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Enlarged Tonsils and Adenoids

by Udayan K. Shah, MD

  • Enlarged tonsils and adenoids in children may result from infections but may be normal.

  • Enlargement usually causes no symptoms but can cause difficulty breathing or swallowing, a sore throat, and sometimes recurring ear or sinus infections or obstructive sleep apnea.

  • Antibiotics may be used if a bacterial infection is suspected, and sometimes the tonsils and adenoids are removed.

Locating the Tonsils and Adenoids

The tonsils are two areas of lymphoid tissue located on either side of the throat. The adenoids, also lymphoid tissue, are located higher and further back, behind the palate, where the nasal passages connect with the throat. The adenoids are not visible through the mouth.

Tonsils and adenoids are collections of lymphoid tissue that may have a role in helping the body fight infection. They trap bacteria and viruses entering through the throat and produce antibodies. The tonsils are located on both sides of the back of the throat. The adenoids are located higher and further back, where the nasal passages connect with the throat. The tonsils are visible through the mouth, but the adenoids are not.


Some preschool and adolescent children have relatively large tonsils and adenoids that are not due to any problem. However, tonsils and adenoids can become enlarged because they become infected with a virus or bacteria that cause throat infections (sore throat—see Sore Throat). In addition, allergies, irritants, and, possibly, gastroesophageal reflux (see Gastroesophageal Reflux in Children) also can cause the tonsils and adenoids to enlarge.

When enlarged, tonsils sometimes interfere with breathing or swallowing, and adenoids may block the nose or the eustachian tubes that connect the back of the throat to the ears. Usually, tonsils and adenoids return to normal size once the infection is over. Sometimes they remain enlarged, particularly in children who have had frequent or chronic infections. Although extremely rare, cancer sometimes causes enlarged tonsils or adenoids in children.


Most enlarged tonsils and adenoids cause no symptoms. However, enlarged tonsils or adenoids can give the voice a stuffy-nose quality (children sound as though they have a cold). Children with enlarged tonsils or adenoids may have an abnormally shaped palate and position of the teeth. Children may also tend to breathe through their mouth.


Enlarged tonsils and adenoids are considered a problem when they cause more serious problems such as the following:

  • Chronic ear infections and hearing loss: These problems result from blockage of the eustachian tube and fluid accumulation in the middle ear.

  • Recurring sinus infections: See Sinusitis.

  • Obstructive sleep apnea (see Sleep Apnea): Some children with enlarged tonsils and adenoids snore and stop breathing for brief periods during sleep. As a result, oxygen levels in the blood may be low, and children may wake up frequently and be sleepy during the day. Rarely, obstructive sleep apnea caused by enlarged tonsils and adenoids has serious complications, such as high blood pressure in the lungs (pulmonary hypertension—see Pulmonary Hypertension) and changes in the heart due to pulmonary hypertension (cor pulmonale—see Cor Pulmonale: A Type of Heart Failure Caused by Lung Disorders).

  • Weight loss or lack of weight gain: Children may not eat sufficiently because of pain or because breathing takes constant physical effort.


To determine whether the cause is an infection, doctors determine how many episodes of sore throat children have had during the past 1 to 3 years. This information is more helpful than the size of the tonsils alone. Very large tonsils may be normal, and chronically infected tonsils may be normal-sized.

Usually, to view the back of the nose and throat, doctors insert a flexible viewing tube through the nose (called a nasopharyngoscope). Doctors also look for redness of the tonsils, enlargement of lymph nodes at the jaw and in the neck, and the effect of the tonsils on breathing.

Obstructive sleep apnea is suspected when parents report that the child stops breathing during sleep. In such cases, doctors may recommend polysomnography. For this test, the child is monitored while sleeping overnight in a lab and certain measurements, including oxygen levels in the blood, are taken.


If they think the cause is allergies, doctors may give a nasal corticosteroid spray or other drugs, such as antihistamines, by mouth. If doctors think the cause may be a bacterial infection, they may give antibiotics. If these drugs are not effective or if doctors think they will not be useful, doctors may recommend surgical removal of the adenoids (called adenoidectomy) and possibly removal of the tonsils (called tonsillectomy) during the same operation.

Tonsillectomy and adenoidectomy are very common operations for children in the United States. Children who benefit from these operations include those who have the following:

  • Obstructive sleep apnea

  • Extreme discomfort when talking and breathing

  • Multiple throat infections (defined by some doctors as more than six infections in 1 year, more than four infections a year for 2 years, or more than two infections a year for 3 years)

  • Cancer (rarely a cause)

Doctors may recommend adenoidectomy alone for children who have the following:

  • Frequent ear infections and persistent collections of fluid in the middle ears

  • Recurring nasal blockages causing voice changes or disturbed sleep

  • Sinus infections

Did You Know...

  • Removing enlarged tonsils and adenoids is useful only when enlargement causes extreme discomfort, breathing problems, or recurring infections.

Tonsillectomy and adenoidectomy do not seem to decrease the frequency or severity of colds or cough.

Tonsillectomy and adenoidectomy are often done on an outpatient basis. These operations should be done at least 2 weeks after any infection has cleared. The surgical complication rate is low, but postoperative pain and difficulty swallowing caused by tonsillectomy may last up to 2 weeks. Children recover from adenoidectomy in 2 to 3 days. Bleeding resulting from tonsillectomy is a less common complication but may occur within 24 hours after surgery or 7 days after surgery. Bleeding after surgery may be serious or even life-threatening in children. Children who have bleeding should go to the hospital or doctor's office.

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