What are the adenoids and tonsils, and how often do they enlarge?
The tonsils are lymphoid tissues on both sides of the throat, and the adenoids are lymphoid tissue behind the nose, in the nasopharynx. Both are structures that play a role in the development of the immune system in childhood and act as a first line of defense against microorganisms entering the body through the airway. These tissues naturally enlarge especially between the ages of three and seven, the period when the immune system is developing intensively, and in most children this growth causes no problems; over time the tissues shrink and gradually regress.
Problems arise when these tissues grow beyond normal and significantly narrow the airway, or become a focus of frequently recurring infections. Enlarged adenoids mostly cause nasal obstruction and ear problems, whereas enlarged tonsils mostly cause complaints related to obstruction of the throat and airway; in many children both tissues may be enlarged at the same time.
Which symptoms matter?
The findings families notice most often are constant nasal obstruction, sleeping with the mouth open and snoring. Restless sleep, frequent waking, sweating and, in some children, short pauses in breathing may be signs that enlarged adenoids and tonsils are affecting breathing during sleep; this picture is called childhood obstructive sleep apnea. Because long-standing mouth breathing can also affect jaw and facial development over time, it is important to recognize it early.
Other important symptoms include frequently recurring upper respiratory tract infections, prolonged or recurrent nasal discharge, reduced hearing due to fluid build-up in the middle ear, and the attention problems or speech delay that may develop as a result. Children with markedly enlarged tonsils may also have difficulty swallowing, voice changes and recurrent throat infections. Excessive daytime tiredness and a drop in school performance can appear as an indirect result of disrupted night-time sleep.
In some children, long-term mouth breathing can also lead to structural changes such as a short upper lip, an elongated-looking face and misaligned teeth; in the medical literature this picture is described as “adenoid facies”. Noticing such findings is an important warning sign that should prompt families to bring their child for evaluation early.
Causes and risk factors
Enlargement of the adenoids and tonsils is largely part of a natural process of immune development specific to childhood; however, recurrent upper respiratory tract infections, frequent exposure to germs in nurseries or crowded settings, exposure to cigarette smoke and allergic rhinitis are factors that promote excessive growth and chronic inflammation of these tissues. A similar history in the family may also increase susceptibility.
In children with underlying allergic rhinitis, chronic inflammation of the mucosa can contribute to enlargement of both the adenoids and the tissues inside the nose; for this reason, in children with recurrent complaints, looking into a possible allergic background is valuable for diagnosis and treatment planning.
Conditions such as gastroesophageal reflux are also known to increase inflammation of adenoid and tonsil tissue. In addition, children who start nursery or preschool early may be more prone to frequent infections because of intense social contact; in some children this can cause enlarged adenoids and tonsils to produce symptoms at an earlier age.
How does the diagnostic process work?
The evaluation begins with detailed questioning about the complaints described by the family and an examination of the child. While the size of the tonsils can be seen directly when the throat is examined, the most reliable way to evaluate the adenoids is nasal endoscopy with a thin, flexible endoscope; children usually tolerate this examination well, and it clearly shows how much the adenoids are narrowing the airway.
When breathing problems during sleep are suspected, a detailed sleep history is taken and, where considered necessary, a sleep study designed for children (polysomnography) may be recommended. In children with reduced hearing, audiological evaluation and middle-ear function tests are added to the diagnostic process; this is especially important when fluid in the middle ear is suspected.
During the evaluation, the child’s growth and development curves, speech development and the family’s observations about school performance are also taken into account. Because long-standing mouth breathing can affect jaw and dental development, in cases where it is considered necessary, collaboration with specialists in dentistry or orthodontics can also contribute to the evaluation.
Treatment options
Conservative approach
Not every enlarged adenoid or tonsil requires surgery. When the enlargement is mild and the symptoms do not significantly affect daily life, sleep or hearing, treating any accompanying allergic rhinitis, using intranasal corticosteroid sprays and monitoring may be the preferred approach. With this approach, the tissues are expected to shrink naturally as the child grows, and the symptoms are followed up at regular intervals.
Surgical treatment
The decision for surgery is made by evaluating together the severity of the complaints, the examination findings, the results of the endoscopic evaluation and, where needed, hearing tests. Pauses in breathing during sleep or marked breathing difficulty, frequent recurrent bouts of throat or ear infection, and long-standing fluid build-up in the middle ear with resulting hearing loss are the main situations in which surgery is recommended. Depending on the situation, the operation may be planned as removal of the adenoids only (adenoidectomy), removal of the tonsils only (tonsillectomy), or both together (adenotonsillectomy).
After the operation: recovery and follow-up
The operations are performed under general anesthesia, and most children can go home the same day or the next day. In the first days, plenty of fluids and a diet of soft, lukewarm foods are recommended; avoiding acidic drinks, hard or crusty foods and very hot foods makes healing easier. Throat pain, difficulty swallowing and pain radiating to the ears are expected, normal findings during the first week and can be controlled with the painkillers recommended by the doctor.
Rising fever, bleeding that does not stop or gets worse, or a severe drop in fluid intake must always be reported to the physician. Children can usually return to school and daily activities within a week; however, avoiding strenuous physical activity and crowded settings with a high risk of germ transmission is recommended for the first two weeks. After surgery, improvement in hearing and breathing is usually clearly noticeable within a short time; where considered necessary, a follow-up examination and, if needed, an audiological evaluation are planned.
It is important for families to closely monitor the child’s pain level, fluid and food intake and general condition after surgery. Because young children cannot express pain in words, indirect signs such as restlessness, loss of appetite or disturbed sleep should also be taken into account. Attending the follow-up appointments recommended by the doctor regularly is important both for monitoring recovery and for detecting rare complications early.
After surgery, a temporary change in the child’s voice (less nasal-sounding speech) may be noticed; this is a natural process of adjustment to the wider airway and normalizes over time. Families usually notice a marked improvement in sleep patterns and daytime energy within the first weeks after surgery.
Frequently asked questions
Does adenoid surgery weaken immunity? No, removing the adenoids and tonsils does not weaken the child’s overall immune system; the body has other lymphoid tissues that take on this role.
Can the adenoids grow back? Rarely, particularly in children operated on at a young age, a remaining piece of tissue may grow again over time; however, this is not expected in every case.
At what age can the operation be done? The decision for surgery depends more on the severity of the symptoms and the examination findings than on age; where considered necessary, it can also be performed safely at a young age.
When can my child go back to a normal diet after surgery? The first days start with soft, lukewarm foods; as swallowing becomes more comfortable, a normal diet can be resumed gradually within a few days.
Does every child who snores need surgery? No, snoring alone does not require surgery; additional findings such as witnessed pauses in breathing, marked sleep disturbance or recurrent infections need to be present and confirmed by examination.
For the summary:
Back to the short articleThis article is for general information purposes only; please consult your physician for diagnosis and treatment.