For over 10 years, parents and primary caretakers of children of all ages have come to see me to discuss whether their child needs to have his/her tonsil/adenoid removed.
These families are either referred by their friends, neighbors, pediatricians, family physicians, or even found information online and read up on symptoms which may suggest the need to consider this surgical procedure. Before we talk about whether he/she may benefit from removal of these tissues, let me help clarify what exactly the tonsils and adenoid are.
Adenoid is a single bed of lymphoid tissue which is considered a part of our immune system. Research suggest that the adenoid serves to “protect” against bacteria and virus 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 upper respiratory tract infections. In fact, once children reach the age of approximately 10 years this bed of tissue generally shrinks and does not stay enlarged. There are no exact ways to predict which child would have an enlarged adenoid bed, even though often families tell me that big adenoid “runs” in their family, meaning the parents or others underwent adenoidectomy early in childhood.the need to consider this surgical procedure. Before we talk about whether he/she may benefit from removal of these tissues, let me help clarify what exactly the tonsils and adenoid are.
Our immune system is perfectly functional without adenoid tissue, and our bodies are not more likely to get sick or have any long-term problems after it is removed. The adenoid pad is often removed at the same time as tonsil removal surgery. This is tonsils and adenoid tissue are often both enlarged so if surgery is needed to remove one, removal of the other may be recommended to make sure there is maximum space in the center of the head for airflow from your child’s nasal passages to the back of the throat.
The adenoid pad is located in the very back of the nasal airway 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, or camera, 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”, these tissue 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 being enlarged in some children, but currently this is not proven.
How would you know if your 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 mouth open all the time – despite your best efforts to teach the good manners of chewing with mouth closed. 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 mouthbreathing during sleep is definitely a concern and not normal. 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 tends to always sound like they are congested, medically we describe this as “Hyponasality” which means not enough air flow through the nose.
- Speech evaluation at school may lead to a diagnosis of “hyponasality”, 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 +/- 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 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 about it under “top 3 reasons your child won’t stop coughing.”
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, 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 are similar lymphoid tissues, one may be enlarged without the other. When tonsils and/or adenoid become too big, they may take up too much space and block the nasal and/or throat passage causing a child to have snoring 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 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 back to its pre-infection size. 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
1) 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 exam is consistent with very enlarged tonsils, then tonsillectomy may be recommended. Only an overnight sleep study (polysomnogram) can tell medical professional 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 only snoring without problems with air exchange or oxygenation, or may actually have “obstructive sleep apnea”, where there is 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 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 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.
2) Recurrent tonsil infection (tonsillitis) – most commonly medical professionals are concerned with infections caused by streptococcal bacteria because of the risk of Rhematic 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.
If your child has any of the symptoms above, talk to your child’s primary care physician about this and 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 are not fellowship trained to only treat children and may not take care of complex ENT issues in children). I take pride in being a mother first, so each and every day when I meet a child and his/her family, I make sure that I get a detailed history, great exam, use a screening pediatric sleep questionnaire, and then discuss with the family my recommendation for the child as if he/she were my Claire. I know I would want Claire’s doctors and specialist to do the same each and every day when making recommendations to us.
Dr. Julie Wei is a pediatric ear, nose, and throat specialist and the author of A Healthier Wei. As a mother herself, Dr. Wei is a passionate advocate for improving children's health through better diet and dietary habits. She has been committed to helping parents learn how to eliminate their child's ear, nose, and throat problems simply by reducing excessive sugar and dairy intake, as well as minimizing habitual late night snacking. She hopes to raise awareness for the need for accountability by both medical professionals and parents to ensure that children are not prescribed or take unnecessary medications long term.
When she is not in the clinic, operating room, or conducting research, you will find her in the kitchen preparing food with love along with her daughter Claire. If you sit next to her on the plane, she will likely share with you information about how to minimize choking hazards in young children, and many other tips for improving your child's health.