An experienced mother of four is in the office with her youngest child who is three years old. She is worried and frustrated because of the severe snoring that her daughter must endure every night. None of her other children did anything like this. "She snores so loudly that you can hear her in the next room. There are times when she doesn't take a breath--it can last as long as 15-20 seconds. I'm worried and have spent too many sleepless nights," she pleads. "Shouldn't she have her tonsils taken out?"
A family is in the office for the fifth time in seven months because the eight year old daughter has a sore throat again. This time dad comes to the visit...it must be a real problem. She has missed too much school because of the repeated bouts of strep throat. As I walk into the room with the results of the strep test, both parents ask in a defeated voice, "Strep again, huh?" as if they knew what the results would be. Not able to conceal his frustration, the dad says, "This is getting real old, doc! Can't we just take out her tonsils?"
As I enter the exam room of the third patient, what is striking is the loud mouth-breathing of the four year old patient. He is sitting up, leaning forward, and is unable to breathe through his nose. His voice is muffled and it is uncomfortable to be in the same room and watch him try to breathe. But that is not even why he is here today. Mom informs me that he breathes like this all the time. "Always has", she exclaimed. He is here today because he has had three ear infections in the past four months, and has had fluid behind his ear drums the entire time. He failed the hearing test given at his pre-school. Mom, very matter of factly, states that she would like her son's tonsils removed.
Lastly, there is the parent who brings her son in for his kindergarten physical. "Look at the size of those tonsils, doctor. They are like golf balls. Shouldn't they come out? I had mine taken out when I was in the second grade," she states. Interestingly enough, her son had absolutely no symptoms related to his large tonsils.
As a child, I remember being envious of my classmates who had their tonsils removed. A few days of missed school (legitimately), and all the ice-cream one could hope for. I was not one of those "fortunate ones" and still have my full complement of tonsils. It is a wonder, too, because in the late 1950's and early 1960's removing the tonsils was performed almost routinely. The peak year for tonsillectomies (removing tonsils) was 1959, and it has been on the decline since.
Four different scenarios, yet in each the parents are asking...pleading that their child have their tonsils removed. When is the correct time to remove the tonsils--or adenoids--or both? If this were the early 60's, all four patients would have had their tonsils removed long ago.
Let me try to explain why some patients should have their tonsils or adenoids removed, and others not. Just what are the tonsils and adenoids, and what do they do? The tonsils are the oval or round masses that occupy both sides of the back of the throat. The adenoids are a grape-like cluster of tissue that are located high in the back of the throat. They cannot be seen by the naked eye. A special mirror must be used to visualize them. Both the tonsils and adenoids are involved in the production of antibodies that help the body fight off infections. These antibodies are produced by other organs in the body such that a person who has had their tonsils or adenoids removed are at no greater risk for infection.
Tonsils and adenoids are usually removed by an ear, nose and throat surgeon (ENT) in a procedure called a tonsillectomy or adenoidectomy. The primary doctor is typically the one who refers the child to the ENT for surgery. One of the more common referrals to the ENT is that of the first patient we discussed, the 3 year old "snorer." She has enlarged tonsils that cause her obstructed breathing at night. Upon further questioning of mom, it is revealed that the little girl is fine during the day. This is not uncommon. When she is asleep, usually flat on her back, the tissues in the back of her throat are completely relaxed...the tonsils fall back and partially obstruct the airway. The difference in daytime versus nighttime breathing can be dramatic. In these cases, it is helpful to have the parents video-tape, or tape record the child's sleep. This can be most useful in deciding whether or not to do surgery.
Some of these children not only snore (and scare their parents half-to-death), there may be associated problems that occur. These include daytime fatigue, chronic bad-breath, eating and swallowing problems, hyper-nasal speech, night terrors and bed wetting.
A more serious problem is that of obstructive sleep apnea. Apnea is defined as a brief period (6-20 seconds) where there is no air movement in spite of continued respiratory effort. If severe enough, this can lead to undue stress on the heart and actually cause heart failure.
It sounds as if our little patient has severe nighttime obstructive breathing with some degree of sleep apnea and is certainly a candidate for surgery.
The second patient presented, the eight year old with recurrent strep infections, represents another common referral to the ENT. There are certain cases of strep throat that just do not respond to the standard oral antibiotic therapy. In reviewing a child's history, one might find that they have had five documented cases of strep throat in the past 6-8 months. The last episode was even treated with an injection of penicillin because the oral medications didn't seem to be effective...all to no avail. The child comes back with another throat infection that is positive for strep. Such is the case of patient #2. Clearly this is a child who needs a tonsillectomy to get her well, and get her "back in school."
An interesting anecdote to this scenario is that the ENT will often relate that while in the operating room, after removing the tonsils, when they cut into the infected tonsil it is like cutting into a bag of pus. The antibiotics never had a chance of penetrating the tonsil and clearing up the infection. Antibiotics alone, would never have worked.
In some cases, an abscess may form around the infected tonsil (peri-tonsillar abscess). These patients will have a "triad" of symptoms which include garbled speech, inability to open their mouth, and a bulge in the back of the throat which pushes the tonsil off to one side. This needs to be drained immediately. Ultimately the infected tonsil will need to be removed. Some ENT's prefer to let the infection "cool down" with antibiotics for a few days before doing the tonsillectomy--others opt to remove the tonsil when they drain the abscess.
Parents must be aware that the size of the tonsils alone has absolutely no bearing on whether or not to do surgery. Our last patient illustrates this nicely. Although his tonsils are like "golf balls", he is virtually symptom free. Surgery is not even an option for him. Large tonsils are quite common. Many times during a routine physical one will see tonsils that are so large that they touch in the back of the throat...the so-called "kissing tonsils". If they do not cause any problems, then leave them alone!
Because of their location in the upper part of the throat, large adenoids can cause severe mouth breathing. They can also cause obstructive breathing and snoring at night. Children with enlarged adenoids tend to have characteristic hypo-nasal speech. It sounds as if they are pinching their nose when they talk. The obstruction from the adenoids may be so chronic that the child doesn't even realize just how miserable he really is...until the adenoids are removed and he can once again breathe normally.
Since the adenoids can not be seen directly, an x-ray of the throat (a lateral view) is useful in assessing the degree of the obstruction. This is a valuable tool to determine whether or not to proceed with surgery.
The adenoids can also play a role in ear infections. The reason for this is because of where they are located. The adenoids are positioned near the opening of the Eustachian tube which connects the middle ear with the throat. It allows the ear to equalize pressure, and allows fluid to drain from the middle ear. Enlarged adenoids can interfere with the normal function of the Eustachian tube. This can "set up" the child for ear infections, or can prevent ear infections from clearing. This is the case in our third patient. He not only has obstructed breathing with altered speech, he also has a chronic ear infection with abnormal hearing because of the fluid in his middle ear space. This child deserves a trip to the ENT who most likely will elect to remove the adenoids and put in pressure equalizing ear tubes. This will alleviate his symptoms, and his speech and hearing should return to normal.
In the case of large tonsils and adenoids, the decision to do surgery is one that must be made on an individual basis, as each case is different. It must have been easy in the 1950's and 60's when tonsillectomies and adenoidectomies were done at the drop of the hat. We know alot more now, and have become more selective in who we send for surgery. It requires interfacing between the primary physician, the parents and the ENT surgeon. Sometimes the primary physician must resort to "detective work" to get all of the facts. Although it takes more time, it makes our work more challenging...and rewarding.