleep is not normal and is definitely a concern. During sleep, our bodies are designed to breathe through our nose as it is the only organ which can humidify the air. If the nasal passage is blocked, the body must rely on mouth breathing.
Constant dry mouth in the morning
Even if you never realized your child was a mouth breather all night long, he/she may always complain of dry/sore throat in the morning which results from mouth breathing since the mouth can’t humidify the air.
Your child sounds like he/she has a “cold” ALL THE TIME!
Children who can’t breathe normally through the nose tend to always sound like they are congested. Medically we describe this as “Hypo-Nasality,” which means there is not enough air flow through the nose.
Speech evaluation at school may lead to a diagnosis of “hypo-nasality” or “speech issues”
Assessments at school may bring this to your attention. If your child has difficulty with pronunciation, and/or has speech that is difficult to understand by others, this may be why. Despite speech therapy, these children do not get better until the anatomy is “fixed,” and as soon as normal airflow is established through their nasal passage, their speech will “clear up.”
Chronic runny nose
This is one of the most frustrating things for parents: having a child who always has runny nose with or without congestion, even when he or she is not sick. This is more of a subjective recommendation as research does not prove that removing adenoid tissue guarantees reduced runny noses, especially in toddlers. The scientific data supporting removal of adenoid tissue to get rid of excessive bacteria is the concept of “biofilm.” Any surface area can contact biofilm, and since we all have bacteria living in all parts of our body at all times, our noses are never “sterile.”
History of recurrent “sinus” infection with symptoms including runny nose with thick yellow/green mucous, cough and/or asthma that’s poorly controlled
Sinus infection as a topic deserves another blog by itself, and in fact I have written a blog about it: Top 3 Reasons Your Child's Cough Won't Go Away.
Now, the tonsils: they too are lymphoid tissues, like the adenoid, and seem to also protect against airborne bacteria and viruses by containing B and T cells, which are 2 types of immune cells. The B cell produces the 5 major classes of human immunoglobulin or antibodies which help fight infections. Again, our immune system still works without them. A person is not more likely to get sick or have any long-term problems after tonsils are removed. Research has shown that longevity of life is not affected by presence or absence of tonsils, and despite some measurable differences in lab tests in those with versus without tonsils, clinically people are not different from a health standpoint whether their tonsils are present.
The tonsils are easily seen as round lumps on either side of the uvula, or the “punching bag,” in the back of the throat when you look into someone’s open mouth. While tonsils and adenoid tissue are similar lymphoid tissues, one may be enlarged without the other. When tonsils and/or adenoid tissue become too big, they may take up too much space and block the nasal and/or throat passage causing a child to snore, as well as other problems.
During an acute infection, it may be easy to notice how large the tonsils are. Often there may be “white spots” during acute tonsillitis, but it is not necessary to have “spots” in order to have a tonsil infection. Not all acute tonsil infections are due to Streptococcus, or “strep” throat, but strep infections are generally treated with oral antibiotics because failure to treat strep throat may lead to a small risk of developing complications related to “Rheumatic Fever.”
After a bout of tonsillitis, even after a child finishes a round of antibiotics, the tonsils may not always become smaller or shrink back to its pre-infection size. The decision to recommend adenoidectomy and/or tonsillectomy in your child by a health care provider or ENT specialist is likely based on current national recommendations and clinical practice guidelines.
INDICATIONS FOR TONSILLECTOMY
Sleep-Disordered Breathing or Obstructive Sleep Apnea
If your child has history of significant and almost nightly snoring, mouth breathing, increased work of breathing, frequent awakening, restless sleep, bed-wetting, and even behavioral symptoms, and an exam is consistent with very enlarged tonsils, then tonsillectomy may be recommended.
Only an overnight sleep study (polysomnogram) can tell medical professionals just how severe your child’s snoring is, if your child has obstructive sleep apnea, and if it’s a medical concern. Your child may be snoring without problems with air exchange or oxygenation, or may actually have “obstructive sleep apnea,” where there is an actual decrease in airflow during a breath.
Children can have several episodes lasting many seconds when they are not moving air and it may cause a drop in their blood oxygen level. Most healthy children do not need to undergo an overnight sleep study prior to tonsillectomy. Indications for who needs a sleep study prior to tonsillectomy have been published. However, even without OSA, if a child has habitual snoring, that alone can affect their school performance, daytime alertness, memory, behavior and quality of life.
Recurrent Tonsil Infection (Tonsillitis)
Medical professionals are concerned with infections caused by streptococcal bacteria because of the risk of Rheumatic Fever, if it’s not treated. Even if strep tests are negative, if a child has severe symptoms (fever, sore throat, trouble swallowing, body aches, etc.), health care professionals may prescribe antibiotics anyways. Such episodes may also qualify for consideration of tonsillectomy.
Current national guidelines suggest that for benefits to outweigh the risks of tonsillectomy surgery, specifically for recurrent infections, your child should have close to 7 episodes per year, 5 episodes 2 years in a row or 3 infections per year for 3 years in a row. Guidelines exist to help make sure that your child does not suffer the painful recovery and rare risk of post tonsillectomy bleeding, and even death, without justifiable indications.
WHAT I DO BEFORE SCHEDULING TONSIL/ADENOID SURGERY
The Academy of Otolaryngology—Head Neck Surgery has developed Clinical Practice Guidelines for indications for tonsillectomy. While it only takes an ENT surgeon 10-15 minutes to remove the tonsils, there are risks associated with bleeding and the rare risk of death (1 in 33,000 based on limited data). Unless benefits far outweigh the risk, don’t let your child’s tonsils go so quickly without truly understanding what the risks are.
If your child has any of the symptoms above, talk to your child’s primary care physician about this. If they won’t refer you, go ahead and make your own appointment to see a pediatric ENT specialist or general ENT specialist (they care for both adults and children, but ENTs who are not fellowship trained to only treat children typically do not work in children’s hospital settings and may not take care of complex ENT issues in children, or work in settings that can support tonsillectomy surgery in a child with medically complex issues like heart defects, or bleeding disorders).
I take pride in being a mother first, surgeon second. Each and every day when I meet patients and families for snoring, here is what I do before ever scheduling a surgery:
Get a detailed history about snoring from parents.
Do an exam. If tonsils are small, but we suspect adenoid tissue is enlarged, a x-ray can be done to show that or, more often, I perform the awake flexible “scope” with the child in the parent’s lap. I use a little numbing spray in those older than one, and this takes only a few seconds (beware there is an additional charge for this).
If tonsils are huge, there is no need to check the adenoid. If surgery is recommended to create space, then the adenoid tissue should be removed at same time.
I use a screening pediatric sleep questionnaire if a sleep study hasn’t been done. This can predict with almost 90% sensitivity if a child has obstructive sleep apnea or not, which saves money and time.
Certain children should have a sleep study before surgery: those with down syndrome, neurologic disorders, cardiac disorders, etc. We also have a guideline for when a sleep study is recommended.
I ask about their eating and drinking habits to make sure the child doesn’t have the “Milk and Cookie Disease”. Acid reflux is not a cause for congestion and snoring. If child routinely eats/drinks close to bedtime, or has nightly milk before bed, we stop that first and many end up not needing surgery.
Every day, I make recommendations on whether surgery is needed, as if my patient was my own child. I know as a parent, I would want my child’s doctor(s) and specialist(s) to do the same when treating my child.
Blog updated on January 31, 2019.