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THE CONUNDRUM OF SWOLLEN TONSILS AND ADENOIDS


Source: Google images

Source: Google images

“Never in the history of medicine have so many physicians owed so much economic security to a single operation as tonsillectomy.” (Lyman Richards, Quoted in The New York Times,1953)

Tonsils, located at the back of one’s throat  and adenoids, present high up behind the nose are part of the immune system and help protect the body from infection by trapping germs coming in through the mouth and nose. They are collections of tissue producing cells that attack the invading microorganisms and counteract their toxins by forming antibodies. They swell up temporarily whenever there is active infection.

Though tonsils were removed frequently in earlier times the present scenario has changed because doctors believe that the positive role of tonsils in helping the owner for a lifetime cannot be ruled out (even though there is no proven evidence as of now). We also know that speech is the miracle brought about by the various oro-pharyngeal tissues modulating the laryngeal jet of air and therefore contributory role of these tissues to good voice cannot be ignored.

As of now the operation is beneficial when done for few specific indications, namely, repeated attacks of tonsillitis (The American Academy of Otolaryngology defines repeated infections in children as seven episodes in one year, or five episodes in each of two years, or three episodes in each of three years) and evidence of chronic infection (unresponsive even after the bugs are identified and treated with a full course of medication ). A certain bacteria called “streptococcus” if housed long enough in this tissue may affect many organs of the body and sometimes the ENT surgeon might consider removing the tonsils. Bleeding and malignancy can occur in the tonsils even in adults necessitating tonsillectomy. Please remember that the surgery is never done during active infection and is not an emergency. Complications are not threatening except for bleeding. However it should be emphasised that having the tonsil removed doesn’t mean that you will never get a sore throat again!

With adenoids the situation is knotty. Swollen adenoids are quite annoying as they cause mouth breathing (leading to foul breath), nasal congestion (affecting speech) and snoring,  can be severe enough to stop spontaneous breathing (called obstructive sleep apnoea) as well as recurrent ear and sinus infections. More serious long-term effects, typically secondary to obstructive sleep apnoea, include behavioural and learning difficulties, poor attention span, hyperactivity, and very rarely, a drop in a child’s intelligence quotient. In later years, there can elevated blood pressure and heart problems. It also contributes to stunted growth. Therefore with considerably swollen adenoids, an adenoidectomy (with tonsillectomy in cases of coexisting tonsillar hypertrophy) is the typical management strategy for patients. However, potential complications (bleeding, damage to bones of the face and neck although rare) and the absence of a complete resolution of symptoms have prompted the investigation of non-surgical alternatives especially in children.

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Dr. Krishna Mahathi holds diplomas in Pediatrics and in the management of allergies and asthma. Years of working and interacting with children and parents have given her insight into developmental disabilities. She wishes that there was more awareness and acceptance of the issues that differently-abled children face and hopes that through this blog, she can enable thse children and their families to make sensible and informed choices.


7 thoughts on “THE CONUNDRUM OF SWOLLEN TONSILS AND ADENOIDS

  1. Kritika Srinivasan

    Thank you Krishna… high time that we had a post on this! As a mother of a six-year old who suffered from swollen adenoids continuously from teh age of 2 to 5, I have a few questions. I tried all kinds of treatments for her from homeopathy to anti-histamines to puffs. It is only now, since we have moved to Singapore and with continuous use of puff for over 6 months that there has been some improvement in her condition. The worst part was that every time her adenoids were swollen (around 25 days in month), her nose would also run continuously – allergic rhinitis I believe.

    We did consider removing her adenoids; after a point of time, even her paediatrician gave up and advised us to, but luckily my own childhood ENT took a look at her and strongly advised us not to, saying that she would outgrow the condition in time. So I wanted to ask you, since you have mentioned when tonsillectomy becomes necessary, when does removal of the adenoids become necessary. Also, is it true that adenoidal breathing can lead to the structure of the jaw and mouth changing? Finally, will she have attacks of swollen adenoids through life? She has been swimming regularly for the past couple of years now – do you think that would have had a beneficial effect?

    Thanks!

    Reply
  2. Krishna

    Ok Kritika,I think I can explain the decisions of your pediatrician and ENT specialist here.Tonsils even in normal children are slightly enlarged between ages two and six and shrink a little after that.If your daughter’s weight and height were appropriate and she didn’t have excessive day time sleepiness,irritability and difficulty concentrating in school(which are symptoms suggesting sleep apnea)there is no need for surgery immediately.The improvement with nasal steroid sprays is because they have properties to reduce inflammation and control the allergy.I think the change in residence also helped because you have managed to keep away from triggers like the dust mite.I suggest that your daughter have an allergy evaluation as well.The fact that she is able to swim without difficulty or frequent ear infections suggests a well controlled scenario.I do not think that swimming has any specific role to play except for overall well being.As far as changes in the facial structures go they usually happen by age two or three and your doctors would have noticed them by now.It is unlikely for such changes to happen in her case considering her age and medication history.I hope this helps.

    Reply
  3. Karthik

    Krishna, Very timely post for me. My daughter is 3 and I can relate to most of what is mentioned here. For almost 20 days in a month, she has dry cough and mildly grown tonsils. And her dry cough most often appears only after she sleeps (like 30 mins to an hour of sleeping) and he sleep gets disturbed and a round of vomiting get her back to normal sleep. Our doctor (we moved from Allopathy to Homepathy) gives us medicine to treat this but the Bangalore air quality and frequent changes in weather makes it a challenge. Many days does mouth breathing while sleeping but her activity during the day seem to be okay. I keep wondering if there are any effective home remedies that can help or ease this?

    Reply
  4. Jody Meyer

    This function is performed in the first few years of life, but it is less important as the child gets older. In fact, there is no evidence that tonsils or adenoids are important after the age of three. One recent large study showed, by laboratory tests and follow-up examinations, that children who must have their tonsils and adenoids removed suffer no loss whatsoever in their future immunity to disease.

    Reply
  5. Geneva D. Prince

    Your adenoids and tonsils are small lumps of tissue that help fight ear, nose and throat infections. Your adenoids lie where your throat meets the back of your nose. Your tonsils lie at the back of your throat, one at each side. When you have a cold or a throat infection your adenoids and tonsils can become infected and swell up, causing symptoms such as a sore throat, headache and fever. They can also block your airways, making it difficult for you to breathe, especially when you’re asleep. This can cause problems such as snoring. In severe cases, swollen adenoids and tonsils can stop you breathing for a short time during sleep – this is known as sleep apnoea. Swollen adenoids can also block your eustachian tube, which is the tube that connects the back of your throat to the middle part of your ear. This can lead to ear infections and a build-up of sticky fluid in your ear – called glue ear. This can make it difficult to hear properly and, as a result, can cause delays in learning. If you suffer from sleep problems due to a blocked nose, or if you have recurrent or persistent sore throats and ear infections, your doctor may recommend that you have both your adenoids and tonsils removed in an adenotonsillectomy. Alternatively, your doctor may recommend that you have just your tonsils removed (tonsillectomy) or just your adenoids (adenoidectomy). Most operations to remove the tonsils and adenoids are done in children but adults can have these operations too.

    Reply
  6. vikas

    Hello Krishna, I have a 3yrs 5 months old son who has developed enlarged adenoids detected around 8-9 months back. He has typical symptoms of snoring even when their is no infection (no cold/mucus/nasal discharge). Since last 2 weeks he has developed cold with thick yellow mucus which didn’t improve after oral antibiotics course. On advise of doctor, we got admitted to hospital and since last 3 days, he has been taking antibiotics over IV..the mucus colour is now changed to transparent from yellow earlier but still snoring and cough is there.
    Blood CBC report shows no abnormalities..all values within range. X-Ray chest is clear and last adenoid x-ray done in March this year (when he had infection) showed 70% blockage.
    ENT has suggested for surgery for adenoids removal. Also doctor has started on huff-puff spray. I am worried about surgery as as a child (when i was 5) myself has got tonsillitis surgery done but still (30 yrs after) i am still very prone to throat infections. From an overall perspective, my son is 17.8 Kgs and is very active.We didn’t notice any hyperactivity or any other behavioural issues yet. ENT also got ear test done and has measured a negative pressure on ear around -150. I want your suggestions on what should be our course of action…why there is no improvement after heavy dose of antibiotics..i have noticed previously also that whenever their is rainy season in bangalore..he develops cold and it improves once sunny days are back. Need your suggestions pls.
    A worried parent.

    Reply
  7. krishna

    Dear all,
    First of all I’m really sorry for responding late,I overlooked checking on the page after initial comments.
    Karthik,your child’s problem seems to be related to an allergic condition than her tonsils/adenoids.She has allergic rhinitis which needs to be addressed right away.Her discomfort during sleep is because secretions from the back of her nose trickle down her palate and irritate her.Steam inhalation or just saline nebulization will relieve her of discomfort if you can get her to cooperate for the exercise.You can also consult an ENT specialist for a short course of treatment with a nasal spray.My training in Allergy has involved interacting with many specialists from Bangalore and they have often quoted about pollen and moulds growing in the area that precipitate allergies.Attending to it will give you a lot of relief.
    Jody your comment on immunity status post tonsil/adenoid removal is true.The decision for surgery is taken based on the severity of symptoms and not just the age of the child.
    Vikas, your child definitely has distress due to swollen adenoids and this is persisting for almost a year from your description.Do you notice excessive sleepiness in the day?How many days in a month does he miss school?How many times have you needed to give him antibiotics for a fever with cold in the last six months?How has the child responded to the spray?I am sure your ENT specialist would have considered these factors and not just the X ray before advising surgery. Adenoidectomy does not always require a tonsil removal and yes your child weighs appropriate for his age.I want to emphasise that the decision is not made on a single reason and it’s not the first option in this situation.
    I hope this helps.
    Regards,
    Krishna

    Reply

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