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All About Tonsils

A generation ago, the cure for chronic sore throats in kids was to remove their tonsils and adenoids. Thanks to advances in medicine, the demand for surgery has diminished greatly. But even today, tonsillectomy is still one of the most common childhood operations, with about 383,000 performed each year. Read on for the latest on tonsils and adenoids and the problems they cause.

What exactly are tonsils and adenoids?

They're small lymph-node-like masses of tissue in the back of the throat that help filter out germs that might otherwise enter the lungs. The tonsils are the pinkish lobes on either side of the archway to the throat. (You can see them when your child sticks out her tongue and says "aah.") Adenoids, which are similar to the tonsils in makeup and function, are hidden behind the nose and above the roof of the mouth and can only be seen with special medical devices or in X rays.

How do they cause trouble?

Tonsils and adenoids are somewhat spongelike, lined with tiny holes and crevices. "They can become so overwhelmed by bacteria and other microorganisms that they become inflamed," says Kathleen Yaremchuk, M.D., vice chairperson of the otolaryngology department at Henry Ford Hospital, in Detroit. The result? Tonsillitis and other painful illnesses, including middle-ear and sinus infections. With each illness, tonsils and adenoids pump up to mount an immune response, and that can leave them chronically enlarged. "It can take anywhere from three to nine months for the swelling to go down," Dr. Yaremchuk says.

In extreme cases, adenoids get so big they plug the nasal passages, forcing children to become mouth breathers. Oversize adenoids may also make speech sound nasal. In addition, they may cause middle-ear infections by clogging the eustachian tubes (which connect the back of the nose to the ear).

Enlarged tonsils, meanwhile, can interfere with swallowing, and when both tonsils and adenoids are oversize; they can cause snoring and sleep disorders.

What's the difference between tonsillitis and a run-of-the-mill sore throat?

Tonsillitis is a more severe sore throat. Caused by a number of different viruses and bacteria, tonsillitis leaves the throat red, swollen, and very tender. Every swallow hurts, and your child might balk at eating. He may also have a white, gray, or yellowish coating on his tonsils (use a small flashlight to check them yourself). Other symptoms of tonsillitis include a fever higher than 101?F, an earache, hoarseness, bad breath, fatigue, vomiting, and swollen lymph glands. But the vast majority of sore throats are the run-of-the-mill variety, caused by the same pesky viruses that bring on colds or the flu -- and do not involve the tonsils. These viral throat infections typically don't last long or cause high fevers. And, like all viral infections, they do not require antibiotics. "You just have to wait for the virus to run its course," says Kay Chang, M.D., pediatric otolaryngologist and professor at Stanford University Medical School.

Always call your pediatrician about any sore throat that doesn't improve after a few days or is accompanied by a fever, Dr. Chang says. And make sure your child sees a doctor if he refuses to eat or drink or is drooling (a sign that tonsils are so large that swallowing is nearly impossible).

What's the best treatment for tonsillitis?

It all depends on whether bacteria or a virus sparked the problem. First, your doctor will probably check for streptococcus, a bacterial infection that causes sore throats in children. She can take a quick swab of the back of the throat, and you'll usually have the results within a few minutes. If that test is negative, but your doctor still suspects strep, she might take a throat culture to get a definitive answer. That test is far more accurate, though you have to wait a day or so for results. Strep is generally treated with a ten-day course of antibiotics.

If it's not a bacterial infection, the likely cause is a virus. Then the only treatment is to keep your child comfortable.

Can tonsil problems really lead to snoring?

Yes, indeed. Snoring is a key symptom of enlarged tonsils and adenoids -- which, if left untreated, can lead to childhood obstructive sleep apnea (OSA). Children with OSA briefly stop breathing during sleep and lose oxygen. Their bodies react by partially waking up to jump-start the breathing process, sometimes with a gasp or snort, explains Carole L. Marcus, M.D., director of the pediatric sleep center at Johns Hopkins University.

Not surprisingly, the lowered oxygen levels and constant awakenings leave children tired and cranky. In fact, some children with OSA are misdiagnosed with attention deficit hyperactivity disorder, since many of the symptoms -- distractibility, excessive fidgeting, aggression, and irritability -- are so similar. The cure: tonsillectomy and adenoidectomy.

Keep in mind, though, that not all snoring is cause for alarm. An estimated 10 percent of children snore, often because of colds, allergies, or other routine problems. Nevertheless, you should have your child's tonsils and adenoids examined if you hear him breathing loudly at night. If your pediatrician suspects problems, he may recommend a sleep study to check for apnea.

Is it true tonsil trouble can also cause dental problems?

Yes. Bulging tonsils and adenoids can lead to mouth breathing, which dries out the gums, which can lead to periodontal disease. "Mouth breathing can put a child at greater risk for tooth decay," says Michael Roberts, D.D.S., chairman of pediatric dentistry at the University of North Carolina, in Chapel Hill.

How do I decide if my child's tonsils should be removed?

It's often a tough call. Tonsillectomy (and typically a simultaneous adenoidectomy) is absolutely recommended if the tonsils are so large they obstruct breathing or swallowing, or if your child is diagnosed with OSA. And surgery is also recommended if children have chronic strep throat, tonsillitis, middle-ear infections, mononucleosis, or similar illnesses -- particularly if they don't respond well to antibiotics.

What constitutes a chronic condition? The American Academy of Otolaryngology-Head and Neck Surgery points to a study showing the benefit of tonsil removal for kids who have had three or four tonsil infections in a year. Other medical groups, including the American Academy of Pediatrics, say it's not necessary unless the child has had seven infections in one year or five infections in each of two years. "There's no research that definitively proves what's most appropriate," Dr. Chang says.

Is there any reason not to have tonsils taken out?

Definitely. A tonsillectomy is considered extremely safe, but like all surgeries, it involves risks. The operations are performed under general anesthesia, a risk in itself. And though removing the adenoids is relatively swift and simple, removing tonsils can cause up to 14 days of throat pain, sometimes quite severe.

If my child needs surgery, what should I expect?

Tonsil-adenoidectomy is often done on an outpatient basis: Children go home after a few hours in the recovery room. After surgery, pain can be anything from mild to awful. Children won't want to eat or drink much -- but they need fluids in order to avoid dehydration. Be prepared to push liquids, and give your child acetaminophen to make swallowing easier (avoid ibuprofen after surgery because it increases the potential for bleeding). Your child may vomit, since pain medication can cause tummy turmoil.

Copyright © 2003 Amy Linn. Reprinted with permission from the October 2003 issue of Parents Magazine.