Enlarged tonsils and adenoids in children may result from infections but may be normal.
Enlargement usually causes no symptoms but can occasionally cause difficulty breathing or swallowing and sometimes recurring ear or sinus infections or obstructive sleep apnea.
The diagnosis is based on nasopharyngoscopy and sometimes on the results of a sleep study.
Antibiotics may be used if a bacterial infection is present, and sometimes, if infections are recurring, 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.
A Look Inside the Throat
Tonsils Throat The throat (pharynx) is located behind the mouth, below the nasal cavity, and above the hollow tube that leads from the throat to the stomach (esophagus) and windpipe (trachea) (see figure A... read more and adenoids Throat The throat (pharynx) is located behind the mouth, below the nasal cavity, and above the hollow tube that leads from the throat to the stomach (esophagus) and windpipe (trachea) (see figure A... read more 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 and adenoids are largest in children who are 2 to 6 years of age.
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.
Causes of Enlarged Tonsils and Adenoids
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 Sore Throat Sore throat is pain in the back of the throat. The pain can be severe and is usually worsened by swallowing. Many people with sore throat refuse to eat or drink. Sometimes pain is also felt... read more ). In addition, allergies (such as seasonal allergies Seasonal Allergies Seasonal allergies result from exposure to airborne substances (such as pollens) that appear only during certain times of the year. Seasonal allergies cause itchy skin, a runny nose, sneezing... read more or year-round allergies Year-Round Allergies Year-round (perennial) allergies result from indoor exposure to airborne substances (such as house dust) that are present throughout the year. The nose is congested, itchy, and sometimes runny... read more ), irritants, and, possibly, gastroesophageal reflux Gastroesophageal Reflux in Children Gastroesophageal reflux is the backward movement of food and acid from the stomach into the esophagus and sometimes into the mouth. Reflux may be caused by the infant’s position during feeding... read more also can cause the tonsils and adenoids to enlarge. Ongoing exposure to children who have bacterial or viral infections, such as children at child care centers, increases the risk of infection.
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.
Symptoms of Enlarged Tonsils and Adenoids
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 can also cause nosebleeds Nosebleeds Some people get nosebleeds rather often, and others rarely get them. There may be just a trickle of blood or a strong stream. If people swallow the blood, they often vomit it because blood is... read more , bad breath Bad Breath Bad breath is a frequent or persistent unpleasant odor to the breath. Certain diseases produce substances that are detectable on the breath, but these odors are typically mild and not considered... read more , and cough Cough in Children Cough helps clear materials from the airways and prevent them from going to the lungs. The materials may be particles that have been inhaled or substances from the lungs and/or airways. Most... read more .
Enlarged tonsils and adenoids are considered a problem when they cause more serious problems such as the following:
Chronic ear infections Chronic Middle Ear Infection in Children Chronic middle ear infection results from recurring infections that may damage the eardrum or lead to formation of a cholesteatoma, which in turn promotes more infection. Chronic middle ear... read more and hearing loss Hearing Impairment in Children Hearing loss in newborns most commonly results from cytomegalovirus infection or genetic defects and in older children results from ear infections or earwax. If children do not respond to sounds... read more : These problems result from blockage of the eustachian tube and fluid accumulation in the middle ear.
Obstructive sleep apnea Obstructive sleep apnea in children Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide... read more : 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 Pulmonary Hypertension Pulmonary hypertension is a condition in which blood pressure in the arteries of the lungs (the pulmonary arteries) is abnormally high. Many disorders can cause pulmonary hypertension. People... read more ) and changes in the heart due to pulmonary hypertension (cor pulmonale Cor Pulmonale Cor pulmonale is enlargement and thickening of the ventricle on the right side of the heart resulting from an underlying lung disorder that causes pulmonary hypertension (high pressures in the... read more ).
Weight loss or lack of weight gain: Children may not eat sufficiently because of pain resulting from infections or because breathing takes constant physical effort.
Diagnosis of Enlarged Tonsils and Adenoids
Sometimes a sleep study
Very large tonsils may be normal, and chronically infected tonsils may be normal-sized. To help determine whether infections are the cause of enlarged tonsils, doctors ask how many episodes of strep throat children have had during the past 1 to 3 years.
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 Obstructive sleep apnea in children Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide... read more is suspected when parents report that the child stops breathing during sleep. In such cases, doctors may recommend the child undergo a sleep study (polysomnography) Testing The most commonly reported sleep-related problems are insomnia and excessive daytime sleepiness. Insomnia is difficulty falling asleep or staying asleep, waking up early, or a disturbance in... read more . For this test, the child is monitored while sleeping overnight in a sleep laboratory and chest x-rays and certain measurements, including oxygen levels in the blood, are taken.
Treatment of Enlarged Tonsils and Adenoids
Treatment of other causes (allergies and infections)
Sometimes, adenoidectomy, tonsillectomy, or both
If they think the cause is allergies, doctors may give a nasal corticosteroid spray or other drugs, such as antihistamines, by mouth. If the cause appears to be a bacterial infection, doctors 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 only adenoidectomy for children who have the following:
Frequent ear infections and persistent collections of fluid in the middle ears
Recurring nosebleeds or nasal blockages causing voice changes or disturbed sleep
Frequent sinus infections
Did You Know...
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 typically recover from adenoidectomy in 2 to 3 days.
Bleeding resulting from tonsillectomy is a less common complication but may occur at 2 peak times, within 24 hours after surgery or at about 7 days after surgery. Bleeding after surgery may be serious or even life-threatening in children. Children who have bleeding after surgery should go to the hospital or doctor's office.
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