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Tonsils and Adenoids

In years past, tonsils were removed routinely, at the discretion of the doctor. All it took was one infection, and out they came. A tonsillectomy and adenoidectomy were once one of the most common surgical procedures in the U.S. Not any more. Unless children (and adults) meet certain surgical criteria, most insurance companies will not approve their removal.

The tonsils and adenoids are lymphoid tissue; the same as the lymph nodes they you often feel in your neck during infections. Even though tonsil and adenoids are grouped together as one entity, they are distinct, unique structures. They are an integral part of our immune system that protects the upper respiratory tract, fighting off infection in a never-ending battle. As we age and our overall immune system improves, tonsils and adenoids are less problematic.

The tonsils are located on each side of the back of the throat and are easy to see with a good flashlight. Children tend to have relatively large (hypertrophic) tonsils. Some children even have “kissing tonsils” – tonsils that are so large that they touch (kiss) each other. Their appearance alone often concerns parents. Tonsils are filled with little craters or crypts that can trap food or other debris, giving a false impression of being infected.

Of course, large tonsils do not necessarily mean you have tonsillitis (an infection in the tonsils). Normal tonsils are pink; similar to the color of the lining of your mouth. When infected, tonsils appear bright red and inflamed, are painful, and can result in difficulty swallowing. A sore throat (pharyngitis) is different than tonsillitis, although it is common to have both.

The adenoids cannot be seen by looking in the throat, since they are located higher up in the nasopharynx (the area between the back of the nose and the throat). They can only be seen with an endoscope (a flexible, fiberoptic scope that is introduced through the nose), or a laryngeal mirror. A special x-ray of the neck is also used to estimate adenoidal size. The adenoids are located near where the eustachian tubes enter the throat from the middle ear space. Enlarged or diseased adenoids may compromise the normal ventilation and drainage function of the eustachian tubes. Children with enlarged adenoids may have a nasal quality to their voice, mouth-breathe, and can even develop an adenoidal facies – a characteristic facial appearance and dental malocclusion due to chronic airway obstruction. Middle ear fluid (effusion), otitis media, and sinusitis can also develop from enlarged and/or infected adenoids. It is quite common to have the adenoids removed when tubes (Pressure Equalization Tubes) are inserted.

Tonsils and adenoids frequently become infected. The vast majority (90%) of these infections are viral; the other 10% are bacterial, such as Streptococcus (Strep). Mononucleosis (Mono) will also cause tonsillar enlargement. Tonsils that are frequently infected, several times per year, may need to be surgically removed. Rarely, tonsils will develop an abscess on one side (peritonsillar abscess), resulting in severe throat pain (often referred to the ear), difficulty swallowing, and fever. Peritonsillar abscesses often cause the uvula (the little hanging tissue at the back of the throat) to deviate to one side. Peritonsillar abscess may need to be surgical drained; and tonsils may need to be surgically removed for recurrent abscesses. Frequent Strep infections or people that are Strep carriers may also be surgical candidates.

Tonsils and adenoids that are chronically enlarged my compromise the airway, resulting in disturbed sleep, frequent sleep arousals, snoring, and even true apnea (the temporary cessation of breathing). Children who do not sleep well are frequently tired and cranky during the day and can have problems concentrating in school. Obstructive sleep apnea should be considered if your child has an apnea spell lasting ten seconds, loud storing, or daytime sleepiness. Sleep studies, as well as a full cardiac examination should be performed in anyone with sleep apnea.

A frequently-asked question on the WebMD Ear, Nose & Throat message board is about tonsillitis, or tonsillar stones. Food and other debris can build-up in the crypts and craters of the tonsils, and harden to a stone-like consistency. When these tonsillar stones dislodge, they result in a terrible taste in the mouth and halitosis. The only definitive cure for tonsilliths is the surgical removal of the tonsils. As an interim solution, gargling with warm salt water after every meal may help prevent the build-up of this hard debris.

In the adult population, especially in people who smoke, one-sided tonsillar enlargement could indicate a tumor. Lymphomas and HIV infections can also cause tonsillar enlargement, so it is very important to have a thorough medical evaluation.

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