• 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 help 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, for example, they become infected with bacteria that cause pharyngitis. When enlarged, tonsils sometimes interfere with breathing or swallowing, and adenoids may block the nose. 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.

Symptoms

Most enlarged tonsils and adenoids cause no symptoms. However, children with enlarged tonsils or adenoids may have a sore throat and discomfort or pain during swallowing. Enlarged adenoids can give the voice a pinched nose quality and change the shape of the palate and the position of the teeth.

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 and nosebleeds
• 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) and changes in the heart due to pulmonary hypertension (cor pulmonale—see Pulmonary Hypertension: Cor Pulmonale: A Disorder Stemming From Pulmonary Hypertension).
• Weight loss or lack of weight gain: Children may not eat sufficiently because of pain or because breathing takes constant physical effort.

Diagnosis

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. Enlarged tonsils are more likely to be the result of a disorder in children who have had frequent episodes of sore throat. Very large tonsils may be normal, and chronically infected tonsils may be normal-sized. 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 frequently during sleep. Doctors may also recommend polysomnography. For this test, oxygen levels in the blood are measured and the child is observed while sleeping.

Treatment

Doctors may give antibiotics if they think the cause may be a bacterial infection. If antibiotics are not effective or if doctors think antibiotics will not be useful, doctors may recommend surgical removal of the tonsils and adenoids (tonsillectomy and adenoidectomy).

Tonsillectomy and adenoidectomy used to be very common operations for children in the United States. But they are much less common now that doctors are more aware of which children benefit from the operation. Children who benefit from surgery include those with the following:

Did You Know... Removing enlarged tonsils and adenoids is useful only when enlargement causes extreme discomfort, breathing problems, or recurrent infections.

• Obstructive sleep apnea
• Extreme discomfort when talking and breathing
• Multiple throat or ear infections (defined by some as seven or more infections in 1 year, five or more infections a year over 2 years, or three or more a year over 3 years)
• Cancer (rarely a cause)

Doctors may recommend adenoidectomy alone for the following:

• Ear infections
• Recurring nasal congestion
• Sinus infections

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

Tonsillectomy and adenoidectomy are usually done on an outpatient basis. These operations should be done at least 3 weeks after any infection has cleared. The surgical complication rate is low, but postoperative pain and difficulty swallowing may last up to a week. Bleeding is a less common complication but may occur anytime from the first day of surgery to the tenth day after surgery.

Last full review/revision January 2009 by Robert J. Ruben, MD