This is one of those questions that many parents face with inadequate information. Often times it is first-time parents who find themselves being asked to make a decision about a very young child’s health with what must seem like a poor understanding of possible risks and benefits of the procedure. Hopefully, this review and commentary will help you make the right decision for your child.

Tonsils and adenoids are really just old-fashioned terms for a type of tissue called lymphoid tissue that surrounds the throat. Really, there are three sets of tonsils: the adenoids, the left and right palatine tonsils (often referred to as “tonsils”), and the lingual tonsils, which make up much of the surface of the very back of the tongue. Only the palatine tonsils and adenoid tissue are routinely removed during a tonsillectomy or tonsillectomy and adenoidectomy. The lingual tonsil is more commonly removed in adults for reasons of airway obstruction or to rule out tumors.

What do Tonsils and adenoids do?

I am often asked by patient’s and parents “what do they do?”. This is an excellent question which unfortunately has a somewhat complicated answer. The short answer is that the tonsils and adenoids, as well as all the lymphoid tissue in the human body (of which the tonsils and adenoids make up only a very small portion), help the body’s immune system to make antibodies. The problem is that this short answer would seem to suggest that removal of the tonsils and adenoids might in some way impair the body’s immune system. That is simply not the case. I repeat, there is no clinical evidence we are aware of, nor has there ever to my knowledge been a reputable physician who has suggested that removal of the tonsils and adenoids would in any way adversely affect the immune system of an otherwise healthy patient. The body has immense redundancy and many of its important functions. In the case of the tonsils and adenoids, removal of this tissue in no way impaired as the body’s ability to make antibodies or fight infection. Rather, by removing a potential source of chronic infection in selected patients, tonsillectomy and adenoidectomy can actually significantly improve the general health of the patient over time. An excellent rule of thumb when making this calculation is to not remove tonsils and adenoids “just because”, but to make sure that they are only removed when there is a clear clinical benefit to the patient. This is a judgment that is best made after discussion with your otolaryngologist.

Adenoids

The “adenoids” should properly be called the nasopharyngeal tonsils. They reside at the very back of the nose, above the soft palate. Therefore, they cannot be well seen through the mouth without the use of a mirror, which is often difficult in children. For this reason physicians will often order a lateral x-ray to try to ascertain the size of the adenoid pad. Adenoids are a midline structure and therefore there is not a left and right adenoid. While “adenoids” are referred to in the pleural, the reality is that they are a single pad of lymphoid tissue at the back of the nose. When adenoid tissue becomes inflamed or enlarged, symptoms include a high midline sore throat, nasal obstruction, and hearing loss due to fluid back up into the middle ears. The adenoids sit at the same level as the openings of the eustachian tubes into the throat. Therefore, it is common for children requiring myringotomy and tube placement to also be advised to undergo an adenoidectomy, especially when a second set of tubes is placed. Removal of adenoid tissue is generally very straightforward with minimal bleeding and extremely low risk in children. The benefits are most commonly improved breathing through the nose, decreased nasal congestion and snoring, and long-term improvement in eustachian tube function such that a child’s ears might not get infected or filled with fluid is easily.

Tonsils

“Tonsils”, or palatine tonsils, are very similar to adenoid tissue, but they are located on the sides of the throat. A careful examination of the throat through the mouth generally reveals some lumpy tissue with small pockets called “crypts” on the side of the throat. These are the palatine tonsils. They can be rated as 1+ to 4+ in size with 1+ being small and 4+ suggesting the tonsils are so large they are touching in the midline. Typically, tonsils are removed due to chronic or recurring infection (often called strep throat if the bacteria infecting the tonsils is, in fact, strep), or enlargement of the tonsils which can cause difficulty breathing while sleeping, snoring, witnessed episodes of apnea, and even choking on solid foods. Removal of tonsils is significantly more uncomfortable than removal of adenoids due to the increased sensation required at the back of the throat to allow for swallowing. For this reason, techniques such as Coblation tonsillectomy have been developed to decrease the severity of the discomfort and improve the healing process and speed of recovery while decreasing the frequency of the most common complications of surgery. These complications include primarily the risk of bleeding during the healing process (generally around 7-10 days after surgery) and dehydration (most common in children under age 3). With the use of Coblation, recovery from tonsillectomy with or without adenoidectomy in young children is generally 7-10 days of moderate to severe sore throat. This is a marked improvement from the 2-3 weeks of severe sore throat and the third degree burn of the throat that most patients experienced with more traditional electrocautery excision of tonsils and adenoids.

Is a tonsillectomy and adenoidectomy, or adenoidectomy appropriate for your child?

When deciding whether tonsillectomy and adenoidectomy, or adenoidectomy, is appropriate for your child, you should factor in not only the risks of the procedure(s), but also the risks of not undergoing the procedure. This is where a conversation with your otolaryngologist can be critical. Each child has their own set of circumstances and concerns clinically. These are too many to enumerate here, but should be fully explored with your otolaryngologist prior to agreeing to schedule your child for tonsillectomy and adenoidectomy. Our surgeons take great pride in discussing not only the reasonable expectations of surgery, but also our reasons for recommending the surgery, and our concerns should the surgery not be undertaken. If you are continuing to struggle with this difficult decision, please do not hesitate to contact our office to schedule a consultation with one of our surgeons, to be evaluated.

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