Disclosure :: This post is sponsored by Dr. Duncan Hanby. The purpose of the post is to give some background on a childhood issue and surgical procedure. Seeking a medical opinion via a physician of your choice is always advised.
How to Know if Your Child May Need Their Tonsils Removed
The procedure to remove the tonsils (tonsillectomy) and the adenoids (adenoidectomy) is one of the most common surgeries performed in the United States. The tonsils are located at the back of the mouth on either side of the uvula (the teardrop shaped portion of the soft palate that hangs down). They are composed of lymphoid tissue which is the same tissue that you find in your lymph nodes and many other areas of the body. Much like the appendix, the tonsils are part of the immune system that people do not need to fight off infection because of the large amount of lymphoid tissue elsewhere in the body. The adenoid is a collection of lymphoid tissue located behind the soft palate at the back of the nose between the two Eustachian tube openings. Similar to the tonsils and the appendix, the adenoid pad is not an absolutely necessary part of the human immune system.
As Otolaryngologists (Ear, Nose and Throat doctors), we are often called to see patients who are having health problems related to these structures. There are many disease processes that can involve these areas and many of them ultimately require either a biopsy (removal of a small portion of tissue) or more commonly a tonsillectomy and/or adenoidectomy (complete removal of these structures). Below, we will briefly describe some of the more common indications for tonsillectomy.
Infections involving the tonsils and adenoids can result in missed school, missed work productivity and a significant decrease in quality of life. We are often asked to evaluate patients when these infections are happening frequently or when they are severe enough to require multiple courses of antibiotics and/or hospitalization. The American Academy of Otolaryngology (the governing board of our specialty) has set up specific guidelines both for the definition of a significant episode of tonsillitis and for the criteria that would lead to tonsillectomy. A significant episode of tonsillitis is defined as a sore throat associated with one or more of the following:
- Temperature > 38.3 degrees C (100.9 F)
- Cervical Lymphadenopathy (tender lymph nodes or > 2cm)
- Tonsillar exudates
- Positive culture for Group A Beta-hemolytic Streptococcus (“strep throat”)
The American Academy of Otolaryngology (AAO) recommends watchful waiting / medical treatment unless the patient has documentation of frequent significant episodes of tonsillitis defined as:
- 7 episodes in one year
- 5 episodes in two consecutive years
- 3 episodes in three consecutive years
- Tonsillitis/sore throat that lasts 12 weeks or more
There are exceptions to these criteria including peritonsillar abscess associated with tonsillitis (see below), PFAPA (periodic fever apthous stomatitis, pharyngitis and adenitis) and multiple antibiotic sensitivity/allergy.
Sleep disordered Breathing/Sleep Apnea
Sleep disordered breathing occurs when our airway is either partially or completely obstructed during sleep. These obstructions can lead to a drop in our oxygen level and an increase in our carbon dioxide level which signals the brain to wake up. Pediatric patients that present with this condition often have loud snoring, excess hyperactivity during the day, bed wetting, a decrease in normal physical growth patterns and other conditions. Pediatricians are becoming more aware that this is a real issue in their patient population, and we receive referrals for this condition as much or possibly more than for tonsillitis. Adults with suspected sleep disordered breathing or sleep apnea are always referred for a polysomnogram or sleep study in which we use multiple sensors and pieces of equipment to measure things like oxygen saturation, brain waves, eye movements, muscle movements, nasal and oral airflow and more. Children, on the other hand, are only referred for sleep studies from our office if there is some doubt regarding our diagnosis. In our pediatric patients, we depend on our parents to give us an appropriate history (snoring, bed wetting, witnessed gasping etc.) and on our physical exam to determine if they will benefit from surgery. Aside from the history given the parents or caregivers, our examination of the tonsils at the back of the throat is the most important portion of our exam. We grade the tonsils on a 0 – 4 scale with 4 being the proverbial “kissing” tonsils (tonsils that touch each other in the midline). In a child with an appropriate history and tonsillar hypertrophy (enlargement), we can feel confident that they will benefit from a Tonsillectomy and Adenoidectomy.
The tonsils sit at the back of the mouth in a small pocket formed by three muscles. In normal, healthy patients, these muscles are very closely approximated to the surface of the tonsil. However, a bacterial tonsil infection or tonsillitis can spread into this normally closed area between the tonsil and the surrounding muscle and cause an abscess (collection of pus). These abscesses push the tonsil into the airway causing changes in the patients voice and even airway obstruction. Patients with a peritonsillar abscess have more pain than would be expected with regular tonsillitis, and a muffled or “hot potato voice” caused by the swelling and inflammation in the tonsil area. Initially, these infections are often treated with an I&D (incision and drainage) under local anesthesia (numbing medicine) either in the office or the emergency room followed by systemic steroids, antibiotics and pain medicine. A peritonsillar abscess may lead us to recommend a tonsillectomy especially if it has happened more than one time.
The tonsils should be roughly the same size. If one tonsil is bigger than the other, we have to ask ourselves what is causing this asymmetry (mismatch in size). Our biggest concern is that this could be a malignancy (cancer) of some sort. If we see that the tonsils are asymmetric, we will often place the patient on a short course of antibiotics and have them return to the office at the end of that course to re-evaluate them. If the tonsils continue to be asymmetric at that point, we will often recommend a tonsillectomy.