Parents often hear from their child’s paediatrician that a particular fever is due to infected tonsils and adenoids. While they accept the verdict, only a few really understand the nature of these tissues and how they affect children. Dr N Pandian, surgeon and promoter of Pandian Hospital in Chennai, answers the common questions related to tonsils and adenoid problems.
What are tonsils and adenoids?
These are lymphatic tissues at the back of the throat, forming a circle. They stimulate an immune response from various ingested antigens. As children have underdeveloped immune systems, these tissues serve as a useful back-up. Tonsils are located on either side of the tongue at the back of the mouth. They stick out and can be easily seen.
Adenoids sit between the tonsils, higher up in the roof of the mouth, in the naso-pharyngeal area. As adenoids are hidden behind the roof of the mouth, they cannot be seen easily without special mirrors or X-rays. These tissues increase in size in the first 6-7 years of life and they can be particularly large in some children.
What causes inflammation of tonsils and adenoids?
I find that children drinking ice water, fruit drinks/buttermilk from stalls, water from packets, and cool drinks are particularly susceptible to the problem. At first the jugulodigastric lymph node (which is located inside the throat at the base) gets inflamed as this node receives the lymphatic drainage or fluids from the pharynx, tonsils and tongue. Then the tonsils and sometimes adenoids get inflamed. The process is followed by cold, fever, and sore throat. Sometimes, the tonsils enlarge so much that they touch each other, creating the phenomenon known as ‘kissing tonsils’.
What are the problems caused by large and inflamed adenoids and tonsils?
If the adenoids and tonsils are large, as is common in children (even without specific inflammation), they narrow the airways and reduce the flow of air into and out of the lungs. Breathing difficulties are less noticeable while a child is awake - although they may cause some symptoms like a stuffy nose, ‘nasal’ speech and breathing through the mouth (particularly associated with adenoid problems).
During sleep though, the muscles of the throat relax. The combination of relaxed muscles and a narrow airway cause what is known as ‘collapse of the throat’ and the child will be unable to breathe (apnoea). After a few seconds of struggling, the child is partially aroused from his sleep, although not completely awake. The muscle tone returns, and the throat opens - often with a gasp. A child may go through many of these cycles in an hour, resulting in a disturbance of normal sleep patterns known as Obstructive Sleep Apnoea.
When it is severe, Obstructive Sleep Apnoea can result in serious conditions such as heart strain, abnormalities in heart rhythm, growth disturbance, behavioural problems and concentration difficulties. Lesser degrees of sleep disturbance can cause bedwetting, or daytime sleepiness. Sleep disturbance can also occur even without complete apnoea, if the child is struggling to breathe against resistance and airflow is reduced.
Owing to inflamed or large adenoids and tonsils, the child has difficulty swallowing. He snores during sleep. Inflamed adenoids also lead to purulent discharge into the ear leading to middle ear infection. This is because the Eustachian tube in children - the tube leading from the nasopharynx to the middle ear - is very short, building up pus in the ear drum. This can result in a hole in the drum, resulting in impaired hearing. If a child comes with an ear infection, and we spot a hole in the drum, we first try to reduce the tonsil and adenoid infections before attending to the hole.
Do adenoids and tonsils retain their sizes post-adolescence?
Adenoids are known to shrink and almost disappear during teens. Tonsils also shrink with age but take a little longer - tonsils operations can be performed in a child as old as 18 years. Typically, surgery for removing adenoids and tonsils is done when the child is between 5-13 years of age.
How do doctors assess the need to remove tonsils and adenoids?
We check if the child has a serious eating difficulty, breathing difficulty, and persistent infections (cold, fever, and sore throat). Clinically, we check the jugulodigastric lymph node,
the tonsils and adenoids for enlargement. If the child has a history of having six infectious episodes a year, we recommend surgery.
We advise parents that persistent infections can lead to fatal heart and kidney conditions when the child grows up as streptococcal infections in tonsils and adenoids are often very hard to treat, even if they are detected. If not treated properly, they can cause serious problems like rheumatoid fever affecting the heart, glomerulonephritis affecting the kidney and even meningitis, affecting the brain, and pneumonia.
What are the side effects of the surgery?
It may happen that the soft palate (roof of the mouth) keeps air from flowing backwards from the mouth to the nose during speech and while swallowing. As there is more room at the back of the throat, the voice will be ‘whiny’ in children. Some children will experience food (liquids) coming into the nose. With time, this improves as the palate compensates for the larger space.
Don’t we need tonsils and adenoids? Tonsils and adenoids are at the fringes of the immunity system but do not comprise it totally. There have not been any consistent findings of decreased immune function or increased disease rates following the surgery.
What do parents need to know about the surgery?
Tonsillectomy and adenoidectomy can be performed together, if both warrant removal. Usually, children are asked to check in the previous evening into the hospital after all the mandated blood tests, urine tests and ECG are done.
The ECG is important because general anaesthesia is given to the child. Tonsils are snipped while adenoids are curetted (shaved off). A little bit of adenoid tissue is left behind to prevent damage and scarring of important blood vessels below the region. For the same reason, if a surgeon prefers to use laser to remove adenoids, great care should be deployed.
Adenoid bleeding can be stemmed immediately within 5 minutes with gauze. There is no restriction in food intake after the surgery.
After tonsils surgery, however, the child is given ice-cream or something cold to shrink the tissue. The child is told to eat only soft foods for one week and avoid sharp foods totally. The pain is managed by anti-inflammatory tablets. Severe bleeding can reoccur after the scab from the tonsil surgery falls off after some days. This is an emergency condition, though extremely rare. I have performed over 5,000 tonsil surgeries and have never seen this.