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When Should the Tonsils and Adenoids Be Removed

Parents frequently are faced with the decision of whether or not to have their child's tonsils or adenoids removed. While the number of tonsillectomies and adenoidecotomies in the United States has decreased over the last 30 years,"T and A's" are still the most commonly performed operation on children in our country with over 400,000 per year. Prior to World War II, removal of the tonsils was described as an American ritual and many children had their tonsils removed as a matter of course or after one sore throat . The medical reason for recommending these procedures has changed over the years, however, and continues to be a subject of debate among physicians.

The tonsils and adenoids form a ring of infection fighting tissue in the back of the throat and are similar in structure and function to lymph nodes located in other parts of the body. The tonsils are below and behind the soft palate, the part of the throat from which that dangling piece of tissue, the uvula, hangs. When parents look inside their child's mouth, the tonsils can be seen as reddish tissue, one on either side, at the base of the tongue. The tonsils become enlarged and inflamed as they fill with lymphocytes - one of the body's disease fighting cells - in response to an infection (viral or bacterial) or an allergic reaction.

The adenoids are hard to see without a special mirror. They are located at the back of the nose just above the roof of the mouth. Before a child's fourth birthday, the tonsils and adenoids are the major producers of the cells and proteins that help kids protect themselves against being infected with viruses or bacteria. By virtue of their location, the adenoids and tonsils are the first line of defense for germs entering the body through the mouth and nose.

The most common reasons to consider removal of the adenoids and tonsils are recurrent infections and a condition known as obstructive sleep apnea (OSA). Children with OSA usually snore loudly and constantly during sleep with intermittent episodes of apnea, or greatly diminished breathing efforts. Enlarged adenoids also cause mouth breathing, which is so difficult than the normal pattern it can result in permanent changes in the shape of the face. Enlarged adenoids may block the opening to the eustachian tube, altering middle ear pressure and contributing to the development of ear infections. Other problems caused by enlarged adenoids include difficulty breathing through the nose, poor school performance and daytime sleepiness due to inadequate restful sleep at night, and unclear or muffled speech (speech lacking the normal amount of nasal resonance.) On rare occasions, the tonsils and adenoids can get so large that they impede breathing to the point that blood oxygen is dangerously reduced. Among the many complications of this problem is a form of heart pump failure.

While chronically enlarged tonsils can also cause some airway obstruction, the main reason for recommending their removal is abscess formation. A peritonsillar abscess can become a serious medical problem and usually needs to be treated with intravenous antibiotics in the hospital. If a child has had one episode of peritonsillar abscess, there is a greater chance that he or she will have another attack. Recurrent bouts of strep throat are often used to justify removal of the tonsils, especially if the child has had seven episodes in one year, five episodes over each of two years, or at least three episodes in each of three years. Other factors, such as numerous school absences, may affect the decision to remove the tonsils.

Parents frequently become concerned when they look into their child's throat and see white patches on the tonsils. Often this is mistaken for an infection, even though the child does not appear to be sick. What parents are seeing is dead skin dropping off the tonsils or getting stuck in the pits of the tonsils. Most often this is of no medical significance. Furthermore, large tonsils do not necessarily mean the child needs to have them removed unless they are touching each other. The tonsils are normally large during childhood and begin to shrink in size after a youngsters eighth birthday.

Most pediatricians are hesitant to recommend adenotonsilectomy unless it is absolutely necessary, since having the tonsils removed will not prevent throat infections and will not decrease the episodes of colds. These infections are likely until a child develops immunity or protection against the viruses that cause them. Contrary to popular folklore, a "T and A" will not improve a picky appetite or prevent bad breath. Fortunately, the removal of the tonsils and adenoids does not cause problems that we know of with immune deficiencies in the child.

An ENT doctor (ear, nose and throat, or otolaryngologist) will be consulted by your child's pediatrician to make the ultimate decision with you over whether or not the surgery is indicated. Most "T and A's" are performed in an outpatient surgery center or in a hospital under general anesthetic ("deep sleep"). Usually children are able to go home the same day and will only miss a few days of school.

While the surgery itself is now safer than ever before, parents and physicians must always weigh the risks versus the benefits gained from the procedure. When considering an adenotonsilectomy, parents should always seek the advice of their child's doctor, who has the information necessary to determine if the procedure is in the child's best medical interests.


As a reminder, this information should not be relied on as medical advice and is not intended to replace the advice of your child’s pediatrician. Please read our full disclaimer.

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